Publications
Scottish Health Boards' Dental Epidemiological Programme
Deprivation and Dental Caries
A Collaborative Study Undertaken by:
Patrick Sweeney*, Duncan McColl*, Zoann Nugent# and Professor Nigel Pitts#
Argyll and Clyde Health Board* and
The Dental Health Services Research Unit,
University of Dundee#
Published by:
University of Dundee
Dental Health Services Research Unit
ISBN 1 899809 14 7
Based on results from the Scottish Health Board's Dental Epidemiological Programme 1995/96 Survey of 5 Year Old Children
The most recent data for Scottish 5 year olds (including deprivation effects) can be found in the 1999 / 2000 Scottish Health Board's Dental Epidemiological Programme Survey.
Table of Contents
1.Introduction
4.Methodology
- 5.Results
- 5.1 Representativeness of the 5 Year Old SHBDEP Sample
- 5.2 The mean number of d3, m, f and mean d3mft of 5 year old children by Deprivation Category (DEPCAT) Score
- 5.3 The mean number of d3, m, f and mean d3mft of 5 year old children by DEPQUIN
- 5.4 Strength of Association Between Deprivation and Dental Disease
- 6.Discussion
- 6.1 Deprivation and Dental Caries Status
- 6.2 Inequalities in Dental Health - What Can be Done?
1. Introduction
Dental caries is a preventable multi-factorial disease associated with considerable morbidity and costs. Although caries levels in Scottish 5 year old children showed some improvement in the 1980’s, this trend now appears to have halted. There remains a long way to go if the existing national target for 5 year olds is to be met which is that 60% of 5 year old school entrants should have no carious fillings or extractions by the year 2000. Full results of the 1995/96 5 year old survey are available from the previously published SHBDEP Report (Pitts, N.B., Nugent, Z.J. and Davies, J.A. 1996).
Inequalities in health continue to be an area of concern and debate within health and social policy. There is a wealth of literature providing evidence that lower socio- economic groups have worse health than those from more affluent groups. The Scottish Office Policy Document Scotland’s Health: A Challenge to Us All (1992), identifies 5 priority areas for improvements in health. These are:
- Coronary Heart Disease
- Cancers
- HIV/Aids
- Accidents
- Dental and Oral Health
The Policy Document also identified the following 4 personal behaviours which influence health and illness:
- Diet
- Smoking
- Alcohol misuse
- Exercise
National targets were set for improvements, both in the priority conditions and their associated personal behaviours.
2 Deprivation and Health
2.1 Deprivation and General Health
Over the last century health has improved significantly. This improvement, however, has not been experienced equally across the population, being considerably greater among the better off. Several reviews of the relationship between socio-economic factors and morbidity and mortality have been published (DHSS 1980, Whitehead 1987) , but until publication of Deprivation and Health in Scotland (Carstairs and Morris 1991), few had included Scottish data. All the priority conditions and health behaviours identified by the Scottish Office Policy Document are influenced by socio- economic status and do not occur evenly throughout the population. Rates of coronary heart disease (CDH), cancers, HIV and Aids, and accidents are higher among poorer socio-economic groups. Currently available information relates mainly to CHD and cancers as discussed recently by Macintyre (1994). Whatever measure of socio- economic status is used, individuals from the more socially deprived groups are at higher risk of developing CHD. In addition, risk factors associated with CHD are influenced by social group, for example, smoking, obesity and raised blood pressure.
Death rates from the majority of cancers in Scotland are similarly related to socio- economic status and risk factors for several cancers are higher in the more disadvantaged social class groups. Many features of the Scottish diet, including alcohol misuse, high fat and low fruit and vegetable consumption may be cancer promoting (The Scottish Diet: A Challenge to Us All 1993).
2.2 Deprivation and Oral/Dental Health
Dental health surveys of children carried out by the Social Survey Division of the Office of Population Census and Surveys (OPCS) first included Scotland in 1983. These surveys show that caries levels in 5 year old children show a marked geographic gradient with caries prevalence lowest in England, rising in Wales then Scotland, and highest in Northern Ireland (Todd and Dodd 1985, O’Brien 1994). This north/south gradient, with higher disease levels towards the north and west of the United Kingdom, is confirmed by the regular caries prevalence studies co-ordinated by the British Association for the Study of Community Dentistry (BASCD) and, in Scotland by the Scottish Health Board’s Dental Epidemiological Programme (SHBDEP) (Pitts and Palmer 1994).
In Scotland, children from the higher social classes have less caries experience than those from lower social classes, but have higher levels of disease compared with English children of the same social class.
Socio-economic factors are also highlighted as being related to caries prevalence in the National Diet and Nutrition Survey of 1½ to 4½ Year Olds (Hinds and Gregory 1995). Children from homes where the head of the household is in a “manual” social class have higher disease levels than those from higher social classes. Receipt of Income Support, Family Credit, lack of mother’s educational qualifications and lone parentage were other factors associated with higher levels of disease.
Localised studies in England, using a classification of residential neighbourhoods (ACORN) as a descriptor of socio-economic status, found that children from the more disadvantaged groups had the poorest dental health. In addition, they were more likely to have suffered from toothache and less likely to have had their teeth brushed with toothpaste by their first birthday (Whittle and Davies 1992, Elley and Langford 1993). The caries experience of 5 year old children from Leeds increased significantly with material deprivation (Prendergast et al 1995). In addition those children from the most deprived enumeration districts were more likely to access the Community Dental Service than those from the more affluent districts.
A three year follow-up of the dental health of 12 and 15 year old school children in Glasgow found that while dental health had improved over a 3 year period in all social groups, the percentage improvement in the more affluent groups was almost 3 times as great as that in the poorer areas. In both years of the study those from the poorer socio-economic groups had the worst dental health (Attwood, Blinkhorn and MacMillan 1990).
Local Glasgow data from the 1995/96 SHBDEP survey of 5 year olds reveals that those children from the most disadvantaged Greater Glasgow neighbourhood type areas 7 and 8 had a dmft of 4.97 and 80.4% had disease experience, compared with a dmft of 2.25 and 51.0% with disease experience in the better off neighbourhood type 1 and 2 areas. Dental health status has also been compared at Local Government District areas in some Boards.
At a national level, however, data on socio-economic circumstances have not, until recently, been routinely collected in relation to dental health as part of the SHBDEP surveys. Information on postcode of residence for children examined was first collected on a pilot basis during the 1993/94 survey of 5 year olds. Having confirmed its feasability, this information was again collected in the recent 1995/96 survey. Analysis of the data collected in the 1993/94 SHBDEP survey of 5 year olds found showed that higher deprivation scores were significantly associated with a lower frequency of registration (Pitts and Nugent 1995). In addition, those children who were registered with a dentist at the time had a significantly lower mean d3mft and a smaller proportion had caries experience than those who had never been registered under the capitation system.
3 Measures of Deprivation or Socio-Economic Status
It is apparent from previous studies investigating the association between deprivation and health that a wide variety of indices have been used to measure deprivation and socio-economic status. No clear cut and universally accepted definition of deprivation exists and a number of indicators of social inequality have been used. The most common are occupation, classifications of social class or socio-economic group based on occupation, income and education. The most commonly used measures of socio- economic status are now briefly reviewed.
3.1 Social Class
In the United Kingdom, the earliest and most widely used measure of social class is the Registrar General’s Classification of Occupations (Leete and Fox 1977), which categorises households into one of six social classes based on the occupation of the head of the household. Due to the significant changes that have occurred in society in recent decades, this classification is now considered to have limitations (Locker 1993). Certain high risk groups, such as long-term unemployed and single parents not in the labour force, cannot be classified under this system and there are also problems with respect to retired people and women. The increasing participation of women in the labour market has raised the question as to whether it is appropriate to classify married women by the occupation of her spouse rather than by her own occupation.
3.2 Composite Measures
A report on the 1971 census data first highlighted the variations in social and economic circumstances which exist between areas in Great Britain (Holterman 1975). Subsequent to this, several composite indices of socio-economic status were devised which use different variables from such census data. The most commonly used measures include, in England and Wales, the Jarman Score, the Townsend Score and, in Scotland, the Carstairs Score (Jarman 1983 and 1984, Townsend et al 1988, Carstairs and Morris 1991). The variables included in these respective scores are detailed in Tables 1 and 2.
Table 1 Variables used to derive the Jarman and Townsend Scores
| Jarman Underprivileged Area Scores (UPA’s) | Townsend Deprivation Indicator |
| Elderly living alone | Economically active who are unemployed |
| Population under 5 | Households with no car |
| One parent families | Households that are not owner-occupied |
| Social class V | Households overcrowded |
| Unemployed | |
| Overcrowded | |
| Changing address within the past year | |
| Ethnic minorities |
Townsend et al. (1988) attempted to clarify the concept of deprivation by proposing a distinction between material and social forms of deprivation. Social deprivation, relates to social contacts, membership in society and roles and relationships; - universal measures are not readily available for these. Material deprivation refers to lack of resources and amenities, services, and of a physical environment which are considered the norm in society.
Table 2 Census variables used to derive the Carstairs Score
| CENSUS VARIABLE | DESCRIPTION |
| Overcrowding | Persons in private households living at a density of >1 person per room as a proportion of all persons in private households. |
| Male Unemployment | Proportion of economically active males who are seeking work. |
| Low Social Class | Proportion of all persons in private households with head of household in social class 4 or 5. |
| No car | Proportion of all persons in private households with no car. |
3.2.1 The Carstairs Score
The selection of variables for inclusion in the Carstairs Score is based upon previous work which looked at health and deprivation in Glasgow and Edinburgh (Carstairs 1981). Carstairs Scores are derived by combining the above variables which are taken from small area census data, usually postcode sectors, and appropriately weighted. The variables are expressed as the proportion of individuals with one or more of the selected variables, for example, the proportion having no car or the proportion in any particular postcode sector being in social class 4 or 5 (McLoone 1994).
The derived Carstairs Score ranges from a minimum value of -7.3 (the most affluent), to a maximum value of 12.27 (the most deprived). The deprivation scores for postcode sectors can also be collapsed and restructured into seven deprivation categories to give the DEPCAT Score which ranges from DEPCAT 1 (the most affluent postcode sectors) to DEPCAT 7 (the most deprived postcode sectors).
Scores, or DEPCAT variables, at the extremes of the scale describe postcode sectors whose populations are homogenous in terms of being either affluent or deprived. Those at the middle of the scale, for example, DEPCAT 3,4 or 5 are more heterogenous and reflect a mix of household types contained within those areas and apply to the majority of postcode sectors in Scotland. 62% of the Scottish population live in areas designated as DEPCAT 3,4 or 5.
The heterogeneity of these middle scores arises as a result of how postcode sectors are designed and is influenced by their geographical size, the density of their populations and their actual location within Scotland. Due to these variations, the Carstairs Score provides a better account of affluence or deprivation in urban rather than rural areas. Urban postcode sectors are geographically smaller and socially more homogeneous, while rural postcode sectors are larger and include populations with much more heterogeneous socio-economic characteristics.
The proportion of the Scottish population resident in each DEPCAT score and the distribution of Scottish postcode sectors by DEPCAT score is illustrated in Table 3.
Table 3 Distribution of the Scottish population by Deprivation Category (DEPCAT) 1991 (Source McLoone 1994)
| DEPCAT SCORE | Scottish Population | % | Postcode Sectors | % |
| 1 | 305,725 | 6.1 | 94 | 9.4 |
| 2 | 688,018 | 13.8 | 171 | 17.1 |
| 3 | 1,090,483 | 21.8 | 226 | 22.6 |
| 4 | 1,270,597 | 25.4 | 231 | 23.1 |
| 5 | 741,664 | 14.8 | 125 | 12.5 |
| 6 | 567,492 | 11.4 | 97 | 9.7 |
| 7 | 334,285 | 6.7 | 57 | 5.7 |
| Total | 4,998,264 | 100.0 | 1001 | 100.0 |
The Carstairs Scores can also be collapsed into fifths giving a deprivation category known as a DEPQUIN, again ranging from DEPQUIN 1 (the most affluent fifth) to DEPQUIN 5 (the most deprived).
What Does the Carstairs Score Identify?
The Carstairs Score is described as a measure which reflects access to material resources (Carstairs and Morris 1991). The scores are not a measure of the extent of material well-being or relative disadvantage experienced by individuals, but rather are a summary measure applied to populations contained within small geographic localities, normally postcode sectors. It is a method of quantifying levels of relative deprivation or affluence in different localities.
The Carstairs Score and deprivation categories are the most commonly used measures of deprivation in relation to health and disease within Scotland.
To date, however, Carstairs and DEPCAT Scores have not been routinely linked to postcode information sectors collected during the Scottish Health Board’s Dental Epidemiological Programme’s Surveys to allow an investigation of the association between deprivation and dental health. The need for more detailed information at a national level formed the basis of this study with the following aims and objectives:
Aim
To investigate the relationship between socio-economic status as determined by postcode sector of residence and the dental caries status of 5 year old children examined in the 1995/96 SHBDEP survey, using the Carstairs and DEPCAT Scores.
Objectives
- To obtain a download of anonymised data for all 15 Health Boards from the 1995/96 SHBDEP 5 Year Old Survey giving details of Health Board, full postcode sector of residence, d, m and f components of dmft for each child examined in the survey.
- To link the postcode sector of each record with its appropriate Carstairs Score, DEPCAT Score and the 4 1991 census variables used to derive in the Carstairs Score.
- To undertake analysis of this data for Scotland and individual Health Boards and investigate the relationship between:
- d3
- m
- f
- d3mft
- % ‘free’ of caries experience (d3mft=0)
4 Methodology
The 7,007 records from the 1995/96 SHBDEP 5 Year Old Survey were anonymised and downloaded by the Dental Health Services Research Unit, Dundee to the author. Each record contained the following information: Health Board, age, sex, the number of decayed, missing and filled teeth, and full postcode sector of residence.
With the assistance of the Information Services Department of Argyll and Clyde Health Board, the SHBDEP survey data was linked through a complicated multi-stage data linking process with a file containing the 1991 Carstairs Scores, Deprivation Categories and the 4 variables used in deriving the Carstairs Score for each postcode sector in Scotland. A total of 6,650 (95%) records from the 1995/96 5 year old survey were successfully linked via the childrens’ postcode sectors of residence to their appropriate Carstairs Score and Deprivation Category. The 356 records of children examined in the survey which could not be linked successfully, either:
- had no postcode of residence recorded at the time of examination
or
- the postcode had been incompletely recorded
or
- the postcode recorded did not in fact exist.
The linking process also corrected for postcode sectors which were split across Local Government Districts (LGDs) to prevent duplication of records.
The end result of this linking process gave a data file containing 6,650 records from the 1995/96 SHBDEP Survey of 5 Year Olds with each record now containing the following information: Health Board, age, gender, full postcode sector of residence, the Carstairs Score for that postcode sector, the DEPCAT score and proportions of the population in each of the 4 variables used to derive the Carstairs Score in addition to the d, m, and f components of dmft.
The data were then analysed using the SPSS software package.
5 Results
5.1 Representativeness of the 5 Year Old SHBDEP Sample
The data were analysed by DEPCAT variable to compare the distribution of the SHBDEP 5 year old sample with that for the Scottish population. This breakdown of the SHBDEP sample by DEPCAT score is shown in Table 4 and Figure 1. The SHBDEP sample showed a very similar distribution to that of the Scottish population.
A Chi-sqaured analysyis confirmed there were no statistically significant differences between the SHBDEP sample distribution and that of the Scottish population.
The distribution of the 5 year old sample was also investigated by DEPQUIN, ranging from the most affluent fifth to the most deprived fifth of the 1995/96 SHBDEP sample. This breakdown is shown in Table 5. The 5 year old SHBDEP sample was equally distributed among the 5 Carstairs Score DEPQUINS.
Table 4 DISTRIBUTION OF THE 1995/96 SHBDEP 5 YEAR OLD SAMPLE BY DEPCAT
| DEPCAT SCORE | n | % |
| 1 | 388 | 5.8 |
| 2 | 779 | 11.7 |
| 3 | 1683 | 25.3 |
| 4 | 1600 | 24.1 |
| 5 | 872 | 13.1 |
| 6 | 757 | 11.4 |
| 7 | 571 | 8.6 |
| TOTAL | 6650 | 100 |
Table 5 DISTRIBUTION OF THE 1995/96 SHBDEP 5 YEAR OLD SAMPLE BY DEPQUIN CATEGORY
| CARSTAIRS SCORES and DEPQUIN CATEGORY |
n | % |
| Score < - 2.689 DEPQUIN 1 (Most Affluent) |
1330 | 20.0 |
| Score > - 2.689 & < - 1.285 DEPQUIN 2 |
1338 | 20.1 |
| Score > - 1.285 & < .455 DEPQUIN 3 |
1321 | 19.9 |
| Score > .455 & <
2.839 DEPQUIN 4 |
1333 | 20.0 |
| Score > 2.839 DEPQUIN 5 (Most Deprived) |
1328 | 20.0 |
5.2 The mean number of d3, m, f and mean d3mft of 5 year old children by Deprivation Category (DEPCAT) Score
The data were analysed by each of the 7 DEPCAT Scores. Mean values for d3, m, f, d3mft along with the Care Index and the percentage of children with and without disease experience in each category are presented in Table 6 and Figures 2 and 3 (more detailed results are presented in Appendix 1a). The mean d3mft ranged from 1.48 in the most affluent group to 4.87 in the most deprived. The proportion of 5 year olds ‘free’ of caries experience decreased from 62.4% for children resident in postcode sectors with a DEPCAT score of 1, to 19.8% for those resident in a DEPCAT 7 area.
The major component of d3mft was untreated decay (d3), but a similar rise in the missing component was seen with increasing deprivation. The mean number of missing teeth for children resident in a DEPCAT 1 area was 0.17 which rose to 1.37 for those resident in the most deprived areas.
The f component of d3mft, however, showed very little association with the DEPCAT Score, although there was a trend towards a reducing Care Index (ft/d3mft) on moving from the most affluent to the most deprived DEPCAT Scores. Five year old children resident in a DEPCAT 1 area had a Care Index of 10.8 compared with only 2.9 for children resident in a DEPCAT 7 area. The Care Index for the intermediate DEPCAT Scores showed a much more variable pattern ranging from 6.7 to 10.1.
The differences in mean values for dmft between the 7 DEPCAT Scores were subjected to a series of planned comparisons using the Kruskal-Wallis non-parametric test. p was adjusted for multiple comparisons using the Bonferroni method. The increase in mean d3mft with increasing deprivation was statistically significant at the P < 0.05 level for all comparisons, except for the increases in mean d3mft between DEPCAT 2 and 3 and between DEPCAT 5 and 6 which were not statistically significant.
The differences in the proportion of 5 year old children with disease experience between the different DEPCAT Scores were subject to Chi-square analysis which showed a highly significant (P < 0.01) association between increasing deprivation and an increasing proportion of children with disease experience. Caries experience was not independent of the DEPCAT Score (see Appendix 1b).
Table 6 The mean values of d3, m, f, d3mft of 5 year old children, Care Index and percentage ‘free’ of caries experience (d3mft=0) by DEPCAT Score
(1995/96 SHBDEP 5 year old survey)
| DEPCAT SCORE | d3 | m | f | d3mft | Care Index (ft/d3mft) | % ‘free’ of caries experience (d3mft=0) |
| 1 | 1.15 | 0.17 | 0.16 | 1.48 | 10.8 | 62.4 |
| 2 | 1.51 | 0.25 | 0.16 | 1.92* | 8.3 | 53.3 |
| 3 | 1.73 | 0.40 | 0.24 | 2.37 ns | 10.1 | 48.4 |
| 4 | 2.13 | 0.58 | 0.29 | 3.00 ** | 9.6 | 39.6 |
| 5 | 2.50 | 0.72 | 0.28 | 3.50 * | 8.0 | 33.0 |
| 6 | 2.66 | 0.82 | 0.25 | 3.73 ns | 6.7 | 30.3 |
| 7 | 3.36 | 1.37 | 0.14 | 4.87 ** | 2.9 | 19.8 |
* denotes a statistically significant increase in mean dmft between DEPCAT Scores p < 0.05;
** denotes a statistically significant increase in mean dmft between DEPCAT Scores p < 0.01;
(p adjusted for multiple comparisons using the Bonferroni method).
The horizontal line represents the percentage required to meet the National Target for the year 2000.
5.3 The mean number of d3, m, f and mean d3mft of 5 year old children by DEPQUIN
A similar trend was visible when the data were analysed by dividing the Carstairs Score into Quintiles, as shown in Table 7 and Figures 4 and 5 (more detailed results are presented in Appendix 1c). The 20% of 5 year olds resident in the most affluent postcode sectors had a mean d3mft of 1.83 compared with 4.23 for the 20% resident in the most deprived DEPQUIN. Similarly, the percentage with caries experience increased from 44.5% for those in DEPQUIN 1, to 74.2% in DEPQUIN 5.
As with the analysis by DEPCAT Score, no obvious trend was detectable for the f component of d3mft when examined by DEPQUIN. The Care Index, again, was low for all groups and no obvious trend with deprivation was detectable, although it was lowest among the most deprived, DEPQUIN 5 group.
A chi-square analysis of the proportions with and without caries experience in each of the DEPQUINS, again showed a strong and statistically significant association between increasing levels of deprivation and a higher proportion of 5 year olds with caries experience (see Appendix 1d).
Table 7
The mean values of d3, m, f, d3mft of 5 year old children, Care Index and percentage ‘free’ of caries experience by DEPQUIN
(1995/96 SHBDEP 5 year old survey)
| DEPQUIN | d3 | m | f | d3mft | Care Index (ft/d3mft) | % ‘free’ of caries experience (d3mft=0) |
| 1 Most Affluent |
1.42 | 0.24 | 0.17 | 1.83 | 9.3 | 55.5 |
| 2 | 1.77 | 0.42 | 0.24 | 2.43 | 9.9 | 46.9 |
| 3 | 1.98 | 0.50 | 0.31 | 2.79 | 11.1 | 43.2 |
| 4 | 2.45 | 0.70 | 0.25 | 3.40 | 7.4 | 34.2 |
| 5 Most Deprived |
2.96 | 1.06 | 0.21 | 4.23 | 5.0 | 25.8 |
The horizontal line represents the percentage required to meet the National Target for the year 2000.
5.4 Strength of Association Between Deprivation and Dental Disease
To further explore the association between the Carstairs Score, the variables used to derive it and dental disease, the data were also subject to Spearman Rank correlations. The correlation co-efficents and an indication of whether the association was positive or negative along with the significance levels are presented in Table 8. The d3 and m components of d3mft, showed a strong positive association with increasing deprivation. A worsening or more deprived Carstairs Score was positively associated with a higher number of decayed or missing teeth and a higher mean d3mft value. This positive association was also found between the individual variables used to derive the Carstairs Score. The f component of d3mft, however, showed no such association with deprivation, values for f being similar in all deprivation categories.
Table 8 Spearman’s Rank Correlation Coefficients and Significance Levels for Carstairs Score and 1991 Carstairs Census Variables by d3, m, f and d3mft
| CARSTAIRS SCORE | d3 | m | f | d3mft |
| Carstairs 81 | +.2259** | +.1954** | +.0034 | +.2562** |
| Carstairs 91 | +.2223** | +.1895** | +.0168 | +.2552** |
| 1991 Carstairs Census Variables | ||||
| % Male unemployment | +.2059** | +.1784** | +.0009 | +.2345** |
| % Socio-economic group 45 | +.2234** | +.1843** | +.0214 | +.2527** |
| Overcrowding 1991 | +.2135** | +.1796** | - .0071 | +.2396** |
| % with no car 1991 | +.2059** | +.1784** | +.0009 | +.2345** |
+/- indicates positive or negative association
P adjusted for multiple comparisons (Bonferroni)
**=P < 0. 01
6 Discussion
The strong similarity between the Scottish population and the 5 year old SHBDEP sample in the proportions resident in each of the 7 deprivation categories confirms the representative nature of the current SHBDEP sampling technique. This is further supported by the even distribution of the 5 year old sample among the 5 DEPQUIN categories.
As discussed in the introduction, several of the priority areas for health, identified by the Scottish Office, have been investigated in relation to deprivation using the Carstairs and DEPCAT Scores in the past. This is the first time that such social variations in dental health have been investigated so comprehensively at a Scottish level, although the association between capitation status and deprivation and capitation status and dental caries status has been reported (Pitts and Nugent 1995). It also confirms the association between material deprivation, (as measured by the Townsend Index), and higher caries experience demonstrated for 5 year olds in Leeds (Prendergast et al 1995).
The study was facilitated by the inclusion of postcode sector of residence in the personal data recorded for each child examined in the SHBDEP surveys. It was encouraging that a total of 95% (6,650) of records collected in the 1995/96 5 year old survey could be successfully linked to their respective Carstairs and DEPCAT Scores. Congratulations are, therefore, extended to all examiners and scribes for their painstaking attention to detail in recording postcode information which facilitated this successful linkage. It is anticipated that it may be possible to increase the percentage of successfully linked records in future surveys.
6.1 Deprivation and Dental Caries Status
As with other adult diseases, such as coronary heart disease and cancers, those children resident in the most deprived postcode sectors experience more dental disease. There is a sequential rise in the number of decayed and missing teeth on moving from the more affluent to the most deprived postcode sectors.
Five year old children from the most deprived areas, as determined by their postcode sector of residence, have more than 3 times the amount of dental disease experienced by those children living in the most affluent postcode sectors.
In addition, a significantly greater proportion of children from deprived areas experience dental disease. Five year old children resident in a postcode sector with a DEPCAT Score 1 have in fact already exceeded the National Target for the year 2000 that 60% of 5 year old school entrants should have no cavities, fillings or extractions. This contrasts sharply with the situation for children resident in an area with a DEPCAT Score of 7, where less than 20% are ‘free’ of caries experience.
What is also apparent is that on moving from the most affluent to the most deprived areas, 5 year olds have experienced more extractions as illustrated by the rising m component of dmft. This trend of increasing active decay and numbers of missing teeth with worsening levels of deprivation does not, however, extend to the level of restorative care received by 5 year olds. There is no discernible association or trend between relative levels of affluence or deprivation and the amount of restorative care which had been provided for the 5 year olds examined in this survey, although those resident in postcode sectors with a DEPCAT score of 7 did have the lowest Care Index among the sample.
The very low Care Index and f component of dmft may reflect a failure of the existing capitation scheme to address the restorative needs of all in this age group. Although previous studies of children’s dental health have shown that children from the higher social classes are more likely to access dental services, this does not seem to be reflected in the subsequent provision of restorative care in this study. What is apparent from these results is that those children who do access dental services are more likely to have teeth extracted than receive restorative care, irrespective of whether they come from affluent or deprived backgrounds.
6.2 Inequalities in Dental Health - What Can be Done?
Despite conclusive evidence that inequalities in health exist within the United Kingdom, it has been recognised that there is little practical guidance currently available on effective interventions within the Health Service to tackle such variations. This realisation led, in 1994 to the establishment of a working group to advise the Chief Medical Officer of the Department of Health for England on what steps the Department of Health and the NHS could take to address these variations in health. The subsequent Report “Variations in Health - What can the Department of Health and the NHS do?”, was published in 1995.
The conclusions and recommendations of this Report included an affirmation that an important way of achieving national targets is:
- ‘by improving the health of the least healthy group to the levels of health attained by the most healthy groups’.
In relation to the dental health of Scottish 5 year olds this presents Health Boards with a considerable challenge. There is a need to selectively reduce both the proportion of children experiencing decay and the extent of the disease they experience in the more deprived areas, (especially those areas with a DEPCAT Score of 6 or 7).
In practical terms, since the NHS has little or no direct influence on the socio- economic status of communities, this means that the Health Board’s task is to attempt to influence the behaviours associated with oral and dental health.
For 5 year olds the key behaviours associated with the onset of dental caries and disease are diet, oral hygiene (especially exposure to topical fluoride) and dental attendance for preventive check-ups, advice and treatment as appropriate. It is worth highlighting at this point that the SHBDEP Report of the 1995/96 survey of 5 year old children reports a statisitically significant association between increasing plaque levels and higher mean d3mft values.
Previous studies have shown that the above behaviours are also influenced by socio- economic factors. Children from more deprived areas are less likely to have had their teeth brushed with a fluoride toothpaste by their first birthday and more likely to attend a dentist only when having dental problems (Whittle and Davies 1992, Hinds and Gregory 1995).
In addition, children from deprived areas consume, from an early age, sugary food and drinks more frequently than those from more affluent backgrounds (Silver 1987, Hinds and Gregory 1995).
The Department of Health Report, ‘Variations in Health’ (1995), highlighted that evidence on effective interventions to address such inequalities in health was generally lacking. There was, however, some evidence that certain features are common to several of the more successful interventions. These features include:
- Planned systematic and intensive action
- Multi-agency working
- A combination of strategies/range of services
- The provision of materials, support and resources
- The development of skills in the target group
- Precise and intensive focusing on the target group
- Consumer involvement
- Prompts to use services
The majority of these features have been specifically highlighted in the recently published Oral Health Strategy for Scotland.
In particular, the Oral Health Strategy recognises the considerable influence which other agencies, both at national and local level, can bring to bear on improving oral health. These agencies include Government departments other than the Department of Health, Local Authorities, voluntary groups, the manufacturing and retail sectors, communities and individuals themselves.
Health Boards have been identified as having responsibility for identifying health variations at a locality level as part of health needs assessments, setting local targets for improving health, providing effective access to health care services promoting multi- agency working, allocating resources according to relative need and putting in place public health programmes which build on available best practice and which should be evaluated.
Previous SHBDEP reports have highlighted the skewed distribution of dental disease among the child population. In the 1995/96 5 year old survey report, for example, all the decayed surfaces were found in 54% of the children, while 10% of the sample had half the decayed surfaces. The use of postcode sector information linked to Carstairs and DEPCAT Scores in the 1995/96 SHBDEP survey has facilitated a detailed investigation of the variations in dental health according to socio-economic status at a national level.
The considerable variations in dental health revealed in this study raise challenging issues for all concerned with improving oral and dental health in Scotland. The finding, that children resident in postcode sectors with a DEPCAT score of 1 have already reached the Scottish Office target for the year 2000, perhaps highlights the need for more specific targeting of resources.
Previous studies have shown that health education programmes have better outcomes in schools with more affluent catchment areas, as opposed to little or no benefit in the most deprived schools (Schou et al 1991). Targeting resources which encourage behaviour change inducive to oral health gain among more mixed populations would need to address this issue if inequalities are to be reduced rather than actually increased as has been reported previously (Schou and Wight 1993).
Interventions to reduce dental caries experience among children from the more homogenous areas with DEPCAT Scores of 6 or 7 face an even greater challenge. Altering health behaviours in these deprived areas will almost certainly require programmes including all the features listed in the Department of Health’s report on ‘Variations in Health’. It is, perhaps, the non-NHS agencies such as local authorities and the voluntary sector who may have the greater influence in these areas. This reinforces the need for a multi-agency approach to oral health gain as detailed in the ‘Oral Health Strategy for Scotland’.
It is hoped that this report will provide useful information to assist all those with an interest in improving oral and dental health in Scotland. Specifically it may help Health Boards in taking the lead in the development, implementation and monitoring of their local oral and dental health strategies and facilitate targeting of resources to help reduce the current inequalities in dental health among 5 year old children in Scotland.
7 Conculsion and Recommendations
7.1 Conclusions
- The collection of information relating to postcode sector of residence at the time of dental examination was generally viable. An acceptable proportion (95%) of records were successfully linked to their respective Carstairs and DEPCAT Scores.
- There is a strong association between increasing deprivation and increasing caries experience. A significantly higher proportion of 5 year old children from the most deprived postcode sectors have experienced dental disease. In addition they also have a greater burden of disease as demonstrated by significantly higher values for mean d3mft .
- Children from the most deprived areas have significantly more untreated decay and a significantly greater number of missing teeth.
- No association was found between deprivation and the amount of restorative care received by these 5 year old children. The Care Index for all groups was low.
7.2 Recommendations
- Information on postcode sector of residence should in the future be routinely collected as an integral part of the rolling programme of 5, 12, and 14 year old SHBDEP surveys. This would enable the Programme and Health Boards to monitor the effectiveness of strategies aiming to reduce inequalities in dental and oral health.
- Attempts should be made to increase further the accuracy of the recording of such postcode information in order to maximise the proportion of successfully linked records.
- The results of this study should be disseminated to Health Boards and key NHS agencies to assist those with the responsibility for improving oral and dental health in Scotland.
- The findings should also be communicated to other agencies identified in the Oral Health Strategy for Scotland, as having an important role in improving oral, dental and general health.
Acknowledgements
The authors are indebted to Ms Shona Hynds for her assistance and untiring work in helping to compile and produce this report. Thanks also to Professor Sally MacIntyre, MRC Medical Sociology Unit, University of Glasgow, for her guidance and support.
References
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Appendix 1a
The mean values of d3, m, f, d3mft of 5 year old children, Care Index and percentage ‘free’ of caries experience (d3mft=0) by DEPCAT (1995/96 SHBDEP 5 year old survey)
Standard deviations are shown in brackets
| DEPCAT SCORE | d3 | m | f | d3mft | Care Index (ft/d3mft) | % ‘free’ of caries experience (d3mft=0) |
| 1 n=388 |
1.15 (2.12) |
0.17 (0.85) |
0.16 (0.67) |
1.48 (2.67) |
10.8 | 62.4 |
| 2 n=779 |
1.51 (2.37) |
0.25 (0.99) |
0.16 (0.59) |
1.92* (2.86) |
8.3 | 53.3 |
| 3 n=1683 |
1.73 (2.68) |
0.40 (1.33) |
0.24 (0.75) |
2.37 ns (3.36) |
10.1 | 48.4 |
| 4 n=1600 |
2.13 (2.90) |
0.58 (1.56) |
0.29 (0.82) |
3.00 ** (3.56) |
9.6 | 39.6 |
| 5 n=872 |
2.50 (3.00) |
0.72 (1.73) |
0.28 (0.82) |
3.50 * (3.79) |
8.0 | 33.0 |
| 6 n=757 |
2.66 (3.06) |
0.82 (1.88) |
0.25 (0.76) |
3.73 ns (3.76) |
6.7 | 30.3 |
| 7 n=571 |
3.36 (3.28) |
1.37 (2.35) |
0.14 (0.55) |
4.87 ** (4.03) |
2.9 | 19.8 |
*denotes a statistically significant increase in mean dmft between DEPCAT Scores p < 0.05;
**denotes a statistically significant increase in mean dmft between DEPCAT Scores p < 0.01;
( p adjusted for multiple comparisons using the Bonferroni method).
Appendix 1b
Chi Square Analysis: Proportion of Children with Caries Experience by DEPCAT
| DEPCAT SCORE | % ‘free’ of caries experience (d3mft=0) |
% with caries experience (d3mft > 0) |
Row Total (n) |
| 1 | 62.4 | 37.6 | 388 |
| 2 | 53.3 | 46.7 | 779 |
| 3 | 48.4 | 51.6 | 1683 |
| 4 | 39.6 | 60.4 | 1600 |
| 5 | 33.0 | 67.0 | 872 |
| 6 | 30.3 | 69.7 | 757 |
| 7 | 19.8 | 80.2 | 571 |
| Column Total (n) |
2735 | 3915 | 6650 |
| Chi-Square | Value | DF | Significance |
| Pearson | 326.40299 | 6 | .00000 |
| Linear Association | 320.97468 | 1 | .00000 |
Minimum Expected Frequency - 159.576
Appendix 1c
The mean values of d3, m, f, d3mft of 5 year old children, Care Index and percentage ‘free’ of caries experience DEPQUIN (1995/96 SHBDEP 5 year old survey)
Standard deviations are shown in brackets
| CARSTAIRS DEPQUIN | d3 | m | f | d3mft | Care Index (ft/d3mft) | % ‘free’ of caries experience (d3mft=0) |
| 1 n=1330 Most Affluent |
1.42 (2.31) |
0.24 (1.01) |
0.17 (0.63) |
1.83 (2.87) |
9.3 | 55.5 |
| 2 n=1338 |
1.77 (2.178) |
0.42 (1.34) |
0.24 (.753) |
2.43 (3.36) |
9.9 | 46.9 |
| 3 n=1321 |
1.98 (2.82) |
0.50 (1.46) |
0.31 (0.87) |
2.79 (3.49) |
11.1 | 43.2 |
| 4 n=1333 |
2.45 (3.01) |
0.70 (1.71) |
0.25 (0.75) |
3.40 (3.77) |
7.4 | 34.2 |
| 5 n=1328 Most Deprived |
2.96 (3.18) |
1.06 (0.68) |
0.21 (2.12) |
4.23 (3.99) |
5.0 | 25.8 |
Appendix 1d
Chi Square Analysis: Proportion of Children with Caries Experience by DEPQUIN
| DEPQUIN SCORE | % ‘free’ of caries experience (d3mft=0) |
% with caries experience (d3mft > 0) |
Row Total (n) |
| 1 | 55.5 | 44.5 | 1330 |
| 2 | 46.9 | 53.1 | 1338 |
| 3 | 43.2 | 56.8 | 1321 |
| 4 | 34.2 | 65.8 | 1333 |
| 5 | 25.8 | 74.2 | 1328 |
| Column Total (n) |
2735 | 3915 | 6650 |
| Chi-Square | Value | DF | Significance |
| Pearson | 290.33075 | 4 | .00000 |
| Linear Association | 286.25441 | 1 | .00000 |
Minimum Expected Frequency - 543.299
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