“By creating we think, by living we learn” Patrick Geddes
N.B. Pitts(1), D.J. Evans(2) and Z J Nugent(3)
1 BASCD Dental Epidemiology
Programme Scientific Coordinator, Dental
Health Services Research Unit, University
of Dundee, Dundee, UK;
2 BASCD Dental Epidemiology
Programme Service Coordinator, Newcastle and North Tyneside Health Authority,
Newcastle-upon-Tyne, UK;
3 Statistician/IT Manager, Dental Health Services Research
Unit, University of Dundee,
Dundee, UK
Correspondence to: Professor N B Pitts, Dental Health Services Research Unit, Dental School, Park Place, Dundee, Scotland, DD1 4HR.
Key Words:dental caries, dental epidemiology, caries prevalence, national surveys, oral health
This paper sets out the results of the most recent series of surveys, of 12-year-olds, conducted within the National Health Services (NHS) under the auspices of the British Association for the Study of Community Dentistry (BASCD) Dental Epidemiology Programme during 1996/97. The programme seeks to monitor the dental health of children and contributes to the national monitoring of service provision and targets, while providing data locally to aid in service planning and evaluation of Oral Health Strategies.
The agreed BASCD criteria (Pitts et al., 1997) and conventions set out in the BASCD trainer's pack (Mitropoulos et al,, 1992) were employed. Within each part of the United Kingdom (UK) and within each English "region", a designated NHS epidemiology coordinator was responsible for the local delivery of the programme, assisted by a "regional" trainer who attends the biennial national training and calibration exercise. Representative samples were drawn from participating health authorities and boards according to the agreed BASCD guidelines (Pine et al , 1997). Results for this survey are reported according to the current NHS organisational boundaries.
Dental caries was diagnosed at the caries into dentine (D3) threshold using a visual method without radiography, fibre-optic transillumination, or compressed air. As the D3 diagnostic threshold excludes all enamel and precavitation lesions, it will produce lower estimates of caries experience than are found in situations when enamel lesions can also be scored, using the D1 threshold (Pitts and Fyffe, 1988), or when diagnostic aids are used. The results in the abstract and tables therefore use the D3MFT nomenclature but, for brevity, DMFT has been used in the text.
A total of 129,941 twelve-year-old children from across the United Kingdom (UK) and the Isle of Man were examined, some 14% less than in the 1992/93 Great Britain survey (Pitts & Palmer, 1994). On average this represents 20 per cent of the total population of this age group, although in the different areas there was a wide range in the size of samples chosen according to local needs and practices. Table 1 shows total populations and samples, results for DMFT and its components, sealed teeth, the percentage of and mean disease experience for children with DMFT > 0 and DT > 0, and values for care index percentage (FT/DMFT x 100) for every participating Health District or Board, and for the current "regions"; (of the National Health Service in England) and countries.
The results demonstrated a wide variation in prevalence across the UK, with mean values for DMFT for regions and countries ranging from 0.66 in Thames - South to 2.55 in Northern Ireland (NI). The mean value for DMFT across the United Kingdom was 1.13 (DT=0.48, MT=0.10, FT=0.54). The variation in mean disease levels within regions and countries was also marked.
Overall, the extremes for District/Board mean DMFT values ranged between 0.51 for Warwickshire and 3.28 for Northern Health Board NI. The corresponding values for DT ranged from 0.10 in Solihull to 1.61 for Northern Health Board NI, while for MT they ranged from 0.01 in East Kent to 0.29 for Northern Health Board NI. Although a mean of 44 per cent of 12-year-old children in the UK had evidence of dentinal caries experience (DMFT> 0), the regional / country means ranged between 31 per cent (Thames - South) and 72 per cent (Northern Ireland). The (UK) mean DMFT for those with disease at the dentinal threshold was more than double the overall mean at 2.55.
The overall number of filled teeth remains very low (UK mean FT=0.54) and there were low proportions of restored dentinal caries in areas with higher or lower disease levels. The UK mean care index was 48 per cent with a regional/country range from 42-63 per cent. In individual Districts and Boards the range of care index was from 76 per cent in Sandwell to 27 per cent in Southampton & South West Hampshire.
The geographical variation of caries experience is highlighted in map form in Figure 1. The lower levels of mean caries prevalence (DMFT < 1.0) were mainly in the south, the west, and the midlands, whilst the rest of England, Wales, and the Isle of Man had mean DMFT levels between 1.01 and 1.50. Higher levels were seen in areas of Scotland and in Northern Ireland.
Figure 2 presents the mean DMFT information as a bar chart; this shows an overall ranking of the regions and countries including the 95 per cent confidence intervals. The bar chart reveals that the UK can be seen as comprising three broad groupings, the 6 "southern" areas with mean DMFT values less than 1.0, Wales and the two more northerly English areas (together with the Isle of Man) with mean DMFT between 1.0 and 1.5, and Northern Ireland and areas of Scotland with higher mean values of DMFT.
Figure 3 shows a comparison of the mean DMFT results (and components) from 1996/97 with those from the 1992/93 surveys using the original NHS boundaries in place in 1992/93, with Northern Ireland and the Isle of Man included for the first time for this age group.
Results of the survey are also available (down to the District/Board level) on the BASCD web-page and, in England, they will also be on the Public Health Common data set (see Oral Health Indicators). Comparative data from earlier surveys are available in tabular form (Nugent and Pitts, 1997). Note that for this survey values reported from Trent (only) for mean DT and per cent DT>0 are the result of computations based on mean overall values and may be subject to rounding errors; some data collected in Trent is not reported here as it was subject to non-standard criteria.
Although there is an increasing focus on local and regional variations in dental health, the bar chart in Figure 2 should not be seen, or used, as a simple league table; as small differences between means which do not exceed the 95 per cent confidence intervals should not be given undue weight and intra-regional variation is considerable. These 1996/97 results can be compared with those of earlier BASCD coordinated surveys of 12-year-olds conducted in 1992/93 (Pitts and Palmer, 1994) and 1988/89 (Evans and Dowell, 1990). Trends over time demonstrate an improvement of 15 per cent in overall DMFT for Great Britain since 1992/93, compared to the 20 per cent seen over the previous four year period.
The care index (FT/DMFT x 100%) reflects the restorative care of those who have suffered disease, it therefore has to be viewed in conjunction with DMFT. These results are of interest in studying the provision of dental services to this age group. The data in Table 1 shows the wide variations in the care index. The overall level is disturbingly low with just 48 per cent of the dentinal caries in permanent teeth being restored across the UK which compares with the (still low) figure of 59 per cent found in the teeth of UK 14 year-old children in 1994/95 (Pitts and Evans, 1996).
There is marked variation in the percentage of children with at least one pit and fissure sealant, with a tendency for low use in low caries areas. The mean percentage values of England (26) and Wales (28) were significantly below those seen for Northern Ireland (47) and Scotland which , once again, had the highest level of sealant use (54).
Taken overall with an apparent slow down in improvements combined with static levels in the mean numbers of Decayed and Missing teeth, these findings demonstrate the continuing need for more effective preventive strategies and treatment services for this important age group. As the condition of the permanent teeth at age 12 years will, to a large extent, determine the future dental health of emerging population cohorts of young adults, there is thus a continuing need for the monitoring of trends at both the local and national levels. This is also required to establish whether Oral Health Strategy targets can be met.
The authors are indebted to all of the very large number of people who contribute to the BASCD coordinated NHS Dental Epidemiology Programme. Particular thanks are due to, Dr Cynthia Pine and Mr Phillip Jenkins (BASCD R&D;Associates), to the regional NHS Epidemiology Coordinators and Trainers, and to staff of the Dental Health Services Research Unit for their help. Professor Pitts acknowledges support from the Chief Scientist Office of the Scottish Office Department of Health. The views expressed are those of the authors and not necessarily those of the Scottish Office or Health Departments.
Evans, D.J. and Dowell, T.B. (1990): The dental caries experience of 12-year-old children in Great Britain. A survey coordinated by the British Association for the Study of Community Dentistry in 1988-89. Community Dental Health 7, 307-314.
Mitropoulos, C., Pitts, N.B. and Deery, C. (1992): British Association for the Study of Community Dentistry BASCD trainer's Pack for caries prevalence studies 1992/93. Dundee: University of Dundee.
Nugent, Z.J. and Pitts, N.B. (1997): Patterns of change and results overview 1985/6-1995/6 from the British Association for the study of Community Dentistry (BASCD) co-ordinated National Health Service surveys of caries prevalence: Community Dental Health 14, (Suppl 1) 30-54.
Pine, C., Pitts, N.B., and Nugent, Z.J. (1997): British Association for the study of Community Dentistry (BASCD) guidance on sampling for surveys of child dental health. A BASCD coordinated dental epidemiology programme quality standard. Community Dental Health 14, (Suppl 1) 10-17.
Pitts, N.B. and Evans, D.J. (1996): The dental caries experience of 14-year-old children in the United Kingdom. Surveys coordinated by the British Association for the Study of Community Dentistry in 1994/1995. Community Dental Health 13, 51-58.
Pitts, N. B. and Fyffe H. E. (1988): The effect of varying diagnostic thresholds upon clinical caries data for a low prevalence group. J Dental Research 67, 592-96.
Pitts, N.B. and Palmer, J. (1994): The dental caries experience of 5-, 12-, and 14-year-old children in Great Britain. Surveys coordinated by the British Association for the Study of Community Dentistry in 1991/92, 1992/93, and 1990-91. Community Dental Health 11, 42-52.
Pitts, N.B., Evans, D.J., and Pine, C. (1997): British Association for the study of Community Dentistry (BASCD) diagnostic criteria for caries prevalence surveys - 1996/97. Community Dental Health 14, (Suppl 1) 6-9.
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