Chapter 5.10: Major public health problems dental health

Scandinavian Journal of Public Health, 2006; 34(Suppl 67): 139 146 Chapter 5.10: Major public health problems dental health AGNETA EKMAN National Board of Health and Welfare, Stockholm, Sweden N Children s and young people s dental health has improved generally since the middle of the 1980s. From around 1996 97, however, the favourable trend has levelled off and among 12-year-olds there is a slight tendency towards a deterioration. N Dental health among children in socioeconomically weak groups is deteriorating. N The regional differences in dental health among children and young people are notable. N Among adults, dental health has improved but the social differences persist. Specially vulnerable groups are people with foreign backgrounds and single women with children. N The proportion of people with only their own natural teeth has increased significantly since the early 1980s. N Among people over 65 years, 20% of men and 26% of women stated that they had no natural teeth. N Fewer and fewer people aged 25 34 have visited a dentist during the past 2 years, particularly men. Every fourth person in this age group claims to have needed dental care without consulting a dentist. N People with foreign backgrounds have visited dentists more seldom than the population in general. Children s and young people s dental health is good but the favourable trend has stagnated The National Board of Health and Welfare has followed the development of children s and young people s dental health since 1985. Between 1985 and 2000, the proportion of caries- free children and adolescents increased continually for the ages reported to the Board by the Public Dental Service [1] (Figure 5:72). However, in 2001 and 2002 for the first time no continued improvement was noted compared to the previous year of this period. Among 12-year-olds there was even a marginal deterioration. This may be interpreted to mean that the continuous improvement in children s dental health in Sweden described since the 1970s has tapered off. Yet an alternative explanation may be that not all children are still examined every year. Instead, the checks for caries-free children have been thinned out so that resources may be concentrated to children with greater need. The WHO study Schoolchildren s Health Behaviour [2] also lends support to a weak tendency towards deterioration in schoolchildren s dental hygiene. In the latest investigation in 2001 02, a certain decrease in the proportion of 11-, 13- and 15-year-olds that regularly brush their teeth was noted, compared with the preceding investigation in 1997. However, 84% of girls and 77% of boys of these ages still brush their teeth at least twice a day. In a European perspective, Swedish children s dental health holds up fairly well, even though 12- year-olds in many other European countries e.g. the Netherlands, Great Britain, Denmark and Switzerland reported somewhat better dental health among 12-year-olds than Sweden in 2000. Regarding teeth-brushing, however only Switzerland has a better situation than Sweden [2]. Correspondence: Agneta Ekman, National Board of Health and Welfare, SE-106 30 Stockholm, Sweden. Tel: +46 8 555 530 00. E-mail: agneta.ekman@soc.lulea.se ISSN 1403-4956 print/issn 1651-1905 online/06/010139-8 # 2006 Taylor & Francis DOI: 10.1080/14034950600677170

140 A. Ekman Dental health has deteriorated among children in socioeconomically weak groups Figure 5:72. Proportion of caries-free children and adolescents at certain ages, as reported by the Public Dental Service, 1985 2002. For 19-year-olds, the values refer to the proportion of young people with caries-free proximal tooth surfaces, i.e. tooth surfaces that are in contact with each other. Information lacking for 1996. Source: National Board of Health and Welfare. Large regional differences in children s dental health There are relatively large regional differences. The mean value for the number of decayed and filled teeth (DFT) varies between 0.5 and 1.6 for 12-yearolds and 2.3 and 4.2 for 19-year-olds (Figure 5:73). In Värmland just over 70% of 12-year-olds were reported to be caries-free in 2002, but only 50% of 12-year-olds in Halland. The variation in dental health is even larger in county comparisons. Several county councils have shown that dental health is poorer in socioeconomically weak areas. Appreciably poorer dental health has been reported among children from socioeconomically weak groups compared with other children [1,3]. According to a study based on the Statistics Sweden Survey of Living Conditions (ULF) from 1996 97, it was 20 50% more common for children from blue-collar workers homes to have caries than for children from white-collar workers homes to do so [3]. This was particularly evident among children of foreign origin. This is probably explained by the fact that many parents born abroad had no experience of caries-prevention during their own childhood in the way that native-born Swedish parents had [4,5]. In many county-council areas, e.g. Stockholm, Skåne and Västra Götaland, preventive efforts have therefore been reinforced in various housing areas with residents of foreign origin, or where people are socially exposed in other respects [1]. New caries index gives a fairer picture of dental health The Significant Caries Index (SiC Index) is a new caries index for children and young people presented by the WHO some years ago. The background to this index was that reporting the mean value was considered to give a false picture of the dental health position since dental health was improving overall and only a diminishing proportion of the population Figure 5:73. Mean values for numbers of decayed and filled teeth (DFT) among 12-year-olds and 19-year-olds* in various counties, according to reports from the Public Dental Service 2002. *Information lacking for 12-year-olds from Uppsala, Jönköping and Jämtland counties and for 19-year-olds from Jönköping and Jämtland counties. Source: National Board of Health and Welfare.

Major PH problems dental health 141 had many decayed and filled teeth. People with much caries damage were thus hidden in the statistics. The National Board of Health and Welfare has for a number of years stressed the importance of following changes in the proportion of the population with many decayed and filled teeth and surfaces. To illustrate whether the dental services have succeeded in reducing tooth decay for the part of the population with most caries, dental health development for 12-year-olds is presented partly through DFT, that is the mean value for the number of decayed, filled teeth and partly through SiC Index, which shows the mean value of DFT of the one-third of the population with the worst dental health (Table 5:17). As mentioned earlier statistics from the past few years indicate a tapering-off between 2001 and 2002 compared with the earlier improvement of dental health among 12-year-olds [1]. The SiC calculations show that caries frequency declined slightly among those with the highest numbers of decayed and filled teeth between 1997 and 2001. By and large, however, the risk group has not changed notably over time. The mean values for the reported measures differ only insignificantly between girls and boys. The WHO goal that the SiC Index for 12-year-olds should be below 3 DFT by 2015 at the latest in all WHO member countries has thus already been achieved in Sweden. Improved dental health among adults It is considerably harder to describe dental health and its development among adults than among children and young people. This is partly because there is little up-to date information at national level and partly because there is no consensus on what measures are suitable. Oral health is not only a product of possible diseases but is also largely an effect of socioeconomic and cultural factors. If dental lesions do not remineralize, dental disease increases with time. A tooth that has been damaged by caries and that has been filled should, for example, be considered as permanently damaged. Table 5:17. Development of dental health among 12-year-olds. Year Mean DFT value SiC 1997 0.98 2.82 2001 0.94 2.62 2002 1.07 2.76 Source: National Board of Health and Welfare. With rising age, large differences in oral health appear between different people. This involves problems in deciding what measurements are relevant, and also how the results from different surveys of adults should be interpreted. Social differences in dental health persist Ever since the dental insurance was introduced, the National Swedish Social Insurance Board has followed the development of its costs and has reported statistics on completed treatment. For the development of dental health, however, information is lacking. Nor is there any compiled information on the oral health of Sweden s population based on clinical investigation. In what follows, dental health is described, instead, using the answers to questions on self-rated dental health obtained via the Surveys of Living Conditions of Statistics Sweden. The Surveys of Living Conditions show that oral health among those who have only their own natural teeth has changed greatly during recent decades. Both caries and tooth loosening (periodontitis) can lead to loss of teeth. Hence, knowledge of the frequency of tooth loss affords important information on which to judge the oral health situation. With more remaining teeth, chewing ability probably also improves. Own natural teeth and toothlessness In the 2002 03 Survey of Living Conditions questions on dental health were asked only of persons aged 55 84 years. The proportion of these people with only their own teeth had increased significantly since 1980 81, when 39% of men and 36% of women exclusively had their own natural teeth. The corresponding proportions in 2002 03 were 68% and 67%, respectively, giving an increase of about 30 percentage units. This means that just under one third in the age group 55 84 have either their own teeth in combination with dentures, or dentures alone. During the period 1980 81 to 2002 03, the largest increase in the prevalence of own-teeth-only was among women aged 65 74 years. The increase was by 36% percentage units, from 30% to 66%. Among men, too, the increase was greatest in the age group 65 74 years. For 2002 03 it is impossible to see any sizeable gender differences in the prevalence of own-teeth-only in the age group 55 84 years. The largest improvement in dental health for ages 55 84 was among women in the group skilled blue-collar workers. Here the proportion with only natural teeth has increased by almost 35 percentage units since 1980 81.

142 A. Ekman General dental insurance and the Dental Services Act When appraising the development of dental health over time, political directives on dental health must be taken into account. This emerges from the Dental Services Act (1985:125) [6], various decisions by the Riksdag on general dental care insurance, and also from political decisions involving alterations to this. Paragraph 2 of the Act states that the goal for dental care is good dental health and dental service on equal terms for the whole population; and the goal of the dental care insurance scheme introduced in Sweden in 1974 was that good, and affordable, dental care should be available to all citizens. The community s commitment to child and youth dental care, which previously offered free dental care up to the age of 16, was extended so that from 1974 dental care has been free for all children and young people up to and including the year of their nineteenth birthday [7]. For adults, the insurance initially covered all types of treatment, and the subsidy comprised all measures. Thanks to investment in preventive care at the same time, the dental health of the Swedish people improved steadily during the decades following the introduction of the dental care insurance. Worsening government finances, however, made it necessary to reduce state support to adult dental care, and dental insurance became increasingly directed towards support for costly treatment for particular groups. The demand for regular, basic dental care hence decreased. At the end of the 1990s some 80% of the funds allocated were spent on 5% of dental care patients [6]. The reformed system of dental care subsidies, which entered into force on 1 January 1999 (government bill 1997/98:112) [8] aimed to provide all adults with improved financial support for basic dental care and better support for certain groups in health care and social services. In addition, a high-cost protection was introduced for those with high treatment costs for prosthetic measures, i.e. crowns, bridges, fixed prostheses and removable dentures. A further change was made in the form of a cost ceiling for prosthetics, to apply from the calendar year of one s 65th birthday (government bill 2001/02:51) [9]. Reimbursement of dental care costs is 100% of the fee over 7,700 SEK, except for the cost of certain materials. However, this change has hardly had time to affect the outcomes reported in this chapter. In a few years we will in all probability see an increase in the prevalence of implant-supported prosthetics (fixed prostheses). On the other hand price increases that have affected patients following the introduction of free pricing in dental care in 1999 have affected visit frequency. They have also contributed somewhat to people not seeking care even though they consider they need it [10,11]. There are still considerable socioeconomic differences in the prevalence of own-teeth-only. Even though the differences during the past 15 years have decreased in favour of blue-collar workers, a considerably higher proportion of white-collar workers at middle and upper levels have only natural teeth. This applies to both sexes. Regarding toothlessness, e.g. total loss of natural teeth, the latest national data for the whole population aged 16 84 is in the Survey of Living Conditions for 1996/97. At that time 5% of men and 7% of women (25 84 years) had no natural teeth. There are no sizeable changes for either sex for the ages up to 64 years between 1980 81 and 1996 97 regarding the lack of one s own teeth. As opposed to this, developments are particularly positive for higher ages (65 84 years), where toothlessness has declined by 28% percentage units, to 20% among men and 26% among women. In the oldest groups (65 74 years and 75 84 years) 17% and 36%, respectively, were completely toothless [12]. The proportion of elderly edentulous people is higher in the north of Sweden than in other parts of Sweden. Regional cross-sectional studies in the counties of Norrbotten in 2001 [13] and Västerbotten in 2002 [14] show, however, that the proportion of people with no natural teeth declined for all age groups during the most recent 10-year period even though toothlessness in these parts of the country is still higher than the national average. In Norrbotten, almost 40% of 75 year olds were without their own teeth in 2001, which is the same proportion as for 65-year-olds in 1991. Toothlessness, however, is still common among 65-year-olds, where 11% in Västerbotten (2002) and 25% in Norrbotten (2001) entirely lacked natural teeth. For the group of 50-year-olds, on the other hand, only just under 1% were toothless in these two counties. If the development continues at the same pace as earlier, it is reckoned that fewer than 1% of the population up to 65 years in both counties will have no natural teeth in 2010.

Major PH problems dental health 143 Figure 5:74. Proportions of men and women aged 55 84 years with exclusively their own natural teeth, 1980 81 to 2002 03. Source: Survey of Living Conditions, Statistics Sweden. Chewing ability The ability to chew, in the sense of being able to chew hard foods such as crisp bread or apples without difficulty, has improved for the whole population. At the beginning of the 1980s one-tenth of the population of both sexes (16 84 years) stated that they had chewing problems. By 1996 97, the proportion of men and women who stated that they had difficulties in chewing hard foods had sunk to 6% and 8%, respectively. A somewhat higher proportion of men than women at that time had exclusively their own natural teeth [12]. In the 2002 03 Survey of Living Conditions only people aged 55 84 years were asked about chewing difficulties. Even though the proportion of men and women with natural teeth only had increased since the 1996 97 survey, both sexes aged 55 64 to a larger extent than formerly reported that they had chewing problems (Figure 5:75). In the oldest age group (75 84), on the other hand, a lower proportion of those asked in the 2002 03 survey judged that they had chewing difficulties than did the proportion in 1996/97 [12]. The largest improvements in chewing ability among men since 1980 81 appeared among unskilled blue-collar workers and among female white-collar workers at middle level. For both genders, white-collar workers at middle and upper levels have the least problems of chewing capacity and blue-collar workers have the greatest problems; but the social differences are not significant. Dental visits during a two-year period The proportion of the adult population who have not visited a dentist for at least two years has declined since the beginning of the 1980s (Figure 5:76). The reduction has been appreciable, primarily in the age groups 55 and older, which probably reflects the fact that increasing numbers still have their own teeth. The largest difference over time in visit frequency is among the very oldest Figure 5:75. Proportions of men and women aged 55 84 years stating impaired chewing capacity, 1980 81 to 2002 03. Source: Survey of Living Conditions, Statistics Sweden.

144 A. Ekman Figure 5:76. Proportions of men and women by age group who had not visited a dentist during the previous two years, 1980 81 to 2002 03. Source: Survey of Living Conditions, Statistics Sweden. (75 84 years). At the beginning of the 1980s, about two-thirds of those asked who were aged 75 84 had not visited a dentist during the previous two years. Since about 60% of this group lacked natural teeth and had removable dentures at that time, they probably less often felt a need for dental care [12]. Thus a positive development can be seen among the elderly, which unfortunately does not apply to people under 35. Almost every third man and every fifth woman aged 25 34 has not visited a dentist during the past two years even though almost every fourth man and woman state that they had needed dental care without seeking it. Our good dental health, which is a result of cause-directed treatment among children and adolescents in the public dental service, thus risks being impaired. It is impossible to state with assurance why the frequency of dental visits has decreased. From the situation some 10 years ago when people commonly visited their dentist every year, visiting frequency has declined in consequence of the fact that it is now more often a person s dental health and need for dental treatment that decide how often one visits dental care. However, this cannot explain the whole difference. A further reason may be the feeling that no treatment is needed since one s teeth are in good condition. In addition, changes in the dental insurance system, especially during recent years, with increased costs to the patient, may be a contributory reason for visiting a dentist less often. Many younger people have, moreover, poorer economies, owing to increased labour-market difficulties. The somewhat reduced demand for dental care reported in a number of studies indicates that people with poorer economies often refrain from visiting a dentist. According to the 1999 survey of households incomes [15] close to 15% (approximately 1 million people) stated that they had abstained from dental care because of the cost. Social differences The socioeconomic groups with the best dental health also visit dental care most frequently. During the whole of the 1980s the proportion of blue-collar workers who had not visited a dentist for at least two years decreased, and the decrease continued, although more slowly, until 1996/97 among both sexes. In the white-collar group no obvious changes occurred among women, the most frequent visitors. Among male white-collar workers at middle and upper levels, i.e. the group with the best dental status, on the other hand, there is a tendency for periods between visits to become longer (Figure 5:77). This means that the social differences regarding dental visits are declining among men. Persons with foreign backgrounds 1 visit dental care more seldom than the population in general; their visiting frequency is largely the same as that of blue-collar workers, and this frequency differs little between the sexes. More than every fifth person with a foreign background, the same for men and for women, also stated that they had needed dental care but had not consulted a dentist. Schooling in the Swedish public health tradition, with preventive

Major PH problems dental health 145 Figure 5:77. Proportions of men and women aged 16 84 years who had not visited a dentist during the previous two years, by socioeconomic group (left) and educational level (right). The figures are given in percentages and the values are age-standardized. Source: Survey of Living Conditions, Statistics Sweden. dental care and regular visits to a dentist, probably takes a long time. This may be one explanation of the differences. Another explanation may be that when one moves to a new country one has other, higher-priority, needs that must be met first before one makes contact with the dental service. Single women with children are the group that since the early 1980s has visited dentists least. In recent years, moreover, the proportion who have not visited a dentist during the past two years has increased. More than every sixth single woman aged 15 65 with children states that she has not visited the dentist for two years or more. It is also the single women with children who to the largest extent do not seek dental care despite a perceived need for care. In spite of generally improved dental health, people with foreign backgrounds and single women with children appear to be the groups that are worse off in terms of dental care. the population. The figure shows what proportions of the population at any given time may be expected to belong to the different generations. In a ten-year perspective, however there should be no large differences in aggregate care needs compared with the present. The various generations in Figure 5:78 may be explained as follows: N The future generation is the one that will have very small needs for care because it has throughout the years had access to regular dental-health promotion and cause-directed care. The future Future needs for dental care The need for dental care in the future may be seen in a fairly short-term perspective and in a fairly long one. Given the shortage of epidemiological material regarding the adult population, the description of future care needs is based on available regional cross-sectional studies and on the Board s follow-up of dental health among children and adolescents since 1985. Figure 5:78 shows schematically how dental health has developed in that the healthier generations the future generation and the fluoride generation represent increasing proportions of Figure 5:78. Schematic presentation of the relationship between dental health in different generations, their proportions of the population in 1990 and a forecast until 2030. Source: Nordic University College of Health Sciences (included in unpublished material on social odontology).

146 A. Ekman generation will gradually represent an increasing part of the population. N In the fluoride generation are those who while growing up were included in the great investment in preventive action based on oral hygiene and fluoride programmes. This generation will have a moderate need for care. N The filling generation consists chiefly of those born in the 1940s and 1950s. These will continue to need relatively extensive care. This applies to both restorative care in the form of fillings, crowns, bridges and dental implants and periodontal care against tooth-loosening conditions. N In the extraction and dentures generation belong older people who to a large extent have removable dentures at present, but also the large proportion of older people who retain more of their own teeth. The need for care is great, and even though this generation represents a small and diminishing proportion of the population, it is here that major care efforts will be needed in the future. Note 1 See appendix 1 for a definition of foreign background. References [1] Tandhälsan hos barn och ungdomar 1985 2002 (Dental health in children and young people). Lägesrapport. Stockholm: Socialstyrelsen; 2003. [2] Svenska skolbarns hälsovanor 2001/02 (Swedish schoolchildren s health habits 2001/02). Rapport 2003:50. Stockholm: Statens folkhälsoinstitut; 2003. [3] Hjern A, Grindefjord M, Sundberg H, Rosén M. Social inequality in oral health and use of dental care in Sweden. Community Dent Oral Epidemiol 2001;29:167 74. [4] Hjern A, Grindefjord M. Dental health and access to dental care for ethnic minorities in Sweden. Ethn Health 2000;5:23 32. [5] Grindefjord M, Dahllöf G, Nilsson B, Modéer T. Stepwise prediction of dental caries in children up to 3.5 years of age. Caries Res 1996;30:256 66. [6] SFS 1985:125. Tandvårdslag; 1985 (The Dental Services Care Act). [7] Tandvården till 2010: Slutbetänkande av utredningen tandvårdsöversyn 2000 (Dental care until 2010: Final report of the dental health survey commission). 2002:53 S. [8] Reformerat tandvårdsstöd. Prop (Reformed dental care support. Govt. Bill). 1997/98:112. [9] Bättre tandvårdsstöd för äldre m.m (Improved dental care support for the elderly, etc. Govt. bill). Prop. 2001/02:51. [10] Tandvården i fyra län: En intervjuundersökning 1999 (Dental care in four counties. An interview survey). Stockholm: Socialstyrelsen; 2000. [11] Utvärdering av det reformerade tandvårdsstödet. Stockholm: Riksförsäkringsverket; Riksförsäkringsverket anser 2000:3 (Evaluation of the reformed dental care support. The Swedishs Social Insurance Administration considers 2000:3). [12] Tandhälsa och tandvårdsutnyttjande 1975 1999. Levnadsförhållanden: Rapport 94. Stockholm (Dental health and dental care consumption). Statistiska centralbyrån (SCB); 2001. [13] EPI-Norr 2001: En tvärsnittsundersökning av vuxna norrbottningars munhälsa (Cross-sectional survey of adult oral health in Norrbotten). Norrbottens läns landsting: Rapport 2004. [14] Tillståndet i mun och käkar bland Västerbottens vuxna befolkning. En epidemiologisk undersökning bland 35-, 50-, 65- och 75-åringar (Oral and maxillary status among adults in Västerbotten. Epidemiological survey among persons aged 35, to, 65 and 75). Västerbottens läns landsting och Umeå universitet: Rapport 2003. [15] Inkomstfördelningsundesökningen (HINK/HEK) (Survey of income distribution). Stockholm: Statistiska centralbyrån (SCB); 1999.