Children's Dental Health Survey Research Articles

The relationship between the source of oral health information and dental caries: Findings from Child Dental Health Survey 2013 in England.

To determine the magnitude and shape of the relationship between dental caries experience and the source of oral health information in England. This was a cross-sectional study using the Child Dental Health Survey 2013 in England. Using a negative binomial model, the relationship between the number of decayed, missing, filled teeth (DMFT) of 12- and 15-year-old students and their primary source of oral health information was assessed. The sources of oral health information included parents, television, newspapers, the Internet, and social media. The adjusted model included age, sex, and the Index of Multiple Deprivation (IMD). R was used for data handling, analysis and reporting. Overall, 2,372 children were assessed (48.7% female, 48.6% 12-year-old). For the majority, the primary source of oral health information was their parents (89.5%) followed by the Internet (43.4%). Over nine-tenth of the participants had a DMFT = 0. The adjusted model showed that the prevalence rate of DMFT for the children whose primary source of information is their parents (0.45) or television (0.62) is lower than 1. The prevalence rate for the Internet (1.17) and social media (1.67) was higher than 1, but they were removed from the final model due to being non-statistically significant. Age and deprivation had a direct relationship with the prevalence rate of DMFT, meaning that 15-year-olds and children from more deprived areas had a higher prevalence rate of DMFT. Children whose primary source of oral health information was their parents or television had a lower DMFT. On the contrary, using the Internet or social media as the source of oral health information was associated with higher caries experience among schoolchildren.

Ethnic inequalities in child oral health behaviours among five- and eight-year-old children from England, Wales and Northern Ireland.

Aim To examine whether there are ethnic inequalities in child oral health behaviours and the role of parental socioeconomic status (SES) in explaining them.Methods Data from 2,186 five- and eight-year-olds of white, Asian, Black and other ethnicity, who participated in the 2013 Children's Dental Health Survey, were analysed. Parents reported their children's toothbrushing and dental attendance. Logistic regression was used to explore ethnic inequalities in child behaviours, adjusting for demographic factors and parental SES.Results Children of Asian ethnicity were less likely to start brushing early in life (odds ratio [OR]: 0.25; 95% confidence interval [CI]: 0.15-0.43), brush regularly (OR: 0.56; 95% CI: 0.32-0.97) and have a check-up last year (OR: 0.28; 95% CI: 0.16-0.49) than those of white ethnicity. Children of Black ethnicity were less likely to have a check-up last year (OR: 0.39; 95% CI 0.17-0.89) than those of white ethnicity. Children of other ethnicity were less likely to start brushing early in life (OR: 0.41; 95% CI: 0.23-0.77) and brush regularly (OR: 0.45; 95% CI: 0.23-0.87) than children of white ethnicity. Inequalities in toothbrushing frequency and regular dental attendance between children of Black and white ethnicity were fully attenuated after adjustment for parental SES.Conclusion There were ethnic inequalities in child toothbrushing and dental visiting, with children of Asian ethnicity being the most affected. Parental SES only explained part of these inequalities.

Health-risk behaviours co-occur among children with untreated caries.

The aim of this study was to examine whether an aggregate of health risk behaviours is associated with the number of untreated dental caries among 12- and 15-year-old children in England, Wales and Northern Ireland. Data were from the Children's Dental Health Survey (CDHS) 2013, a nationally representative sample of England, Wales and Northern Ireland. The survey included assessment of oral health and data on socioeconomic, demographic and behavioural factors pertaining to children aged 12-15 years. Tooth condition (decayed, missing and filled) was assessed by NHS dentists. The survey included questions on age, sex, country, index of multiple deprivation, smoking, alcohol consumption, frequent sugar consumption and sweetened sodas, infrequent dental visit, infrequent toothbrushing and infrequent consumption of fresh fruits. Health risk behaviours were summed up to create an aggregate variable of health risk behaviour. The association between number of untreated caries and the aggregate of health risk behaviours was assessed using negative binomial regression and adjusting for age, sex, country and deprivation. The total number of children included in the analysis was 4414. The mean number of untreated caries was generally higher among children with health risk behaviours. The aggregate of risk behaviour was associated with greater prevalence of untreated dental caries with rate ratio (RR) 1.26 (95% confidence interval: 1.18, 1.36). This study demonstrated an association between an aggregate of health risk behaviours and untreated caries. The findings highlight the importance of addressing multiple risk factors not only those directly related to dental caries.

Pulp therapy and root canal treatment techniques in immature permanent teeth: an update.

Background According to the Children's Dental Health Survey 2013, around one in ten children in Wales, Northern Ireland and England will have sustained dental trauma to a permanent incisor by the of age 15. Management of an exposed pulp in an immature permanent incisor is often urgent and has an impact on the long-term outcome of the tooth; therefore, it is essential that general dental practitioners feel confident in managing such a scenario to achieve an optimal outcome. This paper discusses the indications, technique, materials and outcomes.Aims This article aims to review the literature, which discusses various treatment modalities and materials for pulpal therapy and root canal treatment in the immature permanent tooth.Method Electronic searches were limited to English language, human studies, published within the past five years and the medical subject heading terms used were: direct pulp capping, apexogenesis, Cvek pulpotomy, full pulpotomy/pulpectomy, partial pulpotomy, apexification, non-vital pulp therapy and mineral trioxide aggregate apexification. Older, seminal articles identified through the references sections have also been included.Conclusion A number of options are available for the management of immature permanent teeth that have suffered an insult such as caries or trauma. This paper reviews the various methods of pulpal treatment, preservation therapy and root canal treatment options depending on the extent of the damage.

Greater child dental health inequality in England compared to Wales and Northern Ireland, despite lower average disease levels.

Dental caries and inequalities in dental health are major public health concerns. To report variation in dental caries experience across deprivation quintiles and the magnitude of inequalities between countries. Secondary analyses of cross-sectional data from the 2013 Child Dental Health Survey (CDHS) in England, Wales, and Northern Ireland. Distribution of dental caries across deprivation quintiles were estimated using as proportions and means. The magnitude of inequalities was calculated using the Relative Index of Inequality (RII). Dental caries experience as indicated by the prevalence (%dmft/DMFT>0) and severity (dmft/DMFT) of 'obvious' and 'clinical' decay experience in both primary and permanent dentitions. Children from more deprived quintiles showed higher prevalence and severity of dental caries. RIIs for dental caries were greater in England than Wales or Northern Ireland, indicating greater relative inequalities despite lower average dental caries experience. The prevalence and severity of dental caries among the most deprived children in England were 1.7 to 3.7 times greater than those of the least deprived. There is a deprivation gradient in child dental caries in all three countries, with England showing the greatest inequalities.

Maternal characteristics, home environment, and other factors associated with traumatic dental injuries in preschool children.

The importance of external factors such as maternal and home characteristics on traumatic dental injuries needs to be investigated. The aim of this study was to evaluate the association between maternal and home characteristics and dental trauma in preschool children. This cross-sectional study using a cluster random sample evaluated children between 3 and 4years of age from Porto Alegre, Brazil. Mothers completed the Brazilian version of the Beck Depression and Anxiety Inventories (BDI and BAI). They answered questions about sociodemographics, maternal behaviors, and home characteristics. Dental trauma was assessed by the Children's Dental Health Survey criteria. Malocclusion and deleterious habits were also assessed. The multinomial logistic regression model was used to investigate the association of exploratory variables with different categories of dental trauma. Odds ratios (OR) and 95% confidence intervals were calculated. A total of 163 pairs of children and mothers agreed to participate (78.4% response rate). The prevalence of dental trauma was 49.8%. Mother's work outside the home, overjet, and anterior crossbite were associated with the occurrence of enamel trauma, while having a younger mother, families having more siblings, and having a mother with university education were associated with increased odds of dentin/pulp trauma. Depression and anxiety in the mothers were not associated with dental trauma, while malocclusion characteristics were more relevant for less severe, enamel trauma. Socioeconomic and home environment characteristics played a role in more severe, dentin/pulp trauma.

How does dental anxiety affect the oral health of adolescents? A regression analysis of the Child Dental Health Survey 2013.

Introduction Dental phobia has been widely studied but there is limited research on the effect of dental phobia on oral health. This research is an analysis of the 2013 Child Dental Health Survey, to explore the impact of dental anxiety on factors relating to oral health in the adolescents.Aim To examine if dental anxiety predicts poor oral health in 12- and 15-year-olds.Design Regression analysis of data from 4,950 children aged 12 years and 15 years who participated in the Child Dental Health Survey 2013.Setting National epidemiological survey of UK schools.Materials and methods A series of logistic regressions was carried out to examine if dental anxiety, socio demographic factors and oral health-related behaviour could predict oral health status, the impact of the child's oral health on their own quality of life and the impact of their oral health on the family's quality of life. Additional outcomes examined were self-perceived dental health and general health.Results Dental anxiety was not a predictor of poor oral health but did predict a greater impact of the child's oral health on everyday life. Adolescents with dental anxiety had negative thoughts regarding their dental and general health.Conclusions Dental anxiety affects the everyday life and psychological wellbeing of adolescents.

The impact of dental anxiety on the oral health of children aged 5 and 8 years: a regression analysis of the Child Dental Health Survey 2013.

Introduction Dental anxiety and fear is widely prevalent in the population, including children. This research is a further analysis of the Child Dental Health Survey 2013, to explore the impact of dental anxiety on factors relating to oral health.Aim To explore the relationship between dental anxiety and oral health and the impact dental anxiety has on the quality of family life.Design Regression analysis of data of 4,916 children aged 5 years and 8 years who participated in the Child Dental Health Survey 2013.Setting National Epidemiological Survey in schools in the UK.Materials and methods A series of logistic regression analyses was carried out for markers of oral health and impact of the child's oral health on the family's quality of life. The variables entered as predictors in the models included dental anxiety, socio demographic status and oral health-related behaviours.Results Dental anxiety was associated with poorer oral health on nearly all measures (decay experience p = <0.001, active decay p = <0.001, primary tooth being restored p = 0.010, signs of oral infection p = 0.007) and had a greater impact on their family's quality of life (p = <0.001).Conclusions Dentally anxious children have more dental disease and this has a greater impact on their family's quality of life.

Inequalities in orthodontic outcomes in England: treatment utilisation, subjective and normative need.

To investigate inequalities in three aspects of access to orthodontic care: uptake of orthodontic treatment, normative need and subjective need in England. We used data from two surveys in England: 12 and 15-year-olds from the 2013 Child Dental Health Survey (CDHS 2013) and 12-year-olds from the 2008/2009 NHS Dental Epidemiology Programme for England (NDEP 2008/2009). Summary variables representing orthodontic status were calculated. Two regression-based summary measures of inequalities were used to investigate the relationship between deprivation level and orthodontic outcomes: Slope and Relative indices of Inequality. There were significant absolute and relative inequalities in uptake of orthodontic treatment. The least deprived were 1.9 times more likely to have received orthodontic treatment compared to the most deprived in both surveys. Normative need was not associated with deprivation in either the analyses of CDHS 2013 (SII= 0.03, 95% CI: -0.04, 0.1; RII=1.06, 95% CI: 0.91, 1.24) or the NDEP 2007/2008 (SII= 0.03, 95% CI: -0.02, 0.07; RII=1.06, 95% CI: 0.96, 1.18). There was greater willingness to have teeth straightened in more deprived children from CDHS 2013 (SII=-0.09, 95% CI: -0.16, -0.03; RII=0.85, 95% CI: 0.75, 0.96) but not in NDEP 2007/2008 (SII=0.03, 95% CI: 0, 0.06; RII=1.07, 95% CI: 0.99, 1.15). Being deprived was associated with lower uptake of orthodontic treatment. Normative need was not related to deprivation. The association between deprivation and subjective need was only partly established, with poorer children showing a greater desire to have their teeth straightened in one survey.

The oral health of dentally anxious five- and eight-year-olds: a secondary analysis of the 2013 Child Dental Health Survey.

Introduction Little research has been conducted into the relationships between dental anxiety and factors relating to oral health in small children. This research takes advantage of data from the Child Dental Health Survey 2013 to perform a secondary analysis for the five- and eight-year-old age groups. Aim To compare the oral health of groups of children aged five and eight years old, classified into three levels of anxiety.Design Secondary analysis of data from 2,289 children aged five and eight years in the Child Dental Health Survey 2013.Materials and methods Participants were divided into three groups, depending on the parent's report of their child's dental anxiety. Descriptive analyses compared the three groups on social demographic factors, clinical status, self-reported oral health status, oral health-related behaviours and oral health impact. Results Dentally anxious children were more likely to have active decay and decay experience. Parents of children with dental anxiety were more likely to report that the child's oral health had a negative effect on family life. Highly anxious children were less likely to attend the dentist or engage in oral health-related behaviours. Conclusions Dentally anxious children have more dental disease and their parents express that the child's oral health has a greater impact on their family's quality of life.

The oral health of dentally phobic 12- and 15-year-olds: a descriptive analysis of the 2013 Child Dental Health Survey.

Introduction Dental anxiety has been shown to be related to poorer oral health. Limited data exist exploring the relationship between oral health status and dental anxiety in non-clinical populations in children.Aim To compare the oral health of phobic and non-phobic children aged 12 and 15 years.Design Secondary analysis of data from 12-year-old and 15-year-old children in the Child Dental Health Survey 2013.Materials and methods Participants were grouped into non-phobic and phobic groups, depending on their self-reported dental anxiety (MDAS). Descriptive analyses compared the two groups on social demographic factors, clinical status, self-reported oral health status, oral health-related behaviours and oral health impact.Results A total of 601 children were classed as dentally phobic with 4,144 classed as non-phobic. Dental phobic children were more likely to be female, had more active decay and untreated dental disease, and rated their dental health as poorer. Phobic children were more likely to report that their oral health had a negative effect on their everyday life. This group were less likely to brush their teeth regularly or attend the dentist for check-ups.Conclusions Dentally phobic children have more dental disease and express greater impact on their everyday life.

Socioeconomic Variation in the association between Malocclusion and Oral Health Related Quality of Life.

Oral health related quality of life (OHRQoL) has been linked to malocclusion. We aimed (a) to investigate the association between malocclusion and OHRQoL among children, and (b) to examine whether this association varied by socioeconomic status. Cross-sectional analysis of data for 4,217 children aged 12 & 15 years, who participated in the 2013 Children Dental Health Survey (CDHS); a nationally representative survey of children in England, Wales, and Northern Ireland. Malocclusion was determined using the modified Index of Orthodontic Treatment Need (IOTN). OHRQoL was measured using the Child Oral Impacts on Daily Performance (Child-OIDP). For socioeconomic status, we used the pupils' eligibility for free school meals (FSM) and Index of Multiple Deprivation (IMD). Adjusted marginal effects were estimated controlling for confounding variables. Separate analyses were carried out for the two age groups. Malocclusion was associated with 6% and 15% increases in the probability of reporting negative impact of OHRQoL for 12- and 15-year olds respectively, which was significant for 15-year olds (marginal effect=0.15, 95% CI=0.08-0.22). Malocclusion was associated with the prevalence of oral impacts for 12 year olds (marginal effect=0.1, 95% CI=0.02-0.17) and 15-year olds (marginal effect=0.2, 95% CI 95%=0.13-0.28) not eligible for FSM and for 15-year olds in the most (marginal effect=0.2, 95% CI=0.1-0.29) and least (marginal effect=0.26, 95% CI=0.13-0.4) deprived IMD quintiles. Malocclusion was associated with impacts on OHRQoL for 15-year olds. There was evidence of a relationship between SES, malocclusion and OHRQoL.

The relationship between overweight/obesity and dental erosion among a group of Saudi children and adolescents.

As childhood obesity is emerging in Saudi children and adolescents with high prevalence, it is considered as one of the major public health concerns. Therefore, it has been studied in relation to other diseases as a cause factor. The aim of this study is to investigate whether childhood obesity is a risk indicator for dental erosion and to obtain information on dietary habits that are related to dental erosion in overweight/obesity in a group of Saudi children and adolescents. The study involved 370 children of both genders aged 4-18 years. The convenient sample included 190 overweight/obese children attending obesity clinic and 180 controls. Body mass index (BMI) (kg/m2) was calculated and BMI percentile obtained based on the age- and sex-specific according to the Centers for Disease Control chart (normal 5th to <85th percentile, overweight 85th to <95th percentile, and obese ≥95th percentile). Dental examination and questionnaire were carried out by one calibrated and trained examiner on these children using the UK Children's Dental Health Survey Classification for dental erosion. The prevalence of dental erosion was more significant in the study group (8.42%) than the normal group (2.78%). Its severity was higher in the form of loss of enamel surface characterization in the study group (86.36%) compared to controls (13.64%). Carbonated drinks that were taken at night and drinks that were taken at night and drunk without a straw showed higher prevalence of dental erosion (33.3% and 10.3%) in overweight/obese participants. Dental erosion can be regarded as a risk indicator of childhood obesity in the form of loss of enamel surface characterization. Efforts should be taken to reduce carbonated drinks intake and to change the method of drinking erosive potential drinks among overweight/obese children.

Consumption frequency of added sugars and UK children's dental caries.

To examine the association between consumption frequency of foods and drinks with added sugar and dental caries experience in the permanent teeth of 12- and 15-year-old children in England, Wales and Northern Ireland, using the Children's Dental Health Survey 2013 (CDHS) data. Four thousand nine hundred and fifty children aged 12 and 15 have the following information available: daily consumption frequency of foods and drinks with added sugar, tooth-brushing frequency, dental attendance, and water-drinking frequency. The children's dental caries experience was available as a DMFT score (number of decayed, missing, filled permanent teeth). A zero-inflated negative binomial model (ZINB) was used to fit the DMFT score. Lower socioeconomic status (SES), nonregular dental check-ups, and low water-drinking frequency were associated with higher consumption frequency of added sugar (all P<0.05). The consumption frequency of both drinks and foods with added sugar also differed by region (P<0.001), and children who more frequently consumed foods with added sugars also consumed drinks with added sugars more often (P<0.001). Using the Zero-Inflated Negative Binomial model, DMFT scores were not associated with consumption frequency of added sugars for children with caries (DMFT>0), but the chance of being free of obvious caries (DMFT=0) was lower for children with high frequency (≥4) of sugar-added foods than for children reported to have a sugar-free diet (OR=0.5, 95% CI [0.3, 0.8]). Consumption frequency of added sugars was associated with dental caries and a number of child demographic and lifestyle characteristics. Children who consume foods and drinks with added sugar more frequently are more likely to develop dental caries, but higher consumption frequency of drinking water in fluoridated areas might reduce dental caries. The findings add to the evidence for the association between children's dental caries and added sugar consumption.

Socioeconomic and ethnic inequalities in oral health among children and adolescents living in England, Wales and Northern Ireland

ObjectivesAlthough adolescence is a sensitive developmental period in oral health, the social equalization hypothesis that suggests health inequalities attenuate in adolescence has not been examined. This study analyses whether the socioeconomic gap and ethnic disadvantage in oral health among children aged 5 reduces among adolescents aged 15.MethodsData from the cross‐sectional Children's Dental Health Survey 2013 were analysed, comprising of 8541 children aged 5, 8, 12 and 15 attending schools in England, Wales and Northern Ireland. Oral health indicators included decayed and filled teeth, plaque, gingivitis and periodontal health. Ethnicity was measured using the 2011 UK census ethnic categories. Socioeconomic position was measured by family, school and residential deprivation. Negative binomial and probit regression models estimated the levels of oral health by ethnicity and socioeconomic position, adjusted for demographic and tooth characteristics.ResultsThe predicted rate of decayed teeth for White British/Irish children aged 5 was 1.54 (95%CI 1.30‐1.77). In contrast, the predicted rate for Indian and Pakistani children was about 2‐2.5 times higher. At age 15, ethnic differences had reduced considerably. Family deprivation was associated with higher levels of tooth decay among younger children but not among adolescents aged 15. The influence of residential deprivation on the rate of tooth decay and filled teeth was similar among younger and older children. Moreover, inequalities in poor periodontal health by residential deprivation was significantly greater among 15‐year‐old children compared to younger children.ConclusionsThis study found some evidence of smaller ethnic and family socioeconomic differences in oral health among British adolescents compared to younger children. However, substantial differences in oral health by residential deprivation remain among adolescents. Community levels of deprivation may be particularly important for the health of adolescents.

Factors associated with use of general anaesthesia for dental procedures among British children.

Objectives To assess the demographic, socioeconomic, behavioural and clinical factors associated with use of dental general anaesthesia (DGA) among British children.Methods This study used data from 3053 children who participated in the 2013 Children's Dental Health Survey in England, Wales and Northern Ireland. Data were collected through parental questionnaires and clinical examinations. The crude and adjusted association of demographic (sex, age, ethnicity and country of residence), socioeconomic (socioeconomic classification and area deprivation), behavioural (age toothbrushing started, age when first went to the dentist, usual reason for dental visit and dental anxiety) and clinical factors (numbers of decayed and filled teeth) with DGA was assessed in logistic regression models.Results The lifetime prevalence of DGA use was 9.1%. Older children and those living in Wales, with higher levels of dental anxiety and more dental fillings, who visited the dentist only when in trouble, and who had parents in routine/manual occupations and parents who never worked have greater odds of reporting having ever used DGA.Conclusion This study shows that family socioeconomic background, usual reason for dental visit and country of residence were associated with DGA use among British children, over and above the effect of child age, dental anxiety and dental status.

Socioeconomic inequality in the provision of specific preventive dental interventions among children in the UK: Children's Dental Health Survey 2003.

Aim To assess socioeconomic inequality regarding specific preventive interventions (fissure sealants or any treatment to prevent caries) and dental visits among UK children.Method Data were from the Children's Dental Health Survey 2003, which included participants from England, Wales, Scotland, and Northern Ireland. The number of children in the analysis was 2,286. Variables were sex, age, area of residency (for example, England), mother's education, family social class, and deprivation level. Descriptive and regression analyses were performed.Results There were no significant socioeconomic differences in the use of preventive services. Deprivation and family social class (for example, intermediate and manual) were significantly associated with less regular dental visits (odd ratio 0.41, 95% CI [0.28, 0.63]; odd ratio 0.53, 95% CI [0.31, 0.89]; odd ratio 0.37, 95% CI [0.24, 0.58], respectively). Regular dental visits were associated with reporting preventive care for caries (odds ratio 2.25, 95% CI [1.45, 3.49]) and with the number of sealed tooth surfaces (rate ratio 1.73, 95% CI [1.16, 2.60]).Conclusion Despite apparent socioeconomic inequalities in regular dental visits, there was no significant inequality in using specific preventive interventions by children in the UK. This finding should be interpreted with caution considering the relatively small subsample included in this analysis.

The deceptive complexity of caries.

Exploring the potential value of using data on dental extractions under general anaesthesia (DGA) to monitor the impact of dental decay in childrenSocioeconomic inequality in the provision of specific preventive dental interventions among children in the UK: Children's Dental Health Survey 2003.

The orthodontic condition of children in England, Wales and Northern Ireland 2013.

Background The 2013 Children's Dental Health Survey is the fifth in a series of national surveys.Aims This paper reports the orthodontic condition of 12- and 15-year-olds and how they and their parents feel about the appearance of their teeth.Methodology A representative sample of children (5y, 8y, 12y, 15y) in England, Wales and Northern Ireland were invited to participate in dental examinations. A modified Index of Orthodontic Treatment Need (IOTN) was used as a measure of orthodontic treatment need for 12- and 15-year-olds. Children and parents were invited to complete a questionnaire about oral health behaviour and attitudes.Results Nine percent of 12-year-olds and 18% of 15-year-olds were undergoing orthodontic treatment at the time of the survey. Forty-four percent of 12-year-olds and 29% of 15-year-olds expressed a desire for straighter teeth, however over half of this group would not qualify for NHS treatment. Unmet treatment need was higher in children eligible for free school meals (P <0.05 at 15y).Conclusions Provision of and demand for orthodontic treatment is increasing, with a significant proportion of children who desire orthodontic care not eligible to receive it. Children from deprived backgrounds have greater unmet orthodontic treatment need.

Patterns of care and service use amongst children in England, Wales and Northern Ireland 2013.

Background The 2013 Children's Dental Health survey is the fifth in a series of national surveys.Aims This paper describes children's reported use of dental services, their experience of receiving dental treatment and parental satisfaction with services.Methodology A representative sample of children (aged 5, 8, 12 and 15 years) in England, Wales and Northern Ireland were invited to participate in dental examinations. Older children and all parents were invited to complete a questionnaire about oral health behaviours and attitudes.Results Over 80% of 12- and 15-year-olds reported attending for a check-up. According to parents, 9 in 10 children of all ages had visited a dentist in the last year and 9 in 10 parents reported they were satisfied with the last dental practice their child had visited. There was some variation by country with respect to children's experiences of fillings and extractions.Conclusions There has been little change in the reported attendance patterns of children since the 2003 survey. Family deprivation (measured by children's eligibility for free school meals) negatively influenced dental attendance for regular check-ups, attendance within the last 12 months and the likelihood of having experienced difficulties accessing NHS dental services for children.