1. family and parenting
2. children

Tooth decay in five-year-old children
in South East England
Tooth decay in five-year-old children
in South East England
Kate Jones
Christopher Allen
Alison Hill
June 2005
2
Contents
Executive Summary ..............................................................................................................................2
1.
Introduction .......................................................................................................................3
2.
Tooth Decay .......................................................................................................................4
2.1
Methods .............................................................................................................................4
2.2
Trends in Levels of Tooth Decay ........................................................................................5
2.3
Tooth Decay in Five-Year-Old Children at National Level .................................................5
2.4
Tooth Decay in Five-Year-Old Children in the South East Region .....................................7
2.5
Tooth Decay in Five-Year-Old Children by Strategic Health Authority
and Primary Care Trust in the South East Region..............................................................7
2.5.1
Surrey and Sussex SHA ......................................................................................................9
2.5.2
Kent and Medway SHA ....................................................................................................11
2.5.3
Thames Valley SHA...........................................................................................................13
2.5.4
Hampshire and the Isle of Wight SHA .............................................................................15
2.6
Care Index .......................................................................................................................17
3.
Effectiveness of Oral Health Interventions ......................................................................18
3.1
Fluoride ............................................................................................................................18
3.2
Fissure Sealants ................................................................................................................18
3.3
Oral Health Promotion ....................................................................................................18
3.4
National Initiatives ...........................................................................................................18
4.
Conclusions .....................................................................................................................19
5.
Recommendations ...........................................................................................................19
References .........................................................................................................................................20
Reader Information .............................................................................................................................21
1
1
Tooth decay in five-year-old children in South East England
Executive Summary
Background
This report was written to inform the
commissioning of locally sensitive dental services
by Primary Care Trusts (PCT) in the South East
region. Levels of tooth decay in five-year-old
children in the region at PCT and Strategic
Health Authority (SHA) level are described
together with evidence for the effectiveness of
interventions used to promote oral health and
prevent oral disease. The report forms part of
the dental collection of the South East Public
Health Observatory (SEPHO).
The report is based on 2001/02 dental data
collected by the community dental services
in the South East region of England as part
of the national surveys co-ordinated by the
British Association for the Study of Community
Dentistry.
Conclusions
These conclusions are drawn from 2001/02 data
as these data are more comprehensive than the
2003/04 data. Where comparisons can be made
between the two data sets, there has been little
change in tooth decay levels over the two year
period.
There were improvements in oral health in
five-year-old children overall across the South
East region over the period 1995/96 to 2001/02.
However, between 1997/98 and 2001/02, any
improvements in oral health had stopped and
there was a worsening in tooth decay levels in
some areas.
In three of the four SHAs in the region, and
in 22 PCTs, the 2003 national targets for tooth
decay had not been met by 2001. Additionally,
given that improvements in oral health in fiveyear-olds had stopped or started to reverse, these
2003 targets were unlikely to be met.
Although the levels of tooth decay in five-yearold children in the South East region compare
favourably overall with national levels of oral
health, tooth decay has become clustered within
the population and small groups of children still
suffer from significant levels of damaged teeth.
Tooth decay was found to be closely related
to deprivation, as measured by mean income
deprivation score, and inequalities in oral health
were found across the region at both SHA and
PCT level.
The majority of tooth decay in five-year-old
children in the South East region is either
untreated or treated by removal of the affected
tooth.
Recent high quality reviews of the evidence
2
show that the most effective method for
the prevention of tooth decay is the use of
fluoride. No areas in the South East region have
fluoridated public drinking water supplies.
Recommendations
Each SHA area should investigate fluoridation of
the drinking water supplies to improve the oral
health of its local population.
As tooth decay has become clustered within the
population, areas of children with high levels of
tooth decay should be identified and preventive
services should be targeted to these locations.
The Brushing for Life children’s dental health
initiative is currently being evaluated. If this
scheme is proven to be effective, it should
be developed in all areas within Sure Start
programmes and Children’s Centres.
Locally sensitive oral health strategies should be
developed by PCTs to address inequalities in oral
health and to improve access to oral health care
services.
SEPHO should be requested to undertake
further work on access to oral health services
and to update regularly data on tooth decay
levels in five-year-old children on its website in
subsequent years as new data become available.
Key messages
• Oral health has improved in five-year-old
children in the South East region.
• Inequalities in oral health exist at SHA and
PCT level across the region.
• Tooth decay has become clustered in
children living in deprived areas.
• The majority of tooth decay in five-year-old
children is untreated.
• Oral health promotion, including the use of
fluoride, should be targeted to children with
the greatest need.
1. Introduction
National Health Service (NHS) dentistry is
undergoing radical modernisation following
the publication of NHS Dentistry – Options
for Change (DH, 2002), which built on the
Government’s strategy document Modernising
NHS Dentistry: Implementing the NHS Plan
(DH, 2000). Primary Care Trusts (PCTs) are
responsible for local commissioning of oral
health services, including (from April 2006) for
the first time, general dental services to meet the
needs of their population. These changes were
facilitated by the legislation passed in the Health
and Social Care (Community Health and
Standards) Act (UK Parliament, 2003a).
The 1994 national targets set for
five-year-old children were that by 2003:
• a child should have no more than one
decayed, missing or filled tooth
• no more than 30% of children should have
experienced tooth decay.
Responsibility for screening and oral health
promotion has also been shifted to the primary
care trusts from the community dental service.
An Oral Health Strategy for England was
published by the Department of Health (DH) in
1994. The strategy set national targets for tooth
decay in children and adults.
In common with other diseases, tooth decay is
related to deprivation (Watt and Sheiham, 1999;
Locker, 2000). Tooth decay is more common
in people from deprived communities. Both
Modernising NHS Dentistry: Implementing
the NHS Plan (DH, 2000) and NHS Dentistry:
Options for Change (DH, 2002) recognised that
inequalities in oral health persisted and needed
to be tackled.
This report aims to facilitate the commissioning
of locally sensitive dental services by PCTs in the
South East region by describing tooth decay in
five-year-old children in the region together with
evidence for the effectiveness of interventions
used to promote oral health and prevent oral
disease.
3
Tooth decay in five-year-old children in South East England
2. Tooth Decay
Tooth decay is caused by acids produced in the mouth by plaque bacteria from sugars
in the diet. As the tooth decay progresses, cavities form in the teeth and pain, sepsis and
tooth loss will result unless there is appropriate intervention.
Tooth decay is the major cause of tooth loss in children and young adults in the United
Kingdom (UK). However, tooth decay is preventable.
2.1
Methods
Data on tooth decay in schoolchildren are available from the British Association for the
Study of Community Dentistry’s (BASCD) dental health surveys, which are carried out
on a four-year rotational basis. Five-year-old children are examined biennially and in the
intervening years, there have been alternating surveys of 12 and 14-year-old children. The
first survey was carried out in 1987 on five-year-old children. The data are collected to
national standards by trained and calibrated dentists to allow for regional comparisons
and to assess trends over time. Data in this report were collected in the school year
2001/02. The raw data are available on the South East Public Health Observatory (SEPHO),
BASCD and the Compendium of Clinical and Health Indicators 2002 / Clinical and
Health Outcomes Knowledge Base websites. The data were described at area level with
respect to mean dmft (see below) and the proportion of children affected by tooth
decay. Trends over time from 1994/95 to 2001/02 were assessed at SHA level and the
most recent (2001/02) data were analysed at SHA and PCT level. A regression analysis
for the association between the mean dmft and the income domain score from the
Index of Multiple Deprivation 2004 (ODPM, 2004) (derived for PCTs by the Healthcare
Commission) was carried out for the South East region as a whole and for each of the
SHA areas.
The indicator of the level of tooth decay used, the dmft index, is obtained by summing
the number of decayed (d), missing (m) and filled (f) teeth (t). In five-year-old children,
this score is for the deciduous or milk teeth. Mean values are used in population data.
The proportion of children having experienced tooth decay (dmft>0) is used as a
measure of the prevalence of the disease.
There are four strategic health authorities and 49 primary care trusts in the South East
region. Tooth decay data were available for 46 of the PCTs. In Kent and Medway SHA, data
were reported jointly for Medway PCT and Swale PCT, East Kent Coastal PCT and
Canterbury and Coastal PCT, and Ashford PCT and Shepway PCT. In Thames Valley SHA,
data were reported jointly for Wycombe PCT and Chiltern and South Buckinghamshire PCT.
Figure 1
2.0
Mean dmft in fiveyear-old-children
in the South East
region by SHA,
1995/96 to 2001/02
1.5
Mean dmft
Mean dmft =
average number of
decayed, missing or
filled teeth
1995–96
1997–98
1999–2000
2001–02
2003 target
1.0
Source: BASCD
0.5
0.0
Hampshire and
Isle of Wight
Surrey and Sussex
Kent and Medway
Thames Valley
SHA
4
South East
England
In those PCTs with missing data, the samples were too small to allow calculation of a PCT
mean accurately, although the data were included in the SHA level analyses.
The evidence for the effectiveness of preventive measures was taken from well
conducted systematic reviews on the Cochrane Library website, the Health Development
Agency website and from the NHS Centre for Reviews and Dissemination.
2.2
Trends in Levels of Tooth Decay
The 1994 Oral Health Strategy for England set targets for oral health in 2003 and
suggested broad strategies as to how oral health might be improved.
To assess any improvements in oral health in the South East region over the period
since publication of the strategy, trends in oral health were investigated.
All strategic health authorities had an improvement in oral health in five-year-old
children over the period 1995/96 to 2001/02 (Pitts and Evans, 1997; Pitts et al., 1999;
Pitts et al., 2001; Pitts et al., 2003). The greatest improvement was in Kent and Medway
SHA where the average number of decayed, missing and filled teeth fell from 1.32 in
1995/96 to 0.84 in 2001/02. There was very little improvement over the period between
the last two surveys when three of the health authorities had a very small rise in dmft
(Figure 1).
All of the strategic health authorities had an increased proportion of children who were
free from tooth decay between 1995/96 and 2001/02, apart from Surrey and Sussex SHA. The
biggest improvement was in Hampshire and the Isle of Wight SHA where the proportion of
children affected by tooth decay decreased from 40% to 32%. There was a small increase in
the proportion of children affected by tooth decay in Surrey and Sussex SHA (Figure 2).
These trends indicate that although the oral health of five-year-old children has
improved considerably overall, tooth decay has become clustered in a small group of
children, who will have greater numbers of damaged teeth.
2.3
Tooth Decay in Five-Year-Old Children at National Level
Although the oral health of five-year-old children had improved considerably in recent
years, there remained wide variation in disease levels throughout the country in 2001/02,
with the average number of decayed, missing or filled teeth ranging from 0.84 in Kent
and Medway SHA to 2.47 in Greater Manchester SHA (Pitts et al., 2003).
50
Proportion of
children affected by
tooth decay in the
South East region
by SHA,
1995/96 to 2001/02
40
Source: BASCD
30
1995–96
1997–98
1999–2000
2001–02
2003 target
Per cent
Figure 2
20
10
0
Hampshire and
Isle of Wight
Surrey and Sussex
Kent and Medway
Thames Valley
South East
England
SHA
5
Tooth decay in five-year-old children in South East England
2.5
2.0
Mean dmft
Figure 3
Tooth decay in
five-year-old children
by Strategic Health
Authority, 2001/02
Mean dmft =
average number of
decayed, missing or
filled teeth
2003 target
England average
1.5
1.0
0.5
Source: BASCD
0.0
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five-year-old children by 2001/02. The poorer levels of oral health were generally to
be found in children living in the north of the country and in the North London SHAs
(Figure 3).
Greater Manchester SHA area also had the highest proportion of children affected by
tooth decay with 54% of children having experienced the disease (Figure 4). Essex SHA
had the lowest proportion of children affected by tooth decay with 29% of children
having experienced the disease. Only three SHAs achieved the 2003 national target for
60
Figure 4
Source: BASCD
2003 target
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Proportion of fiveyear-old children
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2001/02
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the proportion of children affected by tooth decay by 2001/02. They were Kent and
Medway SHA, West Midlands South SHA and Essex SHA.
This pattern reflects the strong inequalities that exist in levels of tooth decay, with
the exception of the areas of West Midlands South SHA and Birmingham and The Black
Country SHA, which receive fluoridated public water supplies and whose children benefit
from having amongst the best oral health in the country despite living in areas of high
deprivation.
The proportion of children affected by tooth decay is an important measure. As the
level of tooth decay has fallen, so too has the percentage of children affected by the
disease. Thus whilst in Kent and Medway SHA, children have on average less than one
affected tooth each, as only 30% of children have the disease, these children will have
higher numbers of affected teeth.
2.4
Tooth Decay in Five-Year-Old Children in the South East Region
All of the SHA areas in the South East region had children with better oral health than
the national average. Five-year-old children living in the Kent and Medway SHA area had
the best oral health in the country in 2001/02 (Figure 3).
The national targets for oral health in five-year-old children in 2003 had been achieved
in the Kent and Medway SHA area but not in the other South East SHA areas. Within
the four SHAs, the mean dmft ranged from 0.84 in Kent and Medway SHA to 1.23 in the
Thames Valley SHA (Figure 3) and the proportion of children affected by tooth decay
ranged from 30% in Kent and Medway SHA to 34% in Thames Valley SHA (Figure 4).
2.5
Tooth Decay in Five-Year-Old Children by Strategic Health Authority
and Primary Care Trust in the South East Region
The oral health data were analysed by PCT in the SHA areas. This revealed wide variation
in disease levels and that inequalities existed in the distribution of disease across SHA
areas. The mean dmft varied from 0.62 in South East Oxfordshire and South West Kent
PCTs to 2.30 in Reading PCT (Map 1; Figure 5).
Map 1
Mean levels of
tooth decay in
five-year-old children
by PCT in the South
East region 2001/02
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data unavailable
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© Crown copyright. All
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Licence number
100039906. 2005
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Tooth decay in five-year-old children in South East England
Figure 5
2.5
Tooth decay in
five-year-old children
by PCT and SHA,
2001/02
2003 target
South East
Hampshire & Isle of Wight SHA
2.0
Kent and Medway SHA
Surrey and Sussex SHA
Thames Valley SHA
1.5
Mean dmft
Mean dmft =
average number of
decayed, missing or
filled teeth
1.0
Source: BASCD
0.5
0.0
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Figure 6
South East
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Kent and Medway SHA
50
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Source: BASCD
40
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8
The proportion of children with tooth decay varied from 21% in South West Kent PCT
to 49% in Reading PCT (Figure 6).
These patterns demonstrate the association of tooth decay and deprivation; there are
very low levels of tooth decay in the affluent areas of South West Kent PCT and South
East Oxfordshire PCT and high levels of tooth decay in the more deprived area covered
by Reading PCT. However, there was no statistically significant association between PCT
mean dmft and PCT mean income deprivation score across the South East region as a
whole.
PCT mean income deprivation scores across the South East region are shown below
(Map 2). A higher score reflects a more deprived area. Wokingham PCT had the lowest
mean income deprivation score and Hastings and St Leonard’s PCT had the highest mean
income deprivation score.
Map 2
Mean income
deprivation score
by PCT in the South
East region, 2004
BBaannbbuurryy
M
Miillttoonn K
Keeyynneess
IMD 2004 Income Domain Score
Source: ODPM
0.163 to 0.206 (2)
0.121 to 0.163 (8)
0.079 to 0.121 (14)
0.037 to 0.079 (25)
A
Ayylleessbbuurryy
Oxxffoorrdd
O
© Crown copyright. All
rights reserved. SEPHO.
Licence number
H
Hiigghh W
Wyyccoom
mbbee
SSw
wiinnddoonn
100039906. 2005
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2.5.1 Surrey and Sussex SHA
Data were available for 12 of the 15 PCTs in Surrey and Sussex SHA. Children in East
Elmbridge and Mid Surrey PCT had the best oral health in the area with a mean number
of affected teeth of 0.90. Children in Western Sussex PCT had the worst oral health with
a mean number of 1.25 affected teeth (Map 3; Figure 7).
The proportion of children with disease varied from 27% in East Elmbridge and Mid
Surrey PCT to 37% in Bexhill and Rother PCT (Figure 8).
Six of the PCTs had achieved the 2003 national target for average disease levels in
2001/02 and 7 PCTs had achieved the national target for the proportion of children
affected by tooth decay.
There was no association between PCT mean dmft score and PCT mean income
deprivation score within this SHA.
Data were not available for Crawley PCT, East Surrey PCT and Horsham and
Chanctonbury PCT. Data for these PCTs should be available in the 2003/04 survey, the
results of which will be published later in 2005 on the BASCD website.
9
Tooth decay in five-year-old children in South East England
Map 3
Mean levels of
tooth decay in fiveyear-old children
by PCT in Surrey
and Sussex SHA,
2001/02.
North S urrey
Surrey Heath
and Woking
Mean dmft
Eas t Elmbridge
and Mid Surrey
1.40 to 2.30
1.01 to 1.39
0.10 to 1.00
data unavailable
Eas t Surrey
Source: BASCD
G uildford and Wav erley
© Crown copyright.
Crawley
All rights reserved.
SEPHO. Licence number
100039906. 2005
Mid S us s ex
Sus s ex Downs
and Weald
B ex hill and Rother
Horsham and
Chanc tonbury
Wes tern S us s ex
Adur, Arun
and Worthing
Has tings and
St Leonards
Eas tbourne
Downs
B righton
and Hov e C ity
Figure 7
1.8
Tooth decay in
five-year-old children
in Surrey and
Sussex SHA by PCT,
2001/02
Mean dmft
2003 target
SHA average
1.6
Mean dmft
1.4
Mean dmft =
average number of
decayed, missing or
filled teeth
1.2
1.0
0.8
0.6
I = 95%
confidence limits
0.4
Source: BASCD
0.2
0.0
ey
rr
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rid
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lm
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s
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us
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id
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rt
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d
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ve
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il
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Be
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ur
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th
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ey
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rs
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Figure 8
50
Proportion of fiveyear-old children
with tooth decay
in Surrey and
Sussex SHA by PCT,
2001/02.
Per cent
2003 target
SHA average
40
Per cent
30
I = 95%
confidence limits
20
Source: BASCD
10
0
ey
br
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PCT
2.5.2 Kent and Medway SHA
Seven of the PCTs in Kent and Medway SHA had achieved the 2003 national target for
average disease levels for five-year-old children and Medway and Swale PCTs were very
close to the target for average disease levels at 1.02 affected teeth (Map 4). Children
in South West Kent PCT had the best oral health both in terms of the average number
of affected teeth and the proportion of children with experience of tooth decay. The
children with the poorest oral health were in Swale and Medway PCTs, again in terms of
average disease levels and the proportion of children affected by tooth decay (Figures 9
and 10).
Mean dmft
Map 4
Mean levels of
tooth decay in fiveyear-old children
by PCT in Kent
and Medway SHA,
2001/02.
1.40 to 2.30
1.01 to 1.39
0.10 to 1.00
data unavailable
Dartford, G rav es ham
and S wanley
Medway
S wale
Source: BASCD
C anterbury and C oas tal
E as t K ent
C oas tal
© Crown copyright.
All rights reserved.
SEPHO. Licence number
S outh Wes t K ent
Maids tone Weald
100039906. 2005
As hford
S hepway
11
Tooth decay in five-year-old children in South East England
Figure 9
1.4
Tooth decay in fiveyear-old children in
Kent and Medway
SHA by PCT,
2001/02.
I = 95%
confidence limits
1.2
1.0
Mean dmft
Mean dmft =
average number of
decayed, missing or
filled teeth
Mean dmft
2003 target
SHA average
0.8
0.6
0.4
Source: BASCD
0.2
0.0
South West Kent
Maidstone Weald
East Kent Coastal and
Canterbury & Coastal
Ashford and
Shepway
Dartford, Gravesham Medway and Swale
and Swanley
Ashford and
Shepway
Dartford, Gravesham Medway and Swale
and Swanley
PCT
50
Figure 10
Proportion of fiveyear-old children
with tooth decay in
Kent and Medway
SHA by PCT,
2001/02.
Source: BASCD
40
30
Per cent
I = 95%
confidence limits
Per cent
2003 target
SHA average
20
10
0
South West Kent
East Kent Coastal
and Canterbury &
Coastal
Maidstone Weald
PCT
12
Kent and Medway was the only SHA in the South East region where the SHA averages,
in terms of number of affected teeth and proportion of children affected by tooth decay,
were below that of the national target.
There was no association between PCT mean dmft score and PCT mean income
deprivation score within this SHA.
2.5.3 Thames Valley SHA
The levels of oral health varied considerably throughout the area, with Thames Valley
SHA having the children with amongst the best and the worst oral health in the
South East region (Map 5). The children with the best oral health were in South East
Oxfordshire PCT and the children with the poorest oral health were in Reading PCT,
with these children having almost four times higher the average disease levels of
children living in South East Oxfordshire PCT (2.30 dmft compared to 0.62 dmft) (Figure
11). Seven PCTs had achieved the national target for average disease levels and five had
reached the national target for the proportion of children affected by tooth decay (Figure 12).
There was a weak association between PCT mean dmft score and PCT mean income
deprivation score within this SHA (R2 = 0.45; p<0.01).
Map 5
Mean levels of
tooth decay in fiveyear-old children by
PCT in Thames Valley
SHA, 2001/02.
Milton
Keynes
Mean dmft
1.40 to 2.30
1.01 to 1.39
0.10 to 1.00
data unavailable
Source: BASCD
© Crown copyright.
Cherwell Vale
All rights reserved.
SEPHO. Licence number
North East
Oxfordshire
100039906. 2005
Vale of
Aylesbury
Oxford
City
South West
Oxfordshire
South East
Oxfordshire
Wycombe
Chiltern
and
South
Bucks
Slough
Windsor,
Ascot and Maidenhead
Newbury and
Community
Reading
Wokingham
Bracknell
Forest
13
Tooth decay in five-year-old children in South East England
3.0
Figure 11
Tooth decay in fiveyear-old children in
Thames Valley SHA
by PCT, 2001/02.
Mean dmft
2003 target
SHA average
2.5
Mean dmft
2.0
Mean dmft =
average number of
decayed, missing or
filled teeth
1.5
1.0
I = 95%
confidence limits
0.5
Source: BASCD
0.0
re
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PCT
60
Figure 12
Proportion of fiveyear-old children
with tooth decay in
Thames Valley SHA
by PCT, 2001/02
Per cent
2003 target
SHA average
50
Per cent
40
I = 95%
confidence limits
Source: BASCD
30
20
10
ng
gh
ad
i
Re
Sl
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el
lV
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ty
Ch
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2.5.4 Hampshire and the Isle of Wight SHA
Four out of the 10 PCTs in the Hampshire and Isle of Wight SHA area achieved the
national target for average disease levels and five achieved the national target for the
proportion of children affected by disease. There was variation in oral health across the
SHA area with those children in Portsmouth City PCT having twice the average levels of
tooth decay as those children in North Hampshire PCT (Map 6; Figure 13).
Twenty-five per cent of children were affected by tooth decay in North Hampshire PCT
compared to 44% in Portsmouth City PCT (Figure 14).
There was a strong association between PCT mean dmft score and PCT mean income
deprivation score within this SHA (R2 = 0.8; p<0.01).
Map 6
Mean levels of
tooth decay in fiveyear-old children by
PCT in Hampshire
and the Isle of Wight
SHA, 2001/02.
Source: BASCD
© Crown copyright.
All rights reserved.
North
Hampshire
Blackwater
Valley and
Hart
Mean dmft
1.40 to 2.30
1.01 to 1.39
0.10 to 1.00
data unavailable
Mid Hampshire
SEPHO. Licence number
100039906. 2005
Eastleigh and
Test Valley South
Southampton
City
New Forest
East
Hampshire
Fareham
and
Gosport
Portsmouth
City
Isle of Wight
15
Tooth decay in five-year-old children in South East England
Figure 13
1.8
Tooth decay in
five-year-old children
in Hampshire and
the Isle of Wight
SHA by PCT,
2001/02.
1.6
1.4
1.2
Mean dmft
Mean dmft =
average number of
decayed, missing or
filled teeth
Mean dmft
2003 target
SHA average
1.0
0.8
0.6
I = 95%
confidence limits
0.4
Source: BASCD
0.2
0.0
North
Hampshire
Eastleigh and
Blackwater Mid-Hampshire New Forest
Test Valley
Valley and Hart
South
Fareham and
Gosport
East
Hampshire
Isle of Wight
Southampton
City
Portsmouth
City
PCT
50
Figure 14
Proportion of
five-year-old children
with tooth decay in
Hampshire and the
Isle of Wight SHA by
PCT, 2001/02.
Source: BASCD
40
30
Per cent
I = 95%
confidence limits
Per cent
2003 target
SHA average
20
10
Ea
16
Ci
ty
Ci
ty
Po
rt
sm
ou
th
pt
on
ut
h
So
st
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am
am
os
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an
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re
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PCT
ps
hi
re
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ig
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of
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e
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am
ps
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id
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hi
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re
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ar
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d
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rV
al
at
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w
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ac
k
st
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ig
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s
or
th
H
tV
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y
am
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ps
hi
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re
0
2.6
Care Index
The care index is the proportion of the total number of decayed, missing and filled teeth
that have been filled. It indicates the level of restorative care provided by dentists.
In the South East region, the level of restorative care was variable (Figure 15). The
highest level of restorative care was provided in North East Oxfordshire and Maidstone
Weald PCTs (31%) and the lowest level of care was provided in Bexhill and Rother PCT
(7%). More than 80% of tooth decay in the South East region was either left untreated or
treated by extraction.
The care index in Surrey and Sussex SHA was higher than the national average at 17%
compared to 13% nationally. East Elmbridge and Mid Surrey PCT had the highest care
index (22%) whilst Bexhill and Rother PCT had the lowest care index (7%).
The SHA average level of restorative care in Kent and Medway was much higher than
the national average at 23% compared to 13% respectively. Only two PCTs had an
average less than the national average and they were Canterbury and Coastal PCT and
East Kent Coastal PCT. Maidstone Weald PCT had the highest level of restorative care in
the SHA area (31%).
In Thames Valley SHA, the average level of restorative care was similar to the national
average (14% compared to 13%). North East Oxfordshire PCT had the highest care index
in the SHA area (31%).
The average care index in Hampshire and the Isle of Wight SHA was slightly higher than
the national average at 14%. However, only four PCTs had a care index above the
national average. Fareham and Gosport PCT had the highest care index at 23%.
National average
Figure 15
South East
Hampshire & Isle of Wight SHA
Care index in fiveyear-old children by
PCT and SHA in the
South East Region,
2001/02
Source: BASCD
Surrey and Sussex SHA
Thames Valley SHA
30
25
Care index (%)
Care index =
number of filled
teeth divided by the
number of decayed,
missing and filled
teeth.
Kent and Medway SHA
35
20
15
10
5
0
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17
Tooth decay in five-year-old children in South East England
3. Effectiveness of Oral Health Interventions
Tooth decay is a preventable disease. Strategies to
improve oral health include the use of fluorides,
fissure sealants and dietary advice. Such oral
health promotion strategies should be based on
need and the effectiveness of an intervention.
The following evidence is taken from well
conducted systematic reviews that have
been published for example by the Health
Development Agency and the Cochrane Library.
3.1
Fissure Sealants
Fissure sealing teeth involves placing a coating
over the chewing surfaces of teeth, which
physically protects the tooth from developing
tooth decay. The effectiveness of fissure sealants
at preventing tooth decay has been proven
(Ahovuo-Saloranta et al., 2004). Evidence-based
guidelines on their use have been published by
the British Society of Paediatric Dentistry (2000).
Their use however can be expensive.
Fluoride
The use of fluoride is a proven method of
preventing tooth decay. Fluoride may be
administered systemically or topically through a
variety of vehicles.
One of the most effective means of preventing
tooth decay is through the fluoridation of public
drinking water (NHS Centre for Reviews and
Dissemination, 2000). The effects of fluoridated
drinking water on the levels of tooth decay may
be seen in the 2001/02 data on levels of tooth
decay in children at SHA level. The West Midlands
has amongst the best levels of oral health (Figure
3), despite having many areas with high levels
of deprivation. Recent changes to the Water Act
(UK Parliament, 2003b) have meant that water
companies must fluoridate their water supplies
at the request of a health authority. However,
public consultation and support is a pre-requisite
and currently, guidance is awaited from the
Department of Health on the public consultation
process. There are no water fluoridation schemes
within the South East region.
Other methods of fluoridation include the
use of fluoridated salt, fluoride tablets, fluoride
mouthwash, fluoride toothpaste and milk,
although the effects in milk are equivocal
(Marinho et al., 2003a; Marinho et al., 2003c;
Ketley et al., 2003). The widespread availability
of fluoridated toothpaste is reported to have
been responsible for the big decline in the
prevalence of tooth decay since its introduction
in the 1970s (Murray and Naylor, 1996) and
children who brush their teeth daily with
fluoride toothpaste have less tooth decay than
those who do not. Brushing with fluoride
toothpaste twice a day increases this effect
(Marinho et al., 2003a).
Dentists may also carry out application of
fluoride to the teeth in the form of gels and
varnishes, all of which have proven to be
effective in preventing tooth decay, although the
extra benefit is not great if fluoride toothpaste
is used concurrently (Marinho et al., 2002a;
Marinho et al., 2002b; Marinho et al., 2003b).
The cost effectiveness of the various methods
has yet to be established.
18
3.2
3.3
Oral Health Promotion
Recently, there have been several reviews of
the effectiveness of oral health promotion
interventions (Schou and Locker, 1994; Sprod
et al., 1996; Kay and Locker, 1997; Department
of Human Services, 1999; Watt and StillmanLowe, 2001). Conclusions from the reviews
suggest that strategies need to be focused on the
underlying social, environmental and economic
determinants of health and should involve local
communities and joint working with other
agencies and health workers to promote oral
health. Focusing on common risk factors that
jointly affect oral health and general health, such
as diet, will reduce the workload and tackle
multiple health issues.
3.4
National Initiatives
Sure Start is a national initiative which has been
developed in areas with high levels of deprivation
and is aimed at giving young children a better
start in life. Oral health should form a part of all
Sure Start programmes and the Brushing for Life
programme should be incorporated into Sure Start
programmes.
Brushing for Life is a government initiative that
was introduced in 2001 to reduce inequalities in
children’s oral health. The aim of Brushing for
Life is to establish tooth brushing with fluoride
toothpaste in children as soon as the first baby
teeth appear in the mouth. Advice on brushing
and the correct use of toothpaste is given by health
visitors who distribute Brushing for Life packs at
a child’s 8 month and 18 month developmental
checks; a follow-up pack may be given at 3 years.
A Brushing for Life pack includes a toothbrush,
fluoride toothpaste and an information leaflet
in several languages. Siblings are also included
in the scheme and there may be opportunistic
dissemination of the packs, for example by oral
health promoters at fun-days and at early years
groups. Whilst the effectiveness of the scheme is
still to be established, it has previously been shown
that introducing fluoride toothpaste into a family
encourages its continued use (OPCS, 1995).
4. Conclusions
• Whilst oral health has improved in children
overall, tooth decay has become clustered
within the population and some groups of
children still suffer from significant levels of
damaged teeth.
• Tooth decay is closely related to social
deprivation and inequalities in oral health exist.
• The majority of tooth decay in the South East
region is either untreated or treated by removal
of the affected tooth.
• Any improvements in oral health in five-yearold children since the 1970s have stopped and
there has been a worsening in tooth decay
levels in some areas.
• The 2003 national targets for tooth decay in
five-year-old children had not been met in
2001 and were unlikely to be met given that
improvements in oral health in five-year-old
children had stopped or started to reverse.
• The most important evidence for the
prevention of tooth decay is the use of fluoride.
• No areas in the South East region have
fluoridated public drinking water supplies.
5. Recommendations
• Each SHA area needs to address the issue of
fluoridation of the drinking water supplies.
• Areas with children with high levels of tooth
decay should be identified and preventive
services should be targeted to these locations.
• The Brushing for Life programme, if proven to
be effective, should be developed in all areas
within Sure Start schemes.
• PCTs need to develop locally sensitive oral
health strategies.
• A review of specialist services within primary
care for children should be undertaken.
• SEPHO should be requested to undertake
further work on access to oral health services.
• SEPHO will regularly update data on tooth
decay levels in five-year-old children on its
website as it becomes available.
19
Tooth decay in five-year-old children in South East England
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20
Reader Information
Document Purpose
For information, to facilitate the commissioning of locally sensitive dental
services by PCTs in the South East region of England by describing tooth
decay in five-year-old children in the region together with evidence for
effectiveness of interventions to promote oral health and prevent oral
disease.
Title
Tooth Decay in Five-Year-Old Children in the South East of England
Published by
South East Public Health Observatory
Authors
Kate Jones, Christopher Allen, Alison Hill
Reviewers
We are grateful to all colleagues who have reviewed and commented on
this report, including Jo Watson and Liz Rolfe at the South East Public
Health Observatory.
Acknowledgements
Thanks to Liz Rolfe and Jo Watson at the South East Public Health
Observatory for assistance with mapping and statistical analysis, and to the
Community Dental Services who assisted with the data collection.
Publication Date
June 2005
Target Audience
All those concerned with commissioning local dental services and improving
the oral health and reducing oral health inequalities of children in the
South East region of England.
Description
A report profiling the oral health of five-year-old children in the South East
region of England.
Contact details
Kate Jones, Department of Dental Public Health, New Court, 1 New Road,
Rochester, Kent ME1 1BD
Further information
www.sepho.org.uk
© SEPHO 2005
21
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Tel: 01865 334714