BC Dental Survey of Aboriginal Kindergarten Children 20152016

A Provincial and First Nations School Analysis

August 2019

[2]

Executive Summary This sub-report presents survey findings related to the early childhood dental health of Aboriginal1 children in British Columbia (BC) using data from the 20152016 BC kindergarten dental survey2 The kindergarten dental survey is conducted every three years to identify children with visible decay treated caries (eg fillings) or who are caries-free (ie no visible decay or treated caries) In addition children identified as needing follow up are referred for further dental services A visual inspection of kindergarten childrenrsquos teeth is conducted by public health dental staff using a tongue depressor and a light The survey aims to screen all kindergarten children across British Columbia attending public or independent schools as well as those attending First Nations schools For most children screening occurs at school during the kindergarten school year The goal of the kindergarten dental survey is to improve early childhood dental health in BC by monitoring trends identifying instances where there are significant disparities in dental outcomes and exploring the effectiveness of dental health programming Dental screening for Aboriginal children under age six is a key action item in the Transformative Change Accord First Nations Health Plan3 For the purposes of data analysis a child was considered Aboriginal if their family had self-identified as having Aboriginal ancestry during school registration (at public and independent schools)4 or if the child attended a First Nations school This report summarizes dental health outcomes for Aboriginal children and compares them with outcomes for non-Aboriginal children The latter is done a) by comparing the prevalence for each indicator between the two groups (expressed as percentage point differences) and b) by presenting relative risks (calculated as the prevalence in Aboriginal divided by the prevalence in non-Aboriginal children) Relative risk (RR) is an epidemiological term used to describe the likelihood of an outcome or event occurring in one group compared to another Results are described at the provincial level and broken down by health authority Outcomes for children attending First Nations schools are also summarized and compared with those of Aboriginal children attending public or independent schools Finally trends over time are analyzed

Interpreting Survey Results The kindergarten dental survey involves a visual inspection of a childrsquos teeth and is not the same as a full dental exam As such it is possible that existing decay or treated caries could be missed Despite this limitation survey results are valid and useful to observe general trends in early childhood dental health over time

1 ldquoAboriginalrdquo is used throughout this report in alignment with the terminology currently used by the Ministry of Education in the process by which families at the time of school registration can self-identify as having Aboriginal ancestry This can include status and non-status First Nations Meacutetis and Inuit ancestry We recognize that other provincial ministries and programs use the term ldquoIndigenousrdquo instead of Aboriginal to refer to status and non-status First Nations Meacutetis and Inuit peoples and communities 2 British Columbia Dental Survey of Kindergarten Children A Provincial and Regional Analysis 20152016 can be found at httpswwwhealthgovbccalibrarypublicationsyear2017provincial-kindergarten-dental-survey-report-2015-2016pdf 3 The Transformative Change Accord First Nations Health Plan can be found at httpswwwhealthgovbccalibrarypublicationsyear2006first_nations_health_implementation_planpdf 4 Children or families may also self-identify as Aboriginal at the time of the screening but this is rare Self-identification is typically done by the parent at the time of school registration

[2]

Executive Summary This sub-report presents survey findings related to the early childhood dental health of Aboriginal1 children in British Columbia (BC) using data from the 20152016 BC kindergarten dental survey2 The kindergarten dental survey is conducted every three years to identify children with visible decay treated caries (eg fillings) or who are caries-free (ie no visible decay or treated caries) In addition children identified as needing follow up are referred for further dental services A visual inspection of kindergarten childrenrsquos teeth is conducted by public health dental staff using a tongue depressor and a light The survey aims to screen all kindergarten children across British Columbia attending public or independent schools as well as those attending First Nations schools For most children screening occurs at school during the kindergarten school year The goal of the kindergarten dental survey is to improve early childhood dental health in BC by monitoring trends identifying instances where there are significant disparities in dental outcomes and exploring the effectiveness of dental health programming Dental screening for Aboriginal children under age six is a key action item in the Transformative Change Accord First Nations Health Plan3 For the purposes of data analysis a child was considered Aboriginal if their family had self-identified as having Aboriginal ancestry during school registration (at public and independent schools)4 or if the child attended a First Nations school This report summarizes dental health outcomes for Aboriginal children and compares them with outcomes for non-Aboriginal children The latter is done a) by comparing the prevalence for each indicator between the two groups (expressed as percentage point differences) and b) by presenting relative risks (calculated as the prevalence in Aboriginal divided by the prevalence in non-Aboriginal children) Relative risk (RR) is an epidemiological term used to describe the likelihood of an outcome or event occurring in one group compared to another Results are described at the provincial level and broken down by health authority Outcomes for children attending First Nations schools are also summarized and compared with those of Aboriginal children attending public or independent schools Finally trends over time are analyzed

Interpreting Survey Results The kindergarten dental survey involves a visual inspection of a childrsquos teeth and is not the same as a full dental exam As such it is possible that existing decay or treated caries could be missed Despite this limitation survey results are valid and useful to observe general trends in early childhood dental health over time

1 ldquoAboriginalrdquo is used throughout this report in alignment with the terminology currently used by the Ministry of Education in the process by which families at the time of school registration can self-identify as having Aboriginal ancestry This can include status and non-status First Nations Meacutetis and Inuit ancestry We recognize that other provincial ministries and programs use the term ldquoIndigenousrdquo instead of Aboriginal to refer to status and non-status First Nations Meacutetis and Inuit peoples and communities 2 British Columbia Dental Survey of Kindergarten Children A Provincial and Regional Analysis 20152016 can be found at httpswwwhealthgovbccalibrarypublicationsyear2017provincial-kindergarten-dental-survey-report-2015-2016pdf 3 The Transformative Change Accord First Nations Health Plan can be found at httpswwwhealthgovbccalibrarypublicationsyear2006first_nations_health_implementation_planpdf 4 Children or families may also self-identify as Aboriginal at the time of the screening but this is rare Self-identification is typically done by the parent at the time of school registration

[3]

Results Province-wide Total children screened in 20152016

bull In total 39926 children participated in the provincial kindergarten dental survey (920 of those enrolled)

bull 3363 Aboriginal children participated in the provincial kindergarten dental survey (898 of the estimated enrolled Aboriginal children)

Among all Aboriginal kindergarten children in 20152016

bull 457 were caries-free56 (no visible decay or broken enamel)

bull 307 had treated caries (no visible decay but existing restorations) and

bull 236 had evidence of visible decay Trends over time Since 200920107 the oral health of Aboriginal kindergarten children in BC has improved at the provincial level

bull the prevalence of Aboriginal kindergarten children who are caries-free has increased by 64 percentage points from 393 to 457

bull the prevalence of treated caries among Aboriginal kindergarten children has decreased by 15 percentage points from 322 to 307 and

bull the prevalence of visible decay among Aboriginal children has decreased by 49 percentage points from 285 to 236

Results First Nations Schools During the 20152016 school year 468 kindergarten children attending 49 participating First Nations schools were screened (884 of those enrolled in participating schools) Across BC in 20152016

bull 201 of kindergarten children attending First Nations schools were caries-free (no visible decay or broken enamel) compared to 501 of Aboriginal children attending public or independent schools

bull 485 of kindergarten children attending First Nations schools had treated caries (no visible decay but existing restorations) compared to 277 of Aboriginal children attending public or independent schools

bull 313 of kindergarten children attending First Nations schools had evidence of visible decay compared to 222 of Aboriginal children attending public or independent schools

5 It is difficult to determine if someone is truly caries free through visual assessment alone The term ldquocaries freerdquo is used through this report to indicate that there was no visible decay or broken enamel noted at the time of the survey For example some treated caries may be missed due to white fillings that can be difficult to identify using a pen light Decay between teeth may also be missed 6 Full definitions of caries free treated caries visible decay and other terminology can be found on page 9 ndash 10 7 The 20092010 kindergarten dental survey was the first survey to allow for disaggregation by Aboriginalnon-Aboriginal identity at a provincial level Information on Aboriginal identity was also collected in the 2012-2013 survey

[4]

Trends over time Since 20062007

bull In First Nations schools the prevalence of children who were caries-free has increased by 24 percentage points since the 20062007 survey and decreased by 10 percentage points since the 20122013 survey

bull In First Nations schools the prevalence of children with treated caries has increased by 40 percentage points since the 20062007 survey and has remained relatively unchanged since the 20122013 survey (486 and 485 respectively)

bull In First Nations schools the prevalence of visible decay has decreased by 63 percentage points since the 20062007 survey but increased by 10 percentage point since the 20122013 survey

While there has been overall progress since the 20062007 survey in increasing the percentage of Aboriginal children attending First Nations schools who are caries-free and reducing the percentage who showed signs of visible decay progress on both measures appears to have stalled since the 20122013 survey However if treated caries and visible decay are considered together total experience of dental decay has decreased by 64 percentage points since the 20092010 survey (607 to 543) (Figure 1)

Results Aboriginal and Non-Aboriginal Students While there have been encouraging improvements over the past several years in the early childhood dental health of Aboriginal children some disparities continue to persist when early childhood dental outcomes are compared between Aboriginal and non-Aboriginal children Caries-free

bull In 20152016 the percentage of children who were caries-free was 255 percentage points lower in Aboriginal children (457) than in non-Aboriginal children (712) This difference has remained relatively constant since 20092010 (258 percentage points) suggesting that minimal progress has been made in reducing this gap over time

bull Similarly in 20152016 Aboriginal children were 40 less likely to be caries free than non-Aboriginal children This gap has remained constant over the past three survey cycles

Treated caries

bull In 20152016 the percentage of children with treated caries was 153 percentage points higher in Aboriginal children (305) than in non-Aboriginal children (154) This difference has increased from 134 percentage points in 20092010 suggesting that the gap between Aboriginal and non-Aboriginal children may be widening While the prevalence of treated caries can indicate access to dental treatment it also indicates that early childhood caries existed in the first place

Visible decay

bull In 20152016 the percentage of children with visible decay was 102 percentage points higher in Aboriginal children (236) than non-Aboriginal children (133) This difference has declined slightly from 123 percentage points in 20092010

bull However the relative risk of visible decay for Aboriginal children has remained constant at 18 over the past three survey cycles ndash in other words ndash Aboriginal children have almost

[5]

twice the risk of having visible decay than non-Aboriginal children Although the prevalence of visible decay has declined in Aboriginal and non-Aboriginal children over time the gap between the two groups has persisted

Disparities between Aboriginal and non-Aboriginal early childhood dental health outcomes reflect the complex biomedical and social factors that contribute to early childhood caries and are not unique to BC123 Provincially work is underway to address these gaps An oral health strategy called Healthy Smiles for Life BCrsquos First Nations and Aboriginal Oral Health Strategy was developed in 2014 to guide the delivery of collaborative public health and community services that focus on improving the oral health of First Nations and Aboriginal children aged 0-18 years and their families in BC This strategy provides a comprehensive evidence-based and multi-level set of recommendations to inform public health and community planning policy development and program implementation There is significant opportunity for the development of innovative collaborative and effective strategies to improve the early childhood dental health of Aboriginal children in BC and to reduce ongoing dental healthy inequities The findings of the kindergarten dental survey help identify areas of the province where meaningful progress is being made as well as opportunities for jurisdictions to share innovative and effective practices Future kindergarten dental surveys will allow for ongoing monitoring and support efforts to improve dental health outcomes among Aboriginal children across BC

[6]

Contents Executive Summary 2 Introduction 7 Results Provincial Analysis 9 Aboriginal Children 10 Aboriginal and Non-Aboriginal Children 12 Results Health Authority Analysis 15 Caries-free 15 Treated Caries 17 Visible Decay 18 Decay By Quadrant 19 Referrals 22 Results First Nations Schools 23 Caries-free Treated Caries and Visible Decay 24 Decay By Quadrant 245 Referrals 246 Conclusion and Recommendations 27

[7]

Introduction Background Dental health is a fundamental component of overall health and well-being Caries (tooth decay) is an infectious and transmissible disease that children often acquire through a primary caregiver before the age of three4 Though dental caries are preventable they remain the most common chronic condition in childhood56 Tooth decay can cause pain and negatively affect sleep the ability to eat speech development and self-esteem7 Early childhood caries are also expensive At present the repair of dental decay is the number one reason why Canadians between the ages of 1 and 5 years undergo day surgery with annual costs estimated at $35 million in BC8 Prevention strategies are especially important in the early years to promote healthy development and establish a foundation for oral health throughout onersquos life9 Public health dental programs focus on the prevention of early childhood caries First Nations communities receive a mix of dental health prevention services and programs funded by the First Nations Health Authority (FNHA) and the regional health authorities Some First Nations communities have contracts with other organizations to provide services or they provide services directly Not all communities receive the same level of services or programs this may contribute to geographical disparities in early childhood dental outcomes Some First Nations communities receive services through the Childrenrsquos Oral Health Initiative (COHI) This program was developed to help address oral health disparities between First Nations and Inuit populations and the general Canadian population Launched on a test basis in 2004 the program was transferred to the FNHA from Health Canada in 2013 At the time of this report the program is operating in 79 communities in British Columbia The program focuses on the prevention of dental disease and promotion of good oral health practices In 2014 BC launched Healthy Smiles for Life BCrsquos First Nations and Aboriginal Oral Health Strategy - an oral health strategy to guide the delivery of collaborative public health and community services to improve the oral health of First Nations and Aboriginal infants children and youth (aged 0-18 years) and their families The strategy provides a comprehensive evidence-based and multi-level set of recommendations that inform public health and community planning policy development and program implementation Dental screening for Aboriginal children under age six is also a key action item in the Transformative Change Accord First Nations Health Plan

Methodology Every three years health authority dental staff conduct a provincial kindergarten dental survey via a visual inspection of childrenrsquos teeth using a tongue depressor and a light The survey does not replace a regular dental exam rather its purpose is to determine the prevalence of dental decay to identify trends in dental health at different geographic scales and among different demographics and where possible to obtain a measure of the effectiveness of early childhood dental public health strategies During the survey kindergarten children are assessed for

bull no evidence of visible dental decayno broken enamel (caries-free)

bull no evidence of visible decay but evidence of existing restorations (treated caries)

bull evidence of visible dental decay in one or more teeth (visible decay)

bull the number of dental quadrants affected by decay

bull the need for urgent or non-urgent referral for dental care

[8]

The Public Health Impediments Regulation the School Act and the Freedom of Information and Protection of Privacy Act guide and support the implementation of the kindergarten dental survey Health authorities use the practice of parent notification with an lsquoopt outrsquo process to obtain consent for the dental survey Parents are notified by letter about the upcoming date and purpose of the survey and are provided with the health authority contact phone number if further information is needed or to decline their childrsquos or childrenrsquos participation Parents may lsquoopt outrsquo of the survey services with no consequences to future service provision or care of their child If the parent does not contact public health the child is screened On occasion a school may request that an ldquoopt inrdquo process is used instead whereby the parent of each child must actively give consent for their child to be screened Target Population The population for the provincial dental survey is all kindergarten aged children across British Columbia In the 20152016 school year the kindergarten dental survey was administered in multiple locations including public schools independent schools participating First Nations schools across BC and 39926 children were screened Within this population a total of 3363 Aboriginal children participated representing 898 of the estimated enrolled Aboriginal children at participating schools This report summarizes the prevalence of caries-free treated caries visible decay decay by quadrant urgent referrals and non-urgent referrals among Aboriginal children and compares these indicators to findings in non-Aboriginal children In some cases these comparisons are expressed as relative risks (prevalence in Aboriginal children prevalence in non-Aboriginal children) to facilitate interpretation of the results Health authority specific results including trends over time are also presented Findings for kindergarten children attending First Nations schools are summarized at a provincial level and include comparisons between students at First Nations schools and Aboriginal children attending public or independent schools Children were considered Aboriginal if their family self-identified as having Aboriginal ancestry at the time of school registration (for public or independent schools)8 or if the child attended a First Nations school This method leads to some error as a small number of non-Aboriginal students attend First Nations schools 9 However the impact of this inaccuracy on the examined comparisons is expected to be small Trends in dental outcomes are shown from 20092010 on as information on Aboriginal identity has only been available since the 20092010 survey The report summarizing the findings of the full provincial survey British Columbia Dental Survey of Kindergarten Children A Provincial and Regional Analysis 20152016 can be found at httpswwwhealthgovbccalibrarypublicationsyear2017provincial-kindergarten-dental-survey-report-2015-2016pdf Interpretation and Limitations of the Data The following limitations need to be considered when interpreting the presented data In 2015-2016 survey data were only collected in 49 of 109 First Nations schools across BC that offered kindergarten programming (ie a 45 participation rate for First Nations schools) As these schools may not be representative of all First Nations schools across the province the results for First Nations schools should

8 Children or families may also self-identify as Aboriginal at the time of the screening but this is rare 9 14 non-Aboriginal children attending First Nations schools were screened in the 20152016 survey and their data were included in First Nations schoolsrsquo results

[4]

Trends over time Since 20062007

bull In First Nations schools the prevalence of children who were caries-free has increased by 24 percentage points since the 20062007 survey and decreased by 10 percentage points since the 20122013 survey

bull In First Nations schools the prevalence of children with treated caries has increased by 40 percentage points since the 20062007 survey and has remained relatively unchanged since the 20122013 survey (486 and 485 respectively)

bull In First Nations schools the prevalence of visible decay has decreased by 63 percentage points since the 20062007 survey but increased by 10 percentage point since the 20122013 survey

While there has been overall progress since the 20062007 survey in increasing the percentage of Aboriginal children attending First Nations schools who are caries-free and reducing the percentage who showed signs of visible decay progress on both measures appears to have stalled since the 20122013 survey However if treated caries and visible decay are considered together total experience of dental decay has decreased by 64 percentage points since the 20092010 survey (607 to 543) (Figure 1)

Results Aboriginal and Non-Aboriginal Students While there have been encouraging improvements over the past several years in the early childhood dental health of Aboriginal children some disparities continue to persist when early childhood dental outcomes are compared between Aboriginal and non-Aboriginal children Caries-free

bull In 20152016 the percentage of children who were caries-free was 255 percentage points lower in Aboriginal children (457) than in non-Aboriginal children (712) This difference has remained relatively constant since 20092010 (258 percentage points) suggesting that minimal progress has been made in reducing this gap over time

bull Similarly in 20152016 Aboriginal children were 40 less likely to be caries free than non-Aboriginal children This gap has remained constant over the past three survey cycles

Treated caries

bull In 20152016 the percentage of children with treated caries was 153 percentage points higher in Aboriginal children (305) than in non-Aboriginal children (154) This difference has increased from 134 percentage points in 20092010 suggesting that the gap between Aboriginal and non-Aboriginal children may be widening While the prevalence of treated caries can indicate access to dental treatment it also indicates that early childhood caries existed in the first place

Visible decay

bull In 20152016 the percentage of children with visible decay was 102 percentage points higher in Aboriginal children (236) than non-Aboriginal children (133) This difference has declined slightly from 123 percentage points in 20092010

bull However the relative risk of visible decay for Aboriginal children has remained constant at 18 over the past three survey cycles ndash in other words ndash Aboriginal children have almost

[5]

twice the risk of having visible decay than non-Aboriginal children Although the prevalence of visible decay has declined in Aboriginal and non-Aboriginal children over time the gap between the two groups has persisted

Disparities between Aboriginal and non-Aboriginal early childhood dental health outcomes reflect the complex biomedical and social factors that contribute to early childhood caries and are not unique to BC123 Provincially work is underway to address these gaps An oral health strategy called Healthy Smiles for Life BCrsquos First Nations and Aboriginal Oral Health Strategy was developed in 2014 to guide the delivery of collaborative public health and community services that focus on improving the oral health of First Nations and Aboriginal children aged 0-18 years and their families in BC This strategy provides a comprehensive evidence-based and multi-level set of recommendations to inform public health and community planning policy development and program implementation There is significant opportunity for the development of innovative collaborative and effective strategies to improve the early childhood dental health of Aboriginal children in BC and to reduce ongoing dental healthy inequities The findings of the kindergarten dental survey help identify areas of the province where meaningful progress is being made as well as opportunities for jurisdictions to share innovative and effective practices Future kindergarten dental surveys will allow for ongoing monitoring and support efforts to improve dental health outcomes among Aboriginal children across BC

[6]

Contents Executive Summary 2 Introduction 7 Results Provincial Analysis 9 Aboriginal Children 10 Aboriginal and Non-Aboriginal Children 12 Results Health Authority Analysis 15 Caries-free 15 Treated Caries 17 Visible Decay 18 Decay By Quadrant 19 Referrals 22 Results First Nations Schools 23 Caries-free Treated Caries and Visible Decay 24 Decay By Quadrant 245 Referrals 246 Conclusion and Recommendations 27

[7]

Introduction Background Dental health is a fundamental component of overall health and well-being Caries (tooth decay) is an infectious and transmissible disease that children often acquire through a primary caregiver before the age of three4 Though dental caries are preventable they remain the most common chronic condition in childhood56 Tooth decay can cause pain and negatively affect sleep the ability to eat speech development and self-esteem7 Early childhood caries are also expensive At present the repair of dental decay is the number one reason why Canadians between the ages of 1 and 5 years undergo day surgery with annual costs estimated at $35 million in BC8 Prevention strategies are especially important in the early years to promote healthy development and establish a foundation for oral health throughout onersquos life9 Public health dental programs focus on the prevention of early childhood caries First Nations communities receive a mix of dental health prevention services and programs funded by the First Nations Health Authority (FNHA) and the regional health authorities Some First Nations communities have contracts with other organizations to provide services or they provide services directly Not all communities receive the same level of services or programs this may contribute to geographical disparities in early childhood dental outcomes Some First Nations communities receive services through the Childrenrsquos Oral Health Initiative (COHI) This program was developed to help address oral health disparities between First Nations and Inuit populations and the general Canadian population Launched on a test basis in 2004 the program was transferred to the FNHA from Health Canada in 2013 At the time of this report the program is operating in 79 communities in British Columbia The program focuses on the prevention of dental disease and promotion of good oral health practices In 2014 BC launched Healthy Smiles for Life BCrsquos First Nations and Aboriginal Oral Health Strategy - an oral health strategy to guide the delivery of collaborative public health and community services to improve the oral health of First Nations and Aboriginal infants children and youth (aged 0-18 years) and their families The strategy provides a comprehensive evidence-based and multi-level set of recommendations that inform public health and community planning policy development and program implementation Dental screening for Aboriginal children under age six is also a key action item in the Transformative Change Accord First Nations Health Plan

Methodology Every three years health authority dental staff conduct a provincial kindergarten dental survey via a visual inspection of childrenrsquos teeth using a tongue depressor and a light The survey does not replace a regular dental exam rather its purpose is to determine the prevalence of dental decay to identify trends in dental health at different geographic scales and among different demographics and where possible to obtain a measure of the effectiveness of early childhood dental public health strategies During the survey kindergarten children are assessed for

bull no evidence of visible dental decayno broken enamel (caries-free)

bull no evidence of visible decay but evidence of existing restorations (treated caries)

bull evidence of visible dental decay in one or more teeth (visible decay)

bull the number of dental quadrants affected by decay

bull the need for urgent or non-urgent referral for dental care

[8]

The Public Health Impediments Regulation the School Act and the Freedom of Information and Protection of Privacy Act guide and support the implementation of the kindergarten dental survey Health authorities use the practice of parent notification with an lsquoopt outrsquo process to obtain consent for the dental survey Parents are notified by letter about the upcoming date and purpose of the survey and are provided with the health authority contact phone number if further information is needed or to decline their childrsquos or childrenrsquos participation Parents may lsquoopt outrsquo of the survey services with no consequences to future service provision or care of their child If the parent does not contact public health the child is screened On occasion a school may request that an ldquoopt inrdquo process is used instead whereby the parent of each child must actively give consent for their child to be screened Target Population The population for the provincial dental survey is all kindergarten aged children across British Columbia In the 20152016 school year the kindergarten dental survey was administered in multiple locations including public schools independent schools participating First Nations schools across BC and 39926 children were screened Within this population a total of 3363 Aboriginal children participated representing 898 of the estimated enrolled Aboriginal children at participating schools This report summarizes the prevalence of caries-free treated caries visible decay decay by quadrant urgent referrals and non-urgent referrals among Aboriginal children and compares these indicators to findings in non-Aboriginal children In some cases these comparisons are expressed as relative risks (prevalence in Aboriginal children prevalence in non-Aboriginal children) to facilitate interpretation of the results Health authority specific results including trends over time are also presented Findings for kindergarten children attending First Nations schools are summarized at a provincial level and include comparisons between students at First Nations schools and Aboriginal children attending public or independent schools Children were considered Aboriginal if their family self-identified as having Aboriginal ancestry at the time of school registration (for public or independent schools)8 or if the child attended a First Nations school This method leads to some error as a small number of non-Aboriginal students attend First Nations schools 9 However the impact of this inaccuracy on the examined comparisons is expected to be small Trends in dental outcomes are shown from 20092010 on as information on Aboriginal identity has only been available since the 20092010 survey The report summarizing the findings of the full provincial survey British Columbia Dental Survey of Kindergarten Children A Provincial and Regional Analysis 20152016 can be found at httpswwwhealthgovbccalibrarypublicationsyear2017provincial-kindergarten-dental-survey-report-2015-2016pdf Interpretation and Limitations of the Data The following limitations need to be considered when interpreting the presented data In 2015-2016 survey data were only collected in 49 of 109 First Nations schools across BC that offered kindergarten programming (ie a 45 participation rate for First Nations schools) As these schools may not be representative of all First Nations schools across the province the results for First Nations schools should

8 Children or families may also self-identify as Aboriginal at the time of the screening but this is rare 9 14 non-Aboriginal children attending First Nations schools were screened in the 20152016 survey and their data were included in First Nations schoolsrsquo results

[5]

twice the risk of having visible decay than non-Aboriginal children Although the prevalence of visible decay has declined in Aboriginal and non-Aboriginal children over time the gap between the two groups has persisted

Disparities between Aboriginal and non-Aboriginal early childhood dental health outcomes reflect the complex biomedical and social factors that contribute to early childhood caries and are not unique to BC123 Provincially work is underway to address these gaps An oral health strategy called Healthy Smiles for Life BCrsquos First Nations and Aboriginal Oral Health Strategy was developed in 2014 to guide the delivery of collaborative public health and community services that focus on improving the oral health of First Nations and Aboriginal children aged 0-18 years and their families in BC This strategy provides a comprehensive evidence-based and multi-level set of recommendations to inform public health and community planning policy development and program implementation There is significant opportunity for the development of innovative collaborative and effective strategies to improve the early childhood dental health of Aboriginal children in BC and to reduce ongoing dental healthy inequities The findings of the kindergarten dental survey help identify areas of the province where meaningful progress is being made as well as opportunities for jurisdictions to share innovative and effective practices Future kindergarten dental surveys will allow for ongoing monitoring and support efforts to improve dental health outcomes among Aboriginal children across BC

[6]

Contents Executive Summary 2 Introduction 7 Results Provincial Analysis 9 Aboriginal Children 10 Aboriginal and Non-Aboriginal Children 12 Results Health Authority Analysis 15 Caries-free 15 Treated Caries 17 Visible Decay 18 Decay By Quadrant 19 Referrals 22 Results First Nations Schools 23 Caries-free Treated Caries and Visible Decay 24 Decay By Quadrant 245 Referrals 246 Conclusion and Recommendations 27

[7]

Introduction Background Dental health is a fundamental component of overall health and well-being Caries (tooth decay) is an infectious and transmissible disease that children often acquire through a primary caregiver before the age of three4 Though dental caries are preventable they remain the most common chronic condition in childhood56 Tooth decay can cause pain and negatively affect sleep the ability to eat speech development and self-esteem7 Early childhood caries are also expensive At present the repair of dental decay is the number one reason why Canadians between the ages of 1 and 5 years undergo day surgery with annual costs estimated at $35 million in BC8 Prevention strategies are especially important in the early years to promote healthy development and establish a foundation for oral health throughout onersquos life9 Public health dental programs focus on the prevention of early childhood caries First Nations communities receive a mix of dental health prevention services and programs funded by the First Nations Health Authority (FNHA) and the regional health authorities Some First Nations communities have contracts with other organizations to provide services or they provide services directly Not all communities receive the same level of services or programs this may contribute to geographical disparities in early childhood dental outcomes Some First Nations communities receive services through the Childrenrsquos Oral Health Initiative (COHI) This program was developed to help address oral health disparities between First Nations and Inuit populations and the general Canadian population Launched on a test basis in 2004 the program was transferred to the FNHA from Health Canada in 2013 At the time of this report the program is operating in 79 communities in British Columbia The program focuses on the prevention of dental disease and promotion of good oral health practices In 2014 BC launched Healthy Smiles for Life BCrsquos First Nations and Aboriginal Oral Health Strategy - an oral health strategy to guide the delivery of collaborative public health and community services to improve the oral health of First Nations and Aboriginal infants children and youth (aged 0-18 years) and their families The strategy provides a comprehensive evidence-based and multi-level set of recommendations that inform public health and community planning policy development and program implementation Dental screening for Aboriginal children under age six is also a key action item in the Transformative Change Accord First Nations Health Plan

Methodology Every three years health authority dental staff conduct a provincial kindergarten dental survey via a visual inspection of childrenrsquos teeth using a tongue depressor and a light The survey does not replace a regular dental exam rather its purpose is to determine the prevalence of dental decay to identify trends in dental health at different geographic scales and among different demographics and where possible to obtain a measure of the effectiveness of early childhood dental public health strategies During the survey kindergarten children are assessed for

bull no evidence of visible dental decayno broken enamel (caries-free)

bull no evidence of visible decay but evidence of existing restorations (treated caries)

bull evidence of visible dental decay in one or more teeth (visible decay)

bull the number of dental quadrants affected by decay

bull the need for urgent or non-urgent referral for dental care

[8]

The Public Health Impediments Regulation the School Act and the Freedom of Information and Protection of Privacy Act guide and support the implementation of the kindergarten dental survey Health authorities use the practice of parent notification with an lsquoopt outrsquo process to obtain consent for the dental survey Parents are notified by letter about the upcoming date and purpose of the survey and are provided with the health authority contact phone number if further information is needed or to decline their childrsquos or childrenrsquos participation Parents may lsquoopt outrsquo of the survey services with no consequences to future service provision or care of their child If the parent does not contact public health the child is screened On occasion a school may request that an ldquoopt inrdquo process is used instead whereby the parent of each child must actively give consent for their child to be screened Target Population The population for the provincial dental survey is all kindergarten aged children across British Columbia In the 20152016 school year the kindergarten dental survey was administered in multiple locations including public schools independent schools participating First Nations schools across BC and 39926 children were screened Within this population a total of 3363 Aboriginal children participated representing 898 of the estimated enrolled Aboriginal children at participating schools This report summarizes the prevalence of caries-free treated caries visible decay decay by quadrant urgent referrals and non-urgent referrals among Aboriginal children and compares these indicators to findings in non-Aboriginal children In some cases these comparisons are expressed as relative risks (prevalence in Aboriginal children prevalence in non-Aboriginal children) to facilitate interpretation of the results Health authority specific results including trends over time are also presented Findings for kindergarten children attending First Nations schools are summarized at a provincial level and include comparisons between students at First Nations schools and Aboriginal children attending public or independent schools Children were considered Aboriginal if their family self-identified as having Aboriginal ancestry at the time of school registration (for public or independent schools)8 or if the child attended a First Nations school This method leads to some error as a small number of non-Aboriginal students attend First Nations schools 9 However the impact of this inaccuracy on the examined comparisons is expected to be small Trends in dental outcomes are shown from 20092010 on as information on Aboriginal identity has only been available since the 20092010 survey The report summarizing the findings of the full provincial survey British Columbia Dental Survey of Kindergarten Children A Provincial and Regional Analysis 20152016 can be found at httpswwwhealthgovbccalibrarypublicationsyear2017provincial-kindergarten-dental-survey-report-2015-2016pdf Interpretation and Limitations of the Data The following limitations need to be considered when interpreting the presented data In 2015-2016 survey data were only collected in 49 of 109 First Nations schools across BC that offered kindergarten programming (ie a 45 participation rate for First Nations schools) As these schools may not be representative of all First Nations schools across the province the results for First Nations schools should

8 Children or families may also self-identify as Aboriginal at the time of the screening but this is rare 9 14 non-Aboriginal children attending First Nations schools were screened in the 20152016 survey and their data were included in First Nations schoolsrsquo results

[6]

Contents Executive Summary 2 Introduction 7 Results Provincial Analysis 9 Aboriginal Children 10 Aboriginal and Non-Aboriginal Children 12 Results Health Authority Analysis 15 Caries-free 15 Treated Caries 17 Visible Decay 18 Decay By Quadrant 19 Referrals 22 Results First Nations Schools 23 Caries-free Treated Caries and Visible Decay 24 Decay By Quadrant 245 Referrals 246 Conclusion and Recommendations 27

[7]

Introduction Background Dental health is a fundamental component of overall health and well-being Caries (tooth decay) is an infectious and transmissible disease that children often acquire through a primary caregiver before the age of three4 Though dental caries are preventable they remain the most common chronic condition in childhood56 Tooth decay can cause pain and negatively affect sleep the ability to eat speech development and self-esteem7 Early childhood caries are also expensive At present the repair of dental decay is the number one reason why Canadians between the ages of 1 and 5 years undergo day surgery with annual costs estimated at $35 million in BC8 Prevention strategies are especially important in the early years to promote healthy development and establish a foundation for oral health throughout onersquos life9 Public health dental programs focus on the prevention of early childhood caries First Nations communities receive a mix of dental health prevention services and programs funded by the First Nations Health Authority (FNHA) and the regional health authorities Some First Nations communities have contracts with other organizations to provide services or they provide services directly Not all communities receive the same level of services or programs this may contribute to geographical disparities in early childhood dental outcomes Some First Nations communities receive services through the Childrenrsquos Oral Health Initiative (COHI) This program was developed to help address oral health disparities between First Nations and Inuit populations and the general Canadian population Launched on a test basis in 2004 the program was transferred to the FNHA from Health Canada in 2013 At the time of this report the program is operating in 79 communities in British Columbia The program focuses on the prevention of dental disease and promotion of good oral health practices In 2014 BC launched Healthy Smiles for Life BCrsquos First Nations and Aboriginal Oral Health Strategy - an oral health strategy to guide the delivery of collaborative public health and community services to improve the oral health of First Nations and Aboriginal infants children and youth (aged 0-18 years) and their families The strategy provides a comprehensive evidence-based and multi-level set of recommendations that inform public health and community planning policy development and program implementation Dental screening for Aboriginal children under age six is also a key action item in the Transformative Change Accord First Nations Health Plan

Methodology Every three years health authority dental staff conduct a provincial kindergarten dental survey via a visual inspection of childrenrsquos teeth using a tongue depressor and a light The survey does not replace a regular dental exam rather its purpose is to determine the prevalence of dental decay to identify trends in dental health at different geographic scales and among different demographics and where possible to obtain a measure of the effectiveness of early childhood dental public health strategies During the survey kindergarten children are assessed for

bull no evidence of visible dental decayno broken enamel (caries-free)

bull no evidence of visible decay but evidence of existing restorations (treated caries)

bull evidence of visible dental decay in one or more teeth (visible decay)

bull the number of dental quadrants affected by decay

bull the need for urgent or non-urgent referral for dental care

[8]

The Public Health Impediments Regulation the School Act and the Freedom of Information and Protection of Privacy Act guide and support the implementation of the kindergarten dental survey Health authorities use the practice of parent notification with an lsquoopt outrsquo process to obtain consent for the dental survey Parents are notified by letter about the upcoming date and purpose of the survey and are provided with the health authority contact phone number if further information is needed or to decline their childrsquos or childrenrsquos participation Parents may lsquoopt outrsquo of the survey services with no consequences to future service provision or care of their child If the parent does not contact public health the child is screened On occasion a school may request that an ldquoopt inrdquo process is used instead whereby the parent of each child must actively give consent for their child to be screened Target Population The population for the provincial dental survey is all kindergarten aged children across British Columbia In the 20152016 school year the kindergarten dental survey was administered in multiple locations including public schools independent schools participating First Nations schools across BC and 39926 children were screened Within this population a total of 3363 Aboriginal children participated representing 898 of the estimated enrolled Aboriginal children at participating schools This report summarizes the prevalence of caries-free treated caries visible decay decay by quadrant urgent referrals and non-urgent referrals among Aboriginal children and compares these indicators to findings in non-Aboriginal children In some cases these comparisons are expressed as relative risks (prevalence in Aboriginal children prevalence in non-Aboriginal children) to facilitate interpretation of the results Health authority specific results including trends over time are also presented Findings for kindergarten children attending First Nations schools are summarized at a provincial level and include comparisons between students at First Nations schools and Aboriginal children attending public or independent schools Children were considered Aboriginal if their family self-identified as having Aboriginal ancestry at the time of school registration (for public or independent schools)8 or if the child attended a First Nations school This method leads to some error as a small number of non-Aboriginal students attend First Nations schools 9 However the impact of this inaccuracy on the examined comparisons is expected to be small Trends in dental outcomes are shown from 20092010 on as information on Aboriginal identity has only been available since the 20092010 survey The report summarizing the findings of the full provincial survey British Columbia Dental Survey of Kindergarten Children A Provincial and Regional Analysis 20152016 can be found at httpswwwhealthgovbccalibrarypublicationsyear2017provincial-kindergarten-dental-survey-report-2015-2016pdf Interpretation and Limitations of the Data The following limitations need to be considered when interpreting the presented data In 2015-2016 survey data were only collected in 49 of 109 First Nations schools across BC that offered kindergarten programming (ie a 45 participation rate for First Nations schools) As these schools may not be representative of all First Nations schools across the province the results for First Nations schools should

8 Children or families may also self-identify as Aboriginal at the time of the screening but this is rare 9 14 non-Aboriginal children attending First Nations schools were screened in the 20152016 survey and their data were included in First Nations schoolsrsquo results

[7]

Introduction Background Dental health is a fundamental component of overall health and well-being Caries (tooth decay) is an infectious and transmissible disease that children often acquire through a primary caregiver before the age of three4 Though dental caries are preventable they remain the most common chronic condition in childhood56 Tooth decay can cause pain and negatively affect sleep the ability to eat speech development and self-esteem7 Early childhood caries are also expensive At present the repair of dental decay is the number one reason why Canadians between the ages of 1 and 5 years undergo day surgery with annual costs estimated at $35 million in BC8 Prevention strategies are especially important in the early years to promote healthy development and establish a foundation for oral health throughout onersquos life9 Public health dental programs focus on the prevention of early childhood caries First Nations communities receive a mix of dental health prevention services and programs funded by the First Nations Health Authority (FNHA) and the regional health authorities Some First Nations communities have contracts with other organizations to provide services or they provide services directly Not all communities receive the same level of services or programs this may contribute to geographical disparities in early childhood dental outcomes Some First Nations communities receive services through the Childrenrsquos Oral Health Initiative (COHI) This program was developed to help address oral health disparities between First Nations and Inuit populations and the general Canadian population Launched on a test basis in 2004 the program was transferred to the FNHA from Health Canada in 2013 At the time of this report the program is operating in 79 communities in British Columbia The program focuses on the prevention of dental disease and promotion of good oral health practices In 2014 BC launched Healthy Smiles for Life BCrsquos First Nations and Aboriginal Oral Health Strategy - an oral health strategy to guide the delivery of collaborative public health and community services to improve the oral health of First Nations and Aboriginal infants children and youth (aged 0-18 years) and their families The strategy provides a comprehensive evidence-based and multi-level set of recommendations that inform public health and community planning policy development and program implementation Dental screening for Aboriginal children under age six is also a key action item in the Transformative Change Accord First Nations Health Plan

Methodology Every three years health authority dental staff conduct a provincial kindergarten dental survey via a visual inspection of childrenrsquos teeth using a tongue depressor and a light The survey does not replace a regular dental exam rather its purpose is to determine the prevalence of dental decay to identify trends in dental health at different geographic scales and among different demographics and where possible to obtain a measure of the effectiveness of early childhood dental public health strategies During the survey kindergarten children are assessed for

bull no evidence of visible dental decayno broken enamel (caries-free)

bull no evidence of visible decay but evidence of existing restorations (treated caries)

bull evidence of visible dental decay in one or more teeth (visible decay)

bull the number of dental quadrants affected by decay

bull the need for urgent or non-urgent referral for dental care

[8]

The Public Health Impediments Regulation the School Act and the Freedom of Information and Protection of Privacy Act guide and support the implementation of the kindergarten dental survey Health authorities use the practice of parent notification with an lsquoopt outrsquo process to obtain consent for the dental survey Parents are notified by letter about the upcoming date and purpose of the survey and are provided with the health authority contact phone number if further information is needed or to decline their childrsquos or childrenrsquos participation Parents may lsquoopt outrsquo of the survey services with no consequences to future service provision or care of their child If the parent does not contact public health the child is screened On occasion a school may request that an ldquoopt inrdquo process is used instead whereby the parent of each child must actively give consent for their child to be screened Target Population The population for the provincial dental survey is all kindergarten aged children across British Columbia In the 20152016 school year the kindergarten dental survey was administered in multiple locations including public schools independent schools participating First Nations schools across BC and 39926 children were screened Within this population a total of 3363 Aboriginal children participated representing 898 of the estimated enrolled Aboriginal children at participating schools This report summarizes the prevalence of caries-free treated caries visible decay decay by quadrant urgent referrals and non-urgent referrals among Aboriginal children and compares these indicators to findings in non-Aboriginal children In some cases these comparisons are expressed as relative risks (prevalence in Aboriginal children prevalence in non-Aboriginal children) to facilitate interpretation of the results Health authority specific results including trends over time are also presented Findings for kindergarten children attending First Nations schools are summarized at a provincial level and include comparisons between students at First Nations schools and Aboriginal children attending public or independent schools Children were considered Aboriginal if their family self-identified as having Aboriginal ancestry at the time of school registration (for public or independent schools)8 or if the child attended a First Nations school This method leads to some error as a small number of non-Aboriginal students attend First Nations schools 9 However the impact of this inaccuracy on the examined comparisons is expected to be small Trends in dental outcomes are shown from 20092010 on as information on Aboriginal identity has only been available since the 20092010 survey The report summarizing the findings of the full provincial survey British Columbia Dental Survey of Kindergarten Children A Provincial and Regional Analysis 20152016 can be found at httpswwwhealthgovbccalibrarypublicationsyear2017provincial-kindergarten-dental-survey-report-2015-2016pdf Interpretation and Limitations of the Data The following limitations need to be considered when interpreting the presented data In 2015-2016 survey data were only collected in 49 of 109 First Nations schools across BC that offered kindergarten programming (ie a 45 participation rate for First Nations schools) As these schools may not be representative of all First Nations schools across the province the results for First Nations schools should

8 Children or families may also self-identify as Aboriginal at the time of the screening but this is rare 9 14 non-Aboriginal children attending First Nations schools were screened in the 20152016 survey and their data were included in First Nations schoolsrsquo results

[8]

The Public Health Impediments Regulation the School Act and the Freedom of Information and Protection of Privacy Act guide and support the implementation of the kindergarten dental survey Health authorities use the practice of parent notification with an lsquoopt outrsquo process to obtain consent for the dental survey Parents are notified by letter about the upcoming date and purpose of the survey and are provided with the health authority contact phone number if further information is needed or to decline their childrsquos or childrenrsquos participation Parents may lsquoopt outrsquo of the survey services with no consequences to future service provision or care of their child If the parent does not contact public health the child is screened On occasion a school may request that an ldquoopt inrdquo process is used instead whereby the parent of each child must actively give consent for their child to be screened Target Population The population for the provincial dental survey is all kindergarten aged children across British Columbia In the 20152016 school year the kindergarten dental survey was administered in multiple locations including public schools independent schools participating First Nations schools across BC and 39926 children were screened Within this population a total of 3363 Aboriginal children participated representing 898 of the estimated enrolled Aboriginal children at participating schools This report summarizes the prevalence of caries-free treated caries visible decay decay by quadrant urgent referrals and non-urgent referrals among Aboriginal children and compares these indicators to findings in non-Aboriginal children In some cases these comparisons are expressed as relative risks (prevalence in Aboriginal children prevalence in non-Aboriginal children) to facilitate interpretation of the results Health authority specific results including trends over time are also presented Findings for kindergarten children attending First Nations schools are summarized at a provincial level and include comparisons between students at First Nations schools and Aboriginal children attending public or independent schools Children were considered Aboriginal if their family self-identified as having Aboriginal ancestry at the time of school registration (for public or independent schools)8 or if the child attended a First Nations school This method leads to some error as a small number of non-Aboriginal students attend First Nations schools 9 However the impact of this inaccuracy on the examined comparisons is expected to be small Trends in dental outcomes are shown from 20092010 on as information on Aboriginal identity has only been available since the 20092010 survey The report summarizing the findings of the full provincial survey British Columbia Dental Survey of Kindergarten Children A Provincial and Regional Analysis 20152016 can be found at httpswwwhealthgovbccalibrarypublicationsyear2017provincial-kindergarten-dental-survey-report-2015-2016pdf Interpretation and Limitations of the Data The following limitations need to be considered when interpreting the presented data In 2015-2016 survey data were only collected in 49 of 109 First Nations schools across BC that offered kindergarten programming (ie a 45 participation rate for First Nations schools) As these schools may not be representative of all First Nations schools across the province the results for First Nations schools should

8 Children or families may also self-identify as Aboriginal at the time of the screening but this is rare 9 14 non-Aboriginal children attending First Nations schools were screened in the 20152016 survey and their data were included in First Nations schoolsrsquo results

[9]

be interpreted with caution In addition as noted above childrenrsquos Aboriginal identity was primarily determined via self-identification by a parent at the time of school registration or due to their enrollment in a First Nations school This approach may not accurately identify all children with Aboriginal ancestry In general increasing trends in the percentage of children who are caries-free and decreasing trends in the percentage of children with visible decay can be interpreted as improvement in childrenrsquos dental health over time Changes in the percentage of children with treated caries are more difficult to interpret as this indicator captures both the prevalence of decay as well as access to dental care to treat caries Trends in visible decay and treated caries should be considered together as their sum provides a snapshot of the underlying prevalence of dental decay and may highlight the need for increased primary prevention efforts In this report relative risk has been calculated for several outcomes Relative risk (RR) is an epidemiological term used to describe the likelihood of an outcome or event occurring in one group compared another For example the relative risk of visible decay can be calculated for Aboriginal children compared with non-Aboriginal children This analysis can provide more insight into differences between the two groups

BC Public Health Dental Screening Criteria and Definitions Caries-free1011

No evidence of visible decay (no broken enamel) and no existing restorations

Treated Caries

No evidence of visible decay but evidence of existing restorations

Visible Decay

Evidence of obvious decay in one or more teeth

Decay in Quadrants

Evidence of decay in one or more teeth in 123 or 4 quadrants of the mouth

Urgent referrals Children who were referred for further treatment due to the urgency of their conditions

Non-urgent referrals

Children who did not have urgent conditions but were referred for further treatment

Results Provincial Analysis 3363 Aboriginal children participated in the 20152016 kindergarten dental survey representing 898 of estimated enrolled Aboriginal children at participating schools

10 The categories of caries-free treated caries and visible decay are mutually exclusive A child cannot be represented in more than one category For example if a child has both treated caries and visible decay they are categorized as having visible decay only 11 It is difficult to determine if a child is truly caries-free through visual assessment alone The term ldquocaries-freerdquo is used through this report to indicate that there was no visible decay or broken enamel noted at the time of the survey While this approach may miss some cases of dental decay it is still possible to describe trends in early childhood dental health using this method

[10]

Table 1 compares the number and percentage of Aboriginal children screened by health authorities across three most recent survey cycles Across BC the percentage of Aboriginal children who were screened increased from 835 (20092010) to 897 (20122013) and then plateaued at 895 (20152016) This finding is in line with the overall provincial trend (920 in 20152016 compared to 918 screened in 20122013) Table 1 Number and percentage of Aboriginal children who were enrolled in kindergarten and screened in the last three kindergarten dental surveys (20092010 20122013 and 20152016) by health authority

Aboriginal Children Caries-free Treated Caries and Visible Decay Among Aboriginal kindergarten children in 20152016

bull 457 were caries-free (no visible decay or broken enamel)

bull 307 had treated caries (no visible decay but existing restorations) and

bull 236 had evidence of visible decay Since 2009201012 the dental health of Aboriginal kindergarten children in BC has improved at the provincial level

bull the percentage of Aboriginal kindergarten children who are caries-free has increased by 64 percentage points from 393 to 457

bull the prevalence of treated caries among Aboriginal kindergarten children has decreased by 15 percentage points from 322 to 307

bull the prevalence of visible decay among Aboriginal children has decreased by 49 percentage points from 285 to 236

Figure 1 compares the province-wide dental outcomes for Aboriginal kindergarten children across three survey cycles Progress in increasing the percentage of children who are caries-free and decreasing the percentage of children with visible decay over time is evident Progress in reducing the percentage of children with treated caries has been modest However if treated caries and visible decay are considered together total experience of dental decay has decreased by 64 percentage points since the 20092010 survey (607 to 543)

12 The 20092010 survey was the first to allow for disaggregation by Aboriginalnon-Aboriginal status

20092010 20122013 20152016

Health Authority Enrolled Screened

Screened Enrolled Screened

Screened Enrolled Screened

Screened

Interior 666 547 821 823 722 877 769 676 879

Fraser 748 655 876 752 692 920 875 798 912

Vancouver Coastal 310 265 855 333 297 892 332 298 898

Vancouver Island 647 542 838 855 728 851 886 766 865

Northern 532 416 782 999 936 937 884 825 933

BC 2903 2425 835 3762 3375 897 3746 3363 898

[11]

Figure 1 Percentage of Aboriginal kindergarten children with different dental health outcomes over time (20092010 to 20152016)10

Decay by Quadrant Figure 2 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants over the past three survey cycles The prevalence of decay in all examined categories (1 2 3 or 4 quadrants) has declined since 20092010 However there has been little change in the prevalence of decay in 1 2 and 3 quadrants since 20122013 These two findings are in alignment with the provincial trends in visible decay ie progress has been made overall since 20092010 but improvements since 20122013 have been quite modest

Figure 2 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants over time (20092010 to 20152016)11

More dental appointments may be needed to provide treatment when a child has more quadrants affected with decay However the number of quadrants affected with visible decay is not necessarily a proxy of severity or the number of dental appointments needed to provide treatment the number of teeth affected and the seriousness of decay are not reflected in this metric Referrals Figure 3 compares the percentage of Aboriginal children who received an urgent or non-urgent referral for further dental care over the last three survey cycles The percentage of children requiring urgent

Caries FreeTreatedCaries

VisibleDecay

20092010 393 322 285

20122013 431 320 249

20152016 457 307 236

05

101520253035404550

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

20092010 95 102 37 51

20122013 89 75 33 52

20152016 87 73 33 43

0

2

4

6

8

10

12

14

Pe

rce

nta

ge o

f ch

ildre

n

[12]

referral has increased by 07 percentage points from 20092010 to 20122013 but only a further 01 percentage point from 20122013 to 20152016 The percentage of children requiring non-urgent referrals has steadily decreased over time with an overall decline of 56 percentage points since 20092010

Figure 3 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)12

Aboriginal and Non-Aboriginal Children Caries-free Treated Caries and Visible Decay Despite ongoing improvements in the dental health of Aboriginal kindergarten children over time disparities between Aboriginal and non-Aboriginal children continue to persist Across BC in 20152016

bull 457 of Aboriginal kindergarten children were caries-free this was 256 percentage points lower than non-Aboriginal children (713)

bull 307 of Aboriginal kindergarten children had treated caries this was 153 percentage points higher than non-Aboriginal children (154)

bull 236 of Aboriginal kindergarten children had evidence of visible decay this was 10313 percentage points higher than non-Aboriginal children (133)

Figure 4 compares the percentage of kindergarten students who were caries-free or had treated caries or visible decay at the time of the 20152016 survey between Aboriginal and non-Aboriginal children and presents the associated relative risks Aboriginal kindergarten students had 06 20 and 18 times the risk of being caries-free having treated caries or having visible decay compared to non-Aboriginal students

13 Exact numberspercentage may vary due to rounding

Urgent Non-Urgent

20092010 50 244

20122013 57 204

20152016 58 188

0

5

10

15

20

25

30

Pe

rce

nta

ge o

f ch

ildre

n

[13]

Figure 4 Percentage of Aboriginal and non-Aboriginal kindergarten children with different dental health outcomes in 2015201614 and the associated relative risks (RR)

The gaps in dental health outcomes between Aboriginal and non-Aboriginal children have also remained unchanged over the last three survey cycles Table 2 summarizes the prevalence of caries-free treated caries and visible decay for Aboriginal and non-Aboriginal children over time as well as the percentage point differences and relative risks between the two groups Relative risks for caries-free and visible decay have remained virtually unchanged since 20092010 while the relative risks treated caries have increased slightly from 17 to 20 These findings suggest that gaps in dental health outcomes between Aboriginal children continue to exist compared to their non-Aboriginal peers and may even be widening Table 2 Dental health outcomes in Aboriginal and non-Aboriginal children over time (20092010 to 20152016) - percentage of children with each outcome13 percentage point difference and associated relative risks (RR)

20092010 20122013 20152016

A Aboriginal Caries-free () 393 431 457

B Non-Aboriginal Caries-free () 651 694 713

Point Difference B-A) 258 263 256

Relative Risk (AB) 06 06 06

A Aboriginal Treated Caries () 322 320 307

B Non-Aboriginal Treated Caries () 188 168 154

Point Difference (A-B) 134 151 153

Relative Risk (AB) 17 19 20

A Aboriginal Visible Decay () 285 249 236

B Non-Aboriginal Visible Decay () 162 137 133

Point Difference (A-B) 123 112 102

Relative Risk (AB) 18 18 18

RRlt1 indicates a lower likelihood of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher likelihood eg Aboriginal children were less likely to be caries-free (RR 06) and more likely to have visible decay (RR18) in 20152016

Caries FreeTreatedCaries

VisibleDecay

Aboriginal 457 307 236

Non-Aboriginal 713 154 133

Relative Risk 06 20 18

0

10

20

30

40

50

60

70

80

Pe

rce

nta

ge o

f ch

ildre

n

[14]

Decay by Quadrant Figure 5 compares the percentage of decay within one two three or four quadrants for Aboriginal children and non-Aboriginal children in 20152016 Visible decay was more prevalent in Aboriginal children across all quadrant categories When the relative risk was calculated Aboriginal children had 19 14 22 and 23 times the risk of decay in one two three and four quadrants respectively compared to non-Aboriginal children

Figure 5 Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201614 and the associated relative risks (RR)

Referrals Figure 6 compares the percentage of Aboriginal and non-Aboriginal children who were identified as needing urgent or non-urgent referral for further dental care in 20152016 Both types of referrals were higher among Aboriginal children Aboriginal children had 28 and 16 times the risk of receiving an urgent or non-urgent referral for care respectively compared with non-Aboriginal children

Figure 6 Percentage of Aboriginal and non-Aboriginal kindergarten children who were identified as needing urgent or non-urgent referrals in 2015201615 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrant

s

3Quadrant

s

4Quadrant

s

Aboriginal 87 73 33 43

Non-Aboriginal 47 54 15 18

Relative Risk 19 14 22 23

0

2

4

6

8

10

12P

erc

en

tage

of

Ch

ildre

n

Urgent Non-Urgent

Aboriginal 58 188

Non-Aboriginal 21 115

Relative Risk 28 16

0

5

10

15

20

25

Pe

rce

nta

ge o

f ch

ildre

n

[15]

Results Health Authority Analysis Figure 7 shows the 20152016 dental survey results for Aboriginal children by health authority as well as across BC At the provincial level 457 of Aboriginal children were caries-free Across the health authorities Fraser had the highest percentage of Aboriginal children who were caries-free (540) followed by Interior (522) The Vancouver Coastal Vancouver Island and Northern Health Authorities were below the provincial average with 456 418 and 360 of Aboriginal children found to be caries-free respectively For treated caries the Vancouver Island Vancouver Coastal and Northern Health Authorities were above the provincial average (307) with 352 369 and 336 respectively The average prevalence of visible decay in Aboriginal kindergarten children was 236 across the province Across the health authorities Northern had the highest prevalence (304) followed by Interior (247)

Figure 7 Percentage of Aboriginal kindergarten children with different dental health outcomes in 20152016 by health authority16

Caries-free Trends Over Time Figure 8 shows the trends in the percentage of Aboriginal kindergarten children who are caries-free over time by health authority Since 20092010 the prevalence of caries-free has increased steadily over time in all health authorities except in Northern where a 20 percentage point decrease occurred from 20122013 to 20152016 Of all health authorities Fraser has consistently had the highest percentage of Aboriginal kindergarten students who are caries-free across the last three survey cycles There has been progress in the Interior Health Authority over the past three surveys the percentage of Aboriginal kindergarten students who are caries-free increased by 142 percentage points from 20092010 (380) to 20152016 (522) This is more than double the increase at a provincial level (64 percentage points) over the same period

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Caries Free 522 540 456 418 360 457

Treated Caries 231 277 369 352 336 307

Visible Decay 247 183 174 230 304 236

0

10

20

30

40

50

60

70

Pe

rce

nta

ge o

f ch

ildre

n

[16]

Figure 8 Percentage of caries-free Aboriginal kindergarten children who are caries-free over time (20092010 to 20152016) by health authority17

Aboriginal and Non-Aboriginal Children Figure 9 compares the prevalence of caries-free in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities there is a gap between the two groups with a higher prevalence of caries-free among non-Aboriginal children The greatest difference was found in the Vancouver Island Health Authority where the prevalence of caries-free was 351 percentage points higher in non-Aboriginal children The smallest gap was found in the Fraser Health Authority where the difference was 141 percentage points The relative risk of being caries-free ranged from 05 in the Vancouver Island and Northern Health Authorities to 08 in Fraser Alternately stated non-Aboriginal kindergarten students were 13 to 19 times more likely to be caries-free on average than their Aboriginal peers

Figure 9 Percentage of caries-free Aboriginal and non-Aboriginal kindergarten children who were caries-free in 20152016 by health authority18 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 380 470 392 352 341 393

20122013 457 522 397 398 380 431

20152016 522 540 456 418 360 457

0

10

20

30

40

50

60

70

Pe

rce

nta

ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 522 540 456 418 360 457

Non-Aboriginal 735 681 735 769 691 713

Relative Risk 07 08 06 05 05 06

0102030405060708090

Pe

rce

nta

ge o

f ch

ildre

n

[17]

Treated Caries Trends Over Time Figure 10 shows trends in the percentage of Aboriginal kindergarten students with treated caries over time by health authority Patterns over time for this indicator have varied across health authorities In 20152016 the Interior Health Authority had the lowest percentage of Aboriginal children with treated caries (231) as well as the largest reduction in treated caries among Aboriginal children over time (a 60 percentage point decrease from 291 in 20092010 to 231 in 20152016) However Interior Health has also been above the provincial average for visible decay in each of the last three survey cycles (Figure 10) When the high prevalence of visible decay and the low prevalence of treated caries are considered together these findings suggest that access to timely dental treatment in the early childhood years may be an issue in this health authority In the Vancouver Island Health Authority the percentage of children with treated caries decreased by 50 percentage points from 20092010 (402) to 20152016 (352) however as described in Figure 10 the Vancouver Island Health Authority has also seen an increase of 32 percentage points in the prevalence of visible decay since the 20122013 survey Taken together the trends for treated caries and visible decay may indicate challenges related to accessing timely dental care in this health authority In 20152016 the Vancouver Coastal Health Authority had the highest percentage of Aboriginal children with treated caries (369) This represents a 18 percentage point decrease since 20122013 (287) but a 14 percentage point increase compared to the 20092010 survey results (355) A similar trend was observed in the Fraser Health Authority where the percentage of Aboriginal children with treated caries increased slightly from 20092010 (266) to 20122013 (280) then decreased slightly in 20152016 (277) In the Northern Health Authority the percentage of Aboriginal children with treated caries decreased by 26 percentage points between 20092010 (3227) and 20122013 (301) and then increased to 336 in 20152016 Northern Health has also observed a modest reduction in the prevalence of visible decay since the 20092010 survey (Figure 10) Taken together these trends may suggest an improvement in the prevention andor treatment of early childhood caries in this health authority

Figure 10 Percentage of Aboriginal kindergarten children with treated caries over time (20092010 to 20152016) by health authority19

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 291 266 355 402 327 322

20122013 269 280 387 404 301 320

20152016 231 277 369 352 336 307

0

10

20

30

40

50

Pe

rce

nta

ge o

f ch

ildre

n

[18]

Aboriginal and Non-Aboriginal Children Figure 11 compares the prevalence of treated caries in Aboriginal and non-Aboriginal kindergarten children in 20152016 Provincially Aboriginal children had double the risk of previous dental decay compared to their non-Aboriginal peers (RR 20) Relative risks were highest in Vancouver Island and Vancouver Coastal Health Authorities where Aboriginal children had 28 and 27 times the risk of having treated caries than non-Aboriginal children respectively

Figure 11 Percentage of Aboriginal and non-Aboriginal kindergarten children with treated caries in 20152016 by health authority20 and the associated relative risks (RR)

Visible Decay Trends Over Time Figure 12 shows the percentage of Aboriginal children with visible decay over the last three survey cycles In 20152016 the prevalence of visible decay was lowest in the Vancouver Coastal Health Authority (174) followed by the Fraser Health Authority (183) Like the previous two survey cycles the Northern Health Authority had the highest percentage of Aboriginal children with visible decay (304 in 20152016) From 20092010 to 20152016 the prevalence of visible decay has decreased in all health authorities although the Vancouver Island Health Authority experienced a 47 percentage point decrease from 20092010 to 20122013 followed by a 32 percentage point increase to 20152016 The greatest reductions since 20092010 have been in the Interior and Fraser Health Authorities where the prevalence of visible decay has declined by 82 and 81 percentage points respectively The smallest reductions over this period were in the Northern and Vancouver Island Health Authorities (28 and 15 percentage points respectively)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 231 277 369 352 336 307

Non-Aboriginal 142 174 135 128 164 154

Relative Risk 16 16 27 28 20 20

0

5

10

15

20

25

30

35

40

45

Pe

rce

nta

ge o

f ch

ildre

n

[19]

Figure 12 Percentage of Aboriginal kindergarten children with visible decay by health authority over time (20092010 to 20152016)21

Aboriginal and Non-Aboriginal Children Figure 13 compares the prevalence of visible decay in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities Aboriginal children were at a higher risk of having visible decay than non-Aboriginal children The greatest disparity was in the Vancouver Island Health Authority where Aboriginal children had 22 times the risk of having visible decay than non-Aboriginal children followed by Northern and Interior Health Authorities (RR=21 and RR=20 respectively) The disparity between Aboriginal and non-Aboriginal children was smaller in the Vancouver Coastal and Fraser Health Authorities where Aboriginal children had a 13 times higher risk of visible decay than their non-Aboriginal peers

Figure 13 Percentage of Aboriginal kindergarten children and non-Aboriginal children with visible decay in 20152016 by health authority22 and the associated relative risks (RR)

Decay by Quadrant Figure 14 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants across health authorities in 20152016 Interior had the highest prevalence of decay in 1 quadrant (111) while the

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 329 264 253 245 332 285

20122013 274 198 215 198 318 249

20152016 247 183 174 230 304 236

05

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eh

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 247 183 174 230 304 236

Non-Aboriginal 124 146 130 103 146 133

Relative Risk 20 13 13 22 21 18

05

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[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

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1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

0

2

4

6

8

10

12

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[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

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ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

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f ch

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n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

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[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

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n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

5

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[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

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[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

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[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

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[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

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n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

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f ch

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[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

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Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

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[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[10]

Table 1 compares the number and percentage of Aboriginal children screened by health authorities across three most recent survey cycles Across BC the percentage of Aboriginal children who were screened increased from 835 (20092010) to 897 (20122013) and then plateaued at 895 (20152016) This finding is in line with the overall provincial trend (920 in 20152016 compared to 918 screened in 20122013) Table 1 Number and percentage of Aboriginal children who were enrolled in kindergarten and screened in the last three kindergarten dental surveys (20092010 20122013 and 20152016) by health authority

Aboriginal Children Caries-free Treated Caries and Visible Decay Among Aboriginal kindergarten children in 20152016

bull 457 were caries-free (no visible decay or broken enamel)

bull 307 had treated caries (no visible decay but existing restorations) and

bull 236 had evidence of visible decay Since 2009201012 the dental health of Aboriginal kindergarten children in BC has improved at the provincial level

bull the percentage of Aboriginal kindergarten children who are caries-free has increased by 64 percentage points from 393 to 457

bull the prevalence of treated caries among Aboriginal kindergarten children has decreased by 15 percentage points from 322 to 307

bull the prevalence of visible decay among Aboriginal children has decreased by 49 percentage points from 285 to 236

Figure 1 compares the province-wide dental outcomes for Aboriginal kindergarten children across three survey cycles Progress in increasing the percentage of children who are caries-free and decreasing the percentage of children with visible decay over time is evident Progress in reducing the percentage of children with treated caries has been modest However if treated caries and visible decay are considered together total experience of dental decay has decreased by 64 percentage points since the 20092010 survey (607 to 543)

12 The 20092010 survey was the first to allow for disaggregation by Aboriginalnon-Aboriginal status

20092010 20122013 20152016

Health Authority Enrolled Screened

Screened Enrolled Screened

Screened Enrolled Screened

Screened

Interior 666 547 821 823 722 877 769 676 879

Fraser 748 655 876 752 692 920 875 798 912

Vancouver Coastal 310 265 855 333 297 892 332 298 898

Vancouver Island 647 542 838 855 728 851 886 766 865

Northern 532 416 782 999 936 937 884 825 933

BC 2903 2425 835 3762 3375 897 3746 3363 898

[11]

Figure 1 Percentage of Aboriginal kindergarten children with different dental health outcomes over time (20092010 to 20152016)10

Decay by Quadrant Figure 2 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants over the past three survey cycles The prevalence of decay in all examined categories (1 2 3 or 4 quadrants) has declined since 20092010 However there has been little change in the prevalence of decay in 1 2 and 3 quadrants since 20122013 These two findings are in alignment with the provincial trends in visible decay ie progress has been made overall since 20092010 but improvements since 20122013 have been quite modest

Figure 2 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants over time (20092010 to 20152016)11

More dental appointments may be needed to provide treatment when a child has more quadrants affected with decay However the number of quadrants affected with visible decay is not necessarily a proxy of severity or the number of dental appointments needed to provide treatment the number of teeth affected and the seriousness of decay are not reflected in this metric Referrals Figure 3 compares the percentage of Aboriginal children who received an urgent or non-urgent referral for further dental care over the last three survey cycles The percentage of children requiring urgent

Caries FreeTreatedCaries

VisibleDecay

20092010 393 322 285

20122013 431 320 249

20152016 457 307 236

05

101520253035404550

Pe

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f ch

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n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

20092010 95 102 37 51

20122013 89 75 33 52

20152016 87 73 33 43

0

2

4

6

8

10

12

14

Pe

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f ch

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n

[12]

referral has increased by 07 percentage points from 20092010 to 20122013 but only a further 01 percentage point from 20122013 to 20152016 The percentage of children requiring non-urgent referrals has steadily decreased over time with an overall decline of 56 percentage points since 20092010

Figure 3 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)12

Aboriginal and Non-Aboriginal Children Caries-free Treated Caries and Visible Decay Despite ongoing improvements in the dental health of Aboriginal kindergarten children over time disparities between Aboriginal and non-Aboriginal children continue to persist Across BC in 20152016

bull 457 of Aboriginal kindergarten children were caries-free this was 256 percentage points lower than non-Aboriginal children (713)

bull 307 of Aboriginal kindergarten children had treated caries this was 153 percentage points higher than non-Aboriginal children (154)

bull 236 of Aboriginal kindergarten children had evidence of visible decay this was 10313 percentage points higher than non-Aboriginal children (133)

Figure 4 compares the percentage of kindergarten students who were caries-free or had treated caries or visible decay at the time of the 20152016 survey between Aboriginal and non-Aboriginal children and presents the associated relative risks Aboriginal kindergarten students had 06 20 and 18 times the risk of being caries-free having treated caries or having visible decay compared to non-Aboriginal students

13 Exact numberspercentage may vary due to rounding

Urgent Non-Urgent

20092010 50 244

20122013 57 204

20152016 58 188

0

5

10

15

20

25

30

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[13]

Figure 4 Percentage of Aboriginal and non-Aboriginal kindergarten children with different dental health outcomes in 2015201614 and the associated relative risks (RR)

The gaps in dental health outcomes between Aboriginal and non-Aboriginal children have also remained unchanged over the last three survey cycles Table 2 summarizes the prevalence of caries-free treated caries and visible decay for Aboriginal and non-Aboriginal children over time as well as the percentage point differences and relative risks between the two groups Relative risks for caries-free and visible decay have remained virtually unchanged since 20092010 while the relative risks treated caries have increased slightly from 17 to 20 These findings suggest that gaps in dental health outcomes between Aboriginal children continue to exist compared to their non-Aboriginal peers and may even be widening Table 2 Dental health outcomes in Aboriginal and non-Aboriginal children over time (20092010 to 20152016) - percentage of children with each outcome13 percentage point difference and associated relative risks (RR)

20092010 20122013 20152016

A Aboriginal Caries-free () 393 431 457

B Non-Aboriginal Caries-free () 651 694 713

Point Difference B-A) 258 263 256

Relative Risk (AB) 06 06 06

A Aboriginal Treated Caries () 322 320 307

B Non-Aboriginal Treated Caries () 188 168 154

Point Difference (A-B) 134 151 153

Relative Risk (AB) 17 19 20

A Aboriginal Visible Decay () 285 249 236

B Non-Aboriginal Visible Decay () 162 137 133

Point Difference (A-B) 123 112 102

Relative Risk (AB) 18 18 18

RRlt1 indicates a lower likelihood of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher likelihood eg Aboriginal children were less likely to be caries-free (RR 06) and more likely to have visible decay (RR18) in 20152016

Caries FreeTreatedCaries

VisibleDecay

Aboriginal 457 307 236

Non-Aboriginal 713 154 133

Relative Risk 06 20 18

0

10

20

30

40

50

60

70

80

Pe

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[14]

Decay by Quadrant Figure 5 compares the percentage of decay within one two three or four quadrants for Aboriginal children and non-Aboriginal children in 20152016 Visible decay was more prevalent in Aboriginal children across all quadrant categories When the relative risk was calculated Aboriginal children had 19 14 22 and 23 times the risk of decay in one two three and four quadrants respectively compared to non-Aboriginal children

Figure 5 Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201614 and the associated relative risks (RR)

Referrals Figure 6 compares the percentage of Aboriginal and non-Aboriginal children who were identified as needing urgent or non-urgent referral for further dental care in 20152016 Both types of referrals were higher among Aboriginal children Aboriginal children had 28 and 16 times the risk of receiving an urgent or non-urgent referral for care respectively compared with non-Aboriginal children

Figure 6 Percentage of Aboriginal and non-Aboriginal kindergarten children who were identified as needing urgent or non-urgent referrals in 2015201615 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrant

s

3Quadrant

s

4Quadrant

s

Aboriginal 87 73 33 43

Non-Aboriginal 47 54 15 18

Relative Risk 19 14 22 23

0

2

4

6

8

10

12P

erc

en

tage

of

Ch

ildre

n

Urgent Non-Urgent

Aboriginal 58 188

Non-Aboriginal 21 115

Relative Risk 28 16

0

5

10

15

20

25

Pe

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n

[15]

Results Health Authority Analysis Figure 7 shows the 20152016 dental survey results for Aboriginal children by health authority as well as across BC At the provincial level 457 of Aboriginal children were caries-free Across the health authorities Fraser had the highest percentage of Aboriginal children who were caries-free (540) followed by Interior (522) The Vancouver Coastal Vancouver Island and Northern Health Authorities were below the provincial average with 456 418 and 360 of Aboriginal children found to be caries-free respectively For treated caries the Vancouver Island Vancouver Coastal and Northern Health Authorities were above the provincial average (307) with 352 369 and 336 respectively The average prevalence of visible decay in Aboriginal kindergarten children was 236 across the province Across the health authorities Northern had the highest prevalence (304) followed by Interior (247)

Figure 7 Percentage of Aboriginal kindergarten children with different dental health outcomes in 20152016 by health authority16

Caries-free Trends Over Time Figure 8 shows the trends in the percentage of Aboriginal kindergarten children who are caries-free over time by health authority Since 20092010 the prevalence of caries-free has increased steadily over time in all health authorities except in Northern where a 20 percentage point decrease occurred from 20122013 to 20152016 Of all health authorities Fraser has consistently had the highest percentage of Aboriginal kindergarten students who are caries-free across the last three survey cycles There has been progress in the Interior Health Authority over the past three surveys the percentage of Aboriginal kindergarten students who are caries-free increased by 142 percentage points from 20092010 (380) to 20152016 (522) This is more than double the increase at a provincial level (64 percentage points) over the same period

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Caries Free 522 540 456 418 360 457

Treated Caries 231 277 369 352 336 307

Visible Decay 247 183 174 230 304 236

0

10

20

30

40

50

60

70

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[16]

Figure 8 Percentage of caries-free Aboriginal kindergarten children who are caries-free over time (20092010 to 20152016) by health authority17

Aboriginal and Non-Aboriginal Children Figure 9 compares the prevalence of caries-free in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities there is a gap between the two groups with a higher prevalence of caries-free among non-Aboriginal children The greatest difference was found in the Vancouver Island Health Authority where the prevalence of caries-free was 351 percentage points higher in non-Aboriginal children The smallest gap was found in the Fraser Health Authority where the difference was 141 percentage points The relative risk of being caries-free ranged from 05 in the Vancouver Island and Northern Health Authorities to 08 in Fraser Alternately stated non-Aboriginal kindergarten students were 13 to 19 times more likely to be caries-free on average than their Aboriginal peers

Figure 9 Percentage of caries-free Aboriginal and non-Aboriginal kindergarten children who were caries-free in 20152016 by health authority18 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 380 470 392 352 341 393

20122013 457 522 397 398 380 431

20152016 522 540 456 418 360 457

0

10

20

30

40

50

60

70

Pe

rce

nta

ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 522 540 456 418 360 457

Non-Aboriginal 735 681 735 769 691 713

Relative Risk 07 08 06 05 05 06

0102030405060708090

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n

[17]

Treated Caries Trends Over Time Figure 10 shows trends in the percentage of Aboriginal kindergarten students with treated caries over time by health authority Patterns over time for this indicator have varied across health authorities In 20152016 the Interior Health Authority had the lowest percentage of Aboriginal children with treated caries (231) as well as the largest reduction in treated caries among Aboriginal children over time (a 60 percentage point decrease from 291 in 20092010 to 231 in 20152016) However Interior Health has also been above the provincial average for visible decay in each of the last three survey cycles (Figure 10) When the high prevalence of visible decay and the low prevalence of treated caries are considered together these findings suggest that access to timely dental treatment in the early childhood years may be an issue in this health authority In the Vancouver Island Health Authority the percentage of children with treated caries decreased by 50 percentage points from 20092010 (402) to 20152016 (352) however as described in Figure 10 the Vancouver Island Health Authority has also seen an increase of 32 percentage points in the prevalence of visible decay since the 20122013 survey Taken together the trends for treated caries and visible decay may indicate challenges related to accessing timely dental care in this health authority In 20152016 the Vancouver Coastal Health Authority had the highest percentage of Aboriginal children with treated caries (369) This represents a 18 percentage point decrease since 20122013 (287) but a 14 percentage point increase compared to the 20092010 survey results (355) A similar trend was observed in the Fraser Health Authority where the percentage of Aboriginal children with treated caries increased slightly from 20092010 (266) to 20122013 (280) then decreased slightly in 20152016 (277) In the Northern Health Authority the percentage of Aboriginal children with treated caries decreased by 26 percentage points between 20092010 (3227) and 20122013 (301) and then increased to 336 in 20152016 Northern Health has also observed a modest reduction in the prevalence of visible decay since the 20092010 survey (Figure 10) Taken together these trends may suggest an improvement in the prevention andor treatment of early childhood caries in this health authority

Figure 10 Percentage of Aboriginal kindergarten children with treated caries over time (20092010 to 20152016) by health authority19

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 291 266 355 402 327 322

20122013 269 280 387 404 301 320

20152016 231 277 369 352 336 307

0

10

20

30

40

50

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n

[18]

Aboriginal and Non-Aboriginal Children Figure 11 compares the prevalence of treated caries in Aboriginal and non-Aboriginal kindergarten children in 20152016 Provincially Aboriginal children had double the risk of previous dental decay compared to their non-Aboriginal peers (RR 20) Relative risks were highest in Vancouver Island and Vancouver Coastal Health Authorities where Aboriginal children had 28 and 27 times the risk of having treated caries than non-Aboriginal children respectively

Figure 11 Percentage of Aboriginal and non-Aboriginal kindergarten children with treated caries in 20152016 by health authority20 and the associated relative risks (RR)

Visible Decay Trends Over Time Figure 12 shows the percentage of Aboriginal children with visible decay over the last three survey cycles In 20152016 the prevalence of visible decay was lowest in the Vancouver Coastal Health Authority (174) followed by the Fraser Health Authority (183) Like the previous two survey cycles the Northern Health Authority had the highest percentage of Aboriginal children with visible decay (304 in 20152016) From 20092010 to 20152016 the prevalence of visible decay has decreased in all health authorities although the Vancouver Island Health Authority experienced a 47 percentage point decrease from 20092010 to 20122013 followed by a 32 percentage point increase to 20152016 The greatest reductions since 20092010 have been in the Interior and Fraser Health Authorities where the prevalence of visible decay has declined by 82 and 81 percentage points respectively The smallest reductions over this period were in the Northern and Vancouver Island Health Authorities (28 and 15 percentage points respectively)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 231 277 369 352 336 307

Non-Aboriginal 142 174 135 128 164 154

Relative Risk 16 16 27 28 20 20

0

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35

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45

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[19]

Figure 12 Percentage of Aboriginal kindergarten children with visible decay by health authority over time (20092010 to 20152016)21

Aboriginal and Non-Aboriginal Children Figure 13 compares the prevalence of visible decay in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities Aboriginal children were at a higher risk of having visible decay than non-Aboriginal children The greatest disparity was in the Vancouver Island Health Authority where Aboriginal children had 22 times the risk of having visible decay than non-Aboriginal children followed by Northern and Interior Health Authorities (RR=21 and RR=20 respectively) The disparity between Aboriginal and non-Aboriginal children was smaller in the Vancouver Coastal and Fraser Health Authorities where Aboriginal children had a 13 times higher risk of visible decay than their non-Aboriginal peers

Figure 13 Percentage of Aboriginal kindergarten children and non-Aboriginal children with visible decay in 20152016 by health authority22 and the associated relative risks (RR)

Decay by Quadrant Figure 14 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants across health authorities in 20152016 Interior had the highest prevalence of decay in 1 quadrant (111) while the

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 329 264 253 245 332 285

20122013 274 198 215 198 318 249

20152016 247 183 174 230 304 236

05

10152025303540

Pe

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nta

ge o

f ch

idlr

eh

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 247 183 174 230 304 236

Non-Aboriginal 124 146 130 103 146 133

Relative Risk 20 13 13 22 21 18

05

10152025303540

Pe

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idlr

en

[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

Pe

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1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

0

2

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6

8

10

12

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[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

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n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

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ge o

f ch

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n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

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n

[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

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n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

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[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

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[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

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60

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[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

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[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

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1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

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15

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[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

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Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

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[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[11]

Figure 1 Percentage of Aboriginal kindergarten children with different dental health outcomes over time (20092010 to 20152016)10

Decay by Quadrant Figure 2 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants over the past three survey cycles The prevalence of decay in all examined categories (1 2 3 or 4 quadrants) has declined since 20092010 However there has been little change in the prevalence of decay in 1 2 and 3 quadrants since 20122013 These two findings are in alignment with the provincial trends in visible decay ie progress has been made overall since 20092010 but improvements since 20122013 have been quite modest

Figure 2 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants over time (20092010 to 20152016)11

More dental appointments may be needed to provide treatment when a child has more quadrants affected with decay However the number of quadrants affected with visible decay is not necessarily a proxy of severity or the number of dental appointments needed to provide treatment the number of teeth affected and the seriousness of decay are not reflected in this metric Referrals Figure 3 compares the percentage of Aboriginal children who received an urgent or non-urgent referral for further dental care over the last three survey cycles The percentage of children requiring urgent

Caries FreeTreatedCaries

VisibleDecay

20092010 393 322 285

20122013 431 320 249

20152016 457 307 236

05

101520253035404550

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

20092010 95 102 37 51

20122013 89 75 33 52

20152016 87 73 33 43

0

2

4

6

8

10

12

14

Pe

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ge o

f ch

ildre

n

[12]

referral has increased by 07 percentage points from 20092010 to 20122013 but only a further 01 percentage point from 20122013 to 20152016 The percentage of children requiring non-urgent referrals has steadily decreased over time with an overall decline of 56 percentage points since 20092010

Figure 3 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)12

Aboriginal and Non-Aboriginal Children Caries-free Treated Caries and Visible Decay Despite ongoing improvements in the dental health of Aboriginal kindergarten children over time disparities between Aboriginal and non-Aboriginal children continue to persist Across BC in 20152016

bull 457 of Aboriginal kindergarten children were caries-free this was 256 percentage points lower than non-Aboriginal children (713)

bull 307 of Aboriginal kindergarten children had treated caries this was 153 percentage points higher than non-Aboriginal children (154)

bull 236 of Aboriginal kindergarten children had evidence of visible decay this was 10313 percentage points higher than non-Aboriginal children (133)

Figure 4 compares the percentage of kindergarten students who were caries-free or had treated caries or visible decay at the time of the 20152016 survey between Aboriginal and non-Aboriginal children and presents the associated relative risks Aboriginal kindergarten students had 06 20 and 18 times the risk of being caries-free having treated caries or having visible decay compared to non-Aboriginal students

13 Exact numberspercentage may vary due to rounding

Urgent Non-Urgent

20092010 50 244

20122013 57 204

20152016 58 188

0

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[13]

Figure 4 Percentage of Aboriginal and non-Aboriginal kindergarten children with different dental health outcomes in 2015201614 and the associated relative risks (RR)

The gaps in dental health outcomes between Aboriginal and non-Aboriginal children have also remained unchanged over the last three survey cycles Table 2 summarizes the prevalence of caries-free treated caries and visible decay for Aboriginal and non-Aboriginal children over time as well as the percentage point differences and relative risks between the two groups Relative risks for caries-free and visible decay have remained virtually unchanged since 20092010 while the relative risks treated caries have increased slightly from 17 to 20 These findings suggest that gaps in dental health outcomes between Aboriginal children continue to exist compared to their non-Aboriginal peers and may even be widening Table 2 Dental health outcomes in Aboriginal and non-Aboriginal children over time (20092010 to 20152016) - percentage of children with each outcome13 percentage point difference and associated relative risks (RR)

20092010 20122013 20152016

A Aboriginal Caries-free () 393 431 457

B Non-Aboriginal Caries-free () 651 694 713

Point Difference B-A) 258 263 256

Relative Risk (AB) 06 06 06

A Aboriginal Treated Caries () 322 320 307

B Non-Aboriginal Treated Caries () 188 168 154

Point Difference (A-B) 134 151 153

Relative Risk (AB) 17 19 20

A Aboriginal Visible Decay () 285 249 236

B Non-Aboriginal Visible Decay () 162 137 133

Point Difference (A-B) 123 112 102

Relative Risk (AB) 18 18 18

RRlt1 indicates a lower likelihood of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher likelihood eg Aboriginal children were less likely to be caries-free (RR 06) and more likely to have visible decay (RR18) in 20152016

Caries FreeTreatedCaries

VisibleDecay

Aboriginal 457 307 236

Non-Aboriginal 713 154 133

Relative Risk 06 20 18

0

10

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60

70

80

Pe

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[14]

Decay by Quadrant Figure 5 compares the percentage of decay within one two three or four quadrants for Aboriginal children and non-Aboriginal children in 20152016 Visible decay was more prevalent in Aboriginal children across all quadrant categories When the relative risk was calculated Aboriginal children had 19 14 22 and 23 times the risk of decay in one two three and four quadrants respectively compared to non-Aboriginal children

Figure 5 Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201614 and the associated relative risks (RR)

Referrals Figure 6 compares the percentage of Aboriginal and non-Aboriginal children who were identified as needing urgent or non-urgent referral for further dental care in 20152016 Both types of referrals were higher among Aboriginal children Aboriginal children had 28 and 16 times the risk of receiving an urgent or non-urgent referral for care respectively compared with non-Aboriginal children

Figure 6 Percentage of Aboriginal and non-Aboriginal kindergarten children who were identified as needing urgent or non-urgent referrals in 2015201615 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrant

s

3Quadrant

s

4Quadrant

s

Aboriginal 87 73 33 43

Non-Aboriginal 47 54 15 18

Relative Risk 19 14 22 23

0

2

4

6

8

10

12P

erc

en

tage

of

Ch

ildre

n

Urgent Non-Urgent

Aboriginal 58 188

Non-Aboriginal 21 115

Relative Risk 28 16

0

5

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15

20

25

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[15]

Results Health Authority Analysis Figure 7 shows the 20152016 dental survey results for Aboriginal children by health authority as well as across BC At the provincial level 457 of Aboriginal children were caries-free Across the health authorities Fraser had the highest percentage of Aboriginal children who were caries-free (540) followed by Interior (522) The Vancouver Coastal Vancouver Island and Northern Health Authorities were below the provincial average with 456 418 and 360 of Aboriginal children found to be caries-free respectively For treated caries the Vancouver Island Vancouver Coastal and Northern Health Authorities were above the provincial average (307) with 352 369 and 336 respectively The average prevalence of visible decay in Aboriginal kindergarten children was 236 across the province Across the health authorities Northern had the highest prevalence (304) followed by Interior (247)

Figure 7 Percentage of Aboriginal kindergarten children with different dental health outcomes in 20152016 by health authority16

Caries-free Trends Over Time Figure 8 shows the trends in the percentage of Aboriginal kindergarten children who are caries-free over time by health authority Since 20092010 the prevalence of caries-free has increased steadily over time in all health authorities except in Northern where a 20 percentage point decrease occurred from 20122013 to 20152016 Of all health authorities Fraser has consistently had the highest percentage of Aboriginal kindergarten students who are caries-free across the last three survey cycles There has been progress in the Interior Health Authority over the past three surveys the percentage of Aboriginal kindergarten students who are caries-free increased by 142 percentage points from 20092010 (380) to 20152016 (522) This is more than double the increase at a provincial level (64 percentage points) over the same period

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Caries Free 522 540 456 418 360 457

Treated Caries 231 277 369 352 336 307

Visible Decay 247 183 174 230 304 236

0

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50

60

70

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[16]

Figure 8 Percentage of caries-free Aboriginal kindergarten children who are caries-free over time (20092010 to 20152016) by health authority17

Aboriginal and Non-Aboriginal Children Figure 9 compares the prevalence of caries-free in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities there is a gap between the two groups with a higher prevalence of caries-free among non-Aboriginal children The greatest difference was found in the Vancouver Island Health Authority where the prevalence of caries-free was 351 percentage points higher in non-Aboriginal children The smallest gap was found in the Fraser Health Authority where the difference was 141 percentage points The relative risk of being caries-free ranged from 05 in the Vancouver Island and Northern Health Authorities to 08 in Fraser Alternately stated non-Aboriginal kindergarten students were 13 to 19 times more likely to be caries-free on average than their Aboriginal peers

Figure 9 Percentage of caries-free Aboriginal and non-Aboriginal kindergarten children who were caries-free in 20152016 by health authority18 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 380 470 392 352 341 393

20122013 457 522 397 398 380 431

20152016 522 540 456 418 360 457

0

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20

30

40

50

60

70

Pe

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f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 522 540 456 418 360 457

Non-Aboriginal 735 681 735 769 691 713

Relative Risk 07 08 06 05 05 06

0102030405060708090

Pe

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[17]

Treated Caries Trends Over Time Figure 10 shows trends in the percentage of Aboriginal kindergarten students with treated caries over time by health authority Patterns over time for this indicator have varied across health authorities In 20152016 the Interior Health Authority had the lowest percentage of Aboriginal children with treated caries (231) as well as the largest reduction in treated caries among Aboriginal children over time (a 60 percentage point decrease from 291 in 20092010 to 231 in 20152016) However Interior Health has also been above the provincial average for visible decay in each of the last three survey cycles (Figure 10) When the high prevalence of visible decay and the low prevalence of treated caries are considered together these findings suggest that access to timely dental treatment in the early childhood years may be an issue in this health authority In the Vancouver Island Health Authority the percentage of children with treated caries decreased by 50 percentage points from 20092010 (402) to 20152016 (352) however as described in Figure 10 the Vancouver Island Health Authority has also seen an increase of 32 percentage points in the prevalence of visible decay since the 20122013 survey Taken together the trends for treated caries and visible decay may indicate challenges related to accessing timely dental care in this health authority In 20152016 the Vancouver Coastal Health Authority had the highest percentage of Aboriginal children with treated caries (369) This represents a 18 percentage point decrease since 20122013 (287) but a 14 percentage point increase compared to the 20092010 survey results (355) A similar trend was observed in the Fraser Health Authority where the percentage of Aboriginal children with treated caries increased slightly from 20092010 (266) to 20122013 (280) then decreased slightly in 20152016 (277) In the Northern Health Authority the percentage of Aboriginal children with treated caries decreased by 26 percentage points between 20092010 (3227) and 20122013 (301) and then increased to 336 in 20152016 Northern Health has also observed a modest reduction in the prevalence of visible decay since the 20092010 survey (Figure 10) Taken together these trends may suggest an improvement in the prevention andor treatment of early childhood caries in this health authority

Figure 10 Percentage of Aboriginal kindergarten children with treated caries over time (20092010 to 20152016) by health authority19

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 291 266 355 402 327 322

20122013 269 280 387 404 301 320

20152016 231 277 369 352 336 307

0

10

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30

40

50

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n

[18]

Aboriginal and Non-Aboriginal Children Figure 11 compares the prevalence of treated caries in Aboriginal and non-Aboriginal kindergarten children in 20152016 Provincially Aboriginal children had double the risk of previous dental decay compared to their non-Aboriginal peers (RR 20) Relative risks were highest in Vancouver Island and Vancouver Coastal Health Authorities where Aboriginal children had 28 and 27 times the risk of having treated caries than non-Aboriginal children respectively

Figure 11 Percentage of Aboriginal and non-Aboriginal kindergarten children with treated caries in 20152016 by health authority20 and the associated relative risks (RR)

Visible Decay Trends Over Time Figure 12 shows the percentage of Aboriginal children with visible decay over the last three survey cycles In 20152016 the prevalence of visible decay was lowest in the Vancouver Coastal Health Authority (174) followed by the Fraser Health Authority (183) Like the previous two survey cycles the Northern Health Authority had the highest percentage of Aboriginal children with visible decay (304 in 20152016) From 20092010 to 20152016 the prevalence of visible decay has decreased in all health authorities although the Vancouver Island Health Authority experienced a 47 percentage point decrease from 20092010 to 20122013 followed by a 32 percentage point increase to 20152016 The greatest reductions since 20092010 have been in the Interior and Fraser Health Authorities where the prevalence of visible decay has declined by 82 and 81 percentage points respectively The smallest reductions over this period were in the Northern and Vancouver Island Health Authorities (28 and 15 percentage points respectively)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 231 277 369 352 336 307

Non-Aboriginal 142 174 135 128 164 154

Relative Risk 16 16 27 28 20 20

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35

40

45

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[19]

Figure 12 Percentage of Aboriginal kindergarten children with visible decay by health authority over time (20092010 to 20152016)21

Aboriginal and Non-Aboriginal Children Figure 13 compares the prevalence of visible decay in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities Aboriginal children were at a higher risk of having visible decay than non-Aboriginal children The greatest disparity was in the Vancouver Island Health Authority where Aboriginal children had 22 times the risk of having visible decay than non-Aboriginal children followed by Northern and Interior Health Authorities (RR=21 and RR=20 respectively) The disparity between Aboriginal and non-Aboriginal children was smaller in the Vancouver Coastal and Fraser Health Authorities where Aboriginal children had a 13 times higher risk of visible decay than their non-Aboriginal peers

Figure 13 Percentage of Aboriginal kindergarten children and non-Aboriginal children with visible decay in 20152016 by health authority22 and the associated relative risks (RR)

Decay by Quadrant Figure 14 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants across health authorities in 20152016 Interior had the highest prevalence of decay in 1 quadrant (111) while the

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 329 264 253 245 332 285

20122013 274 198 215 198 318 249

20152016 247 183 174 230 304 236

05

10152025303540

Pe

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ge o

f ch

idlr

eh

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 247 183 174 230 304 236

Non-Aboriginal 124 146 130 103 146 133

Relative Risk 20 13 13 22 21 18

05

10152025303540

Pe

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idlr

en

[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

Pe

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1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

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12

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[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

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1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

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1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

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[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

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Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

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[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

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[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

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[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

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40

60

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[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

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1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

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[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

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ildre

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Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

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f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[12]

referral has increased by 07 percentage points from 20092010 to 20122013 but only a further 01 percentage point from 20122013 to 20152016 The percentage of children requiring non-urgent referrals has steadily decreased over time with an overall decline of 56 percentage points since 20092010

Figure 3 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)12

Aboriginal and Non-Aboriginal Children Caries-free Treated Caries and Visible Decay Despite ongoing improvements in the dental health of Aboriginal kindergarten children over time disparities between Aboriginal and non-Aboriginal children continue to persist Across BC in 20152016

bull 457 of Aboriginal kindergarten children were caries-free this was 256 percentage points lower than non-Aboriginal children (713)

bull 307 of Aboriginal kindergarten children had treated caries this was 153 percentage points higher than non-Aboriginal children (154)

bull 236 of Aboriginal kindergarten children had evidence of visible decay this was 10313 percentage points higher than non-Aboriginal children (133)

Figure 4 compares the percentage of kindergarten students who were caries-free or had treated caries or visible decay at the time of the 20152016 survey between Aboriginal and non-Aboriginal children and presents the associated relative risks Aboriginal kindergarten students had 06 20 and 18 times the risk of being caries-free having treated caries or having visible decay compared to non-Aboriginal students

13 Exact numberspercentage may vary due to rounding

Urgent Non-Urgent

20092010 50 244

20122013 57 204

20152016 58 188

0

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[13]

Figure 4 Percentage of Aboriginal and non-Aboriginal kindergarten children with different dental health outcomes in 2015201614 and the associated relative risks (RR)

The gaps in dental health outcomes between Aboriginal and non-Aboriginal children have also remained unchanged over the last three survey cycles Table 2 summarizes the prevalence of caries-free treated caries and visible decay for Aboriginal and non-Aboriginal children over time as well as the percentage point differences and relative risks between the two groups Relative risks for caries-free and visible decay have remained virtually unchanged since 20092010 while the relative risks treated caries have increased slightly from 17 to 20 These findings suggest that gaps in dental health outcomes between Aboriginal children continue to exist compared to their non-Aboriginal peers and may even be widening Table 2 Dental health outcomes in Aboriginal and non-Aboriginal children over time (20092010 to 20152016) - percentage of children with each outcome13 percentage point difference and associated relative risks (RR)

20092010 20122013 20152016

A Aboriginal Caries-free () 393 431 457

B Non-Aboriginal Caries-free () 651 694 713

Point Difference B-A) 258 263 256

Relative Risk (AB) 06 06 06

A Aboriginal Treated Caries () 322 320 307

B Non-Aboriginal Treated Caries () 188 168 154

Point Difference (A-B) 134 151 153

Relative Risk (AB) 17 19 20

A Aboriginal Visible Decay () 285 249 236

B Non-Aboriginal Visible Decay () 162 137 133

Point Difference (A-B) 123 112 102

Relative Risk (AB) 18 18 18

RRlt1 indicates a lower likelihood of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher likelihood eg Aboriginal children were less likely to be caries-free (RR 06) and more likely to have visible decay (RR18) in 20152016

Caries FreeTreatedCaries

VisibleDecay

Aboriginal 457 307 236

Non-Aboriginal 713 154 133

Relative Risk 06 20 18

0

10

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30

40

50

60

70

80

Pe

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[14]

Decay by Quadrant Figure 5 compares the percentage of decay within one two three or four quadrants for Aboriginal children and non-Aboriginal children in 20152016 Visible decay was more prevalent in Aboriginal children across all quadrant categories When the relative risk was calculated Aboriginal children had 19 14 22 and 23 times the risk of decay in one two three and four quadrants respectively compared to non-Aboriginal children

Figure 5 Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201614 and the associated relative risks (RR)

Referrals Figure 6 compares the percentage of Aboriginal and non-Aboriginal children who were identified as needing urgent or non-urgent referral for further dental care in 20152016 Both types of referrals were higher among Aboriginal children Aboriginal children had 28 and 16 times the risk of receiving an urgent or non-urgent referral for care respectively compared with non-Aboriginal children

Figure 6 Percentage of Aboriginal and non-Aboriginal kindergarten children who were identified as needing urgent or non-urgent referrals in 2015201615 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrant

s

3Quadrant

s

4Quadrant

s

Aboriginal 87 73 33 43

Non-Aboriginal 47 54 15 18

Relative Risk 19 14 22 23

0

2

4

6

8

10

12P

erc

en

tage

of

Ch

ildre

n

Urgent Non-Urgent

Aboriginal 58 188

Non-Aboriginal 21 115

Relative Risk 28 16

0

5

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25

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[15]

Results Health Authority Analysis Figure 7 shows the 20152016 dental survey results for Aboriginal children by health authority as well as across BC At the provincial level 457 of Aboriginal children were caries-free Across the health authorities Fraser had the highest percentage of Aboriginal children who were caries-free (540) followed by Interior (522) The Vancouver Coastal Vancouver Island and Northern Health Authorities were below the provincial average with 456 418 and 360 of Aboriginal children found to be caries-free respectively For treated caries the Vancouver Island Vancouver Coastal and Northern Health Authorities were above the provincial average (307) with 352 369 and 336 respectively The average prevalence of visible decay in Aboriginal kindergarten children was 236 across the province Across the health authorities Northern had the highest prevalence (304) followed by Interior (247)

Figure 7 Percentage of Aboriginal kindergarten children with different dental health outcomes in 20152016 by health authority16

Caries-free Trends Over Time Figure 8 shows the trends in the percentage of Aboriginal kindergarten children who are caries-free over time by health authority Since 20092010 the prevalence of caries-free has increased steadily over time in all health authorities except in Northern where a 20 percentage point decrease occurred from 20122013 to 20152016 Of all health authorities Fraser has consistently had the highest percentage of Aboriginal kindergarten students who are caries-free across the last three survey cycles There has been progress in the Interior Health Authority over the past three surveys the percentage of Aboriginal kindergarten students who are caries-free increased by 142 percentage points from 20092010 (380) to 20152016 (522) This is more than double the increase at a provincial level (64 percentage points) over the same period

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Caries Free 522 540 456 418 360 457

Treated Caries 231 277 369 352 336 307

Visible Decay 247 183 174 230 304 236

0

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30

40

50

60

70

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[16]

Figure 8 Percentage of caries-free Aboriginal kindergarten children who are caries-free over time (20092010 to 20152016) by health authority17

Aboriginal and Non-Aboriginal Children Figure 9 compares the prevalence of caries-free in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities there is a gap between the two groups with a higher prevalence of caries-free among non-Aboriginal children The greatest difference was found in the Vancouver Island Health Authority where the prevalence of caries-free was 351 percentage points higher in non-Aboriginal children The smallest gap was found in the Fraser Health Authority where the difference was 141 percentage points The relative risk of being caries-free ranged from 05 in the Vancouver Island and Northern Health Authorities to 08 in Fraser Alternately stated non-Aboriginal kindergarten students were 13 to 19 times more likely to be caries-free on average than their Aboriginal peers

Figure 9 Percentage of caries-free Aboriginal and non-Aboriginal kindergarten children who were caries-free in 20152016 by health authority18 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 380 470 392 352 341 393

20122013 457 522 397 398 380 431

20152016 522 540 456 418 360 457

0

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20

30

40

50

60

70

Pe

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n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 522 540 456 418 360 457

Non-Aboriginal 735 681 735 769 691 713

Relative Risk 07 08 06 05 05 06

0102030405060708090

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[17]

Treated Caries Trends Over Time Figure 10 shows trends in the percentage of Aboriginal kindergarten students with treated caries over time by health authority Patterns over time for this indicator have varied across health authorities In 20152016 the Interior Health Authority had the lowest percentage of Aboriginal children with treated caries (231) as well as the largest reduction in treated caries among Aboriginal children over time (a 60 percentage point decrease from 291 in 20092010 to 231 in 20152016) However Interior Health has also been above the provincial average for visible decay in each of the last three survey cycles (Figure 10) When the high prevalence of visible decay and the low prevalence of treated caries are considered together these findings suggest that access to timely dental treatment in the early childhood years may be an issue in this health authority In the Vancouver Island Health Authority the percentage of children with treated caries decreased by 50 percentage points from 20092010 (402) to 20152016 (352) however as described in Figure 10 the Vancouver Island Health Authority has also seen an increase of 32 percentage points in the prevalence of visible decay since the 20122013 survey Taken together the trends for treated caries and visible decay may indicate challenges related to accessing timely dental care in this health authority In 20152016 the Vancouver Coastal Health Authority had the highest percentage of Aboriginal children with treated caries (369) This represents a 18 percentage point decrease since 20122013 (287) but a 14 percentage point increase compared to the 20092010 survey results (355) A similar trend was observed in the Fraser Health Authority where the percentage of Aboriginal children with treated caries increased slightly from 20092010 (266) to 20122013 (280) then decreased slightly in 20152016 (277) In the Northern Health Authority the percentage of Aboriginal children with treated caries decreased by 26 percentage points between 20092010 (3227) and 20122013 (301) and then increased to 336 in 20152016 Northern Health has also observed a modest reduction in the prevalence of visible decay since the 20092010 survey (Figure 10) Taken together these trends may suggest an improvement in the prevention andor treatment of early childhood caries in this health authority

Figure 10 Percentage of Aboriginal kindergarten children with treated caries over time (20092010 to 20152016) by health authority19

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 291 266 355 402 327 322

20122013 269 280 387 404 301 320

20152016 231 277 369 352 336 307

0

10

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30

40

50

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n

[18]

Aboriginal and Non-Aboriginal Children Figure 11 compares the prevalence of treated caries in Aboriginal and non-Aboriginal kindergarten children in 20152016 Provincially Aboriginal children had double the risk of previous dental decay compared to their non-Aboriginal peers (RR 20) Relative risks were highest in Vancouver Island and Vancouver Coastal Health Authorities where Aboriginal children had 28 and 27 times the risk of having treated caries than non-Aboriginal children respectively

Figure 11 Percentage of Aboriginal and non-Aboriginal kindergarten children with treated caries in 20152016 by health authority20 and the associated relative risks (RR)

Visible Decay Trends Over Time Figure 12 shows the percentage of Aboriginal children with visible decay over the last three survey cycles In 20152016 the prevalence of visible decay was lowest in the Vancouver Coastal Health Authority (174) followed by the Fraser Health Authority (183) Like the previous two survey cycles the Northern Health Authority had the highest percentage of Aboriginal children with visible decay (304 in 20152016) From 20092010 to 20152016 the prevalence of visible decay has decreased in all health authorities although the Vancouver Island Health Authority experienced a 47 percentage point decrease from 20092010 to 20122013 followed by a 32 percentage point increase to 20152016 The greatest reductions since 20092010 have been in the Interior and Fraser Health Authorities where the prevalence of visible decay has declined by 82 and 81 percentage points respectively The smallest reductions over this period were in the Northern and Vancouver Island Health Authorities (28 and 15 percentage points respectively)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 231 277 369 352 336 307

Non-Aboriginal 142 174 135 128 164 154

Relative Risk 16 16 27 28 20 20

0

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35

40

45

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[19]

Figure 12 Percentage of Aboriginal kindergarten children with visible decay by health authority over time (20092010 to 20152016)21

Aboriginal and Non-Aboriginal Children Figure 13 compares the prevalence of visible decay in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities Aboriginal children were at a higher risk of having visible decay than non-Aboriginal children The greatest disparity was in the Vancouver Island Health Authority where Aboriginal children had 22 times the risk of having visible decay than non-Aboriginal children followed by Northern and Interior Health Authorities (RR=21 and RR=20 respectively) The disparity between Aboriginal and non-Aboriginal children was smaller in the Vancouver Coastal and Fraser Health Authorities where Aboriginal children had a 13 times higher risk of visible decay than their non-Aboriginal peers

Figure 13 Percentage of Aboriginal kindergarten children and non-Aboriginal children with visible decay in 20152016 by health authority22 and the associated relative risks (RR)

Decay by Quadrant Figure 14 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants across health authorities in 20152016 Interior had the highest prevalence of decay in 1 quadrant (111) while the

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 329 264 253 245 332 285

20122013 274 198 215 198 318 249

20152016 247 183 174 230 304 236

05

10152025303540

Pe

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ge o

f ch

idlr

eh

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 247 183 174 230 304 236

Non-Aboriginal 124 146 130 103 146 133

Relative Risk 20 13 13 22 21 18

05

10152025303540

Pe

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ge o

f ch

idlr

en

[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

Pe

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1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

0

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12

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[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

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1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

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1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

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[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

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n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

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[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

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[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

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[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

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[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

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15

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1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

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15

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[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

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Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

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f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[13]

Figure 4 Percentage of Aboriginal and non-Aboriginal kindergarten children with different dental health outcomes in 2015201614 and the associated relative risks (RR)

The gaps in dental health outcomes between Aboriginal and non-Aboriginal children have also remained unchanged over the last three survey cycles Table 2 summarizes the prevalence of caries-free treated caries and visible decay for Aboriginal and non-Aboriginal children over time as well as the percentage point differences and relative risks between the two groups Relative risks for caries-free and visible decay have remained virtually unchanged since 20092010 while the relative risks treated caries have increased slightly from 17 to 20 These findings suggest that gaps in dental health outcomes between Aboriginal children continue to exist compared to their non-Aboriginal peers and may even be widening Table 2 Dental health outcomes in Aboriginal and non-Aboriginal children over time (20092010 to 20152016) - percentage of children with each outcome13 percentage point difference and associated relative risks (RR)

20092010 20122013 20152016

A Aboriginal Caries-free () 393 431 457

B Non-Aboriginal Caries-free () 651 694 713

Point Difference B-A) 258 263 256

Relative Risk (AB) 06 06 06

A Aboriginal Treated Caries () 322 320 307

B Non-Aboriginal Treated Caries () 188 168 154

Point Difference (A-B) 134 151 153

Relative Risk (AB) 17 19 20

A Aboriginal Visible Decay () 285 249 236

B Non-Aboriginal Visible Decay () 162 137 133

Point Difference (A-B) 123 112 102

Relative Risk (AB) 18 18 18

RRlt1 indicates a lower likelihood of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher likelihood eg Aboriginal children were less likely to be caries-free (RR 06) and more likely to have visible decay (RR18) in 20152016

Caries FreeTreatedCaries

VisibleDecay

Aboriginal 457 307 236

Non-Aboriginal 713 154 133

Relative Risk 06 20 18

0

10

20

30

40

50

60

70

80

Pe

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n

[14]

Decay by Quadrant Figure 5 compares the percentage of decay within one two three or four quadrants for Aboriginal children and non-Aboriginal children in 20152016 Visible decay was more prevalent in Aboriginal children across all quadrant categories When the relative risk was calculated Aboriginal children had 19 14 22 and 23 times the risk of decay in one two three and four quadrants respectively compared to non-Aboriginal children

Figure 5 Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201614 and the associated relative risks (RR)

Referrals Figure 6 compares the percentage of Aboriginal and non-Aboriginal children who were identified as needing urgent or non-urgent referral for further dental care in 20152016 Both types of referrals were higher among Aboriginal children Aboriginal children had 28 and 16 times the risk of receiving an urgent or non-urgent referral for care respectively compared with non-Aboriginal children

Figure 6 Percentage of Aboriginal and non-Aboriginal kindergarten children who were identified as needing urgent or non-urgent referrals in 2015201615 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrant

s

3Quadrant

s

4Quadrant

s

Aboriginal 87 73 33 43

Non-Aboriginal 47 54 15 18

Relative Risk 19 14 22 23

0

2

4

6

8

10

12P

erc

en

tage

of

Ch

ildre

n

Urgent Non-Urgent

Aboriginal 58 188

Non-Aboriginal 21 115

Relative Risk 28 16

0

5

10

15

20

25

Pe

rce

nta

ge o

f ch

ildre

n

[15]

Results Health Authority Analysis Figure 7 shows the 20152016 dental survey results for Aboriginal children by health authority as well as across BC At the provincial level 457 of Aboriginal children were caries-free Across the health authorities Fraser had the highest percentage of Aboriginal children who were caries-free (540) followed by Interior (522) The Vancouver Coastal Vancouver Island and Northern Health Authorities were below the provincial average with 456 418 and 360 of Aboriginal children found to be caries-free respectively For treated caries the Vancouver Island Vancouver Coastal and Northern Health Authorities were above the provincial average (307) with 352 369 and 336 respectively The average prevalence of visible decay in Aboriginal kindergarten children was 236 across the province Across the health authorities Northern had the highest prevalence (304) followed by Interior (247)

Figure 7 Percentage of Aboriginal kindergarten children with different dental health outcomes in 20152016 by health authority16

Caries-free Trends Over Time Figure 8 shows the trends in the percentage of Aboriginal kindergarten children who are caries-free over time by health authority Since 20092010 the prevalence of caries-free has increased steadily over time in all health authorities except in Northern where a 20 percentage point decrease occurred from 20122013 to 20152016 Of all health authorities Fraser has consistently had the highest percentage of Aboriginal kindergarten students who are caries-free across the last three survey cycles There has been progress in the Interior Health Authority over the past three surveys the percentage of Aboriginal kindergarten students who are caries-free increased by 142 percentage points from 20092010 (380) to 20152016 (522) This is more than double the increase at a provincial level (64 percentage points) over the same period

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Caries Free 522 540 456 418 360 457

Treated Caries 231 277 369 352 336 307

Visible Decay 247 183 174 230 304 236

0

10

20

30

40

50

60

70

Pe

rce

nta

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f ch

ildre

n

[16]

Figure 8 Percentage of caries-free Aboriginal kindergarten children who are caries-free over time (20092010 to 20152016) by health authority17

Aboriginal and Non-Aboriginal Children Figure 9 compares the prevalence of caries-free in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities there is a gap between the two groups with a higher prevalence of caries-free among non-Aboriginal children The greatest difference was found in the Vancouver Island Health Authority where the prevalence of caries-free was 351 percentage points higher in non-Aboriginal children The smallest gap was found in the Fraser Health Authority where the difference was 141 percentage points The relative risk of being caries-free ranged from 05 in the Vancouver Island and Northern Health Authorities to 08 in Fraser Alternately stated non-Aboriginal kindergarten students were 13 to 19 times more likely to be caries-free on average than their Aboriginal peers

Figure 9 Percentage of caries-free Aboriginal and non-Aboriginal kindergarten children who were caries-free in 20152016 by health authority18 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 380 470 392 352 341 393

20122013 457 522 397 398 380 431

20152016 522 540 456 418 360 457

0

10

20

30

40

50

60

70

Pe

rce

nta

ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 522 540 456 418 360 457

Non-Aboriginal 735 681 735 769 691 713

Relative Risk 07 08 06 05 05 06

0102030405060708090

Pe

rce

nta

ge o

f ch

ildre

n

[17]

Treated Caries Trends Over Time Figure 10 shows trends in the percentage of Aboriginal kindergarten students with treated caries over time by health authority Patterns over time for this indicator have varied across health authorities In 20152016 the Interior Health Authority had the lowest percentage of Aboriginal children with treated caries (231) as well as the largest reduction in treated caries among Aboriginal children over time (a 60 percentage point decrease from 291 in 20092010 to 231 in 20152016) However Interior Health has also been above the provincial average for visible decay in each of the last three survey cycles (Figure 10) When the high prevalence of visible decay and the low prevalence of treated caries are considered together these findings suggest that access to timely dental treatment in the early childhood years may be an issue in this health authority In the Vancouver Island Health Authority the percentage of children with treated caries decreased by 50 percentage points from 20092010 (402) to 20152016 (352) however as described in Figure 10 the Vancouver Island Health Authority has also seen an increase of 32 percentage points in the prevalence of visible decay since the 20122013 survey Taken together the trends for treated caries and visible decay may indicate challenges related to accessing timely dental care in this health authority In 20152016 the Vancouver Coastal Health Authority had the highest percentage of Aboriginal children with treated caries (369) This represents a 18 percentage point decrease since 20122013 (287) but a 14 percentage point increase compared to the 20092010 survey results (355) A similar trend was observed in the Fraser Health Authority where the percentage of Aboriginal children with treated caries increased slightly from 20092010 (266) to 20122013 (280) then decreased slightly in 20152016 (277) In the Northern Health Authority the percentage of Aboriginal children with treated caries decreased by 26 percentage points between 20092010 (3227) and 20122013 (301) and then increased to 336 in 20152016 Northern Health has also observed a modest reduction in the prevalence of visible decay since the 20092010 survey (Figure 10) Taken together these trends may suggest an improvement in the prevention andor treatment of early childhood caries in this health authority

Figure 10 Percentage of Aboriginal kindergarten children with treated caries over time (20092010 to 20152016) by health authority19

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 291 266 355 402 327 322

20122013 269 280 387 404 301 320

20152016 231 277 369 352 336 307

0

10

20

30

40

50

Pe

rce

nta

ge o

f ch

ildre

n

[18]

Aboriginal and Non-Aboriginal Children Figure 11 compares the prevalence of treated caries in Aboriginal and non-Aboriginal kindergarten children in 20152016 Provincially Aboriginal children had double the risk of previous dental decay compared to their non-Aboriginal peers (RR 20) Relative risks were highest in Vancouver Island and Vancouver Coastal Health Authorities where Aboriginal children had 28 and 27 times the risk of having treated caries than non-Aboriginal children respectively

Figure 11 Percentage of Aboriginal and non-Aboriginal kindergarten children with treated caries in 20152016 by health authority20 and the associated relative risks (RR)

Visible Decay Trends Over Time Figure 12 shows the percentage of Aboriginal children with visible decay over the last three survey cycles In 20152016 the prevalence of visible decay was lowest in the Vancouver Coastal Health Authority (174) followed by the Fraser Health Authority (183) Like the previous two survey cycles the Northern Health Authority had the highest percentage of Aboriginal children with visible decay (304 in 20152016) From 20092010 to 20152016 the prevalence of visible decay has decreased in all health authorities although the Vancouver Island Health Authority experienced a 47 percentage point decrease from 20092010 to 20122013 followed by a 32 percentage point increase to 20152016 The greatest reductions since 20092010 have been in the Interior and Fraser Health Authorities where the prevalence of visible decay has declined by 82 and 81 percentage points respectively The smallest reductions over this period were in the Northern and Vancouver Island Health Authorities (28 and 15 percentage points respectively)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 231 277 369 352 336 307

Non-Aboriginal 142 174 135 128 164 154

Relative Risk 16 16 27 28 20 20

0

5

10

15

20

25

30

35

40

45

Pe

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ge o

f ch

ildre

n

[19]

Figure 12 Percentage of Aboriginal kindergarten children with visible decay by health authority over time (20092010 to 20152016)21

Aboriginal and Non-Aboriginal Children Figure 13 compares the prevalence of visible decay in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities Aboriginal children were at a higher risk of having visible decay than non-Aboriginal children The greatest disparity was in the Vancouver Island Health Authority where Aboriginal children had 22 times the risk of having visible decay than non-Aboriginal children followed by Northern and Interior Health Authorities (RR=21 and RR=20 respectively) The disparity between Aboriginal and non-Aboriginal children was smaller in the Vancouver Coastal and Fraser Health Authorities where Aboriginal children had a 13 times higher risk of visible decay than their non-Aboriginal peers

Figure 13 Percentage of Aboriginal kindergarten children and non-Aboriginal children with visible decay in 20152016 by health authority22 and the associated relative risks (RR)

Decay by Quadrant Figure 14 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants across health authorities in 20152016 Interior had the highest prevalence of decay in 1 quadrant (111) while the

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 329 264 253 245 332 285

20122013 274 198 215 198 318 249

20152016 247 183 174 230 304 236

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

eh

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 247 183 174 230 304 236

Non-Aboriginal 124 146 130 103 146 133

Relative Risk 20 13 13 22 21 18

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

en

[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

Pe

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n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

0

2

4

6

8

10

12

Pe

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ildre

n

[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

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ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

rce

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ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

Pe

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nta

ge o

f ch

ildre

n

[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

Pe

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ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

5

10

15

20

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30

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[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

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[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

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ildre

n

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

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[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[14]

Decay by Quadrant Figure 5 compares the percentage of decay within one two three or four quadrants for Aboriginal children and non-Aboriginal children in 20152016 Visible decay was more prevalent in Aboriginal children across all quadrant categories When the relative risk was calculated Aboriginal children had 19 14 22 and 23 times the risk of decay in one two three and four quadrants respectively compared to non-Aboriginal children

Figure 5 Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201614 and the associated relative risks (RR)

Referrals Figure 6 compares the percentage of Aboriginal and non-Aboriginal children who were identified as needing urgent or non-urgent referral for further dental care in 20152016 Both types of referrals were higher among Aboriginal children Aboriginal children had 28 and 16 times the risk of receiving an urgent or non-urgent referral for care respectively compared with non-Aboriginal children

Figure 6 Percentage of Aboriginal and non-Aboriginal kindergarten children who were identified as needing urgent or non-urgent referrals in 2015201615 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrant

s

3Quadrant

s

4Quadrant

s

Aboriginal 87 73 33 43

Non-Aboriginal 47 54 15 18

Relative Risk 19 14 22 23

0

2

4

6

8

10

12P

erc

en

tage

of

Ch

ildre

n

Urgent Non-Urgent

Aboriginal 58 188

Non-Aboriginal 21 115

Relative Risk 28 16

0

5

10

15

20

25

Pe

rce

nta

ge o

f ch

ildre

n

[15]

Results Health Authority Analysis Figure 7 shows the 20152016 dental survey results for Aboriginal children by health authority as well as across BC At the provincial level 457 of Aboriginal children were caries-free Across the health authorities Fraser had the highest percentage of Aboriginal children who were caries-free (540) followed by Interior (522) The Vancouver Coastal Vancouver Island and Northern Health Authorities were below the provincial average with 456 418 and 360 of Aboriginal children found to be caries-free respectively For treated caries the Vancouver Island Vancouver Coastal and Northern Health Authorities were above the provincial average (307) with 352 369 and 336 respectively The average prevalence of visible decay in Aboriginal kindergarten children was 236 across the province Across the health authorities Northern had the highest prevalence (304) followed by Interior (247)

Figure 7 Percentage of Aboriginal kindergarten children with different dental health outcomes in 20152016 by health authority16

Caries-free Trends Over Time Figure 8 shows the trends in the percentage of Aboriginal kindergarten children who are caries-free over time by health authority Since 20092010 the prevalence of caries-free has increased steadily over time in all health authorities except in Northern where a 20 percentage point decrease occurred from 20122013 to 20152016 Of all health authorities Fraser has consistently had the highest percentage of Aboriginal kindergarten students who are caries-free across the last three survey cycles There has been progress in the Interior Health Authority over the past three surveys the percentage of Aboriginal kindergarten students who are caries-free increased by 142 percentage points from 20092010 (380) to 20152016 (522) This is more than double the increase at a provincial level (64 percentage points) over the same period

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Caries Free 522 540 456 418 360 457

Treated Caries 231 277 369 352 336 307

Visible Decay 247 183 174 230 304 236

0

10

20

30

40

50

60

70

Pe

rce

nta

ge o

f ch

ildre

n

[16]

Figure 8 Percentage of caries-free Aboriginal kindergarten children who are caries-free over time (20092010 to 20152016) by health authority17

Aboriginal and Non-Aboriginal Children Figure 9 compares the prevalence of caries-free in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities there is a gap between the two groups with a higher prevalence of caries-free among non-Aboriginal children The greatest difference was found in the Vancouver Island Health Authority where the prevalence of caries-free was 351 percentage points higher in non-Aboriginal children The smallest gap was found in the Fraser Health Authority where the difference was 141 percentage points The relative risk of being caries-free ranged from 05 in the Vancouver Island and Northern Health Authorities to 08 in Fraser Alternately stated non-Aboriginal kindergarten students were 13 to 19 times more likely to be caries-free on average than their Aboriginal peers

Figure 9 Percentage of caries-free Aboriginal and non-Aboriginal kindergarten children who were caries-free in 20152016 by health authority18 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 380 470 392 352 341 393

20122013 457 522 397 398 380 431

20152016 522 540 456 418 360 457

0

10

20

30

40

50

60

70

Pe

rce

nta

ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 522 540 456 418 360 457

Non-Aboriginal 735 681 735 769 691 713

Relative Risk 07 08 06 05 05 06

0102030405060708090

Pe

rce

nta

ge o

f ch

ildre

n

[17]

Treated Caries Trends Over Time Figure 10 shows trends in the percentage of Aboriginal kindergarten students with treated caries over time by health authority Patterns over time for this indicator have varied across health authorities In 20152016 the Interior Health Authority had the lowest percentage of Aboriginal children with treated caries (231) as well as the largest reduction in treated caries among Aboriginal children over time (a 60 percentage point decrease from 291 in 20092010 to 231 in 20152016) However Interior Health has also been above the provincial average for visible decay in each of the last three survey cycles (Figure 10) When the high prevalence of visible decay and the low prevalence of treated caries are considered together these findings suggest that access to timely dental treatment in the early childhood years may be an issue in this health authority In the Vancouver Island Health Authority the percentage of children with treated caries decreased by 50 percentage points from 20092010 (402) to 20152016 (352) however as described in Figure 10 the Vancouver Island Health Authority has also seen an increase of 32 percentage points in the prevalence of visible decay since the 20122013 survey Taken together the trends for treated caries and visible decay may indicate challenges related to accessing timely dental care in this health authority In 20152016 the Vancouver Coastal Health Authority had the highest percentage of Aboriginal children with treated caries (369) This represents a 18 percentage point decrease since 20122013 (287) but a 14 percentage point increase compared to the 20092010 survey results (355) A similar trend was observed in the Fraser Health Authority where the percentage of Aboriginal children with treated caries increased slightly from 20092010 (266) to 20122013 (280) then decreased slightly in 20152016 (277) In the Northern Health Authority the percentage of Aboriginal children with treated caries decreased by 26 percentage points between 20092010 (3227) and 20122013 (301) and then increased to 336 in 20152016 Northern Health has also observed a modest reduction in the prevalence of visible decay since the 20092010 survey (Figure 10) Taken together these trends may suggest an improvement in the prevention andor treatment of early childhood caries in this health authority

Figure 10 Percentage of Aboriginal kindergarten children with treated caries over time (20092010 to 20152016) by health authority19

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 291 266 355 402 327 322

20122013 269 280 387 404 301 320

20152016 231 277 369 352 336 307

0

10

20

30

40

50

Pe

rce

nta

ge o

f ch

ildre

n

[18]

Aboriginal and Non-Aboriginal Children Figure 11 compares the prevalence of treated caries in Aboriginal and non-Aboriginal kindergarten children in 20152016 Provincially Aboriginal children had double the risk of previous dental decay compared to their non-Aboriginal peers (RR 20) Relative risks were highest in Vancouver Island and Vancouver Coastal Health Authorities where Aboriginal children had 28 and 27 times the risk of having treated caries than non-Aboriginal children respectively

Figure 11 Percentage of Aboriginal and non-Aboriginal kindergarten children with treated caries in 20152016 by health authority20 and the associated relative risks (RR)

Visible Decay Trends Over Time Figure 12 shows the percentage of Aboriginal children with visible decay over the last three survey cycles In 20152016 the prevalence of visible decay was lowest in the Vancouver Coastal Health Authority (174) followed by the Fraser Health Authority (183) Like the previous two survey cycles the Northern Health Authority had the highest percentage of Aboriginal children with visible decay (304 in 20152016) From 20092010 to 20152016 the prevalence of visible decay has decreased in all health authorities although the Vancouver Island Health Authority experienced a 47 percentage point decrease from 20092010 to 20122013 followed by a 32 percentage point increase to 20152016 The greatest reductions since 20092010 have been in the Interior and Fraser Health Authorities where the prevalence of visible decay has declined by 82 and 81 percentage points respectively The smallest reductions over this period were in the Northern and Vancouver Island Health Authorities (28 and 15 percentage points respectively)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 231 277 369 352 336 307

Non-Aboriginal 142 174 135 128 164 154

Relative Risk 16 16 27 28 20 20

0

5

10

15

20

25

30

35

40

45

Pe

rce

nta

ge o

f ch

ildre

n

[19]

Figure 12 Percentage of Aboriginal kindergarten children with visible decay by health authority over time (20092010 to 20152016)21

Aboriginal and Non-Aboriginal Children Figure 13 compares the prevalence of visible decay in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities Aboriginal children were at a higher risk of having visible decay than non-Aboriginal children The greatest disparity was in the Vancouver Island Health Authority where Aboriginal children had 22 times the risk of having visible decay than non-Aboriginal children followed by Northern and Interior Health Authorities (RR=21 and RR=20 respectively) The disparity between Aboriginal and non-Aboriginal children was smaller in the Vancouver Coastal and Fraser Health Authorities where Aboriginal children had a 13 times higher risk of visible decay than their non-Aboriginal peers

Figure 13 Percentage of Aboriginal kindergarten children and non-Aboriginal children with visible decay in 20152016 by health authority22 and the associated relative risks (RR)

Decay by Quadrant Figure 14 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants across health authorities in 20152016 Interior had the highest prevalence of decay in 1 quadrant (111) while the

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 329 264 253 245 332 285

20122013 274 198 215 198 318 249

20152016 247 183 174 230 304 236

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

eh

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 247 183 174 230 304 236

Non-Aboriginal 124 146 130 103 146 133

Relative Risk 20 13 13 22 21 18

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

en

[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

0

2

4

6

8

10

12

Pe

rce

nta

ge o

f ch

ildre

n

[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

Pe

rce

nta

ge o

f ch

ildre

n

[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

Pe

rce

nta

ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

5

10

15

20

25

30

Pe

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ge o

f ch

ildre

n

[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

5

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15

20

25

30

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[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

Pe

rce

nta

ge o

f ch

ildre

n

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

Pe

rce

nta

ge o

f ch

ildre

n

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

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n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

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n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

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f ch

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Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

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n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[15]

Results Health Authority Analysis Figure 7 shows the 20152016 dental survey results for Aboriginal children by health authority as well as across BC At the provincial level 457 of Aboriginal children were caries-free Across the health authorities Fraser had the highest percentage of Aboriginal children who were caries-free (540) followed by Interior (522) The Vancouver Coastal Vancouver Island and Northern Health Authorities were below the provincial average with 456 418 and 360 of Aboriginal children found to be caries-free respectively For treated caries the Vancouver Island Vancouver Coastal and Northern Health Authorities were above the provincial average (307) with 352 369 and 336 respectively The average prevalence of visible decay in Aboriginal kindergarten children was 236 across the province Across the health authorities Northern had the highest prevalence (304) followed by Interior (247)

Figure 7 Percentage of Aboriginal kindergarten children with different dental health outcomes in 20152016 by health authority16

Caries-free Trends Over Time Figure 8 shows the trends in the percentage of Aboriginal kindergarten children who are caries-free over time by health authority Since 20092010 the prevalence of caries-free has increased steadily over time in all health authorities except in Northern where a 20 percentage point decrease occurred from 20122013 to 20152016 Of all health authorities Fraser has consistently had the highest percentage of Aboriginal kindergarten students who are caries-free across the last three survey cycles There has been progress in the Interior Health Authority over the past three surveys the percentage of Aboriginal kindergarten students who are caries-free increased by 142 percentage points from 20092010 (380) to 20152016 (522) This is more than double the increase at a provincial level (64 percentage points) over the same period

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Caries Free 522 540 456 418 360 457

Treated Caries 231 277 369 352 336 307

Visible Decay 247 183 174 230 304 236

0

10

20

30

40

50

60

70

Pe

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[16]

Figure 8 Percentage of caries-free Aboriginal kindergarten children who are caries-free over time (20092010 to 20152016) by health authority17

Aboriginal and Non-Aboriginal Children Figure 9 compares the prevalence of caries-free in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities there is a gap between the two groups with a higher prevalence of caries-free among non-Aboriginal children The greatest difference was found in the Vancouver Island Health Authority where the prevalence of caries-free was 351 percentage points higher in non-Aboriginal children The smallest gap was found in the Fraser Health Authority where the difference was 141 percentage points The relative risk of being caries-free ranged from 05 in the Vancouver Island and Northern Health Authorities to 08 in Fraser Alternately stated non-Aboriginal kindergarten students were 13 to 19 times more likely to be caries-free on average than their Aboriginal peers

Figure 9 Percentage of caries-free Aboriginal and non-Aboriginal kindergarten children who were caries-free in 20152016 by health authority18 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 380 470 392 352 341 393

20122013 457 522 397 398 380 431

20152016 522 540 456 418 360 457

0

10

20

30

40

50

60

70

Pe

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f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 522 540 456 418 360 457

Non-Aboriginal 735 681 735 769 691 713

Relative Risk 07 08 06 05 05 06

0102030405060708090

Pe

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ildre

n

[17]

Treated Caries Trends Over Time Figure 10 shows trends in the percentage of Aboriginal kindergarten students with treated caries over time by health authority Patterns over time for this indicator have varied across health authorities In 20152016 the Interior Health Authority had the lowest percentage of Aboriginal children with treated caries (231) as well as the largest reduction in treated caries among Aboriginal children over time (a 60 percentage point decrease from 291 in 20092010 to 231 in 20152016) However Interior Health has also been above the provincial average for visible decay in each of the last three survey cycles (Figure 10) When the high prevalence of visible decay and the low prevalence of treated caries are considered together these findings suggest that access to timely dental treatment in the early childhood years may be an issue in this health authority In the Vancouver Island Health Authority the percentage of children with treated caries decreased by 50 percentage points from 20092010 (402) to 20152016 (352) however as described in Figure 10 the Vancouver Island Health Authority has also seen an increase of 32 percentage points in the prevalence of visible decay since the 20122013 survey Taken together the trends for treated caries and visible decay may indicate challenges related to accessing timely dental care in this health authority In 20152016 the Vancouver Coastal Health Authority had the highest percentage of Aboriginal children with treated caries (369) This represents a 18 percentage point decrease since 20122013 (287) but a 14 percentage point increase compared to the 20092010 survey results (355) A similar trend was observed in the Fraser Health Authority where the percentage of Aboriginal children with treated caries increased slightly from 20092010 (266) to 20122013 (280) then decreased slightly in 20152016 (277) In the Northern Health Authority the percentage of Aboriginal children with treated caries decreased by 26 percentage points between 20092010 (3227) and 20122013 (301) and then increased to 336 in 20152016 Northern Health has also observed a modest reduction in the prevalence of visible decay since the 20092010 survey (Figure 10) Taken together these trends may suggest an improvement in the prevention andor treatment of early childhood caries in this health authority

Figure 10 Percentage of Aboriginal kindergarten children with treated caries over time (20092010 to 20152016) by health authority19

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 291 266 355 402 327 322

20122013 269 280 387 404 301 320

20152016 231 277 369 352 336 307

0

10

20

30

40

50

Pe

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n

[18]

Aboriginal and Non-Aboriginal Children Figure 11 compares the prevalence of treated caries in Aboriginal and non-Aboriginal kindergarten children in 20152016 Provincially Aboriginal children had double the risk of previous dental decay compared to their non-Aboriginal peers (RR 20) Relative risks were highest in Vancouver Island and Vancouver Coastal Health Authorities where Aboriginal children had 28 and 27 times the risk of having treated caries than non-Aboriginal children respectively

Figure 11 Percentage of Aboriginal and non-Aboriginal kindergarten children with treated caries in 20152016 by health authority20 and the associated relative risks (RR)

Visible Decay Trends Over Time Figure 12 shows the percentage of Aboriginal children with visible decay over the last three survey cycles In 20152016 the prevalence of visible decay was lowest in the Vancouver Coastal Health Authority (174) followed by the Fraser Health Authority (183) Like the previous two survey cycles the Northern Health Authority had the highest percentage of Aboriginal children with visible decay (304 in 20152016) From 20092010 to 20152016 the prevalence of visible decay has decreased in all health authorities although the Vancouver Island Health Authority experienced a 47 percentage point decrease from 20092010 to 20122013 followed by a 32 percentage point increase to 20152016 The greatest reductions since 20092010 have been in the Interior and Fraser Health Authorities where the prevalence of visible decay has declined by 82 and 81 percentage points respectively The smallest reductions over this period were in the Northern and Vancouver Island Health Authorities (28 and 15 percentage points respectively)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 231 277 369 352 336 307

Non-Aboriginal 142 174 135 128 164 154

Relative Risk 16 16 27 28 20 20

0

5

10

15

20

25

30

35

40

45

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[19]

Figure 12 Percentage of Aboriginal kindergarten children with visible decay by health authority over time (20092010 to 20152016)21

Aboriginal and Non-Aboriginal Children Figure 13 compares the prevalence of visible decay in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities Aboriginal children were at a higher risk of having visible decay than non-Aboriginal children The greatest disparity was in the Vancouver Island Health Authority where Aboriginal children had 22 times the risk of having visible decay than non-Aboriginal children followed by Northern and Interior Health Authorities (RR=21 and RR=20 respectively) The disparity between Aboriginal and non-Aboriginal children was smaller in the Vancouver Coastal and Fraser Health Authorities where Aboriginal children had a 13 times higher risk of visible decay than their non-Aboriginal peers

Figure 13 Percentage of Aboriginal kindergarten children and non-Aboriginal children with visible decay in 20152016 by health authority22 and the associated relative risks (RR)

Decay by Quadrant Figure 14 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants across health authorities in 20152016 Interior had the highest prevalence of decay in 1 quadrant (111) while the

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 329 264 253 245 332 285

20122013 274 198 215 198 318 249

20152016 247 183 174 230 304 236

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

eh

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 247 183 174 230 304 236

Non-Aboriginal 124 146 130 103 146 133

Relative Risk 20 13 13 22 21 18

05

10152025303540

Pe

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f ch

idlr

en

[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

Pe

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1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

0

2

4

6

8

10

12

Pe

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n

[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

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n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

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f ch

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n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

Pe

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n

[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

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n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

5

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15

20

25

30

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[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

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[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

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20

30

40

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60

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[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

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[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

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1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

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f ch

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[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

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nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

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n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[16]

Figure 8 Percentage of caries-free Aboriginal kindergarten children who are caries-free over time (20092010 to 20152016) by health authority17

Aboriginal and Non-Aboriginal Children Figure 9 compares the prevalence of caries-free in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities there is a gap between the two groups with a higher prevalence of caries-free among non-Aboriginal children The greatest difference was found in the Vancouver Island Health Authority where the prevalence of caries-free was 351 percentage points higher in non-Aboriginal children The smallest gap was found in the Fraser Health Authority where the difference was 141 percentage points The relative risk of being caries-free ranged from 05 in the Vancouver Island and Northern Health Authorities to 08 in Fraser Alternately stated non-Aboriginal kindergarten students were 13 to 19 times more likely to be caries-free on average than their Aboriginal peers

Figure 9 Percentage of caries-free Aboriginal and non-Aboriginal kindergarten children who were caries-free in 20152016 by health authority18 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 380 470 392 352 341 393

20122013 457 522 397 398 380 431

20152016 522 540 456 418 360 457

0

10

20

30

40

50

60

70

Pe

rce

nta

ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 522 540 456 418 360 457

Non-Aboriginal 735 681 735 769 691 713

Relative Risk 07 08 06 05 05 06

0102030405060708090

Pe

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f ch

ildre

n

[17]

Treated Caries Trends Over Time Figure 10 shows trends in the percentage of Aboriginal kindergarten students with treated caries over time by health authority Patterns over time for this indicator have varied across health authorities In 20152016 the Interior Health Authority had the lowest percentage of Aboriginal children with treated caries (231) as well as the largest reduction in treated caries among Aboriginal children over time (a 60 percentage point decrease from 291 in 20092010 to 231 in 20152016) However Interior Health has also been above the provincial average for visible decay in each of the last three survey cycles (Figure 10) When the high prevalence of visible decay and the low prevalence of treated caries are considered together these findings suggest that access to timely dental treatment in the early childhood years may be an issue in this health authority In the Vancouver Island Health Authority the percentage of children with treated caries decreased by 50 percentage points from 20092010 (402) to 20152016 (352) however as described in Figure 10 the Vancouver Island Health Authority has also seen an increase of 32 percentage points in the prevalence of visible decay since the 20122013 survey Taken together the trends for treated caries and visible decay may indicate challenges related to accessing timely dental care in this health authority In 20152016 the Vancouver Coastal Health Authority had the highest percentage of Aboriginal children with treated caries (369) This represents a 18 percentage point decrease since 20122013 (287) but a 14 percentage point increase compared to the 20092010 survey results (355) A similar trend was observed in the Fraser Health Authority where the percentage of Aboriginal children with treated caries increased slightly from 20092010 (266) to 20122013 (280) then decreased slightly in 20152016 (277) In the Northern Health Authority the percentage of Aboriginal children with treated caries decreased by 26 percentage points between 20092010 (3227) and 20122013 (301) and then increased to 336 in 20152016 Northern Health has also observed a modest reduction in the prevalence of visible decay since the 20092010 survey (Figure 10) Taken together these trends may suggest an improvement in the prevention andor treatment of early childhood caries in this health authority

Figure 10 Percentage of Aboriginal kindergarten children with treated caries over time (20092010 to 20152016) by health authority19

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 291 266 355 402 327 322

20122013 269 280 387 404 301 320

20152016 231 277 369 352 336 307

0

10

20

30

40

50

Pe

rce

nta

ge o

f ch

ildre

n

[18]

Aboriginal and Non-Aboriginal Children Figure 11 compares the prevalence of treated caries in Aboriginal and non-Aboriginal kindergarten children in 20152016 Provincially Aboriginal children had double the risk of previous dental decay compared to their non-Aboriginal peers (RR 20) Relative risks were highest in Vancouver Island and Vancouver Coastal Health Authorities where Aboriginal children had 28 and 27 times the risk of having treated caries than non-Aboriginal children respectively

Figure 11 Percentage of Aboriginal and non-Aboriginal kindergarten children with treated caries in 20152016 by health authority20 and the associated relative risks (RR)

Visible Decay Trends Over Time Figure 12 shows the percentage of Aboriginal children with visible decay over the last three survey cycles In 20152016 the prevalence of visible decay was lowest in the Vancouver Coastal Health Authority (174) followed by the Fraser Health Authority (183) Like the previous two survey cycles the Northern Health Authority had the highest percentage of Aboriginal children with visible decay (304 in 20152016) From 20092010 to 20152016 the prevalence of visible decay has decreased in all health authorities although the Vancouver Island Health Authority experienced a 47 percentage point decrease from 20092010 to 20122013 followed by a 32 percentage point increase to 20152016 The greatest reductions since 20092010 have been in the Interior and Fraser Health Authorities where the prevalence of visible decay has declined by 82 and 81 percentage points respectively The smallest reductions over this period were in the Northern and Vancouver Island Health Authorities (28 and 15 percentage points respectively)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 231 277 369 352 336 307

Non-Aboriginal 142 174 135 128 164 154

Relative Risk 16 16 27 28 20 20

0

5

10

15

20

25

30

35

40

45

Pe

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n

[19]

Figure 12 Percentage of Aboriginal kindergarten children with visible decay by health authority over time (20092010 to 20152016)21

Aboriginal and Non-Aboriginal Children Figure 13 compares the prevalence of visible decay in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities Aboriginal children were at a higher risk of having visible decay than non-Aboriginal children The greatest disparity was in the Vancouver Island Health Authority where Aboriginal children had 22 times the risk of having visible decay than non-Aboriginal children followed by Northern and Interior Health Authorities (RR=21 and RR=20 respectively) The disparity between Aboriginal and non-Aboriginal children was smaller in the Vancouver Coastal and Fraser Health Authorities where Aboriginal children had a 13 times higher risk of visible decay than their non-Aboriginal peers

Figure 13 Percentage of Aboriginal kindergarten children and non-Aboriginal children with visible decay in 20152016 by health authority22 and the associated relative risks (RR)

Decay by Quadrant Figure 14 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants across health authorities in 20152016 Interior had the highest prevalence of decay in 1 quadrant (111) while the

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 329 264 253 245 332 285

20122013 274 198 215 198 318 249

20152016 247 183 174 230 304 236

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

eh

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 247 183 174 230 304 236

Non-Aboriginal 124 146 130 103 146 133

Relative Risk 20 13 13 22 21 18

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

en

[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

Pe

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n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

0

2

4

6

8

10

12

Pe

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f ch

ildre

n

[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

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ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

Pe

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ge o

f ch

ildre

n

[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

Pe

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ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

5

10

15

20

25

30

Pe

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n

[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

5

10

15

20

25

30

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[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

Pe

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f ch

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n

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

Pe

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f ch

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n

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[17]

Treated Caries Trends Over Time Figure 10 shows trends in the percentage of Aboriginal kindergarten students with treated caries over time by health authority Patterns over time for this indicator have varied across health authorities In 20152016 the Interior Health Authority had the lowest percentage of Aboriginal children with treated caries (231) as well as the largest reduction in treated caries among Aboriginal children over time (a 60 percentage point decrease from 291 in 20092010 to 231 in 20152016) However Interior Health has also been above the provincial average for visible decay in each of the last three survey cycles (Figure 10) When the high prevalence of visible decay and the low prevalence of treated caries are considered together these findings suggest that access to timely dental treatment in the early childhood years may be an issue in this health authority In the Vancouver Island Health Authority the percentage of children with treated caries decreased by 50 percentage points from 20092010 (402) to 20152016 (352) however as described in Figure 10 the Vancouver Island Health Authority has also seen an increase of 32 percentage points in the prevalence of visible decay since the 20122013 survey Taken together the trends for treated caries and visible decay may indicate challenges related to accessing timely dental care in this health authority In 20152016 the Vancouver Coastal Health Authority had the highest percentage of Aboriginal children with treated caries (369) This represents a 18 percentage point decrease since 20122013 (287) but a 14 percentage point increase compared to the 20092010 survey results (355) A similar trend was observed in the Fraser Health Authority where the percentage of Aboriginal children with treated caries increased slightly from 20092010 (266) to 20122013 (280) then decreased slightly in 20152016 (277) In the Northern Health Authority the percentage of Aboriginal children with treated caries decreased by 26 percentage points between 20092010 (3227) and 20122013 (301) and then increased to 336 in 20152016 Northern Health has also observed a modest reduction in the prevalence of visible decay since the 20092010 survey (Figure 10) Taken together these trends may suggest an improvement in the prevention andor treatment of early childhood caries in this health authority

Figure 10 Percentage of Aboriginal kindergarten children with treated caries over time (20092010 to 20152016) by health authority19

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 291 266 355 402 327 322

20122013 269 280 387 404 301 320

20152016 231 277 369 352 336 307

0

10

20

30

40

50

Pe

rce

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ildre

n

[18]

Aboriginal and Non-Aboriginal Children Figure 11 compares the prevalence of treated caries in Aboriginal and non-Aboriginal kindergarten children in 20152016 Provincially Aboriginal children had double the risk of previous dental decay compared to their non-Aboriginal peers (RR 20) Relative risks were highest in Vancouver Island and Vancouver Coastal Health Authorities where Aboriginal children had 28 and 27 times the risk of having treated caries than non-Aboriginal children respectively

Figure 11 Percentage of Aboriginal and non-Aboriginal kindergarten children with treated caries in 20152016 by health authority20 and the associated relative risks (RR)

Visible Decay Trends Over Time Figure 12 shows the percentage of Aboriginal children with visible decay over the last three survey cycles In 20152016 the prevalence of visible decay was lowest in the Vancouver Coastal Health Authority (174) followed by the Fraser Health Authority (183) Like the previous two survey cycles the Northern Health Authority had the highest percentage of Aboriginal children with visible decay (304 in 20152016) From 20092010 to 20152016 the prevalence of visible decay has decreased in all health authorities although the Vancouver Island Health Authority experienced a 47 percentage point decrease from 20092010 to 20122013 followed by a 32 percentage point increase to 20152016 The greatest reductions since 20092010 have been in the Interior and Fraser Health Authorities where the prevalence of visible decay has declined by 82 and 81 percentage points respectively The smallest reductions over this period were in the Northern and Vancouver Island Health Authorities (28 and 15 percentage points respectively)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 231 277 369 352 336 307

Non-Aboriginal 142 174 135 128 164 154

Relative Risk 16 16 27 28 20 20

0

5

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15

20

25

30

35

40

45

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n

[19]

Figure 12 Percentage of Aboriginal kindergarten children with visible decay by health authority over time (20092010 to 20152016)21

Aboriginal and Non-Aboriginal Children Figure 13 compares the prevalence of visible decay in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities Aboriginal children were at a higher risk of having visible decay than non-Aboriginal children The greatest disparity was in the Vancouver Island Health Authority where Aboriginal children had 22 times the risk of having visible decay than non-Aboriginal children followed by Northern and Interior Health Authorities (RR=21 and RR=20 respectively) The disparity between Aboriginal and non-Aboriginal children was smaller in the Vancouver Coastal and Fraser Health Authorities where Aboriginal children had a 13 times higher risk of visible decay than their non-Aboriginal peers

Figure 13 Percentage of Aboriginal kindergarten children and non-Aboriginal children with visible decay in 20152016 by health authority22 and the associated relative risks (RR)

Decay by Quadrant Figure 14 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants across health authorities in 20152016 Interior had the highest prevalence of decay in 1 quadrant (111) while the

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 329 264 253 245 332 285

20122013 274 198 215 198 318 249

20152016 247 183 174 230 304 236

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

eh

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 247 183 174 230 304 236

Non-Aboriginal 124 146 130 103 146 133

Relative Risk 20 13 13 22 21 18

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

en

[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

Pe

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n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

0

2

4

6

8

10

12

Pe

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ildre

n

[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

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ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

rce

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ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

Pe

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nta

ge o

f ch

ildre

n

[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

Pe

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ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

5

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20

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30

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[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

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[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

Pe

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f ch

ildre

n

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

Pe

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f ch

ildre

n

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

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n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

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ge o

f ch

ildre

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[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

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f ch

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n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

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f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[18]

Aboriginal and Non-Aboriginal Children Figure 11 compares the prevalence of treated caries in Aboriginal and non-Aboriginal kindergarten children in 20152016 Provincially Aboriginal children had double the risk of previous dental decay compared to their non-Aboriginal peers (RR 20) Relative risks were highest in Vancouver Island and Vancouver Coastal Health Authorities where Aboriginal children had 28 and 27 times the risk of having treated caries than non-Aboriginal children respectively

Figure 11 Percentage of Aboriginal and non-Aboriginal kindergarten children with treated caries in 20152016 by health authority20 and the associated relative risks (RR)

Visible Decay Trends Over Time Figure 12 shows the percentage of Aboriginal children with visible decay over the last three survey cycles In 20152016 the prevalence of visible decay was lowest in the Vancouver Coastal Health Authority (174) followed by the Fraser Health Authority (183) Like the previous two survey cycles the Northern Health Authority had the highest percentage of Aboriginal children with visible decay (304 in 20152016) From 20092010 to 20152016 the prevalence of visible decay has decreased in all health authorities although the Vancouver Island Health Authority experienced a 47 percentage point decrease from 20092010 to 20122013 followed by a 32 percentage point increase to 20152016 The greatest reductions since 20092010 have been in the Interior and Fraser Health Authorities where the prevalence of visible decay has declined by 82 and 81 percentage points respectively The smallest reductions over this period were in the Northern and Vancouver Island Health Authorities (28 and 15 percentage points respectively)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 231 277 369 352 336 307

Non-Aboriginal 142 174 135 128 164 154

Relative Risk 16 16 27 28 20 20

0

5

10

15

20

25

30

35

40

45

Pe

rce

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ge o

f ch

ildre

n

[19]

Figure 12 Percentage of Aboriginal kindergarten children with visible decay by health authority over time (20092010 to 20152016)21

Aboriginal and Non-Aboriginal Children Figure 13 compares the prevalence of visible decay in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities Aboriginal children were at a higher risk of having visible decay than non-Aboriginal children The greatest disparity was in the Vancouver Island Health Authority where Aboriginal children had 22 times the risk of having visible decay than non-Aboriginal children followed by Northern and Interior Health Authorities (RR=21 and RR=20 respectively) The disparity between Aboriginal and non-Aboriginal children was smaller in the Vancouver Coastal and Fraser Health Authorities where Aboriginal children had a 13 times higher risk of visible decay than their non-Aboriginal peers

Figure 13 Percentage of Aboriginal kindergarten children and non-Aboriginal children with visible decay in 20152016 by health authority22 and the associated relative risks (RR)

Decay by Quadrant Figure 14 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants across health authorities in 20152016 Interior had the highest prevalence of decay in 1 quadrant (111) while the

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 329 264 253 245 332 285

20122013 274 198 215 198 318 249

20152016 247 183 174 230 304 236

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

eh

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 247 183 174 230 304 236

Non-Aboriginal 124 146 130 103 146 133

Relative Risk 20 13 13 22 21 18

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

en

[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

Pe

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n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

0

2

4

6

8

10

12

Pe

rce

nta

ge o

f ch

ildre

n

[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

Pe

rce

nta

ge o

f ch

ildre

n

[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

Pe

rce

nta

ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

5

10

15

20

25

30

Pe

rce

nta

ge o

f ch

ildre

n

[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

5

10

15

20

25

30

Pe

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ildre

n

[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

Pe

rce

nta

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f ch

ildre

n

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

Pe

rce

nta

ge o

f ch

ildre

n

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[19]

Figure 12 Percentage of Aboriginal kindergarten children with visible decay by health authority over time (20092010 to 20152016)21

Aboriginal and Non-Aboriginal Children Figure 13 compares the prevalence of visible decay in Aboriginal and non-Aboriginal kindergarten children in 20152016 In all health authorities Aboriginal children were at a higher risk of having visible decay than non-Aboriginal children The greatest disparity was in the Vancouver Island Health Authority where Aboriginal children had 22 times the risk of having visible decay than non-Aboriginal children followed by Northern and Interior Health Authorities (RR=21 and RR=20 respectively) The disparity between Aboriginal and non-Aboriginal children was smaller in the Vancouver Coastal and Fraser Health Authorities where Aboriginal children had a 13 times higher risk of visible decay than their non-Aboriginal peers

Figure 13 Percentage of Aboriginal kindergarten children and non-Aboriginal children with visible decay in 20152016 by health authority22 and the associated relative risks (RR)

Decay by Quadrant Figure 14 compares the percentage of Aboriginal children with decay in 1 2 3 or 4 quadrants across health authorities in 20152016 Interior had the highest prevalence of decay in 1 quadrant (111) while the

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

20092010 329 264 253 245 332 285

20122013 274 198 215 198 318 249

20152016 247 183 174 230 304 236

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

eh

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Aboriginal 247 183 174 230 304 236

Non-Aboriginal 124 146 130 103 146 133

Relative Risk 20 13 13 22 21 18

05

10152025303540

Pe

rce

nta

ge o

f ch

idlr

en

[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

0

2

4

6

8

10

12

Pe

rce

nta

ge o

f ch

ildre

n

[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

Pe

rce

nta

ge o

f ch

ildre

n

[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

Pe

rce

nta

ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

5

10

15

20

25

30

Pe

rce

nta

ge o

f ch

ildre

n

[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

5

10

15

20

25

30

Pe

rce

nta

ge o

f ch

ildre

n

[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

Pe

rce

nta

ge o

f ch

ildre

n

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

Pe

rce

nta

ge o

f ch

ildre

n

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[20]

Northern Health Authority had the highest prevalence of decay in 2 3 or 4 quadrants (104 53 and 52 respectively)

Figure 14 Percentage of Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants by health authority in 2015201623

Aboriginal and Non-Aboriginal Children Figures 15 16 17 18 and 19 compare decay by quadrant between Aboriginal and non-Aboriginal children by healthy authority in the 20152016 survey In the majority of cases Aboriginal children were more likely to have visible decay in 1 2 3 or 4 quadrants in all health authorities compared to their non-Aboriginal peers While decay in multiple quadrants is not a proxy for the severity of decay it can be interpreted as an indicator of poor overall dental health In the Vancouver Island Health Authority Aboriginal children had almost five times the risk of having decay in all four quadrants compared to their non-Aboriginal peers In the Interior and Northern Health Authorities the risk of having decay in all four quadrants was almost four times higher for Aboriginal children

Figure 15 Interior Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201624 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

1 Quadrant 111 66 81 81 95 87

2 Quadrants 64 59 57 70 104 73

3 Quadrants 31 23 10 31 53 33

4 Quadrants 41 35 27 47 52 43

-202468

10121416

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

Aboriginal 111 64 31 41

Non-Aboriginal 61 36 16 11

Risk Ratio 18 18 20 39

0

2

4

6

8

10

12

Pe

rce

nta

ge o

f ch

ildre

n

[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

Pe

rce

nta

ge o

f ch

ildre

n

[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

Pe

rce

nta

ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

5

10

15

20

25

30

Pe

rce

nta

ge o

f ch

ildre

n

[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

5

10

15

20

25

30

Pe

rce

nta

ge o

f ch

ildre

n

[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

Pe

rce

nta

ge o

f ch

ildre

n

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

Pe

rce

nta

ge o

f ch

ildre

n

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[21]

Figure 16 Fraser Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201625 and the associated relative risks (RR)

Figure 17 Vancouver Coastal Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201626 and the associated relative risks (RR)

Figure 18 Vancouver Island Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201627 and the associated relative risks (RR)

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 66 59 23 35

Non-Aboriginal 41 64 15 25

Risk Ratio 16 09 15 14

01234567

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 57 10 27

Non-Aboriginal 41 56 15 18

Risk Ratio 20 10 07 15

0123456789

Pe

rce

nta

ge o

f ch

ildre

n

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 81 70 31 47

Non-Aboriginal 52 31 10 10

Risk Ratio 16 23 30 47

0123456789

Pe

rce

nta

ge o

f ch

ildre

n

[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

Pe

rce

nta

ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

5

10

15

20

25

30

Pe

rce

nta

ge o

f ch

ildre

n

[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

5

10

15

20

25

30

Pe

rce

nta

ge o

f ch

ildre

n

[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

Pe

rce

nta

ge o

f ch

ildre

n

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

Pe

rce

nta

ge o

f ch

ildre

n

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[22]

Figure 19 Northern Health Authority - Percentage of Aboriginal and non-Aboriginal kindergarten children with decay in 1 2 3 or 4 quadrants in 2015201628 and the associated relative risks (RR)

Referrals Trends Over Time Figure 20 describes the percentage of Aboriginal children in each health authority who received an urgent or non-urgent referral for further dental care at the time of the 20152016 survey and compares these findings to the 20122013 survey Data for 20092010 were not included in this analysis The Vancouver Island and Northern Health Authorities had the highest percentage of students receiving an urgent referral in 20152016 (69 and 67 respectively) followed by the Fraser (59) Interior (52) and Vancouver Coastal (20) Health Authorities In 20152016 non-urgent referrals were most prevalent in the Northern Health Authority (248) and the least frequent in the Fraser Health Authority (127) From 20122013 to 20152016 the prevalence of urgent referrals increased in the Fraser and Vancouver Island Health Authorities and decreased in the other health authorities For non-urgent referrals the prevalence decreased in all health authorities except Vancouver Island where non-urgent referrals increased by 22 percentage points over this period

Figure 20 Percentage of Aboriginal kindergarten children who were identified as needing urgent or non-urgent referral for further dental care by health authority over time (20122013 to 20152016)29

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

1Quadrant

2Quadrants

3Quadrants

4Quadrants

Aboriginal 95 104 53 52

Non-Aboriginal 61 56 15 13

Risk Ratio 15 19 35 39

0

2

46

810

12

Pe

rce

nta

ge o

f ch

ildre

n

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent 20122013 58 38 27 59 79 57

Urgent 20152016 52 59 20 69 67 58

Non-Urgent 20122013 224 162 195 159 256 204

Non-Urgent 20152016 206 127 158 181 248 188

0

5

10

15

20

25

30

Pe

rce

nta

ge o

f ch

ildre

n

[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

5

10

15

20

25

30

Pe

rce

nta

ge o

f ch

ildre

n

[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

Pe

rce

nta

ge o

f ch

ildre

n

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

Pe

rce

nta

ge o

f ch

ildre

n

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[23]

Aboriginal and Non-Aboriginal Children Figure 21 compares the percentage of Aboriginal and non-Aboriginal children requiring urgent or non-urgent referrals in 20152016 by health authority The greatest disparities appear to be in the Vancouver Island Health Authority where Aboriginal kindergarten children had 42 times the risk of needing urgent referral and 20 times the risk of needing a non-urgent referral compared to non-Aboriginal children In the Northern Health Authority Aboriginal children had 33 times and 19 times the risk for urgent and non-urgent referrals respectively then their non-Aboriginal peers

Figure 21 Percentage of Aboriginal and non-Aboriginal students who were identified as needing urgent or non-urgent referral for further dental care by health authority in2015201630 and the associated relative risks (RR)

Results First Nations Schools In 20152016 482 children enrolled at 49 First Nations schools participated in the provincial dental survey constituting roughly 884 of all eligible kindergarteners at First Nations schools For the purposes of this report the results of all children attending First Nations schools are presented together including those of fourteen children who did not identify as Aboriginal This approach has been taken to ensure comparability with previous survey results Appendix A lists the First Nations schools that participated in the provincial kindergarten dental survey by health authority over the last four screening years It also indicates the year that a Childrenrsquos Oral Health Initiative (COHI) program was established in the community if applicable Table 3 shows the number and percentage of children screened in participating First Nations schools for the past three surveys by health authority At the provincial level the percentage of screened children at First Nations schools increased from 713 in 20092010 to 873 in 20122013 This increase may partly have been due to a change in the consent process In 20092010 signed parental consent was required in First Nations schools prior to providing screening services In 20122013 a process of parent notification and ldquoopt-outrdquo was used in First Nations schools an approach consistent with the process used in public

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a

higher risk

Interior FraserVancouver

CoastalVancouver

IslandNorthern BC

Urgent Aboriginal 52 59 20 69 67 58

Urgent Non-Aboriginal 19 26 14 17 20 21

Non-Urgent Aboriginal 206 127 158 181 248 188

Non-Urgent Non-Aboriginal 106 120 120 91 128 115

Relative Risk - Urgent 27 22 15 42 33 28

Relative Risk - Non-Urgent 19 11 13 20 19 16

0

5

10

15

20

25

30

Pe

rce

nta

ge o

f ch

ildre

n

[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

Pe

rce

nta

ge o

f ch

ildre

n

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

Pe

rce

nta

ge o

f ch

ildre

n

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[24]

and independent schools The overall percentage of kindergarten students at First Nations schools that were screened in 20152016 (884) was comparable to the 20122013 survey cycle (873) although trends varied across individual health authorities Note that the Fraser Health Authority did not have any participating First Nations schools in the 20092010 or 20122013 survey years Table 3 Number and percentage of children screened in First Nations schools by health authority over time (20092010 to 20152016)31

20092010 20122013 20152016

Health Authority

Enrolled Screened

Screened Enrolled Screened Screened Enrolled Screened

Screened

Interior 72 41 569 121 108 893 87 71 816

Fraser 0 0 00 0 0 00 34 29 853

Vancouver Coastal

29 29 1000 45 44 978 53 49 925

Vancouver Island

123 95 772 189 148 783 199 176 884

Northern 93 61 656 189 175 926 172 157 913

BC 317 226 713 544 475 873 545 482 884

Data for First Nations schools in Fraser Health Authority were only available for 20152016

Caries-free Treated Caries and Visible Decay Trends Over Time Figure 22 describes trends in early childhood dental health for students at First Nations schools over time Since 2012-2013 the dental health of kindergarten students at First Nations schools has remained virtually unchanged at the provincial level Since 20122013

bull the percentage of children at First Nations schools who were caries-free has decreased by 14 percentage points

bull the percentage of children at First Nations schools with treated caries has increased by 03 percentage points

bull the percentage of children at First Nations schools with visible decay has increased by 11 percentage points

Figure 22 Percentage of kindergarten children attending First Nations schools with different dental health outcomes over time (20122013 to 20152016)32

CariesFree

TreatedCaries

VisibleDecay

20122013 202 491 307

20152016 188 494 318

0

10

20

30

40

50

60

Pe

rce

nta

ge o

f ch

ildre

n

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

Pe

rce

nta

ge o

f ch

ildre

n

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[25]

First Nations Schools and PublicIndependent Schools Figure 23 compares outcomes between kindergarten students attending First Nations schools and Aboriginal children attending public or independent schools In 20152016

bull 181 of kindergarten students at First Nations schools were caries-free compared with 501 of Aboriginal children attending public or independent schools This means that Aboriginal students attending public or independent schools were 27 times more likely to be caries-free than their peers attending First Nations schools

bull 494 of kindergarten students at First Nations schools had treated caries compared with 277 of Aboriginal children attending public or independent schools This means that a student at a First Nations schools had a 18 times higher risk of having treated caries compared to Aboriginal students attending public or private schools

bull 318 of kindergarten students at First Nations schools had evidence of visible decay compared with 222 of Aboriginal students at public or independent schools This means that students at First Nations schools had a 14 times higher risk of having visible decay than Aboriginal students attending public or independent schools

Figure 23 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with different dental health outcomes in2015201615 and the associated relative risks (RR)

Decay by Quadrant Trends Over Time Figure 24 describes the percentage of kindergarten students at First Nations schools who had decay in 1 2 3 or 4 quadrants over time Prevalence of decay in 1 and 3 quadrants has increased since the 20122013 survey but the prevalence of decay in 2 or 4 quadrants has declined

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Caries Free Treated Caries Visible Decay

First Nations Schools 188 494 318

PublicIndependentSchools

501 277 222

Relative Risk 04 18 14

0

20

40

60

Pe

rce

nta

ge o

f ch

ildre

n

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[26]

Figure 24 Percentage of kindergarten children at First Nations schools with decay in 1 2 3 or 4 quadrants over time (20122013 to 20152016)33

First Nations Schools and PublicIndependent Schools Figure 25 compares decay by quadrant among kindergarten students at First Nations schools and Aboriginal students attending public or independent schools in 20152016 Children attending First Nations schools had 12 to 13 higher risk for decay in 1 2 or 4 quadrants and 24 the risk of decay in 3 quadrants compared to Aboriginal children attending public or independent schools

Figure 25 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools with decay in 1 2 3 or 4 quadrants in 2015201616 and the associated relative risks (RR)

Referrals Trends Over Time Figure 26 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals from 20122013 to 20152016 The prevalence of urgent referrals increased slightly (by 20 percentage points) while non- urgent referrals remained stable over this period

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

20122013 84 110 39 71

20152016 102 91 66 54

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

1 Quadrant 2 Quadrants 3 Quadrants 4 Quadrants

First Nations Schools 102 91 66 54

PublicIndependent Schools 84 70 27 41

Relative Risk 12 13 24 13

0

5

10

15

Pe

rce

nta

ge o

f ch

ildre

n

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[27]

Figure 26 Percentage of kindergarten children at First Nations schools who were identified as needing urgent or non-urgent referral for further dental care over time (20092010 to 20152016)34

First Nations Schools and PublicIndependent Schools Figure 27 describes the percentage of kindergarten students at First Nations schools who received urgent or non-urgent referrals in 20152016 and compares these findings to outcomes for Aboriginal children attending public or independent schools Children who did not have urgent conditions but were referred for further treatment were classified as non-urgent Children attending First Nations schools had a 18- and 14-times higher risk of receiving an urgent or non-urgent referral respectively compared to Aboriginal children attending public or independent schools

Figure 27 Percentage of kindergarten children at First Nation schools and Aboriginal students enrolled in public or independent schools who were identified as needing urgent or non-urgent referral for further dental care in 2015201617 and the associated relative risks (RR)

Conclusion and Recommendations Conclusions The provincial Aboriginal dental survey is an important tool for monitoring regional trends as well as for evaluating the effectiveness of early childhood dental health initiatives across the province Overall there are encouraging trends in Aboriginal early childhood dental health at the provincial level Since the 20092010 survey the prevalence of children who are caries-free has increased (from 393 to 457

RRlt1 indicates a lower risk of that outcome in Aboriginal children compared to non-Aboriginal children while RRgt1 indicates a higher risk

Urgent Non-Urgent

20122013 73 256

20152016 93 253

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

Urgent Non-Urgent

First Nations Schools 93 253

PublicIndependentSchools

53 176

Relative Risk 18 14

05

101520253035

Pe

rce

nta

ge o

f ch

ildre

n

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[28]

and the prevalence of both treated caries and visible decay has declined (from 322 to 307 and from 285 to 236 respectively) However trends in early childhood dental health vary significantly across the province At the health authority level the prevalence of Aboriginal children who are caries-free has increased since 20092010 except in the Northern Health Authority where the prevalence of children who were caries-free declined slightly from 20122013 to 20152016 Northern was also the only health authority to see an increase in the prevalence of treated caries since the 20122013 survey The Vancouver Island Health Authority was the only health authority to see an increase in the prevalence of visible decay since the 20122013 survey Dental health trends in Vancouver Island Health Authority are particularly interesting when data for all kindergarten children in BC were analyzed Vancouver Island had some of the best outcomes in the province However when data for Aboriginal kindergarten students are looked at in isolation Vancouver Island Health Authority has the second lowest prevalence of children who were caries-free and the highest prevalence of urgent referrals This report does not offer definitive conclusions as to what might be influencing trends in early childhood dental health public health professionals in each jurisdiction will be able to interpret survey findings with their specific knowledge of local initiatives challenges and opportunities While there are many encouraging findings for Aboriginal children at both the provincial and health authority level trends in early childhood dental health for kindergarten students at First Nations schools raise some concerns Since the 20122013 survey the prevalence of children who are caries-free at First Nations schools has declined slightly (by 14 percentage points) and the prevalence of visible decay has increased by 11 percentage points In addition there continues to be a significant difference in early childhood dental outcomes for Aboriginal children attending public or independent schools and those attending First Nations schools In 20152016 children at First Nations schools had a 14 times higher risk of developing dental decay and a 18 times higher risk of needing urgent referral compared with Aboriginal children attending public or independent schools However interpreting survey data for First Nations schools is limited by the small sample size In future surveys it would be highly beneficial to encourage increased participation of First Nations schools to gain a more complete picture of early childhood dental health in this population Disparities between Aboriginal and non-Aboriginal kindergarten students continue to be a concern across BC While improvements in early childhood dental outcomes have been observed in both groups at the provincial level the disparities between the two populations not only persist but have remained relatively unchanged over time For example it is notable that the risk of having visible decay has been 18 times higher for an Aboriginal student than a non-Aboriginal student since the 20092010 survey Success in improving early childhood dental outcomes should not just be measured by changes in the overall prevalence of children who are caries-free reducing disparities in early childhood dental outcomes should also be a central metric

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[29]

Recommendations bull In the analysis of future kindergarten dental survey data careful attention should be given to

measures of inequity such as relative risk Reducing inequities in early childhood dental health outcomes should be a central measurement for progress in improving early childhood dental health in BC

bull Increased participation of First Nations schools would improve data quality and inform policy and

planning Alternative means of data collection should be considered for schools that are rural or remote or who are hesitant to participate in the kindergarten dental survey due to other ongoing dental initiatives (eg COHI programming which may already conduct thorough dental examinations on young children) Options to have COHI data contribute to the kindergarten dental survey were explored for the 20182019 survey cycle and this work should continue as part of preparations for the 20212022 survey

bull Early childhood dental health is the result of many interconnected factors While diet dental hygiene

practices and access to dental care play an important role outcomes are also influenced by social determinants of health such as socioeconomic status food security challenges geographic location and other systemic barriers35 Poor dental outcomes may be indicative of other vulnerabilities As such the results of the kindergarten dental survey offer a window of insight into the status of young children across the province and may be helpful to identify where services and supports need to be delivered at greater intensity To achieve ongoing improvements in dental health continued collaboration and program planning is needed between First Nations communities health authorities and other partners and service providers engaged in improving outcomes in the early years

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[30]

Endnotes

1 Peressini S Leake J L Mayhall J T Maar M amp Trudeau R (2004) Prevalence of early childhood caries among First Nations children District of Manitoulin Ontario International Journal of Paediatric Dentistry 14(2) 101-110 2 Schroth R J Smith P J Whalen J C Lekic C amp Moffatt M E (2005) Prevalence of caries among preschool-aged children in a northern Manitoba community J Can Dent Assoc 71(1) 27 3 Schroth R J Harrison R L amp Moffatt M E (2009) Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being Pediatric Clinics of North America 56(6) 1481-1499 4 Evidence Review Dental Health BC Ministry of Health 2014 Accessed Oct 7 2014 from

wwwhealthgovbccapublic-healthpdfDental_Health_Evidence_Reviewpdf 5 Rowan-Legg A Oral health care for children - a call for action Paediatr Child Health 201118(1)37-43 httpwwwcpscaendocumentspositionoral-health-care-for-children 6 Canadian Dental Association (2010) CDA position on early childhood caries Ottawa Canada Canadian Dental Association 7 Centre for Disease Control Division of Oral Health Accessed Oct 7 2014 from

wwwcdcgovoralhealthchildren_adultschildhtm 8 Schroth R J Quintildeonez C Shwart L amp Wagar B (2016) Treating Early Childhood Caries Under General Anesthesia a National Review of Canadian Data J Can Dent Assoc 82(g20) 1488-2159 9 Ibid 10 BC Dental Survey of Kindergarten Children 20092010 - 20152016BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 11 Ibid 12 Ibid 13 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 14 Ibid 15 Ibid 16 BC Dental Survey of Kindergarten Children Population Health Surveillance amp Epidemiology Office of the Provincial Health Officer BC Ministry of Health Data extracted September 1 2017 17 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 (Corrected for 20122013) 18 Ibid 19 Ibid 20 Ibid 21 Ibid 22 Ibid 23 Ibid 24 Ibid 25 Ibid 26 Ibid 27 Ibid 28 Ibid 29 BC Dental Survey of Kindergarten Children 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health March 2016 30 Ibid 31 Ibid 32 BC Dental Survey of Kindergarten Children 20062007 - 20152016 BC Ministry of Health Prepared by Population Health Surveillance and Epidemiology BC Office of the Provincial Health Officer BC Ministry of Health September 2017

[31]

33 Ibid 34 Ibid 35 Davies G N (1998) Early childhood cariesmdasha synopsis Community dentistry and oral epidemiology 26(S1) 106-116