Dental Epidemiology Programme Research Articles

Socioenvironmental sugar promotion and geographical inequalities in dental health of 5-year-old children in England.

To investigate the relationship between socioenvironmental sugar promotion and geographical inequalities in the prevalence of dental caries amongst 5-year-olds living across small areas within England. Ecological data from the National Dental Epidemiology Programme (NDEP) 2018-2019, comprising information on the percentage of 5-year-olds with tooth decay (≥1 teeth that are decayed into dentine, missing due to decay, or filled), and untreated tooth decay (≥1 decayed but untreated teeth), in lower-tier local authorities (LAs) of England. These were analysed for association with a newly developed Index of Sugar-Promoting Environments Affecting Child Dental Health (ISPE-ACDH). The index quantifies sugar-promoting determinants within a child's environment and provides standardized scores for the index, and its component domains that is, neighbourhood-, school- and family-environment, with the highest scores representing the highest levels of sugar promotion in lower-tier LAs (N = 317) of England. Linear regressions, including unadjusted models separately using index and each domain, and models adjusted for domains were built for each dental outcome. Participants lived across 272 of 317 lower-tier LAs measured within the index. The average percentage of children with tooth decay and untreated tooth decay was 22.5 (SD: 8.5) and 19.6 (SD: 8.3), respectively. The mean index score was (0.1 [SD: 1.01]). Mean domain scores were: neighbourhood (0.02 [SD: 1.03]), school (0.1 [SD: 1.0]), and family (0.1 [SD: 0.9]). Unadjusted linear regressions indicated that the LA-level percentage of children with tooth decay increased by 5.04, 3.71, 4.78 and 5.24 with increased scores of the index, and neighbourhood, school and family domains, respectively. An additional model, adjusted for domains, showed that this increased percentage predicted by neighbourhood domain attenuated to 1.37, and by family domain it increased to 6.33. Furthermore, unadjusted models indicated that the LA-level percentage of children with untreated tooth decay increased by 4.72, 3.42, 4.45 and 4.97 with increased scores of the index, and neighbourhood, school, and family domains, respectively. The model, adjusted for domains, showed that this increased percentage predicted by neighbourhood domain attenuated to 1.24 and by family domain rose to 6.47. School-domain was not significantly associated with either outcome in adjusted models. This study reveals that socioenvironmental sugar promotion, particularly within neighbourhood- and family-environments, may contribute to geographical inequalities in dental caries in children. Further research involving data on individual-level dental outcomes and confounders is required.

Why we need to look after baby teeth

A recent survey by the National Dental Epidemiology Programme revealed that almost a quarter of five-year-old children in England have experienced tooth decay, and that there is a link between these problems and deprivation. Dr Linda Greenwall, founder of Dental Wellness Trust - a charity promoting children's oral health through education and intervention programmes, outlines why good dental health is so important in early years and how settings can support children and families to look after baby teeth.

Childhood obesity and dental caries: an ecological investigation of the shape and moderators of the association

BackgroundDespite sharing a common risk factor in dietary sugars, the association between obesity and dental caries remains unclear. We investigated the association between obesity and dental caries in young children in England in an ecological study.MethodsWe analysed data from 326 lower tier English local authorities. Data on obesity and dental caries were retrieved from 2014/15 to 2016/17 National Child Measurement Programme and 2016/17 National Dental Epidemiology Programme. We used fractional polynomial models to explore the shape of the association between obesity and dental caries. We also examined the modifying effect of deprivation, lone parenthood, ethnicity, and fluoridation.ResultsBest fitting second order fractional polynomial models did not provide better fit than the linear models for the association between obesity and prevalence and severity of dental caries; therefore, the linear model was found suitable. Despite significant association, after adjusting for the effect of deprivation, obesity was neither associated with prevalence (coefficient = 0.2, 95% CI − 0.71, 0.75), nor with severity (coefficient = 0.001, 95% CI − 0.03, 0.03) of dental caries. In fully adjusted models, the proportion of white ethnicity and being in fluoridated areas were associated with a decrease in dental caries. The association between obesity and dental caries was moderated by the effect of deprivation, white ethnicity, and lone parenthood.ConclusionsThe association between obesity and dental caries was linear and moderated by some demographic factors. Consequently, interventions that reduce obesity and dental caries may have a greater impact on specific groups of the population.

Deprivation and child dental attendance in England: exploring the shape and moderators.

To describe the shape of the relationship between area deprivation and dental attendance (DA) in children aged 5 years and under in England and the modifying effect of caries prevalence, ethnicity, family profile and dentist-to-population ratio. DA rates were calculated at lower-tier local authority level (LA, n=326) using NHS data for the year to March 2017. LA deprivation was determined by Index of Multiple Deprivation 2015. Caries prevalence was retrieved from the 2016/17 National Dental Epidemiology Programme; ethnicity and family profile from Census 2011 and dentist-to-population ratio from NHS statistics. Fractional polynomial (FP) models explored the shape of the relationship. Multivariable regression models were adjusted for covariates. The effect of moderators was estimated by adjusted marginal effects. English Lower-tier LAs. Shape of the relationship between DA and deprivation and its moderators. Best-fitting second-order FP model (p=0.582) did not provide a better fit for the relationship than the linear model. Therefore, the linear model was selected for final analysis. Deprivation was associated with decreased DA rates (Coefficient=-0.39, 95%CI=-0.53,-0.24; p=⟨0.001); while White ethnicity (Coefficient=0.35, 95%CI=0.29, 0.41; p=⟨0.001), single parenthood (Coefficient = 2.21, 95%CI=0.91,3.51; p=0.001) and caries prevalence (Coefficient =0.34, 95%CI=0.25,0.44; p=⟨0.001) with increased rates. These moderated the relationship. We hypothesised that the shape of the relationship between deprivation and DA could be curvilinear with higher rates in the extreme ends of deprivation. However, the analysis showed a linear association, moderated by the effect of ethnicity, single parenthood and disease level.

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.

Oral health of children in England: a call to action!

Oral health is part of general health and well-being and contributes to the development of a healthy child. The most common oral disease affecting young children is dental caries (figure...

Why are caries levels reducing in five-year-olds in England?

Objective To explore possible reasons for the reduction in population caries levels among 5-year-old children in England since 2008.Design An ecological study to explore possible reasons for the apparent reduction in dental caries, which included changes in survey methods, deprivation levels and ethnic mix of the population, impact of community level oral health improvement interventions, reductions in sugar intake, and increases in the availability of fluoride.Setting Data were drawn from three consecutive epidemiological surveys undertaken in 2007/8 and 2011/12 (NHS Dental Epidemiology programme for England), and 2014/15 (Public Health England Dental Public Health Epidemiology Programme). Evidence about the possible reasons for the observed reduction in caries levels was drawn from a range of national sources.Main outcomes measures Severity and prevalence of caries at dentinal level as measured by visual means alone among children aged five years.Results Reasons relating to changes in methods used in the survey, deprivation and ethnicity were rejected, along with community level interventions, as reasons for whole population level change. The factor relating to reduced sugar intake was neither rejected nor sustained. Reasons relating to increased fluoride availability, in particular that for increased concentration in children's toothpastes, was sustained.Conclusions The reduction in caries levels among 5-year-olds has most likely been brought about by the wider availability of children's toothpaste containing at least 1,000 ppm fluoride, along with other factors.

English

Oral health in England has improved considerably in recent years but continues to show a strong inequalities gradient. This study was aimed at investigating variations in dental decay and relation to social deprivation and local water fluoridation. An ecological analysis using the 2007 and 2008 National Dental Epidemiology Programme survey of 5 year old children in England. Postcode of residence was mapped to census lower super output area (LSOA). LSOAs were assigned a national deprivation quintile and a fluoridation category based upon therapeutic level of 1 mg/L. Multiple logistic regression was applied to determine independent influences on tooth decay. Analysis of covariance (ANCOVA) was used to investigate interactions between fluoridation and deprivation on the mean levels of dental caries. Analysis is based on 142,030 clinical dental examinations, representing 25% of estimated population of 5 year olds in England. Overall, 31% of children had at least one decayed missing or filled tooth (dmft). Multiple logistic regression showed that children living in the most deprived areas were three times more likely to experience tooth decay than those living in affluent areas; whereas children living in fluoridated areas were 1.5 times less likely to have dmft than those living in non-fluoridated areas. Therefore, although both are independently significant, living in the most deprived quintile of social deprivation doubled the impact on the likelihood of dental decay compared to non-fluoridation. ANCOVA showed a strong gradient of increasing mean dmft with increasing social deprivation in both water-fluoridated and non-fluoridated areas, with 3 times more dental decay in more deprived areas than in more affluent areas. In all deprivation quintiles, children living in fluoridated areas have significantly (p < 0.001) lower mean dmft than those living in equivalent deprivation with no water fluoridation. Fluoridated drinking water may moderate dental caries; however, socioeconomic deprivation has a stronger influence on dental decay than local fluoridation of water. Key words: Fluoridation, tooth decay children, social deprivation, ecological epidemiology.

The prevalence of incisor hypomineralisation and its relationship with the prevalence of molar incisor hypomineralisation.

To establish the prevalence of incisor hypomineralisation (IH) in a cohort of 12-year-old children in Northern England and to relate the prevalence to gender, socioeconomic status, and the prevalence of molar incisor hypomineralisation (MIH). The study population comprised 12-year-old children participating in the 2008-2009 National Dental Epidemiological Programme in five regions in Northern England. Participating dentists were trained and calibrated in the use of the modified Developmental Defects of Enamel Index. Children were examined at school under direct vision with the aid of a dental mirror. First permanent molars and incisors were recorded for the presence and type of enamel defects greater than 2mm. A diagnosis of MIH was ascribed to any child with a demarcated defect in any first permanent molar. A diagnosis of IH was ascribed to any child with a demarcated defect in an incisor but with molar sparing. 3,233 children were examined. The prevalence of IH was 11.0% (95% CI 11.0-12.2%). There was a strong positive correlation between the prevalence of MIH and IH in different regions which reached significance (r=0.9, p=0.037) according to Spearman's rho test of correlation. There was a similar pattern of prevalence in the different socioeconomic quintiles although this correlation did not reach significance. The most common teeth affected in IH were the maxillary central incisors, followed by the maxillary lateral incisors and followed by the mandibular incisors. There was no difference in the prevalence of IH by gender. The prevalence of IH was 11.0%. The variation of prevalence between regions and socioeconomic groups and the distribution of lesions in the teeth were very similar to observations seen in MIH children from the same cohort.

Traumatic dental injury and social deprivation in five-year-old children in Scotland 1993-2007

To describe the pattern and time trends of dental injury and its sociodemographic determinants among five-year-old children in Scotland. A retrospective analysis of Scottish Health Boards' Dental Epidemiological Programme (SHBDEP) and National Dental Inspection Programme (NDIP) records for the period 1993-2007. Annual incidences were calculated by age, gender, health board and deprivation categories (DEPCAT). Out of 68,354 children examined only 405 (0.6%) had suffered dental injury with an overall incidence of 5.9/1000 population. There was a remarkable decrease in incidence over time. Virtually the same rates were recorded for the two genders (M:F = 1.13:1.0). The incidence varied significantly between health boards' areas (p <0.001); the highest incidence being reported in Dumfries (14.2/1,000 population), which was 11 times greater than that in Ayrshire (1.3/1,000 population). There was no significant association between risk of dental injury and increasing deprivation (p = 0.956); in DEPCAT 1 (most affluent) the incidence was 6.4/1,000 population, while in DEPCAT 7 (most deprived) the incidence was 5.7/1,000 population. The incidence of dental injury is varied among health boards, though it had significantly decreased since 1993. Gender and deprivation level had no effect on incidence of dental injury.

Untreated decayed teeth and dental sepsis

Objectives To investigate the prevalence of dental sepsis in 5-year-old children in Scotland and the relationship between sepsis, treated and untreated decayed teeth, oral cleanliness (visible plaque on anterior teeth) and socio-economic deprivation. Subjects and methods Six thousand, nine hundred and ninety-four children of mean age 5.3 yearswere examined as part of a survey conducted under the Scottish Health Board's Dental Epidemiological Programme. The presence of dental sepsis was recorded, in addition to caries status and presence of plaque. Postal code information was used to obtain a measure of material deprivation. Relationships between sepsis and its possible contributory factors were explored using stepwise logistic regression. Main results In the whole sample, 4.8% of children examined had dental sepsis, ranging from 2% in the most affluent areas to 11% in the most deprived. Children with sepsis had much higher caries experience (mean dmft 6.30) than those without sepsis (mean dmft 2.36). However, when these factors and the presence of plaque were entered into a logistic regression model to predict presence or absence of dental sepsis, the most important factor was not deprivation, but untreated decay. Conclusions The proportion of children with sepsis increases markedly with caries experience. This disadvantage can be mitigated if more of the caries experience is treated. These findings would not support a policy of non-intervention for deciduous caries if oral sepsis is to be minimised.

An investigation of the relationship between untreated decayed teeth and dental sepsis in 5-year-old children

To investigate the prevalence of dental sepsis in 5-year-old children in Scotland and the relationship between sepsis, treated and untreated decayed teeth, oral cleanliness (visible plaque on anterior teeth) and socio-economic deprivation. Six thousand, nine hundred and ninety-four children of mean age 5.3 years were examined as part of a survey conducted under the Scottish Health Board's Dental Epidemiological Programme. The presence of dental sepsis was recorded, in addition to caries status, and presence of plaque. Postal code information was used to obtain a measure of material deprivation. Relationships between sepsis and its possible contributory factors were explored using stepwise logistic regression. In the whole sample, 4.8% of children examined had dental sepsis, ranging from 2% in the most affluent areas to 11% in the most deprived. Children with sepsis had much higher caries experience (mean dmft 6.30) than those without sepsis (mean dmft 2.36). However, when these factors and the presence of plaque were entered into a logistic regression model to predict presence or absence of dental sepsis, the most important factor was not deprivation, but untreated decay. The proportion of children with sepsis increases markedly with caries experience. This disadvantage can be mitigated if more of the caries experience is treated. These findings would not support a policy of non-intervention for deciduous caries if oral sepsis is to be minimised.

A study to test the feasibility of distributing toothpaste and toothbrushes at school

Objective To test the feasibility of a school based method of delivery of toothbrushes, toothpaste and tooth brushing instruction to first year primary school children. Design Pre and post examinations of children's mouths, pre and post questionnaires to parents and a questionnaire to teachers at the end of the study. Setting In five schools in a unitary authority in Lancashire, UK. Method Examination of the mouth at school, using dental caries criteria used in the NHS national dental epidemiological programme and the Silness and Loe Plaque Index, and questionnaires distributed via school to parents and teachers. Results One hundred and seven children were examined twice and parents returned 57 questionnaires. During the toothbrushing sessions many children said that they did not have a brush or paste. They enjoyed taking part and the examinations revealed that their mouths were cleaner after the study than they were at the beginning. The scheme was acceptable to parents and schools. All schools wished to carry on their involvement in the project. The cost of providing the scheme to 500 children in schools with the highest levels of tooth decay was estimated to be about £4350 per annum. Conclusion A similar programme is worth considering in areas where the levels of tooth decay are known to be high.

Deprivation and dental caries status of 5-year-old children in Scotland.

The aim of this study was to investigate the relationship between the dental caries status of 5-year-old children in Scotland and deprivation, as assessed by the Carstairs score and its DEPCAT categories, which are composite descriptors of socio-economic status. Anonymous records, including postcode sector of residence, from the 1995/96 Scottish Health Board's Dental Epidemiological Programme 5-year-old survey were linked though a multi-stage process to their corresponding Carstairs scores and DEPCAT categories. The data were analysed to investigate the relationship between d3t, mt, ft, d3mft, proportion 'free' of caries experience and socio-economic status for Scotland. When analysed by DEPCAT the mean d3mft ranged from 1.48 for children resident in the most affluent postcode areas (DEPCAT 1) to 4.87 for those in DEPCAT 7. The mean d3mft from the 1995/96 survey of 5-year-old children in Scotland was 2.93. For the percentage 'free' of caries experience (d3mft = 0) the findings in this study ranged from 62.4% (DEPCAT 1) to 19.8% (DEPCAT 7). The d3t and mt components of d3mft and mean d3mft showed a strong positive association with increasing deprivation. The proportion of 5-year-olds experiencing decay was also significantly associated with a more deprived Carstairs score. The f component showed no association with deprivation. The Care Index (ft/d3mft x 100%) ranged from 10.8% (DEPCAT 1) to 2.9% (DEPCAT 7). There was a striking association between increasing deprivation and increasing caries experience. Children from the most deprived areas had significantly more untreated decay and missing teeth. In a population with low levels of restorative intervention, no association was found between deprivation and the amount of restorative care received by Scottish 5-year-old children.

The Scottish Health Boards' Dental Epidemiological Programme: initial surveys of 5- and 12-year-olds

The Scottish Health Boards' Dental Epidemiological Programme, a joint venture between the Scottish Chief Administrative Dental Officers and the Dental Health Services Research Unit at the University of Dundee, was instigated in 1987 in response to the Chief Dental Officer's concern at the lack of any coordinated dental health information about children residing in the 15 Scottish Health Board areas. Each year a standardised dental survey of a random sample of children is now undertaken across Scotland. This paper reports, principally, the caries results of the first three surveys of 5, 12 and 5-year-olds undertaken at the end of 1987, 1988 and 1989, respectively. Marked variations in caries prevalence were found in different parts of Scotland, higher levels being recorded in the urbanised central belt and in the West. While there have been overall improvements since 1983, caries prevalence in Scotland remains substantially higher than in many other parts of the UK (mean DMFT for 12-year-olds in 1988 = 2.23, mean dmft for 5-year-olds in 1989 = 2.82), with 67.8% of 12-year-olds and 59.2% of 5-year-olds (in 1988 and 1989, respectively) still suffering from dentinal caries or past caries experience (DMFT/dmft greater than 0) when assessed by clinical examination alone. No continued improvement in caries prevalence was seen in the 1989 survey of 5-year-olds compared to the 1987 examination. Continued monitoring of this situation is indicated.