This review of the oral health of children in Australia, New Zealand, Canada and the USA demonstrates that significant oral health inequalities exist in each nation. Despite traditionally low levels of disease in Indigenous communities, dental caries is now highly prevalent and of increased severity among Indigenous children in comparison to their non-Indigenous counterparts. Early childhood caries is particularly prevalent. The high level of dental disease experience at an early age is associated with increased rates of general anaesthesia and greater risk of dental caries in later life. The rates and severity of dental caries experienced by young Indigenous children are even more alarming when we consider that dental caries is essentially a preventable disease. The success of specific preventive programmes is encouraging; these approaches should be further evaluated and implemented as part of broader health promotion programmes for Indigenous children and families in order to decrease current oral health disparities.