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Scottish Health Boards' Dental Epidemiological Programme

An Investigation of the Assocation between Deprivation and Dental Caries
Experience among 12-Year-Old Children in Scotland

A Collaborative Study Undertaken by:

Patrick Sweeney*, David Allison*, Janet Davies#, and Professor Nigel Pitts#
Argyll and Clyde Health Board* and The Dental Health Services Research Unit,
University of Dundee#
in Collaboration with the Scottish CADOS/CDPH Group

Published by:

University of Dundee
Dental Health Services Research Unit
ISBN 1 8998 16 3

Based on results from the Scottish Health Boards' Dental Epidemiological Programme1996/97 Survey of 12-Year-Old Children

Table of Contents

1. Introduction

Trends in the level of dental disease among children in the U.K. are well documented. National surveys of children's dental health, undertaken every 10 years by the Office of Population Census and Surveys (OPCS), are complemented by annual caries prevalence studies co-ordinated by the British Association for the Study of Community Dentistry (BASCD), and in Scotland, by the Scottish Health Boards' Dental Epidemiological Programme (SHBDEP)(1, 2, 3).

The results of these surveys highlight considerable geographical variations in dental caries levels with caries prevalence lowest in England, rising in Wales then Scotland and highest in Northern Ireland (2, 3, 4).

Socio-economic factors have also been demonstrated as being associated with caries prevalence. In Scotland, children from the higher social classes have less caries experience than those from lower social classes but have higher disease levels than their English counterparts of the same social class(2). This description of social class is based on the Registrar General's Classification of Occupations; - a measure of socio-economic status based on the occupation of the head of the household(5). Following the significant changes that have occurred in society in recent decades, this measure is now considered to have limitations(6).

Composite measures of socio-economic status based on census data, such as the Townsend Score and the Jarman Score in England and Wales and the Carstair's Score in Scotland(7, 8, 9), are increasingly used in examining the association between deprivation and dental caries status.

The Carstair's Score and its Deprivation Categories (DEPCAT) are the most commonly used measures of deprivation in relation to health and disease in Scotland, as previously described(10,11).

Recent studies have demonstrated a strong association between increasing deprivation and increasing dental caries experience among 5 year old children examined in the 1995/96 SHBDEP survey(10,12) . Five year old children resident in the most affluent areas (DEPCAT 1) of Scotland had a mean d3mft of 1.48, compared with 4.87 for those children resident in the most deprived postcode sectors. In addition, 62% of 5 year olds resident in DEPCAT 1 areas were 'free' of caries experience, thus exceeding the national target for the year 20001(3), compared with only 19.8% of those children resident in the most deprived areas (DEPCAT 7).

Having confirmed the viability of collecting information relating to postcode sector of residence during SHBDEP surveys, and subsequently linking these to respective Carstair's Scores and Deprivation Categories, this process was repeated for the 1996/97 12 year old survey results.

The 1996/97 SHBDEP survey examined 12 year old children and full results of this survey are available from the previously published report14.

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2. Aims and Objectives

The aim of this study was to investigate the relationship between dental caries status and socio-economic status. The latter being determined by postcode sector of residence of 12 year old children examined in the 1996/97 SHBDEP survey using the Carstairs Score and Deprivation Categories (DEPCAT).

Objectives

1 To obtain a download of anonymised data for all 15 Health Boards in Scotland from the 1996/97 SHBDEP 12 Year Old Survey giving details of Health Board, full postcode sector of residence, D3, M and F components of D3MFT for each child examined in the survey.

2 To link the postcode sector of each record with its appropriate Carstairs Score, DEPCAT Score and the four individual 1991 census variables used to derive the Carstairs Score.

3 To undertake analysis of this data for Scotland and individual Health Boards and investigate the relationship between:

and socio-economic status as determined by the linked Carstairs Scores and DEPCAT Scores.

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3. Methodology

The 6,165 records from the 1996/97 SHBDEP 12 year old survey were anonymised and downloaded by the Dental Health Services Research Unit, Dundee. Each record contained the following information: Health Board, age, sex, the number of decayed, missing and filled teeth, as well as the individual components of Decay (Arrested Dentinal Decay [C1], Decay into Dentine [C2] and Decay with Pulpal Involvement [C3]) and full postcode sector of residence.

With the assistance of the Information Services Department of Argyll and Clyde Health Board, the survey data were linked through a complex multi-stage data linkage process with files containing the 1991 Carstairs Scores, Deprivation Categories and the four variables used in deriving the Carstair's Score for each postcode sector in Scotland. The process also corrected for postcode sectors which were split across Local Government Districts to prevent duplication of records. The data were then analysed using the SPSS software package.

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4. Results

4.1 Proportion of SHBDEP Records Successfully Linked to Carstairs Scores and Deprivation Categories

A total of 5858 records from the 1996/97 12 year old survey were successfully linked by the children's postcode sector of residence to their appropriate Carstair's Score and Deprivation Category. This proportion (95%) was similar to that achieved in the previous study of 5 year olds. The proportion of records successfully linked varied among 15 individual Health Boards within Scotland as is shown in Table 1.

Table 1 Proportion of SHBDEP 12 Year Old Records Linked to Respective Carstairs Scores and Deprivation Categories for all 15 Health Boards in Scotland

Health Board Number
Matched		 Number
Unmatched		 Total % Matched
Argyll & Clyde 407 13 420 96.9
Ayrshire & Arran 332 6 338 98.2
Borders 265 0 265 100
Dumfries & Galloway 241 6 247 97.6
Fife 365 8 373 97.9
Forth Valley 284 3 287 99.0
Grampian 202 222 424 47.6
Greater Glasgow 1102 27 1129 97.6
Highland 271 2 273 99.3
Lanarkshire 827 9 836 98.9
Lothian 529 4 533 99.2
Orkney 260 1 261 99.6
Shetland 270 1 271 99.6
Tayside 344 2 346 99.4
Western Isles 159 3 162 98.1
Grand Total 5858 307 6165 95.0

The proportion of SHBDEP records linked with Carstairs socio-economic data ranged from a maximum of 100% for Borders Health Board to only 48% for Grampian Health Board. For the other 13 Health Boards, 97% or more records were successfully linked, a figure of 99% and over being achieved in 6 Health Boards.

4.2 Representativeness of the 12 Year Old SHBDEP Sample

The data were analysed to investigate the distribution of the SHBDEP 12 year old sample by Deprivation Category (DEPCAT). This was compared with that for the total Scottish population and also for the 10-14 year old Scottish population. This breakdown of the SHBDEP sample by Deprivation Category is shown in Table 2 and Figure 1.

Table 2 Distribution of the 1996/97 SHBDEP 12 Year Old Sample by DEPCAT

Table 2

Figure 1: Distribution of the 1996/97 SHBDEP 12 Year old Sample by DEPCAT Compared with Scotland

Figure 1

The SHBDEP sample showed a similar distribution to that of the Scottish population. There appeared to be a slight under-representation from DEPCAT 1 and 2 and over-representation in DEPCAT 3 in the SHBDEP 12 year old sample. A CHI-squared analysis, however, confirmed there were no statistically significant differences between the 12 year old SHBDEP sample distribution and that of the total Scottish or 10-14 year old populations.

The data were also analysed, therefore, to determine the distribution by DEPCAT of the SHBDEP sample for each individual Health Board so that it could could be compared with the respective Health Board's population distribution. These comparisons confirmed that, despite some variations, representative 12 year old samples had been selected for examination in all Boards.

Although less than 50% of SHBDEP records were successfully linked for children resident in Grampian Health Board, the sample population which was linked, showed little variation from the Health Board distribution by DEPCAT and was, therefore, representative.

4.3 The Mean Number of D3, M, F and Mean D3MFT of 12 Year Old Children by DEPCAT

Mean values for D3, M, F and D3MFT along with the Care Index and % of children with and without disease experience in each Deprivation Category are presented in Tables 3 and 4 and Figures 2 and 3 (more detailed results are available in an addendum).

Table 3 The mean values of D3, M, F, D3MFT of 12 year old children, Care Index and percentage 'free' of caries experience (D3MFT=0) by DEPCAT (1996/97 SHBDEP 12 year old survey results)

Table 3

Table 4 The mean values of C1, C2, C3, Components of Decay for 12 year old children by DEPCAT (1996/97 SHBDEP 12 year old survey results)

Table 4

Figure 2: 1996/97 SHBDEP 12 Year Old Survey - Mean No. of Decayed, Missing and Filled Teeth by Deprivation Category (DEPCAT)

Figure 2

(The horizontal line represents the Scottish Office Target for the year 2005).

Figure 3: 1996/97 SHBDEP 12 Year Old Survey - % 'Free of Caries Experience by Deprivation Category (DEPCAT)

Figure 3

Values for which superscripts have the same letter were not significantly different at the p<0.05 level. (p adjusted for multiple comparisons using the Bonferroni method).

The mean D3MFT ranged from 1.05 in the most affluent group (DEPCAT 1), to 3.05 in the most deprived (DEPCAT 7). The missing component (M) was low overall but rose sequentially from 0.05 for children resident in DEPCAT 1 areas to 0.40 for those 12 year olds from the most deprived postcode sectors (DEPCAT 7). The filled component (F) of D3MFT was also low but rose from 0.54 in DEPCAT 1 to 0.95 in the most deprived category (DEPCAT 7).

The Care Index (F/D3MFT x 100) showed a reverse trend falling from 51% for children resident in the most affluent postcode sectors to 31% for those from the most deprived areas.

The proportion of children remaining 'free' of decay experience at 12 years of age fell sequentially from 55% in DEPCAT 1 to 21% in DEPCAT 7.

The majority of decay was decay into dentine (C2) with the mean value rising from 0.44 for children from the most affluent postcode sectors to 1.54 for the most deprived group. Mean values for decay with pulpal involvement (C3) were low overall but highest (0.11) in children from DEPCAT 7 areas.

The differences in mean values for D3 (and its components), M, F and D3MFT in the 7 deprivation Categories were subject to a series of planned comparisons using the Kruskall - Wallis non parametric test (p was adjusted for multiple comparisons using the Bonferroni method). Increases in mean D3MFT and its components which were statistically significant are indicated in Tables 3 and 4. Results for individual Health Boards are available in an addendum.

Variations among Health Boards are evident for mean D3MFT in any one Deprivation Category. For example, the mean D3MFT for 12 year old children resident in DEPCAT 3 postcode sectors varies from 0.72 in Orkney Health Board to 1.95 in the Western Isles. Among the mainland Health Boards the variation ranges from 0.98 in Lothian to 1.81 in Greater Glasgow.

For those children resident in a DEPCAT 4 area the mean D3MFT ranges from a lowest value of 1.00 in Borders Health Board to a maximum of 2.56 in Fife.

4.4 Strength of Association between Deprivation and Dental Disease

The data were subject to Spearman Rank Correlations to investigate the strength of the association between the Carstairs Score, its individual variables and dental disease. The resultant Correlation Coefficients and significance levels, where appropriate, are shown in Tables 5 and 6.

Table 5 Spearman's Rank Correlation Coefficients and Significance Levels for Carstairs Score and 1991 Carstairs Census Variables by D3, M, F and D3MFT

Table 5

+/- indicates positive or negative association

** denotes p < 0. 05

Table 6 Spearman's Rank Correlation Coefficients and Significance Levels for Carstairs Score and 1991 Carstairs Census Variables by C1, C2, and C3 Components of Decay.

Table 6

+/- indicates positive or negative association

** denotes p < 0. 05

D3, M, F, D3MFT and the C2 (decay into dentine) component of D all showed a positive association with increasing deprivation. A higher (more deprived) Carstairs Score was positively associated with a higher number of decayed, missing or filled permanent teeth.

This positive association was also found for the individual variables used to derive the Carstairs Score. The highest correlation coefficients were found between D3MFT and its components and the % 'Male Unemployment' and % 'Overcrowding' variables of the Carstairs Score. Although still statistically significant, a weaker association was found between dental disease and % Resident in Socio-economic Class 4 or 5.

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5 Discussion

A high proportion (95%) of the records for 12 year old children examined in the 1996/97 SHBDEP survey were successfully linked to their corresponding Carstairs Score and Deprivation Category. This proportion is similar to that achieved in the previous study involving 5 year old children(10).

For the majority of Scottish Health Boards over 97% of records were successfully linked, with the exception of Grampian Health Board for which only 48% of the 12 year olds' records were matched with their corresponding Carstairs data. Discussions with the Royal Mail and Public Health Researchers, who originally developed the Carstairs Scores for Scottish postcode sectors, indicated that significant changes have occurred to postcodes within Grampian Health Board since the 1991 census. These changes include both new building developments which generate new postcode sectors of residence, re-naming of existing postcode sectors along with significant boundary changes. There is little prospect, at present, for any improvement in the proportion of Grampian postcode sectors being linked to Carstairs data until after the next population census has taken place in 2001.

In the context of this study, however, the proportion of Grampian Health Board 12 year old records linked to Carstairs Socio-economic data was representative, in that the SHBDEP sample showed a similar distribution by DEPCAT to that of Grampian Health Board's overall population. This was also demonstrated for all other Scottish Health Boards.

Overall, there was a strong similarity between the distribution of the 12 year old SHBDEP sample by DEPCAT and that of the Scottish population (both total and 10-14 year old Scottish populations). As previously reported, this was also demonstrated for the 1995/96 5 year old sample10. The current study, therefore, reaffirms the efficacy of the SHBDEP sampling technique in ensuring that representative samples of children are selected for examination in the annual epidemiological surveys.

Deprivation and Dental Caries Experience

The strong and statistically significant association between increasing deprivation and worsening dental health, demonstrated recently for 5 year olds, also holds true for older children. Twelve year old children in Scotland who live in the most deprived postcode sectors have almost 3 times the amount of dental decay compared with their most affluent peers.

The recently published results of the 1996/97 12 year old survey demonstrated some progress towards the Scottish target of a mean D3MFT of 1.5 by the year 200513-14. When the data is analysed by Deprivation Category (DEPCAT), however, it is evident that 12 year old children from each of DEPCAT 1, 2 or 3 areas have, in fact, already exceeded this national target. Those children resident in DEPCAT 4 areas have a similar mean D3MFT to that found in the overall national survey. In contrast, 12 year old children from the most deprived areas have a considerable way to go to reach the national target, currently having a mean D3MFT of 3.05, which is twice that of the Scottish Office target for 2005.

The majority of the disease experienced by these children is untreated dentinal decay which rises sequentially on moving from the most affluent to the most deprived postcode sectors of residence. In addition to having a greater burden of dental disease, a lower proportion of the most deprived children remain caries 'free' at 12 years of age. They have also experienced significantly more extractions than more affluent 12 year olds.

The almost linear associations between deprivation and the burden of dental disease (Figs. 1 and 2) evident for Scotland as a whole, are less linear at individual Health Board level.

Unlike the previous study of 5 year olds, the F component of D3MFT does show a positive association with increasing deprivation10. On moving from the most affluent (DEPCAT 1) to the most deprived (DEPCAT 7) postcode sectors there is a gradual increase in the amount of restorative care received by 12 year old children resident in these areas. Whereas no association was found between deprivation and the level of restorative care received by 5 year old children, a significant positive relation was demonstrated for the 12 year olds.

While 12 year olds from the most deprived areas may have more fillings than their more affluent peers, it would appear that this merely reflects their greater burden of disease and does not indicate that their restorative needs are being met. When the F component of D3MFT is considered as a proportion of the total burden of disease (mean D3MFT) i.e. the Care Index, a clear inequity between 12 year olds from affluent and more deprived areas becomes evident. As highlighted in the 1996/97 SHBDEP report for 12 year olds, the Care Index nationally is currently low (44%)14. A low Care Index has also been demonstrated for 5, 12 and 14 year olds in England, Wales and Northern Ireland3-4. When the Care Index is examined by DEPCAT, just over 50% of decay has received restorative treatment in children resident in the most affluent areas, compared with only 31% in the most deprived children.

Trends in the level of restorative care received by children in the U.K. since epidemiological surveys began are well documented and have been described elsewhere(3, 4). Recent literature has suggested that the capitation system which existed between 1990 and 1996 combined with other changes in primary care dental services appear to have failed in addressing the restorative needs of children of all ages(15) . From the variation in the Care Index on moving from more affluent to more deprived postcode sectors, it would appear that this is especially true for those children most at risk. This may reflect the issue of access in that previous studies have confirmed that children from more deprived backgrounds are less likely to access primary dental care on a routine, regular and ongoing basis (1, 2, 16).

The results of this study complement a growing wealth of national and international literature highlighting the influence of socio-economic factors on the experience and burden of dental disease(10, 12, 17, 18, 19). Similar inequalities in health have been demonstrated for Coronary Heart Disease, Cancers, HIV and AIDS and their associated risk factors(11) .

The recently published Priorities and Planning Guidance for the National Health Service in Scotland and the White Paper 'Designed to Care' include a new strategic aim of tackling inequalities in health(20, 21). There is now a commitment at the highest level to address inequalities in health and access to health services. Health Boards are charged with developing 5 year Health Improvement Programmes, an integral part of which, should include proposals to analyse and tackle the health inequalities affecting their resident populations.

It is hoped that the results of this study and those of the previous report highlighting the inequalities in dental health among 5 year old children in Scotland will assist Health Boards and other relevant agencies in identifying areas of high dental need in their area so that preventive strategies can be effectively targeted.

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6 Conclusions and Recommendations

Conclusions

  1. An acceptable proportion of 12 year old SHBDEP records were successfully linked to their corresponding Carstairs data. At Health Board level the proportion of records successfully linked ranged from 100% (Borders) to 48% (Grampian). There is little prospect of any improvement in Carstairs data linkage for Grampian postcode sectors until after the next Population Census.
  2. Although the 12 year old SHBDEP sample showed some under-representation in Deprivation Categories 1 and 2 when compared with the Scottish population, this did not reach statistical significance. The strong similarity between the distribution by DEPCAT of the 12 year old sample and that of the Scottish population confirms the validity of the current BASCD/SHBDEP sampling technique.
  3. 12 year old children resident in the most deprived postcode sectors have significantly more decayed, missing and filled teeth than their more advantaged peers. In addition, a higher proportion of those from the most deprived areas have experienced dental disease by this age. This is consistent with previos results for 5 year olds in Scotland.
  4. There was a positive association between increasing deprivation, as determined by the Carstairs Score, and increasing caries experience. This association was found for the Decayed (D3), Missing (M) and Filled (F) components of D3MFT.
  5. Although children from the most deprived areas had significantly more fillings than their more advantaged peers, the Care Index fell from 51% to 31% on moving from DEPCAT 1 to 7 indicating that the restorative needs of the most deprived 12 year olds are not being met .

Recommendations

  1. These findings should be disseminated to Health Boards and Trusts for consideration when developing future Health Improvement Programmes and Trust Implementation Plans so that appropriately targeted preventive programmes can be formulated.
  2. The results of this study should inform the development of plans addressing access to primary care dental services in Scotland.
  3. The findings should also be communicated to NHS agencies who have a responsibility and role in improving the poor oral health record of the Scottish population. Primary Health Care Teams, in particular, are well placed to help identify children 'at risk' of developing dental disease.
  4. The inequalities in dental health identified in this study should also be communicated to and discussed with other agencies identified in the Oral Health Strategy for Scotland13 and the recently published White Paper 'Designed to Care'21, as having an important role in improving oral, dental and general health
  5. The low Care Index (the proportion of decay which is treated) identified in this study, especially among the more deprived children, should continue to be monitored.
  6. Further research should be undertaken to investigate those factors associated with deprivation which influence dental caries status in children.
  7. This study should be repeated for the SHBDEP 14 year old survey to be undertaken in 1998/99, after which the need for further explorations of the association between dental caries and deprivation in national surveys should be reviewed.
  8. Health Boards should seek to implement water fluoridation where this is feasible and cost effective with a view to reducing the inequalities in the prevalence of dental disease identified in this study and the previous study of 5 year olds in Scotland

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References

  1. Todd JE, Dodd T. Children's Dental Health in the United Kingdom 1983. London: Her Majesty's Stationery Office 1995.
  2. O'Brien M. Children's Dental Health in the United Kingdom 1993. London: Her Majesty's Stationery Office 1994.
  3. Pitts NB, Palmer JD. The dental caries experience of 5-, 12- and 14-year-old children in Great Britain. Surveys co-ordinated by the British Association for the Study of Community Dentistry in 1991/92, 1992/93 and 1990/91. Community Dental Health 1994; 11: 42 - 52.
  4. Nugent ZJ, Pitts NB. 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 Health1997; 14 (Supp 1): 30-54.
  5. Leete R, Fox A. The Registrar General's social classes: origins and uses. Population Trends 1977; 8: 1-7.
  6. LOCKER D. Measuring social inequality in dental health services research: individual, household and area-based measures. Community Dental Health 1993; 10: 139-150.
  7. Townsend P, Phillimore P, Beattie A. Health and Deprivation: Inequality and the North. London: Croom Helm 1988.
  8. JARMAN B. Underprivileged Areas: Validation and Distribution of Scores. British Medical Journal 1984; 289: 1587-1592
  9. MCLOONE P. Carstairs Scores for Scottish Postcode Sectors from the 1991 Census. Glasgow : Public Health Research Unit, University of Glasgow, 1994.
  10. SWEENEY P C, McCOLL, NUGENT, Z and PITTS N.B.Scottish Health Board's Dental Epidemiological Programme. Addendum to the 1995/96 Report on 5 Year Olds: Deprivation and Dental Caries 1996. Dundee:University of Dundee.
  11. Carstairs V, Morris R. Deprivation and Health in Scotland. Aberdeen: Aberdeen University Press 1991.
  12. Jones CM, Woods K, Taylor GO. Social deprivation and tooth decay in Scottish schoolchildren. Health Bulletin 1997; 55: 11-15.
  13. The Scottish Office. Scotland's Health, A Challenge to us all: The Oral Health Strategy for Scotland . Edinburgh: Her Majesty's Stationary Office, 1995; 3-36.
  14. PITTS N.B., DAVIES J.A. and FYFFE H.E. Scottish Health Board's Dental Epidemiological Programme: 12 Year Olds Report 1996/97. 1997. Dundee: University of Dundee.
  15. PITTS N B. Do we understand which children need and get appropriate dental care. British Dental Journal 1997; 182: 273-278.
  16. HINDS K, GREGORY J R. National diet and nutrition survey: children age 1.5 to 4.5. Volume 2: Report of the Dental Survey. Her Majesty's Stationery Office 1995.
  17. PETRIDOU E, ATHANASSOULI T, PANAGOPOULOS H, REVINTHI K. Sociodemographic and dietary factors in relation to dental health among Gree adolescents. Community Dentistry and Oral Epidemiology 1996; 24: 307-311.
  18. PRENDERGAST M J, BEAL J F, WILLIAMS, S A. Deprivation and dental health in 5 year olds in Leeds. J Dent Res 1995; 74: 857.
  19. SPENCER A J. Skewed distributions - new outcome measures. Community Dentistry and Oral Epidemiology 1997; 25: 52-55.
  20. NHS MANAGEMENT EXECUTIVE. Priorities and Planning Guidance for the NHS in Scotland: 1998/99. NHS MEL (1997) 44: Edinburgh.
  21. THE SCOTTISH OFFICE: Department of Health, Designed to Care: Renewing the National Health Service in Scotland. 1997: Edinburgh.

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