Introduction. Need in the population current and future

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1 Oral health in children and young people in Buckinghamshire Key contacts/author: Jenny Oliver, Consultant in Dental Public Health, NHS Commissioning Board Introduction The most significant oral disease for children and young people is dental caries (tooth decay). This chapter describes trends in decay over time, the prevalence of tooth decay in children in Buckinghamshire and associated inequalities. It also describes how we can tackle this disease at a population level. At a societal level the financial and opportunity costs of treating oral diseases are significant. For individual children tooth decay can cause both psychological and physical impacts including sleep deprivation, reduced growth, pain and low selfesteem. Many children are free from tooth decay but for those who have it have a substantial amount. Much disease goes untreated. More can be done to prevent disease at an early stage through increasing fluoride delivery to children and young people (e.g. through toothpaste or varnish schemes) and tackling the risk factors that are common to both oral and other chronic diseases, e.g. poor diet and tobacco use. The proportion of children accessing NHS dentists is relatively low compared to the England average. Children with low socioeconomic status are significantly more likely to have poor oral health and less likely to access NHS dental services. More can be done to increase uptake of care and prevent dental decay. Tackling these issues alongside the wider determinants of health has the potential to improve the oral health of the children and young people in Buckinghamshire. Need in the population current and future Tooth decay is an important public health problem for children and young people, the costs of which are significant nearly 3 billion is spent annually on NHS dental treatment in England i. The bulk of this treatment is likely to be as a consequence of tooth decay as a child or young adult. At the level of the individual child tooth decay can cause pain, disfigurement, infections, poor dietary intake, sleep deprivation, days off school and reduced nutritional intake and growth ii. Psychological impacts can also be significant the embarrassment of having broken teeth can have a negative effect on self-esteem and social confidence iii. Tooth decay, like many chronic diseases, exists throughout all social groups but follows a social gradient. This means that children from lower socioeconomic groups tend to have poorest oral health and poorest access to oral health care services iv, v. While there are no significant differences in the incidence of decay in children by gender, decay incidence does increase with age. Data on ethnicity and tooth decay are not routinely collected; however there is some evidence that children from a South Asian background are more likely to have dental caries vi.

2 The risk of experiencing dental decay is increased by certain behaviours, particularly frequent sugar consumption, poor oral hygiene and low use of dental services. Tackling lifestyle risk factors alongside wider determinants of health, such as living conditions, will have greater impact than focusing on lifestyle factors alone, as these determinants are likely to be the main causes of poor oral health vii viii. The most valuable data on oral health comes from regular, nationally co-ordinated surveys of five-year-olds in schools. This group is surveyed every other year and, by convention, results are used as a proxy for the dental health of the whole PCT population. A key measure in oral health is the average number of teeth that are decayed, missing or filled (dmft). The prevalence of dental caries in young children has decreased substantially in the UK over the past 40 years. Trends suggest, however, that disease levels are now static. Decay levels amongst children and young people in Buckinghamshire are relatively low the most recent survey in 2007/08 found that 26% of five year olds in Buckinghamshire had experience of dental decay, compared with 31% in England ix. The population average number of decayed, missing and filled in children in Buckinghamshire is less than one decayed tooth per child and less than the national average of 1.1. The population average, however, masks the true picture, as the children of Buckinghamshire do not equally share dental decay. A minority of children carries the full burden of disease, with between three and four decayed teeth each, as shown in Figure 1. Figure 1: Comparison of mean number of decayed, missing and filled teeth (dmft) and mean dmft in those with decay experience in five-year-olds in Buckinghamshire and England, 2007/08 Source: NHS Dental Epidemiology Programme for England Oral Health Survey of 5-yearolds 2007/08

3 Figure 2: Comparison of dental caries experience in five-year-olds in England and Buckinghamshire, 2007/08 Source: NHS Dental Epidemiology Programme for England Oral Health Survey of 5-yearolds 2007/08 Figure 2 shows that the bulk of decay ( decayed section) is untreated at five years old, a finding consistently found in regional and national surveys. This suggests that young children are not accessing care or are accessing care but not receiving treatment. Where the latter is occurring this has important implications for commissioners. In light of the current economic climate, and the strong association between dental decay and deprivation, it is likely that there will be increased numbers of children and young people suffering from dental disease in the future. This will increase the need for oral health prevention and treatment services. Evidence of what works/good practice The national guidance document Choosing Better Oral Health x emphasises the need to reduce the prevalence of oral diseases and address inequalities by addressing the underlying social, economic and environmental determinants of oral health. It advocates developing locally sensitive interventions that address local needs and priorities through joint working between health professionals and local communities. It also recommends improving oral health alongside general health through the Common Risk Factor Approach to tackle the risk factors common to a number of chronic diseases, e.g. poor diet, smoking, poor hygiene. Areas for action include: Increasing use of fluoride, e.g. through toothpaste or varnish schemes Improving diet and reduce sugar intake Encouraging preventive dental care Reducing smoking Increasing early detection of mouth cancer Reducing dental injuries

4 Fluoride is important in the prevention of tooth decay. It has a number of delivery methods, but fluoride toothpaste and varnish are the most appropriate at a local level. Fluoride works by strengthening teeth and reducing their susceptibility to breakdown through acid attack from the bacteria in plaque xi. Not all of the above can be delivered by generic health promotion interventions. These should be supplemented with specific, community-based, oral health promotion activities that deliver fluoride, promote healthy environments (such as playgrounds designed to limit injury from falls, schools with healthy eating policies), signpost to services and encourage preventive care. This should be further supported at a dental practice level by implementing the prevention in practice guidance document Delivering Better Oral Health xii. Current services in relation to need NHS Buckinghamshire commissions a variety of services that relate to oral health. These are summarised below. General dental services: provide the bulk of NHS dental care. There are 80 high street dental practices in Buckinghamshire offering NHS treatment. Salaried or Community dental service: provides dental care (including sedation) to people who find it difficult to access it from a general dental practice, e.g. people with learning difficulties and those with complex medical conditions. Oral health promotion services: work with a range of organisations and groups within Buckinghamshire to improving the oral health of the population and promote access to services. Specialist dental services: specialist care is available through local and regional acute trusts as well as locally through specialist practices. Buckinghamshire has eight orthodontic practices and is in the process of commissioning a local specialist NHS Restorative service. Availability of NHS dental care is relatively good in Buckinghamshire. However, child attendance is low in comparison national levels at around 62%. xiii Figure 3: Child patients seen by NHS dentist as a percentage of the child population Dec 09 -Mar 12 Source: NHS Information Centre 2012

5 For affluent groups low uptake of NHS dental services is likely to be due to the use of private dental services (no data available), however for more deprived groups this is unlikely to be the case. There are no demographic data on who accesses local dental services. The GP Patient Survey asks a number of questions on experience of NHS Dentistry. Results of the recent GP Patient Survey suggest that 95% of Buckinghamshire respondents who tried to get an appointment in the last three months were successful (the England average is 96%). 19% of those who didn t access care over the past two years report they didn t think they could get an NHS dentist. In terms of satisfaction with services 82% reported their overall experience was good or fairly good xiv. Unmet needs and service gaps Access to NHS dental care for children in a number of deprived wards is low. There is still a misconception amongst a minority that NHS dental services are not available in Buckinghamshire. There is no routine delivery of fluoride (without charge to user) at a community level. Oral health is not fully integrated into relevant generic health promotion interventions and strategies, e.g. on alcohol, tobacco, healthy eating, in all health and non-health care settings that have a remit for young children. Recommendations for consideration by commissioners Promote access to NHS dental services for children in low socioeconomic groups. Increase proportion of childcare workers trained in oral health and the proportion of childcare settings accredited with an oral health award. Work with dental practices to increase provision of fluoride. Integrate oral health into strategies and interventions that tackle common risk factors, such as healthy eating, tobacco use and alcohol use. Fluoride delivery at a community level, e.g. through toothpaste or varnish schemes. i ii iii iv v Department of Health Dental and Eye Care Services (2012). NHS dental contract pilots - Early findings. London: Department of Health. Acs G, Lodolini G, Kaminski S, Cisneros G.J. (1992) Effect of nursing caries on body weight in a paediatric population. Paediatric Dentistry, 14(5), Seremidi, K., Koletsi-Kounari, H., Kandilorou, H. (2009). Self-reported and clinically diagnosed dental needs: determining the factors that affect subjective assessment. Oral Health and Preventative Dentistry, 7(2), Watt, R.G. (2012). Social determinants of oral health inequalities: implications for action. Community Dentistry and Oral Epidemiology, 40(2), Office for National Statistics (2004). Impact of Oral Health: Children s Dental Health in the United Kingdom London: Office of National Statistics

6 vi vii viii ix x xi xii xiii xiv Dugmore, C. R. and Rock, W. P. (2005). The effect of socio-economic status and ethnicity on the comparative oral health of Asian and White Caucasian 12-year-old children. Community Dental Health, 22 (3), Marmot M.G. and Bell R. (2011). Social determinants and dental health. Advances in Dental Research, 23(2), Peres, M.A., Latorre, M.R.D.O., Sheiham, A., Peres, K.G., Barros, F.C., Hernandez, P.G., Maas, A.M.N., Romano, A.R., Victoria, C.G. (2005) Social and biological early life influences on severity of dental caries in children aged 6 years. Community Dentistry and Oral Epidemiology, 33(1), The Dental Observatory. NHS Dental Epidemiology Programme for England (NHSDEP). The Dental Observatory Available at: [Accessed 22 nd October 2012] Department of Health (2007). Choosing Better Oral Health: An Oral Health Plan for England. London: Department of Health Ten Cate, J.M., Featherstone, J.D. (1991) Mechanistic aspects of the interactions between fluoride and dental enamel. Critical Reviews in Oral Biology and Medicine. 2(3), Department of Health and British Association for the Study of Community Dentistry. (2009) Delivering Better Oral Health: An evidence-based toolkit for prevention. Second edition. London: Department of Health NHS Information Centre. Primary care. NHS Information Centre. Available at: [Accessed 23 rd October 2012] Department of Health. GP Patient Survey Dental Statistics; January to March 2012, England. Department of Health. 14 June Available at: [Accessed 23 rd October 2012]