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Reports and abstracts of articles originally published in Community Dental Health

Published in: Community Dental Health volume 20 March 2003

BASCD Survey Report

The Dental Caries Experience of 5-year-old Children in England and Wales in 2001/2002.

Surveys co-ordinated by the British Association for the Study of Dentistry in 2001/2002.

Pitts NB(1), Boyles J(2), Nugent ZJ(1), Thomas N(3) and Pine CM(4)
1 Dental Health Services Research Unit, Dundee Dental Hospital and School, Park Place, Dundee DD1 4HR
2 Bristol South & West PCT, King Square House, King Square, Bristol, BS2 EE
3 Rotherham PCT, Bevan House, Oakwood Hall Drive, Rotherham S60 3AQ
4 Department of Clinical Dental Sciences, University of Liverpool Dental Hospital & School, Pembroke Place Liverpool L3 5PS
Contact: ZJ Nugent

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


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 2001 / 2002. 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.


Methods

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 England and Wales, 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, Pitts and Nugent, 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 threshold excludes all enamel and precavitation lesions and diagnostic aids, it will produce lower estimates of caries experience than are found when clinically detectable enamel lesions are scored (d1) (Pitts and Fyffe, 1988), or when diagnostic aids are used.


Results

A total of 171791 five-year-old children from England, Wales, Isle of Man and Jersey were examined, some 11% less than in the 1999/2000 survey (Pitts, Evans and Nugent, 2001). On average this represents 29% 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 d3mft and its components, the percentage of children with d3mft>0 and d3t >0, and values for the care index percentage (ft/dmft x 100 per cent) for the current NHS regions and Strategic Health Authorities (SHA) in England and for health district in Wales.

The results demonstrated a wide variation in prevalence across England and Wales, with mean values for d3mft for regions and countries ranging from 0.75 in Jersey and 0.84 in Kent & Medway to 2.73 in Gwent and 2.47 in Greater Manchester. The mean value for dmft in England and Wales was 1.52 (d3t=1.11, mt=0.20, ft=0.20). The variation in mean disease levels within regions and countries was also marked.

Overall, the extremes for district/board mean d3mft values ranged between 0.49 in Daventry PCT and 3.87 for Rochdale PCT. The corresponding values for d3t ranged from 0.31 for Daventry PCT to 3.33 for Rochdale PCT, while for mt they ranged from 0.01 in Ipswich PCT to 0.72 in Sheffield North. Although a mean of 40% of 5-year-old children in England and Wales had evidence of dentinal caries experience (dmft>0), the SHA / country means ranged between 23% (Jersey) or 29% (Essex) and 54% (Greater Manchester) or 61% (Gwent). The overall number of filled teeth remains very low (ft=0.20). The mean care index was 13% with a wide regional/country range from 8-29%. In individual districts the range of care index was from 37% in Enfield to 2% in Wyre.

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, although parts of London join the north and west, Wales and the Isle of Man with mean values of greater than 1.5.

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. The bar chart reveals that England and Wales can be seen as a continuum from "southern" areas and the fluoridated Midlands with mean d3mft values of approximately 1.0, through London and the north, to the other extreme in Wales.

Figure 3 shows a comparison of the mean d3mft results (and components) from 2001/2 with those from the previous 1999/2000 survey. Note that the rank ordering of areas has not changed in the two year period, but that the degrees of change vary, that London and North increased slightly while results for South and Midlands and Eastern were virtually unchanged.

Figure 4 shows a similar presentation of the care index values for each area for the 2001/2002 and 1999/2000 surveys ordered according to mean d3mft in 2001/2002. This reveals a wide variation in the amount change but all regions decreasing.

Data from previous years (biennially from 1987 onward) can be roughly assigned to new Strategic Health Authorities in England. Twenty six health authorities have data on d3mft for reports from 1987 to 2001. Data from Kent and Medway and South East London is incomplete. The analysis previously described (Nugent and Pitts 1997) was carried out (Table 2). The dependent variables d3mft, d3t, mt, ft and care index yielded the same pattern with regards the independent variables (SHA and year): both SHAs and years were significantly different for all measures. There is a decrease in dmft, ft and care index but for the latter two, the SHAs are heterogeneous with regards changes. Data for disease frequency for South West Peninsula is incomplete, so only 25 SHAs contributed to the analyses involving frequency. For all these measures, years and SHAs were different. Further analyses were only significant for %dmft>0, which decreased across all SHAs, supporting the previous observation that mean dmft decreased as well.

Figure 5 illustrates the pattern of change for d3t: different between years and SHAs, but no linear trend is evident. In contrast, Figure 6 shows an overall pattern of decreasing care index, although SHAs differ both in their care index and the pattern of change through years.


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 results are also available on the BASCD Web page 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 1999/2000 results with those of earlier BASCD co-ordinated surveys of 5-year-old children conducted in 1999/2000 (Pitts Evans and Nugent op. cit.), 1997/98 (Pitts Evans and Nugent 1999), 1995/96 (Pitts and Evans, 1997), 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 slight increase of 3% in overall d3mft for England and Wales since 1999/2000, compared to the 4% improvement seen for the two previous years. Over recent years the overall trend in this age group seems to be one of modest worsening following a long plateau. The percent affected by dentinal decay (d3t>0) in England and Wales also seems to have risen very slightly (from 34.3% in 1999/2000 to 34.9% in 2001/2002). There have also been some rise in the d3t component of the d3mft index.

The care index reflects the restorative care of those who have suffered disease and has changed very little (14% to 13%) since the last survey of this age group in most areas. This indicator has not 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 study area is negatively correlated with caries prevalence. The magnitude of the care index should be viewed in conjunction with d3mft. For the current survey it would appear that the combination reflects a small worsening in care delivery in an slightly worse environment of oral health. It is important, however, to remember the skewed nature of the disease in the population; the British mean d3mft for those with caries experience (d3mft>0) was 3.83 as opposed to the overall mean of 1.52. At the local level these surveys provide an opportunity to assess the link between material deprivation, ethnicity and oral health (Pine et al., 2003)

These findings show that there has been no overall improvement in the dental health of five-year-old children; that, overall, the provision of operative care for those with dentinal decay has remained almost constant; 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.

When patterns of oral health are examined over 14 years in England, while dmft has improved, the only component that has dropped continuously and significantly is ft (also reflected in the care index). While disease is less common (%d3mft > 0 decreasing) the disease level in those with disease has not decreased consistently.


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 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, the Department of Health, England and the Medical Research Council's Health Services Research Collaboration. The views expressed are those of the authors and not necessarily those of the NHS 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 1985/6-1995/6 from the British Association for the Study of Community Dentistry (BASCD) co-ordinated National Health Service surveys of caries prevalence. Community Dental Health 14 (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.

Pine, C., Burnside, G. and Craven, R.(2003): Inequalities in dental health in the north-west of England Community Dental Health 20, 55-56.

Pitts, N.B. and Evans D.J. (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 Nugent, Z.J. (1999) The dental caries experience of 5-year-old children in the United Kingdom. Surveys coordinated by the British Association for the Study of Community Dentistry in 1997/1998. Community Dental Health 16: 50-56.

Pitts, N.B., Evans D.J. and Nugent, Z.J. (2001) The dental caries experience of 5-year-old children in Great Britain.Surveys coordinated by the British Association for the Study of Community Dentistry in 1999/2000. Community Dental Health 18: 49-55.

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: (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. Journal of Dental Research 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 1991/1992, 1992/1993, and 1990/1991. 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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