“By creating we think, by living we learn” Patrick Geddes
Prepared by:
NB Pitts, ZJ Nugent and P A Smith
Dental Health Services Research Unit, University of Dundee
Published by:
University of Dundee
Dental Health Services Research Unit
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| 1 | Introduction | |
| 2 | Sampling | |
| 3 | Training and Calibration | |
| 4 | Dental Examinations | |
| 5 | Data Processing | |
| 6 | Results and Discussion | |
| 6.1 | Dental Caries Results for Scotland | |
| 6.2 | Dental Caries Experience by Health Board 5 | |
| 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 | |
| 6.11 | Inequalities in Dental Health | |
| 6.12 | The Future | |
| 1 | Number of children examined by Health Board |
| 2 | Results for caries experience for Scotland |
| 3 | Results for caries experience for each Health Board |
| 4 | Skewed distribution of decay |
| 5 | Mean DMFT, Care Index and DMFT for those with "caries experience", by Health Board |
See also List of Tables on Appendices page.
| 1 | Mean number of decayed, missing and filled teeth, by Health Board |
| 2 | Proportion with "caries experience" by Health Board |
| 3 | Distribution of caries experience by tooth |
| 4 | Trends in caries prevalence for Scottish children, 1983-1999 |
| 5 | Proportion of children with sealants/sealant restorations, by Health Board |
| 6 | Proportion of children "free" of caries experience by DEPCAT score |
See also List of Figures on Appendices page.
This programme of surveys is undertaken under the auspices of the Consultants in Dental Public Health and Chief Administrative Dental Officers (CDPH/CADOs Group) and is a joint venture between all fifteen Scottish Health Boards and the Chief Scientist Office's Dental Health Services Research Unit based at the University of Dundee.
The results contained in this report have been obtained as a result of the unstinting efforts of a large team of people from all over Scotland to whom the organisers are very grateful. Appendix A lists the participants.
| Argyll and Clyde | Greater Glasgow |
| Ayrshire and Arran | Highland |
| Borders | Lanarkshire |
| Dumfries and Galloway | Lothian |
| Fife | Orkney |
| Forth Valley | Shetland |
| Grampian | Tayside |
| Western Isles |
British Association for the Study of Community Dentistry (BASCD) Dental Epidemiology Programme.
This Report has been prepared for those interested in the detailed results of the 1998/99 survey. Readers seeking only a brief overview are referred to the Executive Summary. Key results and discussion are included in the body of the Report whilst further results and analyses can be found in the Appendices, printed on blue paper at the end of the Report.
This is the third survey of the dental health of 14 year old children which has been undertaken in the Scottish Health Boards' Dental Epidemiological Programme (SHBDEP). This series of annual examinations of key age groups in Scotland is organised via the Consultants in Dental Public Health and the Chief Administrative Dental Officers Group (CDPH/CADOs Group) and the Chief Scientist Office's Dental Health Services Research Unit (DHSRU) at the University of Dundee, as a joint venture with all fifteen Scottish Health Boards.
Standardised dental surveys are undertaken on randomly selected children across Scotland. The core timetable and criteria for age groups recommended by the British Association for the Study of Community Dentistry (BASCD) are followed (Mitropoulos, Pitts & Deery, 1992; Pitts (ed) 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 allows comparison of the results for Scotland with other parts of the UK.
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) in 14 year olds in Scotland. Assessments were also made of levels of oral cleanliness, the presence of developmental defects of enamel, orthodontic treatment needs and the impact of defects and malocclusions as perceived by the children's claimed satisfaction with the appearance of their teeth. In addition, in keeping with one of the Government's objectives for the nation's wellbeing of reducing inequalities in health (Scottish Office, 1999), the impact of deprivation on the dental health of young adolescents in Scotland is illustrated.
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 III population. The sample sizes utilised provide adequate numbers to allow inter-Board comparisons to be drawn.
The training and calibration courses for this year's survey of 14 year olds were held in Perth immediately prior to the start of the survey examinations. The courses were organised by Mr MCW Merrett of Tayside Health Board in collaboration with the Dental Health Services Research Unit, who provided the training and calibration elements. Details of the courses can be found in Appendix B and the results of the inter-examiner agreement from the calibration (Table C1) are located in Appendix C.
The examinations took place between October 1998 and March 1999, a longer period then is usual due to examiner illness. Table 1 shows the number of children sampled and examined in each Health Board and the proportion of the Secondary III population examined. Overall, 5981 children were examined, representing 10.1% of the Secondary III population, a marginally higher percentage than for the last 14 year olds survey. During the course of the survey a random 10% of subjects were re-examined to allow assessment of intra-examiner agreement (see Appendix C, Table C2).
In order to adhere to BASCD guidelines and international epidemiological criteria, figures for decay (D3) only record dental decay (caries) which clinically appears to have reached dentine. Less severe manifestations of the disease, such as decay confined to the enamel surface of teeth, are recorded as "sound". As in all such studies no additional diagnostic aids (such as radiographs) were employed.
Data processing, analysis and reporting were undertaken by the Dental Health Services Research Unit, University of Dundee.
The format of this Report is broadly similar to that of the last 14 year old survey in 1994/95 but with the results and discussion dovetailed. Key results, tables and figures relating to dental caries are included in the main text of the Report. Appendix D gives a comparison of D3MFT and D3S in 1994/95 and 1998/99 while Appendix E contains more detailed caries results. All results relate to the permanent dentition only.
Appendices F, G, H and I contain, respectively, detailed tables and figures of results relating to dental trauma, oral cleanliness, developmental defects of enamel and orthodontic assessment. Details of the codes used in assessment of caries and sealants and the abbreviations used for the Health Boards can be found in Appendices J and K.
Table 2 shows overall results for Scotland for the mean number of decayed (D3), missing (M) and filled (F) permanent teeth, and information about the presence of fissure sealants and sealant restorations. 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 employed in clinical practice (Pitts et al, 1998).
| Table 2 Overall D3MFT results for Scotland, incorporating the data from the fifteen Scottish Health Boards, appropriately weighted. | ||||
| Weighted mean | Range of means for individual Health Boards | |||
| age (in years) | 14.25 | 13.78 | - | 14.35 |
| "sound" teeth (code G) | 22.0 | 19.5 | - | 23.6 |
| "sound" plus sealed teeth (code G,$) | 24.1 | 23.3 | - | 25.4 |
| sealants / sealant restorations (code N,$) | 2.06 | 1.15 | 5.90 | |
| decayed teeth (D) | 0.91 | 0.46 | - | 1.87 |
| missing teeth (M) | 0.28 | 0.08 | - | 0.41 |
| filled teeth (F) | 1.56 | 0.63 | - | 2.18 |
| DFT (D+F) | 2.47 | 1.24 | - | 3.13 |
| DMFT (D+M+F) | 2.75 | 1.34 | - | 3.47 |
| % | Range for Health Boards | |||
| With caries "experience" DMFT >0 as per | 67.9 | 47.6 | - | 76.6 |
| Without caries "experience" DMFT=0 | 32.1 | 23.4 | - | 52.4 |
| With dentinal decay DT >0 | 37.6 | 20.4 | - | 54.9 |
| % children with 1 or more sealants/sealant restoration* | 56.4 | 38.7 | - | 94.4 |
Teeth with N or $, otherwise "sound"
The mean D3MFT of 2.75 shows an improvement over the figure of 3.14 in the last 14 year old survey in 1994/95 (Pitts, Fyffe & Nugent, 1995). However, it still represents a poorer level of oral health than that found in Great Britain as a whole (D3MFT=1.85) at the last UK survey in 1994 and indeed for the previous survey in 1990 (D3MFT=2.35), (Nugent & Pitts, 1997). A comparison with England where the figure was 1.67 in 1994 is even more stark.
Also shown in Table 2 are different ways to group 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 "caries experience" (D3MFT>0), is given in accordance with BASCD guidelines. Thirdly, the results are expressed as the proportion of children with dentinal "decay" (D3T>0) at the time of the survey examinations. This demonstrates the proportion of children suffering from the level of untreated decay which most dentists would agree requires restorative care (ie a filling). In the present survey more than a third of the children examined fell into this category.
Concern has been expressed in previous surveys at the low levels of restorative care provided for Scottish children, shown by the F component, which has fallen from a mean value of 1.62 in 1994/95 to 1.56 in this survey. This 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 restorations. This has dropped from 67.1% in the last 14 year old survey to 56.4%. Provision of sealants is further discussed in section 6.7.
Table 3 shows the dental caries results for the children in each Health Board. It gives an overall measure of caries experience (D3MFT), a breakdown of this index into its component parts (D3 , M and F) and the percentage of children with "caries experience" (D3MFT>0). Also given is a figure for the mean number of fissure sealants per child ($) for each Health Board.
The variation in disease observed in previous SHBDEP surveys remains a feature this year. The mean D3MFT levels of 3.42 and 3.47 for Highland and Greater Glasgow are more than double the levels experienced in Orkney (1.34) and Borders (1.41). It is of note that in only one Health Board (Orkney) has there been an increase in the mean number of sealed teeth since 1994/95. In all other boards numbers have either remained largely unchanged or have fallen below those previously recorded.
| Table 3 Mean values per child for decayed (D3), missing (M), filled (F) and sealed ($) teeth; percentage with "caries experience" (D3MFT>0) [decay defined as caries into dentine]. | |||||||
| Health Board | D | M | F | DFT | DMFT | % DMFT>0 | $ |
| Argyll & Clyde | 0.78 | 0.36 | 1.71 | 2.49 | 2.85 | 71.3 | 2.30 |
| Ayrshire & Arran | 0.46 | 0.29 | 1.70 | 2.16 | 2.45 | 64.5 | 1.98 |
| Borders | 0.50 | 0.08 | 0.84 | 1.33 | 1.41 | 47.6 | 1.14 |
| Dumfries & Galloway | 0.70 | 0.28 | 1.47 | 2.17 | 2.45 | 65.0 | 1.61 |
| Fife | 0.79 | 0.29 | 1.96 | 2.75 | 3.04 | 71.1 | 2.02 |
| Forth Valley | 0.51 | 0.14 | 1.20 | 1.71 | 1.85 | 51.7 | 2.75 |
| Grampian | 0.59 | 0.34 | 1.22 | 1.82 | 2.16 | 57.9 | 1.28 |
| Greater Glasgow | 1.24 | 0.41 | 1.83 | 3.06 | 3.47 | 76.4 | 1.85 |
| Highland | 1.87 | 0.30 | 1.25 | 3.12 | 3.42 | 75.3 | 2.78 |
| Lanarkshire | 1.09 | 0.21 | 2.04 | 3.13 | 3.34 | 76.6 | 2.09 |
| Lothian | 0.88 | 0.19 | 0.99 | 1.87 | 2.05 | 61.1 | 1.80 |
| Orkney | 0.60 | 0.11 | 0.63 | 1.24 | 1.34 | 48.6 | 3.95 |
| Shetland | 0.53 | 0.08 | 1.21 | 1.74 | 1.82 | 54.0 | 5.84 |
| Tayside | 1.08 | 0.26 | 1.55 | 2.63 | 2.88 | 70.1 | 2.35 |
| Western Isles | 0.69 | 0.21 | 2.18 | 2.87 | 3.08 | 73.0 | 3.58 |
Figure 1 shows the mean D3MFT values for each Health Board and the confidence intervals associated with each mean value. The size of the vertical error bars determines the very limited extent to which the figure can be interpreted as a simple "league table". Differences in the means which fall within the limits of neighbouring error bars are not significant. The same data are presented in the form of a map in Appendix L, Figure L2. Appendix M shows Scotland's poor level of oral health in comparison with the rest of the UK at the time of the last survey. The proportion of children with "caries experience" (D3MFT > 0) in each Health Board is shown in Figure 2 once more demonstrating the uneven spread of dental decay across Health Boards. Overall, 67.9% of children in this age group were found to have already experienced dental decay, or had fillings or extractions as a result of decay. This varied from less than half of 14 year olds in Orkney and Borders having "caries experience" to more than three quarters in Greater Glasgow, Highland and Lanarkshire.
Figure 1
Mean number of decayed, missing and filled teeth (D3MFT) per child, for each Health Board (decay defined as decay into dentine)
Figure 2
Proportion of children with "caries experience" (D3MFT>0) in each Health Board (decay defined as decay into dentine).
Figure 3 demonstrates the distribution of caries experience by tooth. It can be seen that the majority of caries experience was found in the first permanent molars (6s) which had suffered 58% of the disease with a further 20% found in the more recently erupted second permanent molars (7s). Appendix E gives the results for each Health Board broken down to tooth surface level. Table E1 gives the number of decayed, missing, filled and sealed surfaces and the number of surfaces with sealant restorations by Health Board. The distribution of decay by tooth surface (mesial, occlusal, distal, buccal, lingual) is presented in Table E2. Figure E1 gives a graphical representation of the decay experience (D3 and F) by surface. Details of the levels of dental trauma recorded are contained in Appendix F.
Figure 3
Distribution of dentinal decay and past caries experience by tooth (combined totals from fifteen Health Boards, appropriately weighted)
As can be seen in Figure 4, the modest fall in mean D3MFT between 1990/91 and 1994/95 has been sustained in the most recent 4-year period (Davies & Pitts, 1991; Pitts, Fyffe & Nugent, 1995). Although this is an encouraging improvement, it must be remembered that the current levels of caries are still higher in Scotland than those seen in England, and the plateau of no-improvement seen with the 5 year olds may be observed later as these younger cohorts of children move towards age 14. Figure D1 in Appendix D shows that against a trend of improvement, mean D3MFT values rose in two Health Board areas (Argyll & Clyde and Highland) although the increases were not statistically significant.
Trends in caries prevalence for Scottish children, 1983 - 1999.
Table 4 displays the marked skew in disease experience found across the 14 year old population in Scotland. Behind the mean D3MFT value of 2.75 lies the fact that a minority of children have the majority of the disease. An unfortunate 6% had half of the decayed surfaces compared with the figure of 8% in the last survey of this age group.
| Table 4 Skewed distribution of decay (decay defined as caries into dentine). | ||
| Proportion of Children | with | Proportion of Disease |
| 1% of Population | had | 10% of untreated decayed surfaces (D3S) |
| 2% of Population | had | 25% of untreated decayed surfaces (D3S) |
| 6% of Population | had | 50% of untreated decayed surfaces (D3S) |
| 38% of Population | had | 100% of untreated decayed surfaces (D3S) |
Table 5 shows the mean D3MFT for each Health Board, the Care Index and the mean D3MFT for those "with caries experience". The boards are rank ordered on the basis of ascending D3MFT values.
The Care Index ([FT/D3MFT]x100%) gives an indication of the proportion of the caries experience which represents restoratively treated decay. Overall, this shows a modest rise since the last survey from a figure of 51.7 to 56.7. This may be a reflection of the re-introduction of fee for item of treatment in the revised dental contract of 1996 but it may be too soon to tell if the hoped-for beneficial impact of this change has affected the provision of essential restorative care. Most Health Boards lie in the 50-70 band but Highland remains particularly low at 36.5, almost half the level in Western Isles or Ayrshire & Arran.
Table 5 Mean D3MFT, Care Index (CI) and D3MFT for those with caries experience (D3MFT>0), by Health Board (decay defined as decay into dentine).
| Health Board | D3MFT | RANK | CI | RANK | D3MFT for those with D3MFT>0 | RANK |
| Orkney | 1.34 | 1 | 47.2 | 14 | 2.76 | 1 |
| Borders | 1.41 | 2 | 59.4 | 9 | 2.97 | 2 |
| Shetland | 1.82 | 3 | 66.5 | 3 | 3.38 | 4 |
| Forth Valley | 1.85 | 4 | 65.0 | 4 | 3.58 | 5 |
| Lothian | 2.05 | 5 | 48.1 | 13 | 3.36 | 3 |
| Grampian | 2.16 | 6 | 56.6 | 10 | 3.74 | 6 |
| Ayrshire & Arran | 2.45 | 7 | 69.4 | 2 | 3.79 | 8 |
| Dumfries & Galloway | 2.45 | 8 | 60.0 | 7 | 3.76 | 7 |
| Argyll & Clyde | 2.85 | 9 | 59.9 | 8 | 4.00 | 9 |
| Tayside | 2.88 | 10 | 53.7 | 11 | 4.11 | 10 |
| Fife | 3.04 | 11 | 64.6 | 5 | 4.27 | 12 |
| Western Isles | 3.08 | 12 | 70.6 | 1 | 4.22 | 11 |
| Lanarkshire | 3.34 | 13 | 61.2 | 6 | 4.37 | 13 |
| Highland | 3.42 | 14 | 36.5 | 15 | 4.54 | 14 |
| Greater Glasgow | 3.47 | 15 | 52.7 | 12 | 4.54 | 15 |
| Scotland | 2.75 | 56.7 | 4.06 |
Figure 5 shows the proportion of 14 year old children in each Health Board with one or more sealant or sealant restoration in the permanent dentition. A wide variation remains between the various Health Boards ranging from less than half of the 14 year olds in Borders, Grampian and Dumfries & Galloway having had this treatment to almost total coverage in Orkney and Shetland. Overall, the proportion children with sealants in Scotland has fallen from 67.1% in 1994/95 to 56.4% in this year's survey. There was a decline in all the Health Boards barring Orkney and Shetland, although the drop in Grampian and Western Isles was minimal. The SIGN (Scottish Intercollegiate Guidelines Network) guideline on targeted caries prevention for 6 -16 year olds (SIGN, in press) has reviewed the literature and scientific evidence supporting the use of fissure sealants. It has found them to be an effective caries preventive measure when applied according to a protocol (Murray & Nunn, 1993) and maintained over time (Deery et al, 1997).
Figure 5
The proportion of children with one or more sealant or sealant restoration in each Health Board
Oral cleanliness was assessed (as in 1994/95) 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 G, Table G1.
Developmental defects of enamel were assessed using the SCOTS modification of the Developmental Defects of Enamel Index (SCOTS2). Also included were two questions relating to the children's self-perception of any marks on their teeth. Detailed results can be found in Appendix H, Tables H1 - H3.
A simplified version of the Index of Orthodontic Treatment Need (IOTN), an assessment of orthodontic treatment need, was used in this survey. The index consists of two 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 on dental health grounds). A short questionnaire was also administered to elicit the children's satisfaction with the appearance of their teeth, their willingness to wear a brace and the level of unmet subjective treatment need. Further details of the methodology can be found in Appendix I, with results in Tables I1 - I3.
A clear link between postcode-related measures of social deprivation and caries in children has previously been established (Pitts & Nugent, 1995). Addenda investigating this relationship were produced in conjunction with recent reports (Sweeney et al 1996 & 1998) and a section dealing with this topic was introduced into the main body of the report last year. Figure 6 graphically illustrates the gulf between 14 year old children who live in the most deprived areas (DEPCAT 7) and their more fortunate contemporaries residing in DEPCATs 1 and 2. Almost four times as many of the latter are "free" of caries experience (D3MFT=0) compared with children from DEPCAT 7.
Figure 6
The proportion "free" of caries experience (D3MFT=0) by DEPCAT score.
The dental health of young Scottish adolescents still lags behind most of the United Kingdom, as illustrated by the map in Figure M1, Appendix M, based on results from the 1994/95 survey (data is not yet available for England and Wales for 1998/99).
The D3MFT results from this year's survey indicate a slight decrease in caries levels since the last survey, which mirrors the drop between 1991 and 1995. The rate of progress therefore remains very slow and further measures need to be taken if this is to be speeded up and the plateau observed in the five year old surveys avoided. The impact of deprivation is severe on the dental health of 14 year olds and a desire to tackle this and the skewed nature of the distribution of dental disease is at the core of the Government's strategy to improve the nation's dental and oral health. Fluoridation of the water supply has been accepted as the most effective way of tackling the problem, particularly with regard to those living in disadvantaged circumstances and it is hoped that the measures outlined in the recent white paper, "Towards a Healthier Scotland" (Scottish Office, 1999), will facilitate the speedy introduction of this proven caries preventive measure. In parallel to this process, the Government's proposed prevention from birth programme, linked in with the "Starting Well" initiative, is a positive move which recognises the importance of early intervention. It will take some time for the benefits of this approach to be observed in young adolescents but, in tandem with the fluoridation proposals, it offers a prospect of improved dental and oral health to Scottish children. However, it must be stressed that continued monitoring is essential in order that the impact of these proposals can be assessed.
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, the Rector of Perth Grammar School, and the staff and pupils, for accommodating the essential training and calibration exercises.
Thanks also go to the Community Dental Officers and Dental Surgery Assistants who undertook the fieldwork as examining teams (see Appendix A); to the fifteen Health Boards for their financial support of the Programme and to the Chief Scientist Office of the Scottish Office who fund the Dental Health Services Research Unit. The authors would also like to acknowledge the willing support given by their colleagues at the Dental Health Services Research Unit.
The DHSRU is funded by the Chief Scientist Office of the Scottish Office and is part of the MRC Health Services Research Collaboration. The opinions expressed in this report are those of the authors and are not necessarily shared by the Scottish Office or the Medical Research Council.
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Deery C, Fyffe HE, Nugent ZJ, Nuttall NM, Pitts NB Integrity, maintenance and caries susceptibility of sealed surfaces in adolescents receiving regular care from general dental practitioners in Scotland. International Journal of Paediatric Dentistry 1997;77:75-80
Mitropoulos C, Pitts NB & Deery C. BASCD Trainer's Pack for Caries Prevalence Studies 1992/93. University of Dundee, 1992.
Murray JJ & Nunn J. British Society of Paediatric Dentistry: a policy document on fissure sealants. International Journal of Paediatric Dentistry 1993; 3: 99-100.
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Scottish Office Towards a Healthier Scotland - A White Paper on Health.Scottish Office, 1999.
Sweeney P, McColl D, Nugent ZJ, Davies JA. Deprivation and Dental Caries. A collaborative pilot study undertaken by Argyll & Clyde Health Board and Dental Health Services Research Unit, University of Dundee, based on results from the Scottish Health Boards' Dental Epidemiological Programme, 1995/96, survey of 5 year old children. University of Dundee, 1996.
Sweeney P, Allison D, Davies JA, Pitts NB. Deprivation and Dental Caries Among 12 year old children in Scotland. University of Dundee, 1998.
Todd JE & Dodd T. Children's Dental Health in the United Kingdom, 1983. London: HMSO, 1985.
Watkins TR & Pitts NB. Scottish Health Boards' Dental Epidemiological Programme. Protocol. 1994/95 Version. Stirling, 1994.
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