Publications
Scottish Health Boards' Dental Epidemiological Programme (SHBDEP)
Report of the 1999-2000 Survey of 5 Year old Children
Prepared by:
NB Pitts, ZJ Nugent and PA Smith
Dental Health Services Research Unit, University of Dundee
Published by University of Dundee
ISBN 1 899809 11 3
2000
Table of Contents
- Executive Summary [New web page]
- Index to Report
- Appendices [New web page]
- The Programme
- Participating Health Boards
- Co-ordinating Committee
- List of Tables
- List of Figures
Return to Publications index page.
Index to Report
| 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 | |
| 6.3 | The Proportion "Free" of Caries Experience in each Health Board | |
| 6.4 | Tooth and Surface Results | |
| 6.5 | Trends in Caries Prevalence | |
| 6.6 | Skewed Distribution of Disease | |
| 6.7 | Oral Cleanliness | |
| 6.8 | Deprivation | |
| 7 | The Future | |
List of Tables
| 1 | Number of children examined |
| 2 | Results for caries data for Scotland |
| 3 | Results for caries data for each Health Board |
| 4 | Skewed distribution of decay |
| 5 | Levels of disease and severe morbidity in those with disease |
See also List of Tables on Appendices page.
List of Figures
| 1 | Decayed, missing and filled teeth by Health Board |
| 2 | The proportion "with caries experience" by Health Board |
| 3 | Distribution of d3mf around the mouth |
| 4 | Distribution of d3 and f by surface |
| 5 | Trends in caries results for 5 - year - old Scottish children |
| 6 | Progress towards the National Target |
| 7 | Progress towards the National Target by DEPCAT score |
See also a List of Figures on the Appendices page.
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 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 MCW Merrett(1) | Calibration Course Organiser |
| Professor NB Pitts(2,3) | Calibration and Results Co-ordinator |
| Professor KW Stephen | Adviser |
| Mr G Ball | Chairman, CDPH/CADO Group |
| Miss MM Taylor | Representative of Consultants in Dental Public Health |
British Association for the Study of Community Dentistry (BASCD) Dental Epidemiology Programme
1 Service Co-ordinator, BASCD Dental Epidemiology Programme in Scotland
2 Scientific Co-ordinator, BASCD Dental Epidemiology Programme in Scotland
3 Scientific Co-ordinator, BASCD UK Dental Epidemiology Programme
1 Introduction
This Report has been prepared for those interested in the detailed results of the 1999/2000 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 seventh survey of the dental health of 5 year old children 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 Chief Administrative Dental Officers and Consultants in Dental Public Health Group (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 15 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 those of other parts of the UK.
The results of these biennial surveys of 5 year olds, which commenced in 1987, are crucial for monitoring levels of dental health. They illustrate the limited progress achieved since 1991 when the National Target for this age-group (60% of 5 year olds "free" of caries experience by the year 2000) was originally set. The failure to be on track for meeting this target was recognised by the government in 1999 when the target date was extended to 2010 and a series of measures aimed at tackling this lack of improvement was announced (Towards a Healthier Scotland, 1999). The SHBDEP Reports remain an essential source of information for monitoring any improvements in dental health which may result from these government initiatives and due to the rich, historical nature of the data bank are able to forecast trends and assist in planning services.
The aim of this year's survey was to determine current levels of tooth decay, to obtain a simple population measure of the level of oral cleanliness and to illustrate the impact of deprivation on the dental health of five year old children in Scotland.
2 Sampling
As outlined in the SHBDEP Protocol document (Watkins & Pitts, 1994), each 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 Primary 1 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 were held immediately prior to the survey examinations. The courses were held in Perth; the organisation was undertaken by Mr MCW Merrett of Tayside Health Board while the training and calibration elements were provided by the DHSRU. Details of the courses can be found in Appendix B of the Report. Table C1 in Appendix C details the inter-examiner agreement recorded at the calibration sessions. Mean Kappa scores for teeth and surfaces fall in the range of "substantial agreement" as defined by Landis and Koch (1977) and are generally within the required range given in the BASCD guidelines for examiner calibration (Pine, Pitts & Nugent, 1995). One potential examiner was excluded having failed to calibrate.
4 Dental Examinations
The dental examinations took place in November and December 1999 and January 2000. Table 1 shows the number of children sampled in each Board. A total of 6,994 children (89% of the sample) were examined; this represents 11.8% of the Primary 1 population, a slight increase from 1997. The percentage of the Primary 1 population seen this year varied from 6.6% to 91% across the Health Boards. During the course of the survey 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 of children in the sample, number and percentage examined and Primary 1 population in each Health Board. | ||||
| Health Board | Sample | Examined | Examined as % of Population | Primary I Population |
| Argyll & Clyde | 549 | 499 | 9.8 | 5094 |
| Ayrshire & Arran | 333 | 288 | 6.6 | 4338 |
| borders | 307 | 254 | 23.0 | 1105 |
| Dumfries & Galloway | 247 | 221 | 12.7 | 1735 |
| Fife | 462 | 379 | 9.2 | 4126 |
| Forth Valley | 318 | 284 | 8.6 | 3312 |
| Grampian | 927 | 825 | 13.6 | 6085 |
| Greater Glasgow | 1255 | 1143 | 10.6 | 10797 |
| Highland | 415 | 381 | 15.2 | 2507 |
| Lanarkshire | 648 | 556 | 8.3 | 6673 |
| Lothian | 812 | 740 | 8.8 | 8444 |
| Orkney | 248 | 232 | 91.0 | 255 |
| Shetland | 278 | 252 | 82.1 | 307 |
| Tayside | 897 | 797 | 18.5 | 4301 |
| Western Isles | 159 | 143 | 48.5 | 295 |
| All Scotland | 7855 | 6994 | 11.8 | 59374 |
To adhere to BASCD guidelines and international epidemiological conventions, figures presented for "decay" only relate to dental caries which clinically appears to have penetrated dentine (d3). Less severe manifestations of decay, such as that which appears to be confined to enamel, are recorded as "sound" (see Appendix D).
In order to improve comparability of results across Regions and Countries and because of changes in the presentation of disease, the definition of decay used by BASCD was re-specified in 1991/92 to include lesions in which the disease process had obviously penetrated dentine despite there being no obvious cavitation (a "closed" cavity). This evolutionary change in criteria was introduced in order to prevent systematic underestimation of dentinal caries prevalence as a result of the changing manifestation of the disease process. The impact of this change was discussed in detail in Appendix J of the 1993/94 Report (Pitts, Fyffe & Nugent,1994).
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 1997/98 Report with a new Appendix on the prevalence of abscesses (Appendix F). Key results, tables and figures relating to dental caries are included in the main body of the Report. The abbreviations used for the Health Boards in the figures are given in Appendix E. Comparison of Health Board results with those from the previous survey are given in Appendix G; more detailed results using the tooth surface as the unit for measurement can be found in Appendix H; results for oral cleanliness (plaque) are in Appendix I and maps showing the distribution of disease levels across the UK and Scotland are in Appendix J. All results relate to the deciduous dentition only.
6.1 Dental Caries Results for Scotland
Table 2 shows the overall results for Scotland for decayed (d3), missing due to caries (m) and filled (f) deciduous teeth. The decay component has been subdivided as follows: arrested dentinal caries (C1); dentinal lesions (C2 - including both "open" and "closed" cavities); unrestorable decay (C3 - a code employed by the examiners to signify advanced disease approaching the pulp which renders the tooth in need of either extraction or endodontic tretatment). It should be appreciated that dental caries is measured at different levels in epidemiological surveys and clinical practice (SNAP report on Dental Caries in Children - Pitts et al, 1994 & 1998).
The overall mean estimate of caries experience (d3mft) in 5 year olds in Scotland of 2.55 teeth per child is considerably higher than the corresponding values recorded recently for Great Britain or for the United Kingdom as a whole. The BASCD survey of 5 year olds across the UK conducted in 1997/98 (Pitts,Evans and Nugent 1999) produced overall means for d3mft of 1.64 (Great Britain) and 1.68 (UK) with 'regional' means ranging from 1.02 to 2.92. Results from the UK Survey of Children's Dental Health in 1993 (O'Brien, 1994) indicated that, for 5 year olds in the UK, the estimate of total caries experience for deciduous teeth (d3mft) was 2.0. Themap reproduced as Figure J1 in Appendix J demonstrates the marked geographical variation in caries levels and Scotland's unsatisfactory position relative to other areas in 1997/98 (1999/2000 results for England and Wales will not be available until March 2001).
| Table 2: Overall d3mft results for Scotland,incorporating data from the fifteen Health Boards, appropriately weighted(decay defined as decay into dentine). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| * National Target for the year 2010=60% | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The overall value for the proportion of the sample "free" of caries experience at the dentinal level (d3mft=0) was 45.1%. This measure is used in the most recent Government headline target, which is that 60% of 5 year olds should be "free" of dentinal caries experience (d3mft=0) by the year 2010 (Towards a Healthier Scotland, 1999), extending the previous target date of 2000 by ten years. although this year's figure is higher than the 43.3% recorded in the last survey, there has been no sustained improvement in this measure since the first SHBDEP survey of this age group in 1987/88, when a value of 42.4% was recorded. It is recognised that caries prevention in the pre-fives is possible (Hesketh & Stephen, 1996) and the slippage of the target date suggests that serious new initiatives aimed at this age group are required if the objective is to be met by 2010.
As in the last survey of 5 year olds, the proportion of the sample with "caries experience" (d3mft>0, as defined by BASCD) is given, as is the proportion with "current decay" (d3>0), reflecting the proportion of children who had untreated dentinal decay at the time of the survey. All categories of dentinal decay (codes 1,2,3 and 4) are included in this measure.
The Care Index (ft/d3mft) expresses the proportion of the caries experience that has been treated restoratively. The Care Index result for Scotland as a whole (Table 2) indicates that only 9.4% of the teeth with dentinal caries experience had been restored. This shows marginal improvement since the last survey but still discloses a significant need for restorative care as well as preventive care. It was hoped that the re-introduction of fee-for-item of treatment for restorative items for children in the revised dental contract of 1996 would effect a significant change in the amount of restorative care provided to children However as only approximately 50% of children starting school have attended a dentist, this contractual amendment will only have an impact if registration levels among "pre-schoolers" can be improved, a fact recognised by the government which has promised action in this area as part of its prevention from birth programme (Towards a Healthier Scotland, 1999).
The figures for sealants and sealant restorations, both mean numbers and percentages of children in receipt of these preventive measures (Table 2), differ little from the last survey and indicate the low usage of these techniques in the deciduous dentition.
Detailed surface results are given in Appendix H, Table H1. Deciduous molars and canines which are not present are considered "missing due to caries". The ratio of "open" (code 2C) to "closed" (code 2V) cavities found in this survey was roughly 3.3:2.
6.2 Dental Caries Experience by Health Board
Table 3 shows in detail the dental caries results by Health Board. It gives a measure of the total caries experience (d3mft) and a breakdown of the figure into its constituent elements. The variation in disease levels and in the components of the d3mf index seen in earlier SHBDEP surveys remains evident in this year's survey; for example Western Isles and Greater Glasgow with mean d3mft of 3.46 and 3.51 respectively do not compare well with borders and Shetland where the means are 1.39 and 1.58 respectively. The variation in the percentage of children in each Health Board with one or more "unrestorable" cavities (%C3>0) is also striking (4.4% in Grampian and Galloway to 17.7% in Ayrshire and Arran).
It is once more interesting to note the limited use of fissure sealants on deciduous teeth by the different Health Boards, as recorded in Table 3. Shetland remains the only region where this technique is employed widely for this age group although its provision has dropped since the last Survey.
| Table 3: Mean values per child for decayed (d3), missing (m) and filled (f) teeth; percentage "free" of caries experience (d3mft=0); percentage with "unrestorable decay" (C3>0) and mean number of sealed teeth ($) per child (decay defined as decay into dentine).
| ||||||||
| Health Board | d3 | m | f | d3ft | d3mft | %d3mft=0 | %C3>0 | $ |
| Argyll & Clyde | 1.95 | 0.52 | 0.26 | 2.21 | 2.73 | 40.7% | 7.0% | 0 |
| Ayrshire & Arran | 1.61 | 0.54 | 0.22 | 1.83 | 2.37 | 51.7% | 17.7% | 0.02 |
| borders | 0.71 | 0.31 | 0.37 | 1.08 | 1.39 | 64.6% | 5.5% | 0.03 |
| Dumfries & Galloway | 1.23 | 0.51 | 0.29 | 1.52 | 2.03 | 49.8% | 4.5% | 0.06 |
| Fife | 1.40 | 0.35 | 0.18 | 1.59 | 1.94 | 52.8% | 6.9% | 0.03 |
| Forth Valley | 1.62 | 0.64 | 0.19 | 1.81 | 2.45 | 47.2% | 11.3% | 0 |
| Grampian | 1.16 | 0.44 | 0.29 | 1.45 | 1.89 | 56.2% | 4.4% | 0 |
| Greater Glasgow | 2.61 | 0.68 | 0.22 | 2.83 | 3.51 | 34.3% | 12.9% | 0.05 |
| Highland | 1.91 | 0.55 | 0.19 | 2.10 | 2.65 | 41.5% | 6.3% | 0.07 |
| Lanarkshire | 2.03 | 0.49 | 0.21 | 2.23 | 2.73 | 36.7% | 10.1% | 0.02 |
| Lothian | 1.62 | 0.32 | 0.30 | 1.92 | 2.24 | 48.9% | 6.8% | 0.01 |
| Orkney | 1.86 | 0.33 | 0.49 | 2.35 | 2.68 | 44.0% | 13.4% | 0.06 |
| Shetland | 1.00 | 0.29 | 0.29 | 1.28 | 1.58 | 59.1% | 8.7% | 1.43 |
| Tayside | 1.71 | 0.54 | 0.22 | 1.94 | 2.47 | 47.1% | 8.8% | 0.01 |
| Western Isles | 2.41 | 0.31 | 0.74 | 3.15 | 3.46 | 37.8% | 14.7% | 0.04 |
Figure 1 shows the mean d3mft per child for each Health Board and the 95% confidence intervals associated with each mean value and highlights, visually, how little of the total caries experience in this age group is made up of fillings or missing teeth. The size of the vertical error bars indicates the limited extent to which the figure can be interpreted as a "league table". Thus, while there are real differences between the Boards at the right of the figure and those on the left, it is unwise to ascribe too much importance to minor variation in the detailed ranking positions of Boards adjacent to one another in the figure. The same data are expressed in the form of a map in Appendix J, Figure J2.
Comparisons of this year's caries results with the previous survey are illustrated in Appendix G. Figure G1 shows the mean d3mft with 95% confidence intervals for each Health Board in 1997/98 and 1999/2000. Dumfries and Galloway and Tayside exhibited the largest fall in values while both Orkney and Ayrshire and Arran showed a small rise. However, none of these changes were statistically significant.
Figure 1: Mean number of decayed, missing and filled teeth(d3mft) per child for each Health Board (decay defined as decay intodentine).
However, some of the minor changes in d3mft values were sufficient to move Health Boards from one d3mft grouping to another in Figure J2 (Appendix J), thus giving a different look to the map if compared with the previous survey. One Board moved up to the next (worse) grouping, eight stayed in their previous grouping and six moved into a lower (better) grouping.
Figure G2 (Appendix G) demonstrates the mean number of decayed surfaces (d3s) with 95% confidence intervals for each Health Board over the same years. Western Isles showed the largest fall with Ayrshire and Arran, Forth Valley and Greater Glasgow showing a slight rise. However, none of these changes were statistically significant.
6.3 The Proportion "Free" of Caries Experience in each Health Board
The proportion of children "free" of caries experience at the dentinal level (d3mft=0) for each Health Board are given in Table 3.
Figure 2 gives a graphical representation of the percentage of children in each Health Board with current dentinal decay or past caries experience (d3mft>0). The horizontal line represents the percentage required to meet the National Target for the year 2010 (60% with d3mft=0 or, conversely, 40% with d3mft>0). The varying values exhibited by the different Boards in this figure (and those for %d3mft=0 in Table 3) underscore the varying amounts of progress required in different parts of Scotland before this target, which has alreadybeen extended by ten years, can be achieved by individual Health Boards. borders has met the target, Shetland is within 1% and Grampian 5% of doing so. A further six Boards are within 15%. Ayrshire and Arran, Greater Glasgow, Highland, Lanarkshire, Orkney and the Western Isles will require strenuous efforts to approach the target. Greater Glasgow and Lanarkshire have demonstrated very little change since the last Survey.
Figure 2: Percentage with dentinal caries or past caries experiencein each Health Board.
6.4 Tooth and Surface Results
Figure 3 shows the distribution of dentinal decay and past caries experience by tooth type. The values shown are from the combined totals from 15 Health Boards, appropriately weighted. The dentinal decay component has been subdivided into unrestorable (C3) dentinal decay and restorable (non-C3) dentinal decay. From this figure it can be seen that just over 26% of upper Es and around 31% of lower Es (the second deciduous molars) show signs of decay or past caries experience. Figure 3 demonstrates the symmetry of caries attack and the preponderance of caries in deciduous molars and upper incisors.
Figure 3: Distribution of dentinal decay and past caries experienceby tooth (combined totals from fifteen Health Boards, appropriately weighted).
The surfaces of the teeth which are most affected by decay and fillings are shown in Figure 4. The decay component has once again been subdivided into unrestorable (C3) and restorable (non-C3) dentinal caries. There is a three-way split in the distribution of disease, with approximately a third of the dentinal decay and fillings (32%) on the occlusal (or biting) surfaces of the deciduous teeth, a further 33% in approximal (mesial and distal) surfaces and 34% in free smooth surface sites (buccal and lingual surfaces).
Figure 4: Distribution of decayed and filled surfaces by surfacetype, data from fifteen Health Boards appropriately weighted.
The results for each Health Board using the surface as the unit of measurement are presented in Appendix H, Table H1. The decay component is expressed as the total dentinal decay and the mean number of surfaces with arrested dentinal decay (C1), "open" or "closed" dentinal cavitation (C2) and unrestorable (C3) decay. On average, 4.7 tooth surfaces per child were decayed and/or filled (d3fs). Table H2 gives the breakdown, by Health Board, for surfaces affected by unrestorable decay, total dentinal decay and fillings. These data were used to produce Figure 4.
6.5 Trends in Caries Prevalence
Figure 5 shows the changes in d3ft results for Scottish children from 1983 to 2000. A large drop in d3ft occurred between the 1983 Office of Population Censuses and Surveys (OPCS) Child Dental Health Survey (Todd & Dodd, 1985) and the first SHBDEP survey of 5 year olds in 1987/88. The following two surveys of 5 year olds (1989/90 and 1991/92) showed no significant alteration in d3ft levels which appeared to have bottomed out at a d3ft of 2.2-2.3.
Figure 5: Trends in caries results for Scottish children 1983-2000showing changing values for mean numbers of decayed and filled teeth(d3ft).
Some of the increase in d3ft results seen in 1993/94 will have been due to the additional recording of "closed" cavitation (see Appendix J of the 1993/94 Report), which will not affect 93/94 - 99/2000 comparisons. Furthermore, it can be seen that the SHBDEP figure was at the higher end of the 95% confidence interval for the Scottish figure from the OPCS Child Dental Health Survey of the UK carried out in 1993 (O'Brien, 1994). The differences in the width of the confidence intervals is related to the different sample sizes employed by OPCS (smaller) and SHBDEP (larger).
The 1993/94 sample from Greater Glasgow, when viewed in conjunction with both prior and later data, appears to have shown a higher than expected level of disease and this may have been due to the sampling process. As Greater Glasgow accounts for 20% of the 5 year old population, this would have had an adverse impact on the overall result for Scotland. Thus, the difference between the 1993/94 situation and the years both preceding and following may not be as marked as would at first appear. By viewing the results as a series, rather than making year on year comparisons, it can be seen that minimal improvement in mean d3ft has occurred since the start of this series of surveys. This year's figure of 2.05 differs only a little from the original figure of 2.22 in 1987.
Figure 6 offers an alternative view of the trend in caries prevalence, using the percentage "free" of caries experience (d3mft=0). The latest data from the current survey appear to add to the overall picture of a bottoming out of the decline in caries prevalence seen in the eighties, a phenomenon which is being increasingly observed in other areas of Europe (Marthaler et al, 1996). In England (which enjoys lower mean caries levels than Scotland) no improvement was seen between 1983 and 1993 (O'Brien, 1994). The bottoming out of the Scottish results at a higher level than in England may reflect the general poorer health status of Scotland in relation to England, dietary habits and the greater burden of ill-health carried by Scotland in relation to other developed nations. It is possible that the use of fluoride toothpaste in the home and its attendant benefits has penetrated as far as it can under current conditions in Scottish society and that more direct and also more innovative methods of delivering preventive care will have to be considered.
Figure 6: Trends in caries results for Scottish children 1983-2000,showing the percentage of children "free" of dentinal caries experience (d3mft=0) and the level that this percentage must reach to meet the National Target for the year 2010.
6.6 Skewed Distribution of Disease
Table 4 shows the skewed distribution of disease in this representative sample of 5 year old Scottish children. All of the decayed surfaces were found in 50% of the children while 9% of the sample had half of the decayed surfaces. The skew has worsened slightly to that observed two years ago with an unfortunate 9% of the children having all of the surfaces affected by unrestorable(C3) decay. The mean number of decayed and filled surfaces (d3fs) was 23.9 for the worst 10% of the children in this survey, showing no change from the value of 24.0 observed in 1997/98.
| Table 4:Skewed distribution of decay (decay defined as decay into dentine). | ||
| Proportion of Children | with | Proportion of Disease |
| 1% of population | had | 10% of untreated decayed surfaces (d3S) |
| 9% of population | had | 50% of untreated decayed surfaces (d3S) |
| 50% of population | had | 100% of untreated decayed surfaces (d3S) |
| 1% of population | had | 35% of unrestorable surfaces (C3s) |
| 2% of population | had | 50% of unrestorable surfaces (C3s) |
| 9% of population | had | 100% of unrestorable surfaces (C3s) |
Table 5 gives the level of disease for those with disease. In Scotland, for those with disease, the average was 4.65 deciduous teeth decayed, missing or filled. The percentage of total decay (d3mft) which is made up of unrestorable decay (C3) or teeth extracted because of decay (mt) is a measure of severe dental morbidity and is indicative of children likely to have had or need dental general anaesthetics. At present 26.9% of the decay experience falls into this category and 37.7% of those children with dentinal decay are suffering from this severe form of carious attack. These figures show only a marginal improvement from two years ago.
| Table 5: Levels of disease (mean d3mft) and severe dental morbidity (% of d3mft equal to C3 or m) in those with disease, and percentage of children with d3mft>0 who have unrestorable decay (C3) or missing (m) teeth, by Health Board (decay defined as decay into dentine). | |||
| Health Board | d3mft for those with d3mft>0 | % d3mft equal to C3 or mt | % of children with d3mft>0 with C3 or m |
| Argyll & Clyde | 4.6 | 24.0 | 35.1 |
| Ayrshire & Arran | 4.92 | 39.2 | 58.3 |
| borders | 3.92 | 27.5 | 38.9 |
| Dumfries & Galloway | 4.03 | 29.6 | 34.2 |
| Fife | 4.11 | 26.4 | 31.3 |
| Forth Valley | 4.63 | 33.8 | 45.3 |
| Grampian | 4.32 | 27.6 | 35.5 |
| Greater Glasgow | 5.34 | 27.3 | 42.5 |
| Highland | 4.52 | 24.5 | 30.5 |
| Lanarkshire | 4.31 | 26.4 | 34.9 |
| Lothian | 4.39 | 19.0 | 28.8 |
| Orkney | 4.78 | 19.5 | 39.2 |
| Shetland | 3.85 | 26.4 | 37.9 |
| Tayside | 4.67 | 29.0 | 37.2 |
| Western Isles | 5.56 | 15.6 | 31.5 |
| Scotland | 4.65 | 26.9 | 37.7 |
6.7 Oral Cleanliness
For the second time in this series of surveys of 5 year old children, data were collected on a simple measure of oral cleanliness. Training was given in the use of this new measure, but examiners were not calibrated (as the nature of the measure precludes this) and so the results may reflect a certain level of examiner variability. Overall, 64% were considered to have clean teeth. High levels of plaque were not necessarily linked to high d3mft scores, which may underscore the nature of this examiner variability. Other studies have indicated a weak positive association between plaque and caries and this issue is discussed in some detail by Sutcliffe (1996). Boys showed higher levels of plaque than girls, particularly on the measure of "substantial" plaque where over half (58%)of the 4.3% with substantial plaque were boys. Details of the assessment, the above correlations and inter-board comparisons are in Appendix I.
6.8 Deprivation
A clear link between postcode-related measures of social deprivation and caries in children has previously been established (Pitts & Nugent, 1995). Since the 1995/96 Survey we have reported on the relationship between socio-economic status as determined by postcode of residence and dental caries status. (A full description of the methodology is contained in Sweeney et al 1996 & 1998).
Of the total 6994 children examined for this year's Survey, 6957 (99.4%) had full postcode data. Of these, 6100 (89.6%) could subsequently be linked to their respective DEPCAT scores.
Figure 7: The proportion "free" of caries experience (d3mft=0) by DEPCAT score.
Figure 7 graphically illustrates the yawning gap in dental health between 5 year olds residing in the most deprived areas (DEPCAT score 7) and their more fortunate contemporaries from DEPCAT groups 1 and 2. The children from DEPCAT 1 have reached the National Target of 60% caries "free" in the year 2010 and have in fact met this within the original timeframe (the year 2000). Additionally, those from DEPCAT 2 are within 1% of meeting the target. Children from DEPCAT group 7 fall well short with only 20% caries "free". These results have varied little over the last two Surveys.
Four times as many children in DEPCAT groups 6 and 7 require extractions or endodontic treatment (ie. have "unrestorable decay") compared to children in DEPCAT groups 1 and 2. In most cases this means a requirement for a general anaesthetic with the attendant risks which this procedure entails.
7 The Future
The dental health of Scottish 5 year olds still remains poor in comparison with the rest of the UK, as illustrated in the map in Figure J1, Appendix J based on results from the 1997/98 survey (data is not yet available for 1999/2000 for England and Wales).
The d3mft results from this latest SHBDEP survey record a modest drop in caries levels for Scotland similar to the drop between 1993/94 and 1995/96, but little overall significance can be attached to such a small change. Indeed, the lack of progress shown in Figure 5 and Figure 6 indicates that major initiatives are needed if any impact is to be made on the current levels of disease in 5 year old children.
The current government recognises the significance of deprivation to Scotland's record of poor oral health and has stated its support for fluoridation of the water supply as the best means of effecting any improvement in more deprived areas. However, as this measure can only be enacted following a period of consultation at local level it is reasonable to assume that it may be some time before its benefits are felt and any improvements in the dental health of Scottish children will have to be derived from other initiatives.
The profound effects of early influences on lifelong health are stated as central to government policy which includes a prevention from birth programme for dentistry as part of a coordinated approach to child health. It is hoped that the demonstration project in Greater Glasgow "Starting Well" which includes child dental health as part of its remit (Towards a Healthier Scotland, 1999) will develop strategies which will lead to improvements in the vital pre-school years without which the targets set for 2010 are unlikely to be met.
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 their parents. Special thanks go to Mr J Dempsey and Mr P Pierson, Headteachers of Letham Primary School and North Muirton Primary School in Perth, and to the staff and pupils, for accommodating the essential training and calibration exercises.
Thanks also go to the Community Dental Officers and Dental Surgery Assistants who undertook the fieldwork as examining teams (see Appendix A); to the fifteen Health Boards for their financial support of the Programme and to the Chief Scientist Office of the Scottish Office Department of Health 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 opinions expressed in this report are those of the authors and not necessarily of the Scottish Executive.
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