Dental Health

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.

Tooth decay can cause problems with eating, sleeping, communication and socialising, and results in at least 60,000 days being missed from school during the year for hospital extractions alone¹. 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 40 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 the Office for Health Improvement and Disparities (OHID)² 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 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%
• 31.2% of Blackpool's 5 year olds were affected by visually obvious dental decay in 2021/22, a decrease from 33.4% in 2018/19 but still significantly higher than the England average of 23.7%
• 18% of Blackpool's 11 year olds were affected by dental decay in 2022/23, slightly higher than the England average of 16%
• The average number of decayed, missing or filled teeth in 5 year olds in Blackpool is 1.15, higher than the national average of 0.84
• 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

• • The average number of decayed, missing or filled teeth in 3 year olds is 0.67, compared to 0.31 nationally.
    

• • While the number of missing or filled teeth in 3 year old children in Blackpool is similar to England, the number of decayed teeth is significantly higher. By age 11 the number of missing and decayed teeth is higher than average while the number of filled teeth is much lower.

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

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 31.2% of 5 year olds with dental decay, Blackpool is in the second highest quintile (top 40%) for this measure, significantly higher than the England average of 23.7%.

Figure 3: The proportion of children aged 5 years old with experience of visually obvious dental decay, Blackpool compared to upper tier local authorities: 2021/22

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 substantial plaque in Blackpool is 3 times higher than the national average - this is indicative of non-brushing
  • Over three times as many children have enamel caries when compared to the national average, 41% compared to 13.6%.
  • 8% have decay affecting the incisors which is linked with long term use of a feeding bottle with drinks containing sugar.
  • 3.5% have oral conditions resulting from untreated caries; visible pulp, ulceration, a fistula or an abscess (PUFA) compared to only 2% 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 (2.7%) is lower than the North West and England averages, 3.8% and 7.4% respectively
  • The Extraction Index (the proportion of those with decayed, missing or filled teeth related to extraction) was 4.3% among 5 year olds in Blackpool in 2021/22, lower than the average for both England (6.4%) and the North West (7.2%)
  • Given that the oral health of children is significantly worse than average, the lower than average Care Index and Extraction Index suggests that children in Blackpool aren't getting the dental treatment they need.

Figure 4: Measures of disease among 5 year olds, Blackpool compared to the North West and England, 2021/22

Figure 5 shows the same measures of dental disease among 11 year old children. Children who experience early childhood caries are much more likely to develop subsequent problems, including an increased risk of further caries in both their primary and permanent teeth.

• • The Care Index gives an indication of the restorative activity of dentists in each area. The proportion of children aged 11 in Blackpool who have had their decay treated by filling (14.6%) is significantly lower than the North West and England averages, 33.6% and 30.1% respectively
  • The Extraction Index was 11.6% among 11 year olds in Blackpool in 2022/23, significantly lower than the average for England (8.3%)
  • 1 in 7 have substantial amounts of plaque and 1 in 20 report pain with their teeth or mouth.

Figure 5: Measures of disease among 11 year olds, Blackpool compared to the North West and England, 2022/23

NHS England provides data on NHS dental activity (private dental services are not included) and shows:

• • 9,579 (32.9%) children aged 0-17 years in Blackpool received NHS dental care in the twelve months 2022/23, significantly fewer than the 46.2% of children seen across England
  • Numbers accessing dental care fell by almost 80% in March 2020 due to the coronavirus pandemic and while numbers are increasing they are not back to pre-pandemic levels
  • A third of Blackpools children were seen by an NHS dentist in 2022/23 compared to almost half across England.

Figure 6: Trend in NHS Dental Activity in Blackpool children aged 0-17 years and proportion seen 2022/23

Source: NHS England, NHS Dental Statistics: 2022-23

Tooth decay was still the most common reason for hospital admission in children aged between 6 and 10 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 OHID shows that in Blackpool:

• • 285 young people aged 0-19 were admitted to hospital for tooth extraction in 2022/23. This is a rate of 920.2 per 100,000 population
  • The hospital admission rate is 2.5 times higher than the national average of 360.4 per 100,000
  • Hospital admissions for extractions fell in 2020/21 due to the coronavirus pandemic but are now increasing again nationally and locally (figure 7)
  • Almost three quarters of Blackpool children admitted to hospital for tooth extraction in 2022/23 were aged under 10 years old (figure 8)
  • Compared to England, more children in Blackpool are admitted at a younger age, 72% are aged under 10 compared to 54% nationally.

Figure 7: Trend in % of population aged 0-19 admitted to hospital for tooth extraction, Blackpool, England and North West

Figure 8: Hospital admissions - proportion of hospital admissions for simple tooth extraction in children and young people by age group, England and Blackpool: 2022/23

Dental health data for adults is unavailable at a local level but information from the Adult Oral Health Survey 2021 showed:

• • Two thirds (66%) of adults reported they had very good or good oral health. Twenty-six per cent reported they had fair oral health and 7% reported they had bad or very bad oral health
  • 95% of adults in England had at least one natural tooth (were dentate). Dentate adults had on average 25.4 natural teeth
  • 77% of adults with natural teeth brushed their teeth at least twice a day, in accordance with the current guidance. More than half of adults (59%) who brushed their teeth used an electric toothbrush
  • Two thirds of adults said they went to the dentist for regular check-ups, 15% went for occasional check-ups and 18% went to the dentist only when they had trouble with their mouth, teeth or dentures
  • A third of adults (33%) said that the cost of dental care had affected the type of dental care or treatment they had received. A quarter (25%) of adults reported they had had to delay dental care or treatment because of the cost
  • Nearly half of all adults (47%) said they had experienced one or more oral health impacts in the previous 12 months. The most commonly reported impacts were being self-conscious, finding it uncomfortable to eat any foods and having had painful aching in their mouth
  • 1 in 5 (21%) adults reported at least one severe oral impact that had affected their daily life in the previous 12 months. Performances that were most likely to be severely impacted were avoiding smiling, laughing and showing teeth without embarrassment and difficulty eating

NHS Dental Activity from NHS England for adults in Blackpool showed:

• • Almost 41,000 adults were seen by an NHS Dentist in the two years to June 2023
  • 37% of adults received NHS dental care in the 24 months to June 2023. This compares to 41% nationally
  • Almost a fifth (19%) of the activity carried out in Blackpool was for Band 3 treatment (complex treatments including crowns, dentures and bridges) and Urgent treatment (to prevent significant deterioration or address severe pain). In comparison only 16% of activity across England was for Band 3 and Urgent treatment.

Local user views

The GP Patient Survey asks about patients' experiences of local NHS services. Feedback about NHS dental services across Lancashire and South Cumbria (March 2023) showed that:

• • 85% of people already registered with an NHS dentist reported that they were successful in getting an NHS dental appointment,
  • Only 31% of people not already registered with an NHS dentist were able to get an NHS Dental appointment, with 49% saying the dentist was not taking on new patients
  • Of patients who have not tried to get an NHS dental appointment, over a fifth thought they couldn’t get one. 29% are seeing a private dentist.

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 2022 shows that 20% of primary pupils drink fizzy drinks 'on most days'.

National and local guidance

NHS England, Our plan to recover and reform NHS dentistry, February 2024, sets out a national programme of actions for the recovery and reform of NHS dentistry services in England.

OHID, Oral health, February 2024, provides information and resources to improve oral health and reduce inequalities in England

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.

PHE's Commissioning better oral health for children and young people (June 2014) provides an evidence-informed toolkit for local authorities.                

NICE guideline [PH55] Oral health: local authorities and partners (Oct 2014) covers improving oral health by developing and implementing a strategy that meets the needs of people in the local community.

NICE quality standard [QS139] Oral health promotion in the community (Dec 2016) covers activities undertaken by local authorities and general dental practices to improve oral health and focuses on people at high risk of poor oral health or who find it difficult to use dental services. 

Blackpool oral health schemes

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 Primary school reception classes, nurseries and child minders
• Milk fluoridation scheme
• Tooth paste and tooth brush distribution
• Dental epidemiology surveys

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 and in 2022 the programme was opened to Reception classes in primary schools.

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 is offered to all children in Years 1-6 in Blackpool Primary Schools. 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
• Brush twice daily with a with any fluoride toothpaste containing 1,350-1,500ppm fluoride
• Brush last thing at night and on one other occasion
• It is good practice to use a smear of toothpaste, to spit out after brushing and not rinse (this maintains flouride concentration levels in the mouth)
• 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 with a fluoride toothpaste containing 1,350-1,500ppm fluoride
  • Brush last thing at night and on one other occasion
  • Use any 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 in the mouth
  • 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 fluoride toothpaste containing 1,350-1,500ppm fluoride
• Brush last thing at night and on one other occasion
• Use any fluoridated toothpaste (1,350-1,500ppm fluoride)
• Spit out after brushing and do not rinse, to maintain fluoride concentration levels in the mouth
• The frequency and amount of sugary food and drinks should be reduced and kept to meal times

[1] OHID, Child oral health: applying All Our Health March 2022

[2] OHID, Oral health, February 2024. Information and resources to improve oral health and reduce inequalities in England

[3] PHE, Inequalities in oral health in England, March 2021 

[4] OHID, Hospital tooth extractions in 0 to 19 year olds 2022, February 2023

[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] NHS Digital, Child Dental Health Survey 2013, England, Wales and Northern Ireland, 2015

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

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