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Dental Health

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Introduction

Oral health is a key marker of the general health of a community and contributes to general well-being. Tooth decay is still the most common dental disease that affects children.  It can result in significant pain and eventual tooth loss, with an adverse impact on school and family life.

Poor oral health can affect children’s and young people’s ability to sleep, eat, speak, play and socialise with other children. Other impacts include pain, infections, poor diet, and impaired nutrition and growth. Poor oral health also has wider impacts at school and for families. Oral health is an integral part of overall health; when children are not healthy, this affects their ability to learn, thrive and develop1. Maintaining good oral health during childhood is essential and is the basis for good oral health in adulthood. Improvements in oral health are most likely to be achieved by ensuring the adoption of the single most important measure in contributing to improvements in oral health over the last 30 years, namely brushing with flouride toothpaste twice daily.

The management of tooth decay and its consequences is also costly to society. Improving the oral health of children is a national priority and thus the dental health of five year old children is an indicator included in the Public Health Outcomes Framework2. Local Authorities now have the responsibility for the commissioning of community oral health promoting interventions to bring about the expected oral health improvement for children and are supported by Public Health England to discharge this function.

Facts, figures and trends

The oral health of children living in Blackpool is a major concern with levels of tooth decay among the highest in England. This is because, as in common with other non-communicable diseases, tooth decay is associated with deprivation3. Oral health is poor, with levels of decay in children aged 3 years, 5 years and 12 years old significantly worse than the national average. Poor oral health is associated strongly with social deprivation in the child population and although improvements have been made, tooth decay remains one of the most common diseases of childhood affecting physical and psychological wellbeing and quality of life.

Data from the Dental Public Health Epidemiological Programme Oral Health Surveys shows:

    • 17% of Blackpool's 3 year olds are affected by dental decay, significantly higher than the England average of 12%
    • 43% of Blackpool's 5 year olds are affected by dental decay, significantly higher than the England average of 25%
    • 43% of Blackpool's 12 year olds are affected by dental decay, significantly higher than the England average of 33%
    • The average number of decayed, missing or filled teeth in 5 year olds in Blackpool is 1.8, twice the national average of 0.8.
    • The average number of decayed, missing or filled teeth in 12 year olds in Blackpool is 1.1, compared with a national average of 0.7.
    • The average number of missing teeth in 5 year olds in Blackpool is almost 4 times the national average
    • The average number of missing teeth in 12 year olds in Blackpool is twice the national average

Figure 1 shows the proportion of children in Blackpool affected by dental decay as measured by the dmft index (d3mft:  d3-decay into dentine, m-missing, f-filled, t-teeth) compared to the North West and England average. Figure 2 shows the severity of the dental decay, that is, the average number of teeth decayed, missing or filled per child.

Figure 1: Prevalence of dental decay - the proportion of children affected by dental decay, Blackpool compared to England and the North West

Fig 1-Prevalence of dental decay
Source: Dental Public Health Epidemiological Programme Oral Health Surveys
 
    • The average number of decayed or missing teeth in 3 year olds is 0.63, this compares to 0.36 nationally. Results from the survey don't show any 3 year olds in Blackpool with filled teeth.
    • The average number of missing teeth in 5 year olds in Blackpool is almost 4 times higher than the national average, 0.34 compared to 0.09.
    • The proportion of teeth with caries that have been filled in 12 year old children in Blackpool is 42%, this compares to 47% nationally.

Figure 2: Severity of dental decay - the average number of decayed, missing and filled teeth per child, Blackpool compared to England and the North West

Fig 2-severity of dental decay
Source: Dental Public Health Epidemiological Programme Oral Health Surveys

The level of dental decay in 5 year old children is a useful indicator of the success of a range of programmes and services that aim to improve the general health and wellbeing of young children. In the Public Health Outcomes Framework2 one of the indicators is the proportion of 5 year old children free from dental decay. Figure 3 compares Blackpool with all the upper tier local authorities in England for the proportion of children with no dental decay. Blackpool's 5 year olds have significantly more decayed teeth compared to England and North West averages and Blackpool is in the highest 20% of all local authorities for tooth decay.

Figure 3: the proportion of children aged 5 years old who have no dental decay, Blackpool compared to upper tier local authorities: 2014/15

Fig 3-% free from decay-LAs
Source: PHE, Public Health Outcomes Framework, Indicator 4.02

Figure 4 shows other measures of dental disease among 5 year olds in Blackpool, providing further indications of the extent of the oral health of children in Blackpool.

    • The proportion of children in Blackpool with early childhood caries is twice the national average - this pattern of decay is often linked with long-term use of a feeding bottle with sugar-containing drinks.
    • The proportion of 5 year olds with teeth decayed into the pulp (the centre of a tooth) is over twice the national average, 10.2% compared to 4.4% nationally.
    • Levels of plaque on the upper front teeth of children in Blackpool are more than four times the national average, indicative of non-brushing.
    • The proportion of 5 year olds who have had experience of tooth extraction is almost three times the national average. The majority of children who attend hospital for extractions have general anaesthetics for these procedures.

Figure 4: Measures of disease among 5 year olds, Blackpool compared to the North West and England

Figure-4
Source: PHE, Dental health profile for Blackpool, October 2014

Tooth decay is the most common reason for hospital admissions in children aged 5 to 9 years old. General anaesthetic is often given to children undergoing multiple tooth extractions to reduce pain and anxiety and dental treatment under general anaesthesia presents a small but real risk of life-threatening complications for children4. Data from the Dental Public Health Intelligence Programme shows that in Blackpool:

    • 389 (1.2%) young people aged 0-19 were admitted to hospital for tooth extraction in 2015/16
    • This is over two times higher than the national average of 0.5%.
    • 74% of Blackpool children admitted to hospital for tooth extraction between 2013/14-2015/16 were aged under 10 years (Figure 6)
    • Children in Blackpool are being admitted to hospital for tooth extraction at a younger age than the national average.

Figure 5: Trend in % of population aged 0-19 in admitted to hospital for tooth extraction, Blackpool, England and North West

Fig 5-0-19 admitted tooth extraction
Source: Public Health England, Dental Public Health Intelligence Programme, HES Extractions Data 2011-2016

Figure 6: Hospital admissions - proportion of hospital admissions for simple tooth extraction in children and young people by age group, England and Blackpool: 2013/14 to 2015/16

Fig 6-Hosp adm age group-1314-1516
 Source: Public Health England, Dental Public Health Intelligence Programme, HES Extractions Data 2013/14-2015/16

Dental health data for adults is unavailable at a local level but information from the Adult Dental Health Survey 2009 shows that in the North West:

    • 93% of the population have at least some of their natural teeth and the proportion of people who did not have any teeth has fallen from 28% in 1978 to 7% in 2009.
    • 30% of adults have some dental decay and the average number of decayed teeth is 0.9 per person in the North West compared to 0.8 nationally.
    • 88% of adults have one or more fillings.
    • 78% of adults said they cleaned their teeth twice a day and 20% said they did this once a day. Only 1% said they never cleaned their teeth.
    • 63% of adults reported attending the dentist for regular check-ups; 7% reported attending occasionally; 29% reported attending only when they had trouble with their teeth. 1% reported never attending the dentist.

Local user views

The GP Practice Survey asks about patients experiences of local NHS services and feedback about NHS dental services in Blackpool (July 2016) showed that:

    • 13% of Blackpool residents reported no longer having any natural teeth, this is more than double the national average of 6%.
    • 93% reported that they were successful in getting an NHS dental appointment
    • 85% stated that their overall experience of NHS dental services was very good or fairly good. 5% reported it to be poor or very poor.
    • 2% said they were on a waiting list to get an NHS dentist and 14% reported staying with a dentist who moved from NHS to private practice.

Risk factors

Risk factors for oral diseases include: poor diet, tobacco, alcohol, poor oral hygiene, lifestyle and as with all non-communicable chronic diseases, has strong social determinants. Dental decay is the most common food-related disease which affects all families and which has a parallel impact to that of diabetes, obesity and heart disease.

Populations living in relatively deprived circumstances are most at risk of poor dental health. It is these populations who are most likely not to have a dentist or not to visit the dentist regularly. These groups are also more likely to have poorer diets high in sugar and sugar-sweetened beverages,  to consume alcohol in quantities above recommended limits and to smoke. This is why they are known to be at particular risk, though in some cases, other factors come into play such as low usage of toothpaste, particularly fluoride toothpaste and ineffective or inconsistent tooth brushing techniques and routines. Blackpool experiences considerable levels of disadvantage, with low intake of fruit and vegetables and high levels of smoking and alcohol consumption.

Sugar plays a harmful role in oral health and consuming too many foods and drinks high in sugar can lead to tooth decay5. Soft and fizzy drinks can be high in sugar, with consumption of sugar sweetened drinks particularly high in school age children as well as the most disadvantaged, who also experience a higher prevalence of tooth decay. Data from the Blackpool Lifestyle Survey 2015 shows that 14% of the population report drinking fizzy drinks 6 or more times a week, with younger people and those in more disadvantaged areas more likely to report higher consumption of fizzy drinks.

National and local guidance

PHE, Delivering better oral health (June 2014) is an evidence based toolkit to support dental teams in improving their patient’s oral and general health.

Public Health England's Commissioning better oral health for children and young people provides an evidence-informed toolkit for local authorities                

The Public Health Outcomes Framework (2013-16) domain 4 (healthcare public health and preventing premature mortality) includes an indicator related to "tooth decay in five year old children". Local authorities can use this indicator, sourced from the Dental Public Health Intelligence Programme, to monitor and evaluate children's oral health improvement programmes.

NICE guidelines PH55 Oral health: local authorities and partners Recommendation 1 is to ensure oral health is a key health and wellbeing priority.

Public Health in Blackpool currently commissions a suite of evidence based Oral Health improvement strategies for children and young people. These are evidence based interventions to improve oral health inequalities and include:

    • Smile4Life a strategic framework to reduce dental caries and lay solid foundations for good oral health throughout life
    • Programmes of oral health education for health and social care staff
    • Supervised tooth brushing in Children’s Centres, nurseries and by child minders
    • Dental epidemiology surveys
    • Tooth paste and tooth brush distribution

Blackpool oral health schemes

Supervised tooth brushing scheme

There is much evidence that application of fluoride toothpaste to teeth can reduce dental decay, and that children in deprived areas are less likely to brush their teeth twice daily.6 In 2014 PHE and NICE issued evidence based guidance that supervised tooth brushing programmes in the childcare setting are effective and cost-effective for the prevention of tooth decay.1, 7

A supervised tooth brushing scheme has been in place in Blackpool’s children’s centres since 2016, aimed at improving oral health skills in 2–4 year olds. In March 2017, the Better Start programme rolled out a toolkit for nurseries and child minders to initiate supervised tooth brushing in their own settings.

The tool kit provides childcare settings with everything they need to brush their children’s teeth for a year:

    • toothbrushes
    • fluoride toothpaste (1350-1500ppm)
    • a storage system
    • step by step guidance detailing appropriate quantities of toothpaste to be used and infection control procedures.

Childcare providers are asked to commit to continue the scheme beyond the initial 12 months (at a cost of approximately £1.70/child/year).

The scheme is expected to reach approximately 3,000 children in Blackpool and it is hoped that children who take part in the scheme will encourage behavioural changes within the family, benefitting the wider community.

Milk Fluoridation scheme

The World Health Organization (WHO) recommends fluoride milk as being effective in reducing the incidence of dental decay8 . In November 2016, Blackpool Council introduced a fluoridated milk scheme as an additional vehicle for fluoride administration in the town, to contribute towards improving the high prevalence of dental caries in children. Fluoridated milk was offered to all children in Blackpool in Primary School via the Free School Breakfast initiative. Parents were provided with information on fluoridated milk, and were able to decline inclusion in the scheme if they preferred their children to receive non-fluoridated milk.

The scheme delivers in excess of 11,000 breakfasts daily and as part of the scheme all children are offered free school milk to drink (1/3 pint per day).  76% (8, 400) of the 11,000 children were drinking semi skimmed milk at the introduction of the breakfast scheme. Between Nov/Dec 2016 it is estimated that 78% of all school milk ordered is fluoridated milk meaning approximately 6550 children are drinking fluoridated milk on a daily basis.

Members of the Public Health team continue to monitor uptake and are working to support schools. For more information on the scheme visit Blackpool Council, Fluoridated milk scheme.

Recommendations

Advice to be given:

Children aged up to 3 years 

    • Breast feeding provides the best nutrition for babies
    • From six months of age infants should be introduced to drinking from a free flow cup and from age one year feeding from a bottle should be discouraged
    • Sugar should not be added to weaning foods and drinks
    • Parents /carers should brush or supervise tooth brushing
    • As soon as teeth erupt in the mouth brush them twice daily with a fluoridated toothpaste
    • Brush last thing at night and on one other occasion
    • Use fluoridated toothpaste containing no less than 1,350ppm fluoride
    • It is good practice to use a pea-sized amount of toothpaste
    • The frequency and amount of sugary food and drinks should be reduced and kept to meal times
    • Sugar–free medicines should be recommended

Children aged 3-6 years

    • Brush at least twice daily with a fluoridated toothpaste
    • Brush last thing at night and on one other occasion
    • Use fluoridated toothpaste containing 1,350ppm fluoride or more
    • Parents/carers should brush or supervise tooth brushing
    • It is good practice to use only a pea-sized amount of toothpaste
    • Spit out after brushing and do not rinse, to maintain fluoride concentration levels
    • The frequency and amount of sugary food and drinks should be reduced
    • Sugar –free medicines should be recommended

Young people and adults

    • Brush at least twice daily with a fluoridated toothpaste
    • Brush last thing at night and on one other occasion
    • Use a fluoridated toothpaste( 1,350-1,500ppm fluoride)
    • Spit out after brushing and do not rinse, to maintain fluoride concentration levels
    • The frequency and amount of sugary food and drinks should be reduced and kept to meal times

 


[1] PHE, 2014. Commissioning Better Oral Health for Children and Young People, an evidence informed toolkit for local authorities, June 2014

[2] PHE, Public Health Outcomes Framework Indicator 4.02-Proportion of 5 year old children free from dental decay

[3] Davies, G.M., (2010) Summary of the dental health of three-year-old children in Greater Glasgow, Scotland. Br Dent J. 209(4): p. 176-7.

[4] Royal College of Surgeons, Faculty of Dental Surgery, The state of children's oral health in England, 2015

[5] PHE, Sugar Reduction, The evidence for action, October 2015

[6] Children’s Dental Health Survey 2013 (2015). Report 1: Attitudes, Behaviours and Children’s Dental Health: England, Wales and Northern Ireland.

[7] NICE 2014. Oral health: local authorities and partners (PH55)

[8] WHO 2009. Milk fluoridation for the prevention of dental caries