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Oral Health

Introduction

The level of dental decay in five-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. In the Public Health Outcomes Framework, one of the indicators is the dental decay level in children aged five years (PHE, 2014).

Since 1973, a survey has been carried out every ten years into the dental health of 5, 8, 12 and 15 year old children in England, Wales, and Northern Ireland. The most recent survey (2013) was published in March 2015 by the Health and Social Care Information Centre.

The Public Health England Dental Public Health Intelligence Programme supports the collection of reliable information on oral health needs in local populations. They undertake a rolling programme of surveys into the dental health of specific age groups/populations. They are currently planning on conducting a survey of older people. Older people in Reading will be offered the opportunity to take part in the latest survey. Previous surveys have looked at children attending special schools (2013/14), three year olds (2013) five year olds (2011/12) and 12 year olds (2008/09). (Public Health England).

Facts, Figures, Trends

The World Health Organisation (WHO, 2012) estimates that globally, 60-90% of children and nearly 100% of adults have suffered from dental decay. As part of a series on national epidemiological surveys, Public Health England has recently published the findings of the latest 5 year-old children dental survey. The surveys assess a sample of children by counting the number of teeth they have which are decayed, missing, or filled (DMF). The tables below summarises some key points from the survey:

Tables 1 and 2: Results of dental survey of 5 year-olds 2012

Region

Population (5 years)

Drawn Sample

Percentage Examined

England

635,925

204,640

65.2%

Reading

1,965

466

59.9%

Region

Percentage of children who had experienced tooth decay

Average number of DMF teeth per child in the whole

sample

Average no. of DMF teeth per child in sample of patients with tooth decay

England

27.9%

0.94

3.38

Reading

36.6%

1.43

3.90

Source:  Public Health England

The results reinforce the early presentation of health inequalities. By 5 years of age, children are assessed as having more DMF teeth on average in Reading than in England as a whole. The data also highlights the variation in the distribution of DMF teeth. While the average number of affected teeth for Reading 5-year-olds is 1.43, for those with DMF teeth, the average number of teeth affected is almost 4. Data is available for other age groups and, whilst somewhat of historical importance, all reinforce the inequalities described previously.

Table 3 below brings together survey findings for the other age groups (as well as 5 year olds) comparing Reading against England averages. The data clearly demonstrates that the number of decayed, missing or filled teeth is worse than the England average at all 3 age stages. It is particularly worse at 3 and 5 years of age.

Table 3: Results of dental survey for 3, 5 and 12 year old children

Upper Tier LA Name

Population

Examined

Mean DMFT

 

3 years of age (2013 survey)

England

665744

53814

0.36

Reading

2350

307

0.74

 

5 years of age (2012 survey)

England

635925

133516

0.94

Reading

1965

279

1.43

 

12 years of age (2009 survey)

England

608460

89442

0.74

Reading

1440

329

0.81

Improvement of oral hygiene, particularly for the very young in Reading, should be a serious consideration to help give local young people the best start in life. The chart below at Figure 1 helps to reinforce this information showing again that Reading is worse than the England averages across the age groups.

Figure 1: Results of dental survey for 3, 5 and 12 year old children

image1

Source: Public Health England.

The mean number of decayed, missing or filled teeth (DMFT) for five year olds attending special schools in the Thames Valley was 1.24 compared to 0.88 in England; for 12 years old attending special schools in mean number of DMFT in the Thames Valley was 0.57 compare to 0.69 in England. Numbers are too small for reliable analysis at a local authority level.

Figure 2 below shows the number of children with 2 or more DMF teeth as a percentage of the surveyed sample by Berkshire electoral ward. In the present survey sample, 273 children in Berkshire had two or more DMF teeth. 183 (67%) of these had teeth that had no indication of any care intervention.

Figure 2: Percentage of children with 2 or more DMF teeth

Percentage of children with 2 or more DMF teeth
Percentage of children with 2 or more DMF teeth

Source:  Public Health England.

Figure 3: Decayed teeth by local authority of school 2012

Decayed teeth by local authority of school 2012
Decayed teeth by local authority of school 2012

Source: Public Health England

Figure 3 above shows the percentage of the overall DMF total that was formed by the decayed component by Local Authority. The overall majority of disease experience was untreated at the time of the survey and while variation between the LAs exists, the confidence intervals would suggest that it is not statistically significant.

Identifying children in which 100% of the DMF total was formed by the decayed (D) component alone helps provide an insight into possible barriers to accessing care.

The map in Figure 4 below shows this analysis for children who had a DMF total of two or more. Again, while variation exists, the small sample size means that any interpretations need to be treated with caution. Nevertheless, there would appear to be pockets where children appear not to be accessing care and work is needed to understand why.

Figure 4: Percentage of children sampled with a DMF-T score of 2 or more in which the total score was decay alone.

Percentage of children sampled with a DMF-T score of 2 or more
Percentage of children sampled with a DMF-T score of 2 or more

Source: Public Health England

Dental services have the key role in managing disease once it has occurred. The data below provide details of NHS service usage. The data show the number of patients who have attended for an NHS dental inspection in Reading broken down into age bands for 2008 and 2013.

Table 3: NHS dental service usage 2008 and 2013

 

March 2008

March 2013

Patient Age Group

Current Patients (no.)

Percentage of population

Current Patients (no.)

Percentage of population

0-2

654

10%

905

11%

3-5

2,805

53%

3,890

58%

6-12

8,596

78%

9,875

85%

13-17

6,087

74%

6,258

78%

18-24

5,352

25%

6,109

30%

25-34

9,836

33%

12,358

43%

35-44

9,194

41%

10,714

47%

45-54

5,807

35%

8,179

43%

55-64

4,183

33%

5,288

41%

65-74

3,095

35%

4,030

41%

75+

2,391

27%

3,138

34%

Total

58,000

38%

70,744

45%

Source: NHS Business Service Authority Information Services

While overall there has been an increase in uptake, the data highlights the considerable variation in the percentage of uptake within the age groups. Up to the age of 2, service uptake is very low, possibly with parents perceiving that there are few if any benefits of taking their child to a dental practice before teeth have erupted. For the early teens, both parents and children are concerned about the development of their teeth, especially whether they need orthodontic treatment as the secondary (adult) dentition replaces the primary (baby) teeth.

The drop in uptake in early adulthood corresponds with the introduction of patient co- payments and for the elderly factors influencing service usage include perceived need, many of the elderly having none of their own teeth, and again, co-payments.

A growing oral health problem is oral cancer. The lifetime risk of developing oral cancer and pharyngeal cancer in Europeans is estimated at 1.85% for men and 0.37% for women, with 250 new cases in the Thames Valley per year and 38 new cases per year across Reading, West Berkshire and Wokingham. Although the number of cases appears slow, the prognosis is generally poor. The five-year survival rate for oral cancer is lower than for other more common cancers, for example cervical, breast or prostate cancers.

Factors associated with an increased risk of oral cancer include: smoking, marijuana usage, alcohol consumption, betel quid chewing, poor diet, human papilloma virus (HPV) and poor oral health. The changing epidemiology, particularly the earlier presentation of the condition is thought primarily to be due to sexually practices but the long-term factors, especially the use of tobacco and alcohol remain central.

As highlighted previously, the growing size of the elderly population have increasing dental need. Previous success in care arrangements has allowed this subgroup to retain more of their own teeth and for longer. Many of the teeth are heavily restored and the care needed to address any problems arising is complicated by other factors including patient co-morbidities, not least those individuals suffering from dementia.

A recently published report (Fatania et al., 2013) on a pilot study exploring dental care in care homes across Berkshire highlighted a number of issues. Care home staff reported that with other work pressures, oral health was not a priority and reinforced that patients with dementia were particularly challenging. With an ageing population, the number of elderly patients in care and nursing homes is on the rise.

Programmes are being developed to help support dental personnel to provide care, for example dealing with issues of consent and complex medical histories. There is also an appreciation of the potential role of a wider audience can play in helping promote the contribution that good oral health can make and which recognises the multi-disciplinary nature of care. This would include helping care home staff to support the delivery of care and to increase their confidence when assisting with oral hygiene.

National & Local Strategies (Current best practices)

There are numerous policy documents that have guided the development of arrangements to improve oral health at a national level. These include those associated with the determinants and those affecting care service delivery. Examples include the document 'Delivering Better Oral Health. An evidence-based toolkit for prevention' (Department of Health, 2014) aimed at ensuring that the dental profession were aware of current best practice, and programmes aimed at improving access to services.

More recently NICE have published guidance on how Local Authorities can best use address oral health 'Oral health: Local authorities and partners' (NICE, 2014) which makes recommendations on undertaking oral health needs assessments, developing a local strategy on oral health and delivering community-based interventions and activities.

Locally, the former Berkshire Primary Care Trusts have developed the provision of care aimed at improving access by commissioning increased services and supporting the development of specific oral health promotion schemes such as the 'Brushing for Life' programme currently operating in Reading, Slough and West of Berkshire Local Authority areas.

What is this telling us?

Although oral health has improved over the past five years there remain disparities within the population. Reading local authority has levels of decay that are higher than the average for England.

A significant number of very young children are experiencing difficulties arising from poor oral health that indicate a need to improve efforts aimed at reducing the factors influencing disease and its sequela in children and supporting parents in a targeted manner.

The increasing prevalence of HPV is leading to an increase in the number of oral cancers diagnosed. Working with young people and informing them of oral cancer as well as all of the other risks of contracting a sexually transmitted disease may help to reduce these figures.

Regarding oral cancer, patients may present to their GPs with symptoms. Increasing the training for general practitioners in the early recognition of oral cancer and urgent referral to dental services may be crucial in improving patient's prognoses which means working with the Health Education England. This work stresses the importance of building close collaborative working between health care professions.

The problems of poor oral health are growing within the elderly population. Educating and supporting all care workers about the role of good oral hygiene and how good oral health can contribute to the qualities of life as well will be essential in maintaining physical as well as mental health in these patients.

What are the key inequalities?

While overall, oral health has seen significantly improvements in England over the last few decades, marked inequalities persist. Globally, nationally and locally, there is substantial evidence highlighting that people in the poorer and more deprived areas suffer worse oral health when compared to those living in more affluent areas.

The problems of inequalities in disease experience are further compounded by the inequalities in service uptake; those with greater clinical need tend to use services less. These issues arise for a number of reasons including:

  • Variation in perceived importance of good oral hygiene
  • Low education and literacy levels
  • Cultural differences and language barriers
  • Financial restrictions
  • Fear
  • Low awareness of the risk factors for oral diseases

Priority group who are most likely to experience poor oral health and who are most likely to benefit from preventive interventions are:

  • Early years and parents
  • Vulnerable adults
  • Older people
  • Prisoners
  • Adults with learning difficulties

What are the unmet needs/service gaps?

The current unmet needs are as follows:

  1. The prevalence of children with dental decay highlights that oral health issues have already arisen at 5 years of age. The 'Brushing for Life' programme in place in Reading is designed to help address this and lead to improvements in both overall levels of oral health and reduce inequalities. This programme could also be linked into programmes aimed at helping increase attendance for care.
  2. The growing oral health needs of the elderly population will require appropriate solutions. Work needs to be undertaken to help quantify the needs of this growing section of the population. While currently all new entrants to a care or nursing home have a medical assessment, dental assessments are not included.
  3. The changing epidemiology of oral cancer, and the growing evidence of an association with HPV exposure, suggests that good opportunities would arise through collaboration with the Sexual Health team. Work is also required to understand how patients with the oral health problems are initially accessing primary care services

This section links to the following sections in the JSNA:

Obesity - adult & child

Smoking

Cancer

Sexual Health

General Wellbeing

References

Fatania et al. (2013)

National Institute of Health and Care Excellence (2014). Oral health: local authorities and partners (PH55). [Online]. Available at: https://www.nice.org.uk/guidance/ph55

Public Health England (2014). Delivering Better Oral Health. An evidence-based toolkit for prevention (3rd edition) [Online]. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/367563/DBOHv32014OCTMainDocument_3.pdf

Public Health England (2014). Dental Health Profiles: Reading [Online]. 

World Health Organisation (2012). Fact sheet No.318: Oral Health [Online]. Available at: http://www.who.int/mediacentre/factsheets/fs318/en/

Public Health England (2015). An evaluation of to date of the Brushing for Life programmes operating within Berkshire local authorities. Copy available from: Reading Public Health Team.

Public Health England (2016) Dental Health Intelligence Programme [Online]. Available at: http://www.nwph.net/dentalhealth/

     

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