Publications
Scottish Health Boards' Dental Epidemiological Programme (SHBDEP)
Report of the 1994/95 Survey of 14 Year old Children
Prepared by:
NB Pitts, HE Fyffe and Z Nugent
Dental Health Services Research Unit
University of Dundee
Published by University of Dundee
Dental Health Services Research Unit
ISBN 1 899809 07 4
Table of Contents
- Executive Summary [New web page]
- Index to Report
- Appendices [New web page]
- The Programme
- Participating Health Boards
- Co-ordinating Committee
- List of Tables
- List of Figures and Maps
Return to Publications index page.
Index to Report
| 1 | Introduction | |
| 2 | Sampling | |
| 3 | Training and Calibration | |
| 4 | Dental Examinations | |
| 5 | Data Processing | |
| 6 | Results | |
| 6.1 | Dental Caries Results for Scotland | |
| 6.2 | Dental Caries Experience by Health Board | |
| 6.3 | The Proportion With "Caries Experience" in Each Health Board | |
| 6.4 | Teeth and Surfaces | |
| 6.5 | Trends in Caries Prevalence | |
| 6.6 | Skewed Distribution of Disease and Treatment | |
| 6.7 | Sealants / Sealant Restorations | |
| 6.8 | Oral Cleanliness | |
| 6.9 | Assessment of Developmental Defects of Enamel | |
| 6.10 | Assessment of Supra-gingival Calculus and Caries | |
| 7 | Discussion | |
| 7.1 | Dental Caries Results for Scotland | |
| 7.2 | Dental Caries Experience by Health Board | |
| 7.3 | The Proportion With "Caries Experience" in Each Health Board | |
| 7.4 | Teeth and Surfaces | |
| 7.5 | Trends in Caries Prevalence | |
| 7.6 | Skewed Distribution of Disease and Treatment | |
| 7.7 | Sealants / Sealant Restorations | |
| 7.8 | Oral Cleanliness | |
| 7.9 | Assessment of Developmental Defects of Enamel | |
| 7.10 | Assessment of Supra-gingival Calculus and Caries Risk | |
The Programme
This programme of surveys is undertaken under the auspices of the Chief Administrative Dental Officers and Consultants Group (CADOs Group) and is a joint venture between all fifteen Scottish Health Boards and the Chief Scientist Office's Dental Health Services Research Unit based at the University of Dundee.
The results contained in this report have been obtained as a result of the unstinting efforts of a large team of people from all over Scotland to whom the organisers are very grateful. Appendix A lists the participants.
British Association for the Study of Community Dentistry (BASCD) Dental Epidemiology Programme.
Participating Health Boards
- Argyll and Clyde
- Ayrshire and Arran
- Borders
- Dumfries and Galloway
- Fife
- Forth Valley
- Grampian
- Greater Glasgow
- Highland
- Lanarkshire
- Lothian
- Orkney
- Shetland
- Tayside
- Western Isles
Co-ordinating Committee - Dental Epidemiology, Scotland
- Mr TR Watkins (Chairman)
- Professor NB Pitts1,2 (Calibration and Results Co-ordinator)
- Scientific Co-ordinator, BASCD Dental Epidemiology Programme in Scotland.
- Scientific Co-ordinator, BASCD UK Dental Epidemiology Programme.
- Mr MCW Merrett3 (Calibration Course Organiser)
- Service Co-ordinator, BASCD Dental Epidemiology Programme in Scotland.
- Professor KW Stephen (Adviser)
- Miss MM Taylor (Representative of Consultants in Dental Public Health)
List of Tables
| 1 | Number of children examined by Health Board |
| 2 | Results for caries experience for Scotland |
| 3 | Results for caries experience for each Health Board |
| 4 | Skewed distribution of decay |
| 5 | Mean DMFT, Care Index and DMFT for those with "caries experience", by Health Board |
| D1 | Caries data, by surface, for each Health Board |
| D2 | Distribution of decay by tooth surface |
| E1 | Plaque scores for each Health Board |
| F1 | Frequency of demarcated opacities, diffuse opacities and hypoplasias |
| F2 | Frequency of individual SCOTS classifications, by Health Board |
| F3 | Extent and symmetry of developmental defects |
See also List of Tables on Appendices page.
List of Figures
| 1 | Mean number of decayed, missing and filled teeth, by Health Board |
| 2 | The proportion with "caries experience" by Health Board |
| 3 | Distribution of caries experience by tooth |
| 4 | Trends in caries prevalence for Scottish children, 1983-1994 |
| 5 | Trends in the proportion of 14 year old children with "caries experience" and its components, 1990- 1994 |
| 6 | Mean number of decayed, missing and filled teeth, by Health Board for children with "caries experience" |
| 7 | Proportion of children with sealants/sealant restorations, by Health Board |
| C1 | Impact of revised BASCD diagnostic criteria |
| D1 | Distribution of caries experience by tooth surface |
See also List of Figures on Appendices page.
1.Introduction
This Report has been prepared for those interested in the detailed results of the 1994/95 survey. Readers seeking only a brief overview are referred to the Executive Summary. Key results and discussion are included in the body of the Report whilst further results and analyses can be found in the Appendices, printed on blue paper at the end of the Report.
This is the second survey of the dental health of 14 year old children which has been undertaken in the Scottish Health Boards' Dental Epidemiological Programme (SHBDEP) - a programme of annual dental surveys based on the core programme and guidelines provided by the British Association for the Study of Community Dentistry (BASCD) (Palmer et al., 1984; Dowell & Evans, 1988; Pitts, 1993). The programme is organised via the Chief Administrative Dental Officers and Consultants Group (CADOs Group) and the Chief Scientist Office's Dental Health Services Research Unit (DHSRU) at the University of Dundee, and is a joint venture with all fifteen Scottish Health Boards.
Standardised series of surveys are undertaken on randomly selected children from each Health Board using the criteria and timetable for age groups agreed by the British Association for the Study of Community Dentistry. This programme enables individual Health Boards to compare their results with those of Scotland as a whole and with other parts of Great Britain. The major changes in the contractual arrangements governing provision of dental primary care introduced in October 1990, along with the Government's recent statement according priority to children's dental health and declaring an intent to modify the capitation arrangements for children, make the monitoring of levels of dental disease and provision of dental care a necessary and important activity during this time of change (Pitts, 1993).
The aim of this year's survey was to determine current levels of tooth decay (dental caries) in 14 year olds in Scotland. Information was also collected, from this large representative national sample, on: oral cleanliness; developmental defects of enamel; fissure sealants; and for the first time, supra-gingival calculus.
2.Sampling
Scotland has both the largest and smallest Health Board (or equivalent) in Great Britain making standardisation of sampling problematic. Detailed instructions, based on the BASCD guidelines, were sent to all Health Boards to enable each Health Board to identify the number of schools required to obtain the target minimum sample of 250 Secondary III pupils. Lower minimum sample sizes (75-150 depending on population) were required from the smaller Health Boards (the Islands, Borders, Dumfries and Galloway) but they were encouraged to use larger samples, where possible, to ensure reasonable numbers were available for inter-Board comparisons to be made and to meet the BASCD guidelines and SHBDEP Protocol.
3.Training and Calibration
The training and calibration courses for this year's survey of 14 year olds were held in Perth immediately prior to the start of the survey examinations. The courses were organised by Mr MCW Merrett of Tayside Health Board in collaboration with the Dental Health Services Research Unit, who provided the training and calibration elements. Details of the courses can be found in Appendix B which also contains the results of the inter-dentist agreement for dental caries and fillings from the calibration (Table B1).
4.Dental Examinations
The examinations took place between November 1994 and February 1995. This is a slightly longer period than would normally have been covered but was unavoidable due to a nationwide measles vaccination programme taking place during the same months. Table 1 shows the number of children sampled and examined in each Health Board and the proportion of the Secondary III population examined. Overall, 6007 children were examined, representing 9.5% of the Secondary III population. During the course of the survey a random 10% of subjects were re-examined to allow assessment of intra-examiner agreement (see Appendix B, Table B2).
Table 1: Number of children examined by Health Board. Number in sample, number and percentage of population examined and Secondary III population for each Health Board.
| Health Board | Sample | Examined | Examined as % of population | Secondary III population |
|---|---|---|---|---|
| Argyll and Clyde | 571 | 480 | 8.5 | 5633 |
| Ayrshire and Arran | 440 | 350 | 7.0 | 5023 |
| Borders | 278 | 233 | 19.1 | 1222 |
| Dumfries and Galloway | 265 | 217 | 11.9 | 1821 |
| Fife | 466 | 388 | 8.4 | 4602 |
| Forth Valley | 340 | 296 | 8.5 | 3475 |
| Grampian | 481 | 416 | 6.6 | 6332 |
| Greater Glasgow | 990 | 790 | 7.2 | 10908 |
| Highland | 316 | 275 | 9.1 | 3017 |
| Lanarkshire | 1035 | 869 | 10.8 | 8011 |
| Lothian | 611 | 552 | 7.2 | 7654 |
| Orkney | 274 | 252 | 91.0 | 277 |
| Shetland | 365 | 338 | 88.3 | 383 |
| Tayside | 371 | 318 | 6.9 | 4591 |
| Western Isles | 249 | 233 | 60.7 | 384 |
| Totals | 7052 | 6007 | 9.5 | 63333 |
In order to adhere to BASCD guidelines and international epidemiological criteria, figures for decay (D) only record dental decay (caries) which clinically appears to have reached dentine. Less severe manifestations of the disease, such as decay confined to the enamel surface of teeth, are recorded as "sound". As in all such studies no additional diagnostic aids (such as radiographs) were employed.
In the previous survey of 14 year olds only decay which had progressed sufficiently to produce an open cavity into dentine was recorded. Changes in the manifestation of the disease have, however, necessitated a subtle change in the definition of dentinal "decay" for the purposes of the BASCD co- ordinated surveys. The definition used in this survey (introduced by BASCD in 1992) is that: "if, in the opinion of a trained examiner, a surface has decay into dentine (regardless of whether there is a cavity) a surface will be coded as decayed". The impact of this change in criteria, which was also introduced by BASCD to improve comparability of surveys across Great Britain, is examined in Appendix C.
5.Data Processing
The design of the form used for collecting the information from the dental examinations allows for rapid computer entry of the data. Data processing, analysis and reporting was undertaken by the Dental Health Services Research Unit.
6.Results
For ease of reference and to facilitate comparisons with earlier Reports the key results tables and figures relating to dental caries are included in the main text of the Report. Appendix D contains more detailed caries results. All results relate to the permanent dentition only.
Appendixes E, F and G contain, respectively, detailed tables and figures of results relating to oral cleanliness, developmental defects of enamel and supra- gingival calculus.
6.1 Dental Caries Results for Scotland
Table 2 shows overall results for Scotland for the mean number of decayed (D), missing (M) and filled (F) permanent teeth, and information about the presence of fissure sealants and sealant restorations.
Also shown in Table 2 are two ways to group the children with respect to their experience of the disease. The first measure, the proportion of children with "caries experience" (DMFT>0), is given in accordance with BASCD guidelines. Secondly, the results are expressed as the proportion of children with dentinal "decay" (D>0) which demonstrates the proportion of children suffering from untreated dentinal decay at the time of the survey examinations.
Table 2: Results for caries experience for Scotland. Overall caries experience results for Scotland, incorporating the data from the fifteen Scottish Health Boards, appropriately weighted.
| Weighted mean | Range of means for individual Health Boards | |
|---|---|---|
| age (in years) | 14.26 | 14.22 - 14.38 |
| 'sound' teeth (code G) | 20.92 | 17.92 - 22.47 |
| 'sound' plus sealed teeth (codes G, $) | 23.62 | 22.82 - 24.59 |
| sealants and sealant restorations (codes $, N)* | 2.73 | 1.30 - 6.53 |
| decayed teeth (D) | 1.24 | 0.49 - 1.71 |
| missing teeth (M) | 0.28 | 0.09 - 0.39 |
| filled teeth (F) | 1.62 | 0.97 - 2.12 |
| DFT (D+F) | 2.86 | 1.94 - 3.65 |
| DMFT (D + M + F) | 3.14 | 2.14 - 3.96 |
| % | Range for Health Boards | |
| with 'caries experience' DMFT>0 | 73.9 | 62.8 - 81.0 |
| with dentinal 'decay' DT>0 | 46.6. | 21.7 - 60.8 |
| % of children with 1 or more sealant/sealant restoration* | 67.1 | 42.3 - 83.1 |
| *Teeth with N or $, otherwise sound. Note: Decay is recorded at the visual evidence of caries into dentine threshold. | ||
6.2 Dental Caries Experience by Health Board
Table 3 shows the dental caries results for the children in each Health Board. It gives an overall measure of caries experience (DMFT), a breakdown of this index into its component parts (D, M and F) and the percentage of children with "caries experience" (DMFT>0). Also given is a figure for the mean number of fissure sealants per child ($) for each Health Board.
Table 3: Mean values per child for decayed (D), missing (M), filled (F) and sealed ($) teeth; percentage with 'caries exprience' (DMFT>0). [Defined as caries into dentine].
| Health Board | D | M | F | DFT | DMFT | %DFT>0 | $ |
|---|---|---|---|---|---|---|---|
| Argyll and Clyde | 0.86 | 0.27 | 1.61 | 2.48 | 2.75 | 72.3 | 2.54 |
| Ayrshire and Arran | 0.49 | 0.20 | 1.91 | 2.39 | 2.59 | 68.3 | 2.61 |
| Borders | 0.85 | 0.17 | 1.31 | 2.16 | 2.33 | 63.5 | 1.47 |
| Dumfries and Galloway | 1.71 | 0.21 | 1.43 | 3.15 | 3.36 | 77.0 | 1.60 |
| Fife | 1.12 | 0.37 | 1.88 | 3.00 | 3.37 | 75.3 | 3.08 |
| Forth Valley | 0.98 | 0.2 | 0.97 | 1.94 | 2.14 | 62.8 | 3.99 |
| Grampian | 1.40 | 0.26 | 1.56 | 2.96 | 3.22 | 76.0 | 1.26 |
| Greater Glasgow | 1.66 | 0.39 | 1.76 | 3.43 | 3.81 | 79.7 | 2.46 |
| Highland | 1.57 | 0.25 | 1.19 | 2.76 | 3.01 | 75.3 | 3.63 |
| Lanarkshire | 1.53 | 0.32 | 2.12 | 3.65 | 3.96 | 81.0 | 3.26 |
| Lothian | 0.96 | 0.19 | 1.20 | 2.16 | 2.35 | 65.8 | 2.61 |
| Orkney | 0.95 | 0.09 | 1.25 | 2.19 | 2.28 | 71.0 | 2.37 |
| Shetland | 0.52 | 0.12 | 1.93 | 2.45 | 2.57 | 64.2 | 6.51 |
| Tayside | 1.30 | 0.34 | 1.58 | 2.87 | 3.21 | 75.2 | 3.11 |
| Western Isles | 1.61 | 0.35 | 1.90 | 3.51 | 3.86 | 80.3 | 3.53 |
Figure 1 shows the mean DMFT values for each Health Board and the confidence intervals associated with each mean value. The size of the vertical error bars determines the very limited extent to which the figure can be interpreted as a simple "league table". Differences in the means which fall within the limits of neighbouring error bars are not significantly different. The bottom area of Figure 1 indicates (by means of thick horizontal lines) where differences between means for Health Boards are not significantly different from one another. For a number of smaller Boards and where the confidence interval is wide, differences are significant when compared to adjacent values in the Figure but are nor significant when compared to other Boards further away on the bar chart (i.e. for the two cases with thick and thin horizontal lines).
6.3 The proportion with "Caries Experience" in each Health Board
Figure 2 shows the proportion of 14 year olds with "caries experience" (DMFT>0) of the permanent dentition. Overall 74% of the children were found to have already experienced dentinal decay, fillings or extractions necessitated because of decay.
6.4 Teeth and Surfaces
The distribution of caries experience by tooth is shown in Figure 3. It can be seen that the majority of the caries experience (58.2%) has been suffered by the first permanent molars (6s), although a further 19.4% was accounted for by the relatively recently erupted second permanent molars (7s). Appendix D gives the results for each Health Board broken down to tooth surface level. Table D1 gives the number of decayed, missing, filled or fissure sealed surfaces and the number of surfaces with sealant restorations, by Health Board. The distribution of decay by tooth surface (mesial, occlusal, distal, buccal, lingual) is presented in Table D2.
Table D1: Mean number of surfaces decayed (DS), missing (MS), filled (FS), sealed ($S) and with scalant restorations (NS), per child for each Health Board. [D defined as caries into dentine].
| Health Board | Total | DS | MS | FS | DFS | $S | NS |
|---|---|---|---|---|---|---|---|
| Argyll and Clyde | 480 | 1.39 | 1.36 | 2.59 | 3.98 | 2.71 | 0.02 |
| Ayrshire and Arran | 350 | 1.00 | 0.98 | 2.96 | 3.96 | 2.72 | 0.04 |
| Borders | 233 | 1.18 | 0.86 | 2.36 | 3.54 | 1.65 | 0.05 |
| Dumfries and Galloway | 217 | 2.38 | 1.05 | 2.57 | 4.95 | 1.73 | 0.02 |
| Fife | 388 | 1.83 | 1.86 | 3.39 | 5.22 | 3.18 | 0.02 |
| Forth Valley | 296 | 1.56 | 1.00 | 1.59 | 3.15 | 4.22 | 0.07 |
| Grampian | 416 | 2.38 | 1.31 | 2.86 | 5.24 | 1.36 | 0.04 |
| Greater Glasgow | 790 | 3.02 | 1.93 | 3.44 | 6.46 | 2.70 | 0.09 |
| Highland | 275 | 2.48 | 1.25 | 2.33 | 4.80 | 3.94 | 0.05 |
| Lanarkshire | 869 | 2.75 | 1.58 | 4.35 | 7.10 | 3.39 | 0.05 |
| Lothian | 552 | 1.45 | 0.95 | 2.02 | 3.47 | 2.80 | 0.02 |
| Orkney | 252 | 1.28 | 0.44 | 2.01 | 3.29 | 3.64 | 0.02 |
| Shetland | 338 | 1.00 | 0.58 | 3.35 | 4.35 | 7.05 | 0.03 |
| Tayside | 318 | 1.90 | 1.69 | 2.90 | 4.80 | 3.23 | 0.03 |
| Western Isles | 233 | 2.59 | 1.74 | 3.69 | 6.28 | 3.97 | 0.07 |
| Scotland (weighted values) | 6007 | 2.08 | 1.41 | 2.96 | 5.04 | 2.87 | 0.04 |
*4 surfaces are counted for a missing anterior and 5 for a posterior tooth
**Filled surfaces include codes F, N and R
Table D2: Distribution of decay by tooth surface (m=mesial, o-occlusal, d-distal, b=buccal, 1-lingual): total decay (D) and filled (F) as a % of total DFS, by Health Board, [D defined as caries into dentine].
| Health Board | m-D | o-D | d-D | b-D | l-D | m-F | o-F | d-F | b-F | l-F |
|---|---|---|---|---|---|---|---|---|---|---|
| Argyll and Clyde | 7 | 12 | 4 | 6 | 6 | 9 | 36 | 5 | 6 | 8 |
| Ayrshire and Arran | 5 | 8 | 3 | 4 | 5 | 10 | 44 | 6 | 6 | 8 |
| Borders | 5 | 16 | 3 | 5 | 5 | 9 | 32 | 7 | 11 | 8 |
| Dumfries and Galloway | 7 | 25 | 5 | 6 | 5 | 9 | 26 | 5 | 7 | 6 |
| Fife | 6 | 14 | 5 | 4 | 6 | 9 | 32 | 7 | 8 | 9 |
| Forth Valley | 6 | 22 | 6 | 7 | 9 | 6 | 27 | 4 | 8 | 5 |
| Grampian | 7 | 20 | 8 | 4 | 6 | 8 | 27 | 5 | 8 | 7 |
| Greater Glasgow | 8 | 17 | 7 | 7 | 9 | 7 | 26 | 6 | 7 | 7 |
| Highland | 7 | 23 | 5 | 8 | 10 | 7 | 22 | 5 | 7 | 7 |
| Lanarkshire | 6 | 14 | 5 | 6 | 7 | 8 | 28 | 7 | 9 | 9 |
| Lothian | 6 | 19 | 5 | 6 | 6 | 8 | 31 | 6 | 8 | 6 |
| Orkney | 7 | 20 | 3 | 5 | 3 | 7 | 34 | 5 | 9 | 7 |
| Shetland | 4 | 7 | 3 | 4 | 4 | 12 | 38 | 6 | 12 | 9 |
| Tayside | 6 | 17 | 6 | 5 | 5 | 9 | 29 | 6 | 7 | 9 |
| Western Isles | 9 | 15 | 6 | 5 | 6 | 10 | 26 | 6 | 8 | 9 |
| Scotland (weighted values) | 6.4 | 16.6 | 5.4 | 5.6 | 6.8 | 8.2 | 30 | 5.8 | 7.5 | 7.6 |
Figure D1 gives a graphical representation of the decay experience (D and F) by surface. Details of the levels of dental trauma recorded are also contained in Appendix D.
6.5 Trends in Caries Prevalence
Figure 4 shows the trends in caries prevalence between 1983 and 1994 for 5, 12 and 14 year old Scottish children. The overall caries experience (DMFT) of 14 year olds has been decreasing, but, it is apparent that the rate of decrease has slowed down over the more recent 4 year interval. The extra points on the figure are estimates of the predicted values for dft/DMFT had the 1988 diagnostic criteria been employed (see Appendix C).
Overall the mean DMFT has reduced from a value of 3.55 in 1990/91 to 3.14 in this year's survey. However, in assessing changes in the mean DMFT, it is important to investigate the changes happening in the individual components of the index (D, M and F). The mean value for decayed teeth (D) appears to have more than doubled (from 0.59 to 1.24) but the majority of this increase can be explained by the change in the definition of "decay" in the diagnostic criteria. When the criteria change is allowed for, the mean number of decayed teeth per child has hardly changed (0.59 in 1990/91 and estimate of 0.54 in 1994/95). The mean missing component (M) has stayed at around the same level (0.28) whereas the filled component (F), largely unaffected by the change in diagnostic criteria, has dropped 37% from a value of 2.59 in 1990/91 to 1.62 in this year's survey.
Figure 5 depicts the relative changes in the proportion of children with dental caries experience. The proportion with "caries experience" (%DMFT>0) has fallen slightly whilst the proportion of children with filled teeth (%F>0) has dropped by nearly a fifth. The apparent rise in the percentage of children with current decay (%D>0) is largely accounted for by the change in diagnostic criteria (see Appendix C).
6.6 Skewed Distribution of Disease and Treatment
The distribution of dental caries experience is markedly skewed with a minority of unfortunate individuals suffering the majority of disease. Table 4 shows that all the surfaces with dentinal decay were found in 47% of the 14 year olds examined, with 3% of the children having one quarter of the untreated, dentinal decay.
Table 4: Skewed distribution of decay. [D defined as caries into dentine].
3% of population had 26% of decayed (D) surfaces
8% of population had 50% of decayed (D) surfaces
47% of population had 100% of decayed (D) surfaces
Table 5 presents data for the Care Index (CI), the percentage of the DMFT that has been filled (FT/DMFT x 100). The Boards are rank ordered on the basis of ascending DMFT values. It is evident that the prportion of overall caries experience that has been restored is not directly correlated with mean disease level. The overall CI value shows that only 52% of the dentinal caries in permanent teeth had been filled. The table also gives mean DMFT values for those with caries experience (DMFT>0).
Table 5: Mean DMFT, Care Index (CI) and DMFT for those with 'caries experience', by Health Board
| Health Board | DMFT | RANK | CI | RANK | DMFT for those with DFMFT>0 | RANK |
|---|---|---|---|---|---|---|
| Forth Valley | 2.14 | 1 | 45.1 | 13 | 3.41 | 2 |
| Orkney | 2.28 | 2 | 54.6 | 6 | 3.21 | 1 |
| Borders | 2.33 | 3 | 56.3 | 4 | 3.68 | 4 |
| Lothian | 2.35 | 4 | 51.0 | 8 | 3.57 | 3 |
| Shetland | 2.57 | 5 | 75.3 | 1 | 4.00 | 8 |
| Ayrshire and Arran | 2.59 | 6 | 73.6 | 2 | 3.79 | 5 |
| Argyll and Clyde | 2.75 | 7 | 58.8 | 3 | 3.80 | 6 |
| Highland | 3.01 | 8 | 39.4 | 15 | 4.00 | 7 |
| Tayside | 3.21 | 9 | 49.1 | 10 | 4.28 | 10 |
| Grampian | 3.22 | 10 | 48.4 | 11 | 4.24 | 9 |
| Dumfries and Galloway | 3.36 | 11 | 42.7 | 14 | 4.37 | 11 |
| Fife | 3.37 | 12 | 55.8 | 5 | 4.48 | 12 |
| Greater Glasgow | 3.81 | 13 | 46.3 | 12 | 4.78 | 13 |
| Western Isles | 3.86 | 14 | 49.2 | 9 | 4.81 | 14 |
| Lanarkshire | 3.96 | 15 | 53.6 | 7 | 4.89 | 15 |
| Scotland | 3.14 | 51.7 | 4.25 |
*CI = (FT/DMFT)x100
The mean DMFT for those with disease experience, by Health Board, are shown in Figure 6. Health boards are ordered as in Figure 1.
6.7 Sealants / Sealant Restorations
The presence of sealants and sealant restorations was investigated for this sample of 14 year olds. Fissure sealants are a preventive therapy while sealant restorations are a treatment for caries, usually provided when a small area of decayed tooth tissue has been removed and replaced with a filling material prior to the tooth surface being fissure sealed. Sealant restorations are therefore counted in the calculation of the F component of the DMF index.
Figure 7 shows the proportion of 14 year old children in each Health Board with one or more sealant or sealant restorations in the permanent dentition. There is marked variation between the Health Boards, as was observed in the previous survey of 14 year olds, with almost twice as many of the 14 year olds examined in Shetland having a sealant or sealant restoration compared to those in Grampian.
Overall figures (Table 2) indicates that over two- thirds (67.1%) of 14 year olds have had treatment involving fissure sealants or sealant restorations. Table 3 gives the average number of fissure sealed teeth per child by Health Board, and details of sealant and sealant restoration status by surface are provided in Table D1.
6.8 Oral Cleanliness
Oral cleanliness was measured by assessing the presence or absence of plaque at specific sites on each of six teeth (UL6, UR1, UR6, LR6, LL1 and LL6). The results for the plaque scores for each Health Board are given in Appendix E, Table E1.
Table E1: Mean plaque scores and distribution of total plaque scores for each Health Board.
| Health Board | Mean | s.d. | % of children with each total plaque score | Valid cases | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | ||||
| Argyll and Clyde | 0.33 | 0.35 | 39 | 18 | 13 | 9 | 7 | 6 | 8 | 3960 |
| Ayrshire and Arran | 0.3 | 0.35 | 45 | 16 | 7 | 11 | 9 | 3 | 10 | 3000 |
| Borders | 0.24 | 0.32 | 50 | 18 | 10 | 7 | 7 | 3 | 5 | 2140 |
| Dumfries and Galloway | 0.36 | 0.34 | 36 | 12 | 13 | 14 | 12 | 5 | 8 | 1840 |
| Fife | 0.27 | 0.37 | 60 | 9 | 6 | 6 | 6 | 3 | 11 | 3240 |
| Forth Valley | 0.21 | 0.32 | 57 | 15 | 9 | 6 | 3 | 3 | 6 | 2470 |
| Grampian | 0.19 | 0.25 | 54 | 16 | 12 | 10 | 4 | 2 | 1 | 3640 |
| Greater Glasgow | 0.29 | 0.33 | 46 | 15 | 11 | 10 | 8 | 4 | 5 | 6130 |
| Highlands | 0.27 | 0.32 | 42 | 18 | 11 | 10 | 8 | 4 | 7 | 2440 |
| Lanarkshire | 0.23 | 0.28 | 47 | 17 | 16 | 9 | 5 | 5 | 3 | 7030 |
| Lothian | 0.29 | 0.33 | 44 | 15 | 10 | 12 | 8 | 6 | 5 | 4710 |
| Orkney | 0.16 | 0.24 | 56 | 22 | 9 | 5 | 4 | 2 | 2 | 2250 |
| Shetlands | 0.14 | 0.23 | 62 | 15 | 11 | 5 | 2 | 2 | 1 | 3240 |
| Tayside | 0.44 | 0.39 | 32 | 12 | 9 | 8 | 13 | 8 | 18 | 2760 |
| Western Isles | 0.43 | 0.35 | 26 | 17 | 15 | 8 | 12 | 10 | 13 | 1910 |
| Scotland | 0.28 | 0.33 | 46.3 | 15.3 | 10.7 | 9.4 | 7.2 | 4.5 | 6.6 | 5024 |
Notes:
- Each index tooth recorded as 0 (having no plaque, or 1 plaque present
- Mean score = (total for recorded index teeth)(number of index teeth)
- Index teeth UR6, UR1, UL6, LR6, ll1, LL6 - no substitution if index tooth not present
- Percentages may not add up to 100 due to rounding errors
6.9 Assessment of Developmental Defects of Enamel
The presence and extent of developmental defects of enamel was assessed using the same index and criteria as in the 1990/91 survey of 14 year olds (Davies & Pitts, 1991). The SCOTS Index used is described in Appendix F and the results for prevalence, extent and symmetry are given in Tables F1, F2 and F3.
Table F1: Frequency of demarcated opacities, diffuse opacities and hypoplasias on upper incisors of children by Health Board (this is tooth data and scores for all four incisors counted).
| Health Board | % Demarcated Opacities | % Diffuse Opacities | % Hypoplasias | Sample |
|---|---|---|---|---|
| Argyll and Clyde | 10 | 26 | 5 | 468 |
| Ayrshire and Arran | 9 | 16 | 1 | 340 |
| Borders | 12 | 15 | 1 | 227 |
| Dumfries and Galloway | 15 | 18 | 1 | 214 |
| Fife | 8 | 11 | 2 | 382 |
| Forth Valley | 14 | 23 | 9 | 278 |
| Grampian | 16 | 19 | 13 | 404 |
| Greater Glasgow | 13 | 22 | 3 | 759 |
| Highlands | 5 | 20 | 2 | 261 |
| Lanarkshire | 11 | 9 | 1 | 842 |
| Lothian | 13 | 24 | 2 | 528 |
| Orkney | 5 | 12 | 2 | 242 |
| Shetlands | 15 | 12 | 0 | 322 |
| Tayside | 10 | 18 | 2 | 308 |
| Western Isles | 12 | 9 | 3 | 233 |
| Scotland (weighted values) | 11.5 | 18.6 | 3.8 | 5808 |
Table F2: Frequencies of SCOTS classifications by Health Board (each individual is scored for the highest single value (excluding 9) assigned).
| Health Board | % | % Demarcated | % Diffuse | % Hypoplasia | %Demarcated & Diffuse | % Demarcated & Hypoplastic | Diffuse & Hypoplastic | % Demarcated & Diffuse & Hypoplastic | % Other | % Children aware of Defect(s) | Sample | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 0 | 1 | 2 | ( ) | 3 | 4 | 5 | 6 | 8 | 7 | |||
| ARG | 64 | 7 | 22 | 59 | 3 | 2 | - | 2 | - | - | 31 | 468 |
| AYR | 76 | 7 | 16 | 70 | 1 | <1 | - | - | - | - | 28 | 340 |
| BOR | 74 | 10 | 13 | 80 | 1 | 1 | - | <1 | - | - | 27 | 227 |
| DUM | 71 | 11 | 16 | 68 | 1 | 2 | - | - | - | - | 29 | 214 |
| FIF | 81 | 7 | 9 | 81 | 1 | 1 | <1 | <1 | - | - | 42 | 382 |
| FOR | 65 | 8 | 16 | 48 | 5 | 4 | - | 2 | 1 | - | 17 | 278 |
| GRA | 61 | 11 | 14 | 45 | 10 | 2 | <1 | 2 | <1 | - | 23 | 404 |
| GRE | 69 | 7 | 18 | 49 | 2 | 2 | <1 | 1 | <1 | <1 | 33 | 759 |
| HIG | 75 | 3 | 18 | 48 | 1 | 1 | - | 2 | - | 1 | 31 | 261 |
| LAN | 82 | 8 | 7 | 60 | 1 | 1 | <1 | - | - | - | 38 | 842 |
| LOT | 66 | 9 | 21 | 49 | 1 | 2 | - | 1 | <1 | - | 18 | 528 |
| ORK | 83 | 3 | 12 | 61 | 2 | <1 | - | - | - | - | 38 | 242 |
| SHE | 78 | 10 | 10 | 71 | 0 | 2 | - | - | - | - | 39 | 322 |
| TAY | 74 | 7 | 17 | 33 | 2 | <1 | <1 | - | <1 | - | 23 | 308 |
| WES | 79 | 9 | 7 | 25 | 3 | 2 | - | - | - | - | 29 | 233 |
| Scotland (weighted values) | 71.2 | 7.9 | 15.7 | 54.8 | 2.5 | 1.4 | 0.2 | 0.8 | 0.2 | 0.1 | - | 5808 |
Table F3: Percentage of observations with each extent of defect (measured in thirds of crown height) and degree of symmetry found for opacities and hypoplasias. (Each individual is scored for highest single value [excluding 9] assigned).
Extent
| Developmental defect | <1/3 | 1/3 - 2/3 | >2/3 | Symmetrical | Sample |
| Demarcated Opacities | 77 | 18 | 5 | 19 | 451 |
| Diffuse Opacities | 49 | 31 | 20 | 55 | 837 |
| Hypoplasias | 25 | 46 | 28 | 41 | 123 |
6.10 Assessment of Supra-gingival Calculus and Caries Risk
For the first time in this series of surveys an assessment of the presence or absence of supra-gingival calculus was introduced. Recordings were made of the presence of calculus on the lingual surfaces of four index teeth in the lower anterior area (LR2, LR1, LL1, LL2). The results are presented in Appendix G.
7. Discussion
7.1 Dental Caries Results for Scotland
This is the second survey of the dental health of 14 year old children in Scotland carried out under the auspices of the Scottish Health Boards' Dental Epidemiological Programme and as such allows comparison of the results with those recorded 4 years ago. In this survey a 9.5% representative sample of Scottish 14 year olds were examined, with all Boards having exceeded the minimum sample required. The excellent efforts made by Orkney and Shetland's Boards to reach the target minima involved them in examining 91.0% and 88.3% of their target populations, respectively. The number of children in the sample who were unavailable for examination this year was 1045 or 14.8%. This is an improvement from the 1990/91 survey when 17.0% of the sample could not be examined.
The overall result, a mean number of decayed, missing and filled teeth (DMFT) of 3.14 represents a modest overall improvement from the figure of 3.55 recorded in the previous survey of Scotland's 14 year olds in 1990/91 (Davies & Pitts, 1991), although it was still higher than the mean values reported in 1991 for all but one other area of Great Britain for which figures are available (Pitts & Palmer, 1994). The report of the Office of Population Censuses and Surveys (OPCS) survey of children's dental health in the UK in 1983 (Todd & Dodd, 1985) recorded a DMFT of 6.8 for 14 year olds in Scotland which almost halved to 3.55 over the 7 year period to 1990. In the 4 years since then the rate of improvement appears to have slowed, the decrease in DMFT amounting to only 11.5%. This reinforces previous observations based on data from the reports of 5 and 12 year olds in Scotland (Pitts, Fyffe & Nugent, 1994; Pitts et al., 1993) that, in older age groups, the rate of improvement in the dental health of children in Scotland is declining and for groups of 5 year olds with disease there has been a deterioration. This must be a cause for concern.
The report of the most recent (1993) OPCS survey of the dental health of children in the UK (O'Brien, 1994) gave a value of 2.2 for the mean DMFT of 14 year olds in the UK. The corresponding value for England was 1.9 and for Scotland was 3.0. The OPCS UK-wide survey provides useful comparative data and although dealing with a smaller representative sample of 14 year olds (around 300) than the Scottish Health Boards' Dental Epidemiological Programme (n=6007), it lends weight to the results reported here. The OPCS sample precludes any analyses at Health Board level.
Scottish Health Boards' Dental Epidemiological Programme data reveal that the proportion of children with caries experience (%DMFT>0) also showed a large drop over the 7 year period 1983-1990 (from 95% to 78%) but has since only shown a very small decrease over the last 4 years to 74% in this year's survey. This demonstrates that the caries experience of Scottish children is still worse than their English and Welsh peers as only one region outwith Scotland had a %DMFT>0 of more than 74% in 1990/91 (Pitts & Palmer, 1994). The report of the 1993 OPCS survey of children's dental health in the UK (O'Brien, 1994) recorded that 61% of 14 year olds had experience of caries into dentine (DMFT>0). The corresponding value for England was 58% whilst for Scotland it was 71%. Once again the OPCS results help demonstrate the poorer levels of dental health suffered by children in Scotland and support the results presented in this report. The high proportion of 14 year olds in Scotland with caries experience, at the caries into dentine level of diagnosis, demonstrate that caries is still a significant problem for Scottish children.
The change in criteria introduced by BASCD in 1992 has meant that the results of this year's survey will be more directly comparable with those of the surveys undertaken in different Regions throughout Great Britain in 1994/95. The results of these Great Britain surveys will be published in Community Dental Health in March 1996.
Table B1 demonstrates a higher level of inter-examiner agreement in the diagnosis of decay using the revised criteria and training pack (Mitropoulous et al., 1992) than was observed in the 1990/91 survey of 14 year olds (Davies & Pitts, 1991) prior to the change in criteria. Once again it can be seen that the calibre of the examiners is impressive, as demonstrated by the consistently high levels of intra-examiner agreement (Table B2) recorded during the course of survey.
7.2 Dental Caries Experience by Health Board
As has been found in previous years, there is a large variation between the caries experience of children in the fifteen Health Boards across Scotland, from Forth Valley with a mean DMFT of 2.14 to Lanarkshire with a mean DMFT of 3.96. Figure 1 shows the mean number of decayed, missing and filled teeth (DMFT) for each Health Board and the 95% confidence intervals associated with each mean. Differences falling within the limits of the error bars are not statistically significantly different from one another. It can be seen that in most cases there is no significant difference between the mean for an individual Health Board and the three values above (to the right) and the three values below (to the left) in the figure. There are some exceptions with the smaller Health Boards. This underlines the care required when making simple inter-board comparisons of mean DMFT levels.
Another important aspect to note from Figure 1 is the relatively low proportion of the caries experience which is made up of fillings (see also Table 5). In comparison with the previous survey of Scotland's 14 year olds (Davies & Pitts, 1991) the ratio of fillings to decay is considerably altered in most Health Boards.
7.3 The proportion "With Caries Experience" in each Health Board
Three-quarters of 14 year olds were found to have already experienced decay at the "caries into dentine" level of detection (that is decay penetrating beyond the enamel surface of the teeth). Figure 2 demonstrates the range of values around this mean, from a low of 63% of 14 year olds with caries experience in Forth Valley to a high of 81% in Lanarkshire. Comparison of Figures 1 and 2 emphasise that the Boards in which the children have a higher than average DMFT also exhibit higher than average proportion of children having caries experience, as measured by the survey criteria.
Table 5 shows the range of DMFT values by Health Board for the children who have the decay experience. For these children the mean DMFT values is 4.25 and not 3.14, thus those with disease have on average one more affected tooth than the population mean. The mean DMFT of those with disease in the earlier survey of 14 year olds was 4.57 showing that there has been little improvement over the last four years for those unfortunate children affected by caries.
7.4 Teeth and Surfaces
It must be remembered that the teeth examined in this survey are permanent teeth, and although some may argue that leaving certain decayed deciduous teeth unfilled may be acceptable, the same argument cannot be made for the permanent dentition. Permanent teeth which have decayed through to dentine are normally thought to require restorative treatment.
As more than three-quarters of the decay experience in these teenagers is to be found in the first and second permanent molars (77.6%) it would seem appropriate to focus preventive therapies, such as fissure sealants, on these teeth. The recent guidelines from the British Society of Paediatric Dentistry on provision of fissure sealants (Murray & Nunn, 1993) advises that children with occlusal caries on one first permanent molar (6) should have the occlusal surfaces of the other sound 6s sealed, and that this also indicates a need to fissure seal the second permanent molars (7s) as soon as they have erupted sufficiently. There is a wide variation in the present provision of sealants across the Health Boards (Figure 7). Almost half (47%) of the dentinal decay and fillings was found on the occlusal (or biting) surfaces of the posterior (back) teeth, the surfaces which could benefit from fissure sealing.
7.5 Trends in Caries Prevalence
The modest overall fall in caries experience, although encouraging, represents a slowing of the improvement in dental health as the large reductions in caries levels observed in the 1980s are no longer being observed. This is in line with the trend observed previously through the surveys of 5 and 12 year olds in Scotland. The reduction in DMFT observed (despite the broadening of the diagnostic criteria) masks changes in the individual components of the index. Decay (D) appears to have risen substantially but this is largely due to the change in criteria for measuring decay introduced, for consistency, across Great Britain, in 1992 by BASCD. (When the criteria change is taken into account, there has been little change in the percentage of children with decayed teeth over the four years.) The mean MT component has shown no real change (from 0.38 in 1990/91 to 0.28 in 1994/95) whilst the FT component has fallen by 37% from 2.59 to 1.62. The relative amount of restorative care provided (FT/DMFT, the "Care Index") has fallen from 73% to 52%, and, whilst some of this decrease can be accounted for by the criteria change, this is still a cause for concern.
Figure 4 shows the trends in caries prevalence for the three age groups of children (5,12 and 14) examined in the Scottish Health Boards' Dental Epidemiological Programme. The rates in decline of caries prevalence have slowed for all age groups, while deterioration in caries status is evident among the 5 year olds with disease.
7.6 Skewed Distribution of Disease and Treatment
In interpreting the mean results and planning dental services for the future the skew in the distribution of the decay must be appreciated, as, although just over half of the children (53%) are free from dentinal decay, small groups have very high levels of disease. Half of the untreated decay was found in an unfortunate 8% of the sample (Table 4). Identifying and targeting of groups, such as this 8% who are in need of special attention, is difficult. Once they are identified, delivery of dental services and education may not be an easy matter and it might prove difficult to promote the behavioural changes necessary to improve the dental health. If, however, this small proportion of children could be identified and helped, large improvements could be seen in future surveys of 14 year olds. Targeting of dental services at these high risk groups must therefore become a priority.
The change in patterns of treatment, highlighted in Figure 1 and in Table 5, are a cause for concern. The proportion of the caries experience which is now made up of filled teeth has greatly decreased from a value for the Care Index (CI) of 73% in 1990/91 to a low of 52% in this year's survey. This may indicate that some children have problems of access to the dental services in Scotland or that there is some problem with the delivery of care to those who need it. Recent analyses (Pitts & Nugent, 1995) have shown that a substantial proportion of the high caries risk minority groups may be outwith the General Dental Service (GDS) capitation network and this may be having an effect on the Care Index results - those with the decay may not, for whatever reason, be accessing care from the GDS hence the decay to filling ratio has increased.
At the extremes, the CI value for Highland is less than 40% which means that 60% of the dentinal caries (which requires attention) has not been treated. In Shetland, however, only a quarter of the dentinal caries has been left untreated. On average, for Scotland, almost half of the decay experience of 14 year olds is made up of dentinal caries which requires attention.
7.7 Sealants / Sealant Restorations
Wide variation can be seen across the Health Boards in the provision of sealants and sealant restorations. Dental services in Grampian, Borders and Dumfries and Galloway for example have provided 50% or less of their 14 year olds with sealants or sealant restorations whereas in Highland, Forth Valley, Western Isles and Shetland over 80% of the 14 year olds examined were found to have one or more sealant or sealant restoration.
Sealant restorations appear to make up only a tiny percentage of all the restorations provided (Table D1) with, on average only 0.04 surfaces having a sealant restoration compared with 2.96 surfaces having a more conventional filling. It is interesting to note that the mean number of sealed surfaces (2.87) is comparable with the mean number of filled surfaces but it is unfortunately impossible to identify how many of the surfaces classed "sound and sealed" ($) actually had decay present prior to the surface being sealed. Diagnosis of caries under fissure sealants has been shown to be problematic (Deery et al, 1995). These factors make interpretation of DMFT data in an area with relatively high sealant use problematic (Pearson, 1994).
7.8 Oral Cleanliness
There has been little change in the mean plaques scores either for Scotland as a whole or for the individual Health Boards, with one or two exceptions, since the last survey. Approximately one half of the 14 year olds examined had no plaque (Table E1) whilst 10.7% had one third of index teeth recorded as having plaque present. There has been a decrease in the proportion of 14 year olds free from plaque, as measured by the survey criteria, in 6 Health Boards and an increase in the proportion in 9 Health Boards. Notable declines in oral cleanliness were observed in Highland and Western Isles where there were decreases in the proportion free of plaque from 62% to 42% and from 44% to 26%, respectively.
7.9 Assessment of Developmental Defects of Enamel
Detailed results and some discussion points relating to developmental defects of enamel can be found in Appendix F. On average 71.2% of the 14 year olds examined did not have any developmental defects of enamel as classified by the SCOTS Index, a slightly lower figure than was found for a comparable group of 14 year olds in 1990/91 (Davies & Pitts, 1991). There was little change in the overall frequency of demarcated opacities or hypoplasias but the frequency of diffuse opacities on upper incisors doubled, from 9.2% in 1990/91 to 18.6% in this year's survey (Table F1). Approximately half of the diffuse opacities were symmetrical in nature (Table F2) and could fit into a description of defects attributable to fluorosis. By comparison, a recent survey of regularly attending adolescent dental patients in Scotland (Fyffe & Deery, 1995) found that almost half of the subjects had developmental defects of enamel as classified by SCOTS and that a quarter had diffuse opacities.
It is interesting to note that of the 1570 children with developmental defects of enamel only 25.9% claimed they were aware of a defect on a tooth which had a SCOTS defect. Of the 1990 fourteen year olds only 1.9% had presumptive fluorosis and were aware of it, whilst the corresponding value for the 12 year olds was 2.6% (Stephen & Pitts, 1995 ). In this year's survey 3.1% of the children had presumptive fluorosis and were aware of it. In terms of the impact of developmental defects of enamel on those who have such defects, the problem would seem to be relatively unimportant from a public health perspective.
7.10 Assessment of Supra-gingival Calculus and Caries Risk
For the first time in the Scottish Health Boards' Dental Epidemiological Programme surveys an assessment of supra-gingival calculus was made. Details of the assessment employed and the results obtained are presented in Appendix G. This assessment was introduced to investigate whether presence of calculus could be introduced as a marker for low caries risk in children of this age group. The results have shown that plaque and calculus levels were significantly positively correlated, as calculus levels increase so do plaque levels. Caries experience (DMFT) increases as plaque increases, but as calculus increases DMFT decreases. The effects of plaque and calculus levels on DMFT were found to be independent.
Overall, although the expected inverse correlation between calculus levels and caries experience were observed, the magnitude of the changes mean that the use of calculus as a marker for low caries risk in this age group is of limited value.
Acknowledgements
The Co-ordinating Committee, the authors and the Dental Health Services Research Unit are indebted to all the children, and their parents, who took part in the survey. Special thanks go to Mr C Kiddie, Rector of Perth High School and Mr D Bader, Rector of Perth Grammar School, and to the staff and pupils for accommodating the essential training and calibration exercises.
Thanks also go to the Community Dental Officers and Dental Surgery Assistants who undertook the fieldwork as examining teams (see Appendix A); to the fifteen Health Boards for their financial support for the programme and to the Chief Scientist Office of the Scottish Office Home and Health Department which funds the Dental Health Services Research Unit. The authors would also like to acknowledge the support given by their colleagues at the Dental Health Services Research Unit, in particular Ms JA Davies for help with preparation of the manuscript .
The opinions expressed in this report are those of the authors and not necessarily those of the Scottish Office.
References
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