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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 linked to a key policy - Best Start in Life. Local Authorities now have 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 remains a concern, with high levels of tooth decay.  This is because, as 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:

    • 20% of Blackpool's 3 year olds were affected by visually obvious dental decay in 2019/20, an increase of 3.1% from 2012/13 and significantly higher than the England average of 10.7%
    • 33.4% of Blackpool's 5 year olds were affected by visually obvious dental decay in 2018/19, an increase of 8.5% from 2016/17 and significantly higher than the England average of 23.4%
    • 43% of Blackpool's 12 year olds were affected by dental decay in 2008/09 (last recorded data point), significantly higher than the England average of 33%
    • The average number of decayed, missing or filled teeth in 5 year olds in Blackpool is 1.15, higher than the national average of 0.8
    • In all age groups, decayed teeth are more common than missing or filled teeth.

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

dmft0 2020

 Source: Dental Public Health Epidemiological Programme Oral Health Surveys
 
    • The average number of decayed or missing teeth in 3 year olds is 0.67, compared to 0.31 nationally.
    • The proportion of teeth with caries that have been filled in children in Blackpool (and the North West) is lower in younger children than is seen nationally, though the difference narrows by the age of 12 years.

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

avg no d3mft 2020

 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. Figure 3 compares Blackpool with all upper tier local authorities in England for the proportion of 5 year olds with experience of visually obvious dental decay. With 33.4% of 5 year olds with dental decay, Blackpool is in the highest quintile (top 20%) for this measure, significantly higher than the England average of 23.4%.

Figure 3: The proportion of children aged 5 years old with experience of visually obvious dental decay, Blackpool compared to upper tier local authorities: 2018/19

LA decay 201819

 Source: PHE, Dental Public Health Epidemiology Programme for England: oral health survey of five-year-old-children, 2019

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 severity of dental disease is generally worse than average.

    • The proportion of children with decay experience in Blackpool is higher than the national average - this is indicative of non-brushing.
    • Over three times as many children have oral sepsis when compared to the national average, this is the presence of a dental abscess or sinus infection.
    • 6% have decay affecting the incisors which is linked with long term use of a feeding bottle with drinks containing sugar.
    • 6% have visually obvious decay involving the pulp (in the centre of the tooth, containing blood and nerves), compared to only 3.3% nationally.
    • The Care Index (% of teeth with decay that has been treated by filling) gives an indication of the restorative activity of dentists in each area. The proportion of children aged 5 in Blackpool who have had their decay treated by filling (6.6%) is in line with the North West average but significantly lower than the national average of 10.3%.
    • The Extraction Index (the proportion of those with decayed, missing or filled teeth related to extraction) was 13% among 5 year olds in Blackpool in 2018/19, higher than the average for both England (10.7%) and the North West (10.4%).

Figure 4: Measures of disease among 5 year olds, Blackpool compared to the North West and England, 2018/19

decay breakdown 2020

 
Source: PHE, Dental Public Health Epidemiological Programme for England: oral health survey of five-year-old children, 2019

Tooth decay remains the most common reason for hospital admissions in children aged 5 to 9 years old4. 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 children5. Data from the Dental Public Health Intelligence Programme shows that in Blackpool:

    • 280 young people aged 0-19 (0.9% of the population) were admitted to hospital for tooth extraction in 2019/20.  This is a 25% decrease from 375 (1.2% of the population) in 2018/19.
    • The 2019/20 rate is over two times higher than the national average of 0.4%.
    • 78.6% of Blackpool children admitted to hospital for tooth extraction in 2019/20 were aged under 11 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 admitted to hospital for tooth extraction, Blackpool, England and North West

Percent extractions 2019

 Source: Public Health England, Dental Public Health Intelligence Programme, HES Extractions Data 2011-20120

Figure 6: Hospital admissions - proportion of hospital admissions for simple tooth extraction in children and young people by age group, England and Blackpool: 2019/20

Extraction proportions 2019

 
 Source: Public Health England, Dental Public Health Intelligence Programme, HES Extractions Data 2013/14-2017/18

Dental health data for adults is unavailable at a local level but information from the Adult Dental Health Survey 2009 showed 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 Patient Survey asks about patients' experiences of local NHS services and feedback about NHS dental services in Blackpool (July 2019) showed that:

    • 8% of Blackpool residents reported no longer having any natural teeth, this compares with the national average of 5%.
    • 90% reported that they were successful in getting an NHS dental appointment
    • 83% stated that their overall experience of NHS dental services was very good or fairly good. 9% reported it to be poor or very poor.
    • 5% think NHS dental care is too expensive.

Risk factors

Risk factors for oral diseases include: poor diet, tobacco, alcohol, poor oral hygiene, lifestyle and, as with all non-communicable chronic diseases, there are 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 decay6. 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 2019 shows that 16% of primary pupils drink fizzy drinks 'on most days'.

National and local guidance

PHE, Delivering better oral health (June 2014, updated 4th edition 2021) is an evidence based toolkit to support dental teams in improving their patients' 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.                

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:

    • 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 daily7. 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, 8

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 decay9. 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).  Approximately 76% (8,400) of the 11,000 children were drinking semi skimmed milk in 2021. Since April 2021, approximately 54% of all school milk ordered is fluoridated milk, meaning approximately 4,500 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 smear of toothpaste, to spit out after brushing and not rinse (this maintains flouride concentration levels)
    • Take children to the dentist when their first milk teeth appear
    • 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 of England, Hospital admissions for 5-9 year olds with tooth decay more than double those for tonsilitis, 19 September 2019. [Accessed 17/11/2021]

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

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

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

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

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