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Reports and abstracts of articles originally published in Community Dental Health

Published in: Community Dental Health volume 16 March 1997

BASCD Survey report

The dental caries experience of 5-year-old children in the United Kingdom. Surveys co-ordinated by the British Association for the Study of Community Dentistry in 1997/1998

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 Hospital & School, Park Place, Dundee, Scotland, DD1 4HR.

Key Words: dental caries, dental epidemiology, caries prevalence, national surveys, oral health

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Introduction

This paper sets out the results of the most recent series of surveys, of 5-year-old children, 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 1997/98. 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 the evaluation of local oral health strategy targets.

Method

The agreed BASCD criteria (Pitts et al, 1997) and conventions set out in the BASCD trainers' pack (Mitropoulos et al, 1992) were employed. Within each part of the United Kingdom (UK) and within each former 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).

Dental caries was diagnosed at the caries into dentine (d3) threshold using a visual method without radiography, fibre-optic transillumination, or compressed air. Since this excludes all enamel and precavitation lesions, it will produce lower estimates of caries experience than are found when enamel lesions can also be scored (d1) (Pitts and Fyffe, 1988), or when diagnostic aids are used. For brevity, dmft has been used in the main text to indicate the dentine threshold.

Results

A total of 176,781 five-year-old children from across the UK were examined, some 2% more than in the 1995/96 survey(Pitts & Evans, 1997). On average this represents 25% 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, the percentage of children with dmft>0 and dt >0, and values for the care index percentage (ft/dmft x 100 per cent) for the current NHS regions in England and for every participating health district or board in the remainder of the UK. In two regions there were problems in obtaining the full data set. The mean dt for dt>0 was calculated from whole-sample data, incurring possible rounding errors for Rotherham and Nottingham (Trent) and Berkshire, Buckinghamshire, Northamptonshire and Oxfordshire (Anglia and Oxford). In these Anglia and Oxford authorities, dmft for dmft>0 was also calculated.

The results demonstrated a wide variation in prevalence across the UK, with mean values for dmft for regions and countries ranging from 1.02 in the West Midlands to 2.92 in Northern Ireland (NI). The mean value for dmft across the United Kingdom was 1.68 (dt=1.18, mt=0.26, ft=0.23). The variation in mean disease levels within regions and countries was also marked.

Overall, the extremes for district/board mean dmft values ranged between 0.59 for Solihull and 3.69 for Western Isles, Scotland. The corresponding values for dt ranged from 0.34 in Solihull to 2.87 in Western Isles, Scotland, while for mt they ranged from 0.05 in Suffolk to 0.77 in Greater Glasgow. Although a mean of 43 % of 5-year-old children in the UK had evidence of dentinal caries experience (dmft>0), the regional / country means ranged between 33 % (West Midlands) and 63 % (Northern Ireland).

The overall number of filled teeth remains very low (UK mean ft=0.23). The UK mean care index was 14 % with a wide regional/country range from 9-23 %. In individual districts and boards the range of care index was from 42 % in North and East Herts to 5 % in Western Health Board NI.

The geographical variation of caries experience is highlighted in map form in Figure 1. The lower levels of mean caries prevalence (dmft < 1.5) were towards the south and west of England. Northern and Yorkshire (and the Isle of Man) had mean values of 1.51-2.00, whilst the North West and Wales had mean dmft levels between 2.01 and 2.50. Mean levels between 2.51 and 3.00 were seen in Scotland and Northern Ireland.

Figure 2 presents the mean dmft information as a bar chart; this shows a ranking of the regions and countries including the 95 % confidence intervals. This demonstrates once again that the lowest mean values were found in the fluoridated West Midlands. The bar chart reveals that the UK can be seen as comprising three broad groupings, the 6 "southern" areas with mean dmft values of between 1.0 and 1.4, Wales and the two more northerly English areas (together with the Isle of Man) with mean dmft between 1.9 and 2.5, and Scotland and Northern Ireland with means of around 2.8.

Figure 3 shows a comparison of the mean dmft results (and components) from 1997/98 with those from the 1995/96 survey. Note that the rank ordering of areas has changed in the two year period, that the degrees of improvements vary, that Wales exceptionally has seen an increase in mean dmft.

Figure 4 shows a similar presentation of the care index values for each region/territory for the 1997/98 and 1995/96 surveys ordered according to mean dmft in 1997/98. This reveals that mean care index values have increased in all areas except South West.

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Figure 2 Dental caries experience (d3mft and 95% confidence intervals) of 5-year-old children in the current English regions, Scotland, Wales, and Northern Ireland. BASCD co-ordinated NHS Dental Epidemiology Programme survey of 5-year-old children - 1997/1998.

Figure 3 Comparison of dental caries experience (d3mft and components) of 5-year-old children in the English regions, Scotland, and Wales in 1997/1998 and 1995/1996, BASCD co-ordinated NHS Dental Epidemiology Programme surveys of 5-year-old children.

Figure 4 Comparison of care index (per cent) of 5-year-old children in the English regions, Scotland, and Wales in 1997/1998 and 1995/1996, ordered according to mean caries experience in 1997/1998., BASCD co-ordinated NHS Dental Epidemiology Programme surveys of 5-year-old children.

Discussion

The results of this year's surveys have been produced according to the current NHS boundaries in England. Results and detailed retrospective comparisons of summary information from earlier studies over a ten year period can be found in a supplement to Community Dental Health (Nugent & Pitts, 1997). District/board results are also available on the BASCD World Wide Web page (accessed through http://www.dundee.ac.uk/dhsru/) and, in England, through the Public Health Common data set - Oral Health Indicators.

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". Small differences between means which do not exceed the 95 % confidence intervals should not be given undue weight. When comparing these 1997/98 results with those of earlier BASCD co-ordinated surveys of 5-year-old children conducted in 1995/96 (Pitts and Evans, op.cit.), 1993/94 (Pitts and Palmer, 1995), 1991/92 (Pitts and Palmer, 1994), and 1989/90 (Evans and Dowell, 1991), it is evident that the marked geographic variation seen previously is still evident.

It is particularly important to assess the trends in prevalence in this age group as these data allow an estimation of present caries attack, unmasked by any previous history of operative intervention or past disease activity. Trends over time demonstrate a modest improvement of 8.7 % in overall dmft for Great Britain since 1995/96, compared to the improvement of 6.7 % seen previously. A direct comparison of the 1995/96 results with those of earlier BASCD reports of the biennial surveys of 5-year-old children conducted since 1985/86 is possible for 157 districts and boards (Nugent and Pitts, op. cit.). Over recent years the overall trend in this age group seems to be one of modest improvement following a long plateau. The proportion affected by dentinal decay also seems to have fallen (UK mean from 39.7 % in 1995/96 to 37.4% in 1997/98). There have also been some changes in the components of the dmft index, both dt and mt have fallen while ft has remained unchanged.

The care index reflects the restorative care of those who have suffered disease and has increased since the last survey of this age group in all but one region/territory. This indicator has not, however, regained the levels seen in the past from early national surveys of child dental health. The data in Table 1 and Figure 4 shows the wide variations in the care index across the UK which appears to be independent of mean caries prevalence. The magnitude of the care index should be viewed in conjunction with dmft. For the current survey it would appear that the combination reflects an improvement in care delivery in an improving environment of oral health. It is important, however, to remember the skewed nature of the disease in the population; the UK mean dmft for those with caries experience (dmft>0) was 3.94 as opposed to the overall mean of 1.68.

These findings show that there has been some improvement in the dental health of five-year-old children; that, overall, the provision of operative care for those with dentinal decay has also improved; but that significant groups remain within the population at this age who have dental disease and who are in need of dental care. There is thus a continuing need for more effective preventive and treatment services for the important pre-five age group.

Appendix 1 sets out a number of examples of how the results of the BASCD co-ordinated NHS surveys have been used within the National Health Service.

Acknowledgements

The authors are indebted to the very large number of people who contribute to the BASCD co-ordinated NHS Dental Epidemiology Programme. Particular thanks are due to: Dr Cynthia Pine and Mr Phillip Jenkins (BASCD R&D Associates), the "regional" NHS Epidemiology co-ordinators and trainers and to staff of the Dental Health Services Research Unit, Dundee for all their help. Professor Pitts acknowledges support from the Chief Scientist Office of the Scottish Office Department of Health and the Medical Research Council's Health Services Research Collaboration. The views expressed are those of the authors and not necessarily those of the Scottish Office or the MRC.

References

Evans, D.J. and Dowell, T.B. (1991): The dental caries experience of 5-year-old children in Great Britain. A survey co-ordinated by the British Association for the Study of Community Dentistry in 1989-90. Community Dental Health 8, 185-194.

Mitropoulos, C., Pitts, N.B., and Deery, C. (1992): British Association for the Study of Community Dentistry criteria for the standardised assessment of dental health (1992/93) In: 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 1985/1986-1995/1996 from the British Association for the Study of Community Dentistry (BASCD) co-ordinated National Health Service surveys of caries prevalence. Community Dental Health 14, (Supplement 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 co-ordinated dental epidemiology programme quality standard. Community Dental Health 14, (Supplement 1) 10-17.

Pitts, N.B. and Evans, (1997) The dental caries experience of 5-year-old children in the United Kingdom. Surveys co-ordinated by the British Association for the Study of Community Dentistry in 1995/1996. Community Dental Health, 14, 47-52.

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 - 1996/1997. Community Dental Health 14, (Supplement 1) 6-9.

Pitts, N.B. and Fyffe, H.E. (1988) The effect of varying diagnostic thresholds upon clinical caries data for a low prevalence group.J. Dent. Res. 67, 592-596.

Pitts, N.B. and Palmer, J. (1994): The dental caries experience of 5-, 12- and 14-year-old children in Great Britain. Surveys co-ordinated 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. and Palmer, J. (1995): The dental caries experience of 5-year-old children in Great Britain. Surveys co-ordinated by the British Association for the Study of Community Dentistry in 1993/94. Community Dental Health 12, 52-58.

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Appendix 1

Examples of the use of BASCD co-ordinated epidemiology data within the United Kingdom reported in a questionnaire survey September 1997.

1. Monitoring trends in dental caries experience at national, regional, health authority / board level and in some cases at locality level: especially in one area following the cessation of fluoridation.
2. Setting baselines for objectives and support for allocation of resources, oral health promotion, and service planning.
3. Baseline information for the development of research and development bids.
4. Supporting decision making processes in health authority / boards or trusts.
5. Targeting of resources in terms of manpower and finance.
6. Development of Oral Health Strategies and Annual Public Health reports.
7. Raising the profile of dental diseases within health authority / boards or trusts as well as with general medical and dental practitioners, community health councils, and the media.
8. Extensively used in the public consultation process for new fluoridation schemes in many areas.
9. Providing regular information to schools on the status of the dental health of children. A regular publication is sent to schools in the North West Region providing information after each survey.
10. Providing a widely accessible presentation of the survey results to NHS staff and researchers via the World Wide Web (5089 "hits" between January to November 1998, of which 766 were identifiable as from the UK, 777 from the rest of the world, and 3546 were untraceable).