The Queen Mary Cavity Free Incremental Children s Programme

Transcription

1 The Queen Mary Cavity Free Incremental Children s Programme Programme Overview Oral diseases are preventable and treatable, yet national oral health surveys clearly show that children s oral health is still a significant public health problem in the UK. Almost a third (30.9%) of five year old children had experienced dental decay in 2007/2008 while 27.5% of five year olds had untreated decayed primary teeth (1, 2). Only 18% of five year olds with decay had had their teeth filled (1). Similarly, 33.9% of 12 year old children in the UK in 2008/09 had at least one decayed or filled permanent tooth or a permanent tooth extracted because of dental decay (3). Less than 50% (47%) of 12 year olds had had their decayed permanent filled. Untreated decay is the main cause of toothache and significantly affects children s ability to sleep, eat, and speak (4). Preventing dental decay and improving the quality of oral health care for children in the UK should be a commissioning priority in line with the recently published White Paper Healthy Lives, Healthy People: Our Strategy for Public Health in England (5). This paper underscored the Government s renewed commitment to oral disease prevention and evidence based oral health care specifically focused on children s oral health (5). Developing an effective oral health strategy that includes early preventive interventions and evidence based treatment modalities will have long term benefits for children reducing the need for future costly and more extensive dental treatment as children age through the life course from childhood to adulthood. There is a clear need for change. A dental public health approach is required to address the key issues related to the low uptake of preventive services and the inadequate provision of cost effective high quality dental treatment for children in the UK. Hence, we propose a new programme The Queen Mary Cavity Free Incremental Children s Programme. This school and practice based partnership will provide high quality dental care including the assessment of risk, appropriate evidence based treatment modalities, preventive dental services tailored to the risk level of each child and 1

2 continuing care with evaluated quality assurance. In addition, it will encourage pupil s family practice link. It will incorporate evidence based treatment and preventive services including the Atraumatic Restorative Treatment (ART), fissure sealants, topical fluorides varnish, and oral health education as recommended by the Department of Health, Delivering Better Oral Health: An evidence based toolkit for prevention (6). This incremental programme will target Year 2 children in the first year and include an additional new cohort every subsequent year (Figure 1). It uses an incremental approach that will avoid the high cost of attempting to treat the whole school child population with high levels of untreated decay immediately. Instead, it will distribute the total cost of treatment in year cohorts, treating only the 6 7 year old children cohort in the first year, adding additional cohorts of the same age in subsequent years. Adopting an early intervention strategy to identify children at risk when the first permanent molar teeth erupt will prevent dental decay, or arrest/treat decay in its earliest stages. This highly cost effective approach will follow up each cohort to monitor their risk level (Table 1), ensure continuity of care, and dramatically reduce the likelihood that children will have large cavities in their permanent teeth, which are costly to treat. Therefore, this programme will ultimately allow PCTs to use cost effective, long term cost saving, and continuing care based on preventive and less destructive treatment approaches that will preserve healthy tooth tissue, increasing the likelihood that people keep their teeth for life (7). Figure 1: Schematic representation of the Queen Mary Cavity Free Incremental Children s Programme Year 2 Children (6 to 7 years) Year 2 Children (6 to 7 years) Year 2 Children (6 to 7 years) Year 3 Children (7 to 8 years) Year 3 Children (7 to 8 years) Year 4 Children (8 to 9 years) 2

3 School dental screenings will first categorize Year 2 children into three risk groups, which will determine the core services prescribed for each child. All children will receive tailor made health care depending on their risk. All children will receive health education irrespective of their disease risk. If resources permit, moderate and high risk children will receive additional core evidence based preventive dental services namely fissure sealants, and fluoride varnish applications. Alternatively, only high risk children will receive these preventive services. High risk children will have decay in at least one of their first molars (Table 1), and will receive ART. The ART is a minimally invasive approach used to treat open cavities involving dentine in primary and permanent molar teeth. The ART uses hand instruments rather than mechanical drills to remove dental decay from open cavities, which avoids the need for local anaesthesia (reducing dental anxiety and pain (8, 9), expensive equipment and designated dental clinics (10). Cavities are then restored with Glass Ionomer Cement (GIC), a filling material that adheres to tooth tissue and releases fluorides into the tooth (7). The adhesive restorative material also seals the remaining pits and fissures at risk of decay. This early intervention can successfully arrest decay in children. The ART has a strong evidence base supporting its effectiveness for restoring small cavities in permanent (adult) teeth (8, 10, 11). Systematic reviews have demonstrated the long term benefits of ART, reporting no difference between the long term survival of conventional amalgam restorations and GIC restorations over a two year period (12 15). Four randomized control trials showed that ART GIC restorations had higher success rates than amalgam restorations (12). A South African study reported a 17.4% reduction in permanent teeth extractions resulting from ART over a one year period. We can anticipate significantly larger impacts and absolute reductions in extraction and cavity rates among UK children who have greater access to dental care and lower decay experience. The ART approach also reduces the overall cost of dental treatment because of the lower equipment and operational costs for ART compared to traditional restorative treatment (16). Topical fluoride varnish applications and fissure sealants applied to first permanent molars will adhere to the Department of Health s preventive toolkit recommendations and national clinical guidelines (6, 17). Topical fluoride varnish prevents dental decay by optimizing fluoride exposure which makes tooth surfaces more resistant to acid attack (2) Systematic reviews show that twice yearly 3

4 applications of 2.2% fluoride varnish applied to early decay tooth surfaces reduce decay by up to a third (18 20). The Department of Health preventive toolkit (6) supports the evidence base by recommending that children identified as high risk (Moderate/high risk Table 1) receive three applications of fluoride varnish (2.2%) annually. The occlusal (biting) surfaces of permanent teeth are the most susceptible sites for decay confirmed in the UK Children s Dental Health Survey in 2003 (21, 22). Fissure sealants help to prevent decay by sealing these deep fissures molar teeth with a plastic resin coating. Systematic reviews show that children who have had their molar teeth covered with a resin based fissure sealant are less likely to suffer from dental decay in their molar teeth than children without sealants (23, 24). The long term effectiveness of fissure sealants has been demonstrated by caries reduction rates ranging from 86% at 12 months to 57% at 48 to 54 months (23). The Department of Health prevention toolkit (6) recommends that children at risk of developing decay in their permanent teeth should have fissure sealants placed on all susceptible teeth and sites. 4

5 References 1. NHS Dental Epidemiology Programme For England. Oral Health Survey Of 5 Year Old Children 2007/ Health Development Agency. The Scientific Basis Of Dental Health Education: A Policy Document. Part 2. Fourth Edition Edition. London, Rooney E, Davies G, Neville J, M R, Perkins C, Bellis MA. Nhs Dental Epidemiology Programme For England Oral Health Survey Of 12 Year Old Children 2008/2009., Shepherd MA, Nadanovsky P, Sheiham A. The Prevalence And Impact Of Dental Pain In 8 Year Old School Children In Harrow, England. British Dental Journal 1999;187: Sumbler R. Healthy Lives, Healthy People: Our Strategy For Public Health In England. London: HMSO, Department Of Health Baftsocd. Delivering Better Oral Health: An Evidence Based Toolkit For Prevention. London, Mickenautsch S. An Introduction To Minimum Intervention Dentistry. Singapore Dent J 2005;27: Mandari GJ, Truin GJ, Vanâ T Hof MA, Frencken JE. Effectiveness Of Three Minimal Intervention Approaches For Managing Dental Caries: Survival Of Restorations After 2 Years. Caries Research 2001;35: Frencken JE, Leal SC. The Correct Use Of The Art Approach. Journal Of Applied Oral Science 2010;18: Frencken JE, Pilot T, Songpaisan Y, Phantumvanit P. Atraumatic Restorative Treatment (Art): Rationale, Technique, And Development. Journal Of Public Health Dentistry 1996;56: Van 'T Hof M, Frencken J, Van Palenstein Helderman W, Holmgren C. The Atraumatic Restorative Treatment (Art) Approach For Managing Dental Caries: A Meta Analysis. Int Dent J 2006;56: Mickenautsch S, Yengopal V, Banerjee A. Atraumatic Restorative Treatment Versus Amalgam Restoration Longevity: A Systematic Review. Clinical Oral Investigations Frencken J, Van 'T Hof M, Van Amerongen W, Holmgren C. Effectiveness Of Single Surface Art Restorations In The Permanent Dentition: A Meta Analysis. J Dent Res 2004;83: Frencken JE, Taifour D, Van T Hof MA. Survival Of Art And Amalgam Restorations In Permanent Teeth Of Children After 6.3 Years. Journal Of Dental Research 2006;85: Mickenautsch S, Yengopal V, Banerjee A. Atraumatic Restorative Treatment Versus Amalgam Restoration Longevity: A Systematic Review. Clin Oral Investig 2010;14: Mickenautsch S, Munshi I, Grossman E. Comparative Cost Of Art And Conventional Treatment Within A Dental School Clinic. SADJ 2002;57: Smallridge J. Guideline For The Use Of Fissure Sealants Including Management Of The Stained Fissure In First Permanent Molars. Int J Paediatr Dent 2010;20 Suppl 1: Faculty Of Dental Surgery Of The Royal College Of Surgeons Of England. Faculty Of Dental Surgery National Clinical Guidelines. London, Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride Mouthrinses For Preventing Dental Caries In Children And Adolescents. Cochrane Database Syst Rev 2003: CD Marinho VC. Cochrane Reviews Of Randomized Trials Of Fluoride Therapies For Preventing Dental Caries. European Archives Of Paediatric Dentistry: Official Journal Of The European Academy Of Paediatric Dentistry 2009;10: Batchelor P, Sheiham A. Grouping Of Tooth Surfaces By Susceptibility To Caries: A Study In 5 16 Year Old Children. BMC Oral Health 2004;4: Office For National Statistics. Children's Dental Health In The United Kingdom, London: National Statistics, Ahovuo Saloranta A, Hiiri A, Nordblad A, Mäkelä M, Worthington H. Pit And Fissure Sealants For Preventing Dental Decay In The Permanent Teeth Of Children And Adolescents. Cochrane Database Syst Rev 2008: CD

6 24. Office For National Statistics SSD. Adult Dental Health Survey, 1998 [Computer File]. Colchester, Essex: UK Data Archive, American Academy of Pediatric Dentistry, Policy on Use of a Caries Risk Assessment Tool (CAT) for Infants, Children, and Adolescents

7 Table 1: Revised Individual Caries Risk Assessment used for School Dental Screenings Low Risk Moderate Risk High Risk Clinical Conditions No caries (dmft 0) Caries-free first permanent molars at 6 to 8 years No enamel demineralisation No plaque No gingivitis dmft = 1-4 Caries-free first permanent molars at 6 to 8 years One area of enamel demineralization Caries white spot lesions Some plaque but no visible plaque on anterior front teeth Gingivitis dmft 5 Caries in the first permanent molars More than one area of enamel demineralization Enamel caries, white spot lesions Visible plaque on anterior front teeth Wearing fixed orthodontic appliances Enamel hypoplasia Environmental Characteristics Optimally fluoridated water Regular brushing twice daily with fluoridated toothpaste Consumption of sugary intakes primarily at mealtimes Mother s education: higher degree School located in first IMD quintile neighbourhood (least deprived) Good dental attendance pattern Suboptimal fluoridated water with optimal topical exposure (e.g. regular brushing twice daily with fluoridated toothpaste) Occasional (1-2) sugary intakes between-meal exposures Mother s education: tertiary School located in 2 nd or 3 rd IMD quintile neighbourhood Irregular dental attendance Suboptimal topical fluoride exposure (e.g. 2/day toothbrushing with fluoridated toothpaste No fluoridated water supply 3 sugary intakes between-meals Mother s education: secondary school only School located in 4th or 5 th IMD quintile neighbourhood (most deprived) Poor dental attendance Active caries present in the mother General Health Conditions Children with special needs Based on the American Academy of Pediatric Dentistry guidelines and the Faculty of Dental Surgery of the Royal College of Surgeons of England, Faculty of Dental Surgery National Clinical Guidelines (25). 7