Publications

Scottish Health Boards' Dental Epidemiological Programme

Report of the 1996/97 Survey of 12-Year-Old Children

Prepared by:

NB Pitts, JA Davies, HE Fyffe
Dental Health Services Research Unit, University of Dundee
Published by University of Dundee
Dental Health
Services Research Unit
ISBN 1 899809 15 5
1997

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

Return to Publications index page.

Index to Report

1	Introduction
2	Sampling
3	Training and Calibration
4	Dental Examination
5	Data Processing
6	Results and Discussion
	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	Distribution of Disease and the Care Index
	6.7	Sealants/Sealant Restorations
	6.8	Oral Cleanliness
	6.9	Assessment of Developmental Defects of Enamel
	6.10	Orthodontic Assessment
7	The Future
Acknowledgements References

List of Tables

1	Number of children examined by Health Board
2	Results for caries experience for Scotland
3	Results for caries experience by each Health Board
4	Skewed distribution of decay
5	Mean D3MFT, Care Index and D3MFT for those "with caries experience", by Health Board

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	Mean number of decayed, missing and filled teeth, by Health Board, for children "with caries experience"
4	Distribution of caries experience by tooth
5	Trends in caries prevalence for Scottish children, 1983 to 1997
6	Trends in caries prevalence for 12 year old Scottish children - overall mean plus mean for those "with caries experience", 1983 - 1997
7	Proportion of children with sealants/sealant restorations
8	The future

See also List of Figures on Appendices page.

1 Introduction

This Report has been prepared for those interested in the detailed results of the 1996/97 survey. Readers seeking only a brief overview are referred to the Executive Summary. Key results and discussion are held in the body of the Report whilst further information and results can be found in the Appendices, printed on blue paper at the end of the Report.

This is the third survey of the dental health of Scotland's 12 year old children undertaken in the Scottish Health Boards' Dental Epidemiological Programme (SHBDEP). This series of annual examinations of key age groups is organised via the Chief Administrative Dental Officers and Consultants in Dental Public Health Group (CADOs/CDPH Group) and the Chief Scientist Office's Dental Health Services Research Unit (DHSRU) at the University of Dundee, as a joint venture with all 15 Scottish Health Boards.

Standardised dental surveys are undertaken on randomly selected children across Scotland following the core timetable and criteria for age groups recommended by the British Association for the Study of Community Dentistry (BASCD) - Pitts, Evans, Pine, 1997. The programme provides results for each Health Board and allows comparison of individual Boards' results and the monitoring of trends over time. It also facilitates comparison of the results for Scotland with those of other parts of the UK.

The results of these quadrennial surveys of 12 year olds, the first of which was undertaken in 1988/89 (Pitts, Davies, 1989), are crucial for monitoring levels of dental health and thus illustrating the progress required in order to meet the National Target of a mean number of decayed, missing and filled teeth (D3MFT) of 1.5 by the year 2005, introduced in the Oral Health Strategy for Scotland (SODoH, 1995). The benefit of following selected age groups through a series of surveys is that it allows cohort effects to be identified and trends to be predicted, thus focusing on what action will be required in future to ensure continued improvements in the dental health of Scotland's children.

The aim of this year's survey was to determine current levels of tooth decay (dental caries measured clinically at the dentinal level) and to make an assessment of the levels of oral cleanliness achieved by these children. In addition assessments were made of the presence of developmental defects of enamel and orthodontic treatment needs and, for the first time in this series of surveys, the impact of defects and malocclusions, as perceived by the children's claimed satisfaction with the appearance of their own teeth.

2 Sampling

Sampling was undertaken in accordance with the SHBDEP Protocol document (Watkins, Pitts, 1994). Each Health Board was required to identify the number of schools needed to obtain a representative sample of a given size (dependent on Health Board size) from the Secondary I population. The sample sizes utilised provide adequate numbers to allow meaningful inter-Board comparisons to be drawn.

3 Training and Calibration

The training and calibration courses for this survey of 12 year old children were held in Perth immediately prior to the survey examinations being undertaken. Mr MCW Merrett, Consultant in Dental Public Health to Tayside Health Board, organised the courses 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 with details of inter-examiner agreement from the calibration exercises being provided in Appendix C, Table C1.

4 Dental Examinations

The dental examinations took place between November 1996 and February 1997. Table 1 shows the number of children sampled in each Health Board and the number and proportion of Secondary I children subsequently examined. This year 6165 (10%) Secondary I schoolchildren in Scotland were examined, with no Board examining less than 6% of their own Secondary I population (range 6.85% - 95.26%) and the Island Boards accessing high proportions of 12 year olds. During the course of the survey examinations 10% of the children were re-examined to allow assessment of intra-examiner agreement - these results are presented in Appendix C, Table C2.

Table 1

Number in sample, number and percentage of population examined and Secondary I population for each Health Board.

Health Board	Sampled	Examined	Examined as % of population	Secondary I population
Argyll and Clyde	460	420	7.98	5261
Ayrshire and Arran	390	338	7.05	4791
Borders	309	265	24.49	1082
Dumfries and Galloway	276	247	12.78	1932
Fife	433	373	8.85	4214
Forth Valley	326	287	9.05	3170
Grampian	500	424	6.96	6094
Greater Glasgow	1359	1129	10.37	10889
Highland	292	273	9.78	2790
Lanarkshire	943	836	11.01	7590
Lothian	601	533	6.85	7786
Orkney	274	261	95.26	274
Shetland	280	271	93.77	289
Tayside	404	346	7.39	4681
Western Isles	175	162	46.29	350
Totals	7022	6165	10.07	61193

The Programme

This programme of surveys is undertaken under the auspices of the Committee of Chief Administrative Dental Officers/Consultants in Dental Public Health Group (CADOs/CDPH 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 main participants.

Participating Health Boards

Argyll and Clyde	Greater Glasgow
Ayrshire and Arran	Highland
Borders	Lanarkshire
Dumfries and Galloway	Lothian
Fife	Orkney
Forth Valley	Shetland
Grampian	Tayside
	Western Isles

Co-ordinating Committee - Dental Epidemiology, Scotland

Mr TR Watkins	Co-ordinator
Professor NB Pitts1,2	Calibration and Results Co-ordinator
Mr MCW Merrett3	Calibration Course Organiser
Professor KW Stephen	Adviser
Miss MM Taylor	Representative of Consultants in Dental Public Health

British Association for the Study of Community Dentistry (BASCD) Dental Epidemiology Programme

1 Scientific Co-ordinator, BASCD Dental Epidemiology Programme in Scotland
2 Scientific Co-ordinator, BASCD UK Dental Epidemiology Programme
3Service Co-ordinator, BASCD Dental Epidemiology Programme in Scotland

5 Data Processing

Data processing, analysis and reporting were undertaken by the Dental Health Services Research Unit at the University of Dundee.

6 Results and Discussion

The format of this Report broadly follows that of the 1992/93 report (Pitts, Fyffe, Nugent, Smith, 1993). Key results tables, figures and discussion relating to dental caries are included in the main body of the Report. The codes used for assessment of caries and fissure sealants are in Appendix D, with Appendix E providing a list of the abbreviations used for Health Boards throughout the Report. Appendix F gives a comparison, for each Health Board, of the mean D3MFT values in 1992/93 and 1996/97, with associated confidence intervals. More detailed results using the tooth surface as the unit of measurement are presented in Appendix G. For the first time in this series of surveys information relating to remaining deciduous teeth in 12 year old children is presented and can be found in Appendix H. Results for oral cleanliness are presented in Appendix I, those for developmental defects of enamel are in Appendix J with the results of the assessment of orthodontic treatment need being located in Appendix K. Maps showing the distribution of caries in 12 year olds across Scotland and the UK are in Appendices L and M respectively. All results, except those in Appendix H, relate to the permanent dentition.

6.1 Dental Caries Results for Scotland

Table 2 shows the overall results for Scotland in terms of permanent teeth decayed (D3T), missing due to caries (MT) and filled (FT). It must be appreciated that dental caries (decay) is measured at the level at which the trained examiners are certain that dentinal involvement has occurred. This diagnostic threshold - the D3 threshold - which is routinely used in epidemiological caries surveys may differ from that used in clinical practice (Pitts, Binnie, Gerrish et al, 1994).

The result of a mean D3MFT of 1.75 is an improvement on the result of 2.08 from the previous survey of 12 year old children in Scotland in 1992/93 (Pitts, Fyffe, Nugent, Smith, 1993) and represents some progress toward the target of a mean D3MFT of 1.5 by the year 2005 (SODoH, 1995). However, it still represents a poorer level of oral health than was found in Great Britain as a whole in 1992/93 (D3MFT=1.27) and, in fact, is higher than the mean D3MFT of 1.6 which was found eight years ago in Great Britain (Nugent, Pitts, 1997).

Also presented in Table 2 are different ways of grouping the children with respect to their experience of dental caries. Firstly, an overall value for so-called "zero caries" (no decayed or filled teeth present, D3FT=0) is given as this is a measure used traditionally by many Health Boards in the collection of local data. The second measure, the proportion of children with experience of caries (D3MFT>0) is given in accordance with BASCD guidelines. The third measure demonstrates the proportion of children who have untreated dentinal caries (D3>0), which in the present survey was approximately a third of those surveyed (36.9%). Dentinal decay represents the stage at which most dentists would agree that restorative care (ie a filling) should be provided.

It is important to note the individual components of the DMF Index also presented in Table 2, and to be aware of the low level of restorative care (as shown by the FT component) which has been provided for this group of 12 year old children which is discussed in more detail in section 6.6. A final point to note from Table 2 is the proportion of children with one or more sealant/sealant restoration. This has fallen from a value of 59.2% in 1992/93 (Pitts, Fyffe, Nugent, Smith, 1993) to 54.2% in the present survey. Provision of sealants is further discussed in section 6.7.

Table 2

Overall D3MFT results for Scotland, incorporating data from the fifteen Health Boards, appropriately weighted. Decay defined as decay into dentine.

	Weighted means	Range of means for individual Health Boards
age (in years)	12.26	12.22-12.37
"sound" teeth (code G)	20.45	17.81-21.63
"sound" plus sealed teeth (codes G, $)	22.2	21.78-23.13
sealants/sealant restorations (codes $, N)*	1.76	1.03-5.35
D3T	0.81	0.2-1.26
MT missing teeth	0.17	0.05-0.25
FT filled teeth	0.78	0.36-1.12
D3FT	1.59	0.69-2.08
D3MFT	1.75	0.74-2.32
	%	Range for Health Boards
With "zero caries" D3FT=0	43.8	32.7-64
With "caries experience" D3MFT>0	57.6	36-68.5
With "decay" D3>0	36.9	13.7-49.2
% of children with 1 or more sealant/sealant restorations	54.2	36.2-93.9

*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 gives the mean D3MFT as well as providing information on the mean numbers of decayed, missing, filled and sealed teeth by Health Board. Also presented are the proportion of subjects in each Health Board "with caries experience" (%D3MFT>0), the proportion "with zero caries" experience at the dentinal level (%D3FT=0). This serves to demonstrate the wide variation in decay experience across Scotland, from a mean D3MFT of 0.74 in Orkney to a value of 2.32 in Greater Glasgow. It is worth noting that it is in only three Health Boards (Argyll & Clyde, Orkney and Shetland) that the mean number of sealed teeth has increased since 1992/93 (Pitts, Fyffe, Nugent, Smith, 1993), in all other Boards the mean values have remained very similar or have fallen.

Table 3

Mean values per child for decayed (D3), missing (M), filled (F), and sealed ($) teeth; percentage "with zero caries" (D3FT=0) and “with caries experience” (D3MFT>0). Decay defined as decay into dentine.

Table 3a

Health Board	D3	M	F	D3FT	D3MFT
Argyll and Clyde	0.83	0.2	0.86	1.69	1.89
Ayrshire and Arran	0.29	0.09	1.12	1.41	1.5
Borders	0.58	0.09	0.36	0.95	1.04
Dumfries and Galloway	0.77	0.15	0.6	1.37	1.52
Fife	1.13	0.25	0.81	1.94	2.19
Forth Valley	0.48	0.18	0.57	1.05	1.23
Grampian	0.59	0.11	0.72	1.31	1.42
Greater Glasgow	1.26	0.24	0.82	2.08	2.32
Highland	1.11	0.15	0.49	1.6	1.75
Lanarkshire	0.99	0.19	0.91	1.91	2.09
Lothian	0.52	0.09	0.59	1.12	1.21
Orkney	0.2	0.05	0.49	0.69	0.74
Shetland	0.22	0.07	0.86	1.08	1.15
Tayside	0.67	0.15	0.82	1.49	1.64
Western Isles	0.91	0.21	1.1	2.01	2.22

Table 3b

Health Board	% D3FT=0	% D3MFT > 0	$
Argyll and Clyde	41.9	59.8	2.02
Ayrshire and Arran	46.4	54.1	1.41
Borders	59.6	41.1	1.03
Dumfries and Galloway	46.2	55.9	1.03
Fife	38.3	63.5	1.97
Forth Valley	59.9	42.9	2.65
Grampian	50	51.2	1.11
Greater Glasgow	33.5	68.5	1.44
Highland	43.2	58.2	2.34
Lanarkshire	37.3	63.8	1.99
Lothian	52	48.8	1.6
Orkney	64	36	3.54
Shetland	55.4	45.8	5.32
Tayside	43.9	57.2	2.07
Western Isles	32.7	68.5	2.85

Figure 1 shows the mean D3MFT value for each Health Board and the 95% confidence interval associated with each mean. The size of the vertical error bars gives an indication as to the limited extent to which this figure can be used as a simple league table. Mean values which fall within neighbouring error bars are not statistically significantly different from one another. Nevertheless, there is still a wide variation in levels of oral health seen across Scotland's 15 Health Boards as is demonstrated both on Figure 1 and on the map of Scotland presented in Appendix L. Appendix M shows Scotland's poor level of oral health for 12 year olds in 1992/93 in comparison to that which was found in other areas of the UK using comparable survey methodology (Nugent, Pitts, 1997). National and local initiatives are urgently required to address this issue.

Figure 1

Mean number of decayed, missing and filled teeth (D3MFT) for each Health Board. (Decay defined as decay into dentine).

6.3 The Proportion "With Caries Experience" in each Health Board

The proportion of children "with caries experience" (D3MFT>0) in each Health Board is shown in Figure 2 and this again serves to demonstrate the uneven distribution of dental decay across Health Boards. Overall 57.6% of children were found to have already experienced dentinal decay, or had fillings or extractions as a result of decay. This varies from just over one-third of 12 year olds in Orkney "with caries experience" to over two-thirds of those in Greater Glasgow and the Western Isles.

Figure 2

Proportion of Children "with caries experience" (D3MFT > 0) in each Health Board. (Decay defined as decay into dentine).

Figure 3 shows the mean number of decayed, missing and filled teeth for those "with caries experience" (D3MFT>0) by Health Board, ordered as in Figure 1.

Figure 3

Mean number of decayed, missing and filled teeth (D3MFT) by Health Board, for children "with caries experience" (D3MFT > 0). Health Boards ordered as in Figure 1. (Decay defined as decay into dentine).

6.4 Teeth and Surfaces

Figure 4 demonstrates the distribution of caries experience by tooth and it can be seen that the vast majority of caries experience is concentrated on the first permanent molars (6s), which have experienced 75% of the disease. Table G1 in Appendix G gives the caries data, by surface, for each Health Board and includes the number of surfaces decayed (D3S), missing due to caries (MS), filled (FS), with fissure sealants ($S) and with sealant restorations (NS). Table G2 and Figure G3 clearly demonstrate that much of the disease experience, as well as being concentrated on the first permanent molars, is also largely to be found on the occlusal surfaces of the teeth.

Figure 4

Distribution of caries experience (D3MFT) by tooth. (Decay defined as decay into dentine).

6.5 Trends in Caries Prevalence

Figure 5 illustrates the trends in caries experience for children in Scotland between 1983 and 1997. The fall in D3MFT for 12 year olds between 1992 and 1996 might have been predicted from the data on 5 year olds in the 1980s, as caries experience in the primary dentition is known to be one predictor of caries experience in the permanent dentition (Todd, 1988). The children in this survey were aged 5 in 1989; the children in the 1992/93 survey were aged 5 in 1985. In 1985 the caries rates in 5 year old children were still above the level at which they have subsequently levelled out in the 1990s. By 1989 caries rates in 5 year olds had reached the level at which the fall of the 1980s came to a halt. Thus, children in this survey, who were aged 5 years in 1989, are the first adolescents who can be linked back to the lower caries rate achieved in 5 year olds by the end of the 1980s. As the children of the previous survey of 12 year olds came from a cohort with correspondingly higher rates of caries at age 5 in 1985 it is unsurprising that their caries rates at age 12 years were higher than in the present survey. This cohort effect is discussed further in section 7.

Figure 5

Trends in caries prevalence for Scottish children, 1983 to 1997. (Decay defined as decay into dentine).

The target for this age group for the year 2005 of an average D3MFT of 1.5 (SODoH, 1995) will be measured on children currently aged 4 years. The last survey of 5 year olds showed little change in caries experience from the early 1990s (Pitts, Nugent, Davies, 1996). Unless preventive action is taken now, for example by accessing those in need in order to implement the guidelines for provision of sealants (BSPD, 1993), those Health Boards currently not achieving the target level are unlikely to show marked improvement by 2005.

Figure 6 shows the trends in caries prevalence between the 1983 OPCS survey (Todd, Dodd, 1985) and the present survey of 12 year olds, showing overall mean values for D3MFT and mean values for those "with caries experience" (D3MFT>0). This figure demonstrates that, although overall caries experience has more than halved since 1983, less improvement has been seen for the unfortunate group of children who have caries experience with both the relative and absolute size of the difference between the two values increasing. In 1983 the value for those "with caries experience" (D3MFT>0) was 10% higher than the population value (a difference of 0.5 teeth). In 1996/97 the value is 74% higher and the difference has widened to 1.3 teeth. These children should be targeted to ensure that they receive appropriate preventive and restorative care.

Figure 6

Trends in caries prevalence for 12 year old Scottish children, overall mean values and mean values for those "with caries experience" (D3MFT > 0). (Decay defined as decay into dentine).

6.6 Distribution of Disease and the Care Index

Table 4 demonstrates the marked skew in disease experience found across the 12 year old population in Scotland. The mean D3MFT of 1.75 hides the fact that a minority of these children have the majority of the disease. Just over one-third of the children (37%) had 100% of the decayed surfaces, all of which could be considered, as they represent caries into dentine, to require restorative care. An unfortunate 7% of the population had 50% of the decayed surfaces. Table 5 shows the mean D3MFT for each Health Board, the Care Index and the mean D3MFT for those "with caries experience". The range for overall mean D3MFT is 0.74 to 2.32 whilst for those "with caries experience" it is 2.06 to 3.45 with a mean value of 3.04. These values show a small improvement from the values seen in the previous survey in which the mean D3MFT of those "with caries experience" was 3.26 (range 2.32 to 3.83). It can be seen from Figure 6 that the mean D3MFT of those "with caries experience" has changed at a slower rate than the overall D3MFT over the past 14 years.

The Care Index ([FT/DMFT]x100) gives an indication of the proportion of the caries experience which represents restoratively treated decay. This fell alarmingly from 71.7% in the 1988/89 survey (Pitts, Davies, 1989) to 48.6% in 1992/93 (Pitts, Fyffe, Nugent, Smith, 1993) and has shown a further decrease to 44.3% in the present survey (see Table 5). The 1990 General Dental Service (GDS) contract introduced a capitation system for the payment of dentists for the care of children within the GDS (Statement of Dental Remuneration, 1990). This payment system consisted of a weighted entry payment dependent on DMF level (as determined by their dentist) at the time of registration, and a monthly payment to cover all routine care provided by the practitioner. This contract has since been modified (Statement of Dental Remuneration, 1996) to include a fee-for-item payment for certain items of care such as restorative treatments and extractions and to remove the weighted entry payments. This may have a beneficial impact on the provision of essential restorative care in the future.

Table 4

Skewed distribution of decay. Decay defined as decay into dentine.

Proportion of Children	with	Proportion of Disease
2% of population	had	25% of decayed (D3) surfaces
7% of population	had	50% of decayed (D3) surfaces
37% of population	had	100% of decayed (D3) surfaces

All figures rounded to nearest 1%

Table 5

Mean D3MFT, Care Index (*CI) and D3MFT for those "with caries experience", by Health Board. Decay defined as decay into dentine.

Health Board	D3MFT	Rank	CI*	Rank	D3MFT for those with D3MFT > 0	Rank
Orkney	0.74	1	66.5	3	2.06	1
Borders	1.04	2	34.9	14	2.52	3=
Shetland	1.15	3	74.7	2	2.52	3=
Lothian	1.21	4	49.3	7	2.47	2
Forth Valley	1.23	5	46.6	8	2.88	9
Grampian	1.42	6	50.8	4	2.77	6=
Ayrshire and Arran	1.5	7	75.1	1	2.77	6=
Dumfries and Galloway	1.52	8	39.5	11	2.72	5
Tayside	1.64	9	49.9	5	2.87	8
Highland	1.75	10	27.9	15	3	10
Argyll and Clyde	1.89	11	45.5	9	3.16	11
Lanarkshire	2.09	12	43.7	10	3.28	13
Fife	2.19	13	36.8	12	3.45	15
Western Isles	2.22	14	49.5	6	3.24	12
Greater Glasgow	2.32	15	35.5	13	3.38	14
Scotland (weighted mean)	1.75	-	44.3	-	3.04	-

*CI=FT / D3MFT

6.7 Sealants/Sealant Restorations

The presence of fissure sealants and sealant restorations was also investigated for this sample of 12 year old children. Figure 7 shows the proportion of children with one or more sealant or sealant restoration, by Health Board. It can be seen that there are marked differences in the prevalence of sealants/sealant restorations across Scotland with just over a third of children having any "sealed" teeth in Borders (36.2%) but almost all 12 year old children having some "sealed" teeth in Orkney (93.9%). Table 2 shows that the proportion of children with one or more teeth with a sealant or sealant restoration is 54.2%. Table 3 gives the mean number of teeth with preventive fissure sealants, by Health Board, and again a wide variation can be seen across the country with 12 year olds in Dumfries and Galloway having a mean of 1.03 teeth with preventive fissure sealants and those in Shetland having a mean of 5.32 teeth treated in this manner.

Figure 7

Proportion of children with one or more sealant or sealant restoration in each Health Board.

Since the previous survey of 12 year old children in 1992/93 (Pitts, Fyffe, Nugent, Smith, 1993) all Health Boards have either decreased or remained static in terms of mean number of sealants per child with the exception of Orkney, Shetland and Ayrshire and Arran. Encouragement of provision of appropriate preventive care was one of the objects of the introduction of the capitation system of payment in 1990 (Coventry, Holloway, Lennon et al, 1989) which included preventive fissure sealants as one of the items which could be provided. Unfortunately it would seem that provision of fissure sealants by the General Dental Service (who provide the majority of care for the majority of children) has declined rather than increased during the period of the capitation payment system. As the modified capitation contract, introduced in September 1996 (Statement of Dental Remuneration, 1996) does not provide a fee-for-item payment for fissure sealants it is unlikely, in the absence of any other incentives, that the situation will improve in the near future.

In 1993 the British Society of Paediatric Dentistry introduced updated guidelines for the provision of fissure sealants (BSPD, 1993) which suggested that children in whom one first permanent molar had become decayed should have fissure sealants placed in the other 3 first permanent molars on eruption and that children with a high caries risk should have all 4 first permanent molars sealed on eruption. Approximately two-thirds of the children in Orkney and Shetland had 4 or more sealed teeth, but in all other Health Boards less than a third of children had 4 or more sealants. Fissure sealants provide a proven method of preventing decay on the occlusal surfaces of molar and premolar teeth, and although "Scottish" dentists have been demonstrated to have adopted fissure sealants more readily than their counterparts in other parts of the UK (Nugent, Pitts, 1997) it may be that the treatment has not been targeted appropriately (BSPD, 1993) (although many factors, such as sealant loss, have to be considered).

Overall the provision of fissure sealants has decreased and it is worth noting from Figure 3 that the areas which have been providing fissure sealants have also been providing restorative care, as those with D3MFT>0 in Orkney, Shetland and Ayrshire and Arran had lower levels of untreated disease than were found in other Boards. It should also be noted that in the Island areas, unlike on the mainland, the bulk of care is provided by the salaried Community Dental Service.

What may be required are the establishment of local initiatives in order to provide this proven preventive therapy to the children who are most in need of it. One example of a local health initiative which appears to have had positive benefits is the sealant programme undertaken on Orkney where the mean D3MFT has dropped from 1.14 in the previous survey to 0.74 in the present survey, with over 90% of 12 year olds examined having been provided with fissure sealants.

6.8 Oral Cleanliness

Oral cleanliness was assessed (as in 1992/93) by recording the presence of plaque on six index teeth (UR6, UR1, UL6, LR6, LL1, LL6). The results, by Health Board, for the oral cleanliness assessment are given in Appendix I, Table I1.

6.9 Assessment of Developmental Defects of Enamel

Developmental defects of enamel have, this year, been assessed using the latest version of the SCOTS Modification of the Developmental Defects of Enamel Index (SCOTS2). Detailed results can be found in Appendix J, Tables J1 - J3. One slight modification which has been made, since the 1992/93 survey, in the development of SCOTS2 is that the children were asked to complete a questionnaire, designed for use with DDE and the orthodontic assessment, which asked how the children felt about the appearance of their teeth. This questionnaire replaced the original, single, SCOTS question (Do you have any marks on your teeth which will not brush off?) in an attempt to elicit whether or not the children with developmental defects of enamel were either aware of them or concerned about their presence.

6.10 Orthodontic Assessment

A simplified (BASCD version) of the "IOTN" assessment of orthodontic treatment need was reintroduced for 12 year olds in this survey, a full version having been used in the 1988/89 survey of 12 year olds (Pitts, Davies, 1989), but not the 1992/93 survey (Pitts, Fyffe, Nugent, Smith, 1993). The Index of Orthodontic Treatment Need (IOTN) consists of two separate components, an aesthetic component (which determines the level of need for orthodontic treatment on aesthetic grounds) and a dental health component (which determines the level of need for orthodontic treatment on dental health grounds). Detailed results are presented in Appendix K, Table K1. The Table provides an indication of the prevalence of malocclusions, by Health Board and includes, for those recorded as having an orthodontic treatment need, the children's opinion as to whether they would like their teeth straightened (gleaned from the questionnaire data).

7 The Future

The change in the General Dental Service contract in September 1996 (Statement of Dental Remuneration, 1996), whilst having the potential to improve the Care Index (percentage of caries experience which has been treated restoratively), will, on its own, do nothing to improve the level of dental caries experience as measured by the unweighted D3MFT index.

The Oral Health Strategy for Scotland (SODoH, 1995) target for 12 year olds for the year 2005 is a mean D3MFT of 1.5. The progress needed to achieve this is shown by the lower (solid) line on the right hand side of Figure 8. At first sight this would appear achievable as all it requires is a continued downward trend at a lower rate than that which has been achieved over the past decade. However, this takes no account of the known curtailment in improvement that has been experienced in the 5 year old population.

Figure 8

The Future? Predicting trends in caries prevalence - the cohort effect. (Decay defined as decay into dentine).

Linking results for each age cohort across the 7 year gap between the ages of 5 and 12 years (marked as cohorts A, B and C on Figure 8) shows that a more pessimistic outlook must be faced, as illustrated by the higher (dashed) line on the graph. The children who will be 12 years old at the next SHBDEP survey of this age group (cohort C) were aged 5 years in 1993/94. The 1993/94 result is recognised as possibly being artificially high (due to criteria changes and sampling variation - Pitts, Fyffe, Nugent, 1994; Pitts, Nugent, Davies, 1996) but considering the general trend of results for 5 year olds, it seems unlikely that either the year 2000 or the year 2005 will witness any great improvement in 12 year olds' caries status as measured by the DMF Index unless more effort is made now, with today's primary school children, to safeguard the status of permanent molar teeth as they erupt.

Whilst it must be acknowledged that prediction is an inexact science, it seems that the results of this survey can be taken as advance warning that the year 2005 target may not be met without further positive preventive action. This illustrates the essential role of this programme of surveys in monitoring the dental health of Scottish school children.

Acknowledgements

The Co-ordinating Committee, the authors and the Dental Health Services Research Unit are indebted to all the children, who took part in the survey, and to their parents. Special thanks go to Mr D Bader, Rector of Perth Grammar School, and to the staff and pupils for accommodating the 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 Scottish Health Boards for their financial support for the programme and to the Chief Scientist Office of the Scottish Office Department of Health 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.

The opinions expressed in this Report are those of the authors and are not necessarily shared by the Scottish Office.

References

British Society of Paediatric Dentistry. A policy document on fissure sealants. International Journal of Paediatric Dentistry 1993; 3: 99-100.

Coventry P, Holloway PJ, Lennon MA, Mellor AC and Worthington HV. A trial of a capitation system of payment for the treatment of children in the General Dental Service. Community Dental Health 1989; 6: Supplement 1.

Nugent ZJ and Pitts NB. Patterns of change and results overview 1985/1986-1995/1996 from the British Association for the Study of Community Dentistry (BASCD) coordinated National Health Service surveys of caries prevalence. Community Dental Health 1997; 14: 30-54.

Pitts NB, Binnie V, Gerrish AC, Mackenzie NM and Watkins TR. Scottish Needs Assessment Programme Report - Dental Caries in Children. Scottish Forum for Public Health Medicine: Glasgow, 1994.

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Watkins TR and Pitts NB. Scottish Health Boards' Dental Epidemiological Programme Protocol. 1994/95 version. Stirling, 1994.

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