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Dental Epidemiology Programme for England

Oral Health Survey of
5 year old Children
2007 / 2008

October 2009
Introduction
For the past 20 years nationally coordinated surveys of child dental health
have been undertaken across the UK which produced robust, comparable
information which could be used at local level and compared regionally,
nationally and internationally. These surveys have been jointly run by the NHS
and the British Association for the Study of Community Dentistry (BASCD)
The information produced from the nationally coordinated surveys of child
dental health is used by Primary Care Trusts (PCTs) when conducting oral
health needs assessments at local level and forms an important component of
the World Class Commissioning approach.
In recent years concern was expressed by all parties about compliance with
the programme and the quality of the data. New arrangements were
established in England during 2006/07 which embedded the programme within
the governance of the NHS and maintained the important advisory role of
BASCD in ensuring quality standards. The NHS Dental Epidemiology
Programme for England was established (NHS DEP) and is delivered in
accordance with Directions (DH, 2008) made under the Functions of Primary
Care Trusts (Dental Public Health) (England) Regulations 2006 (OPSI, 2006).
The North West Public Health Observatory (NWPHO) and The Dental
Observatory (TDO) worked with the Department of Health (DH), BASCD and
other stakeholders to develop the NHS DEP.
This report gives details of the survey of 5 year old children in the school year
2007/8, the first dental survey to take place under these new arrangements.
Methods
The survey was undertaken during the school year 2007/8. The sampling
frame was children attending mainstream schools who were aged 5 years at
the time of the survey. Data was collected by trained and calibrated examiners
employed by PCTs. The training and calibration of examiners was carried out
using the methodology described by Pine (Pine et al, 1997a). BASCD criteria
for clinical examination (Pitts et al, 1997) were employed as in previous
surveys. This involves visual-only detection of missing teeth, filled teeth and
teeth with obvious dentinal decay. The presence and absence of plaque and
oral sepsis were also recorded.
The survey was conducted according to a standard protocol which gave details
of the sampling methodology to be employed (based on Pine et al, 1997b).
For the first time the primary sampling unit was Local Authority (LA). Samples
were drawn for each LA in England using the same methods and similar
sampling intensities as used in the past. The methodology also allowed for
representative PCT samples.
October 2009 Page 1
Following guidance from the Deputy Chief Dental Officer in 2005, the protocol
also required that positive consent was obtained prior to the survey from the
child’s parent or from someone with the competence to give consent on behalf
of the child. In previous surveys, parents were informed about the survey and
unless the parents objected, children were examined.
The data were collected using the Dental Survey Plus 2 computer program
and electronic files of the raw, anonymised data were sent to TDO via a secure
web portal. Data cleaning and quality checks were undertaken before the data
was transferred to the NWPHO for analysis.
Population weighting1
was used to calculate estimates of a range of measures
of oral health for each LA and PCT. The postcode of residence for each
record was used to assign a deprivation score and these were then used to
allow weighting of the sample data to more closely match the actual
distribution of deprivation quintiles2
in the source population.
Results
In total 147 out of 152 PCTs took part in the survey covering 338 out of 354
Local Authorities. A total of 139,727 clinical examinations were included in the
final analysis.
The overall response rate to the survey samples was 66.8%. Possible non
response bias cannot be ruled out and comparisons with other surveys should
not be made without reference to the response levels.
Headline results are presented here along with an indication of the range of
results and some high level illustrations. The full tables of results at PCT, LA
and regional level are available at www.nwph.net/dentalhealth Reference to
dental decay in these results relates to obvious dental decay into the dentine
of the tooth and is indicated by d3.
Experience of dental decay at age 5
At a national level there are significantly more children (69.1%) who are free
from obvious dental decay than those who have at least one decayed, missing
or filled tooth (30.9%). At a PCT level however there are wide variations
ranging from the East Riding of Yorkshire where only 17.7% have experience
in dental decay to Middlesbrough PCT where the figure is 53.4%. Figure 1
shows the differences across the country at the Strategic Health Authority
(SHA) level.

1 The sampling methodology utilised for this survey was school based and therefore not truly
representative of the population of five-year-old children by IMD quintile. Thus, the sample was treated as
a stratified random sample i.e. children were selected randomly from each IMD quintile, but the sampling
probability varied between IMD quintiles. For this reason, IMD-weighted estimates were produced to
provide more robust estimates of overall prevalence.
2 Deprivation quintiles divide populations into fifths according to the Index of Multiple Deprivation, and are
used to identify the range of deprived and affluent sections of the population.
October 2009 Page 2
Figure 1 : Percentage of 5 year old children with decay experience (d3mft > 0)
including 95% confidence limits. Strategic Health Authorities, 2007/08.
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
North East
Yorkshire and the Humber
North West
London
England
East Midlands
South West
West Midlands
South Central
East of England
South East Coast
Strategic Health Authority
Percentage
Severity of dental decay at age 5
Across the whole of the population examined the average number of dentinally
decayed missing or filled teeth (d3mft) per child is 1.11. Figure 2 shows the
differences across the country by SHA, whilst the distribution across PCTs is
shown in Figure 3. This ranges from 0.48 in West Kent to 2.50 in Brent.
Figure 2 : Average number of dentinally decayed, missing (due to decay) and
filled teeth (d3mft) in 5 year old children including 95% confidence limits.
Strategic Health Authorities, 2007/08.
0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 1.10 1.20 1.30 1.40 1.50 1.60 1.70
North West
Yorkshire and the Humber
North East
London
England
South West
East Midlands
South Central
West Midlands
East of England
South East Coast
Strategic Health Authority
Average d3mft
October 2009 Page 3
Figure 3 : Average number of dentinally decayed, missing (due to decay) and
filled teeth (d3mft) in 5 year old children. Primary Care Trusts, 2007/08.
0.00 0.25 0.50 0.75 1.00 1.25 1.50 1.75 2.00 2.25 2.50
Average d3mft
England = 1.11
Lowest = 0.48
Highest = 2.50
Given that across England as a whole, this dentinal decay only occurs in
30.9% of the population it is important to consider the average number of
decayed missing or filled teeth among those children who are not free of
obvious disease (i.e. children with a d3mft > 0). Children who have the
disease, have on average 3.45 teeth affected. This figure also varies widely
from 2.40 teeth affected in North Lincolnshire to 5.47 in Brent.
October 2009 Page 4
The number of decayed teeth at age 5
The number of teeth with obvious dentinal decay makes up the largest
component of the d3mft index (Fig 4) and, on average, 5 year old children in
England have 0.87 teeth decayed into dentine. Again there is wide variation
from 0.30 in West Kent to 2.24 in Brent.
The number of filled and missing teeth (due to dental decay) at age 5
The number of filled teeth and missing teeth make up the smaller portions of
the total d3mft index present in 5 year old children. At a national level the
average number of filled teeth is 0.12 and the average number of missing teeth
is also 0.12. The combined components of the d3mft index are shown for each
SHA in Figure 4.
Figure 4 : Components of d3mft (number of dentinally decayed, missing (due to
decay) and filled teeth) in 5 year old children. Strategic Health Authorities,
2007/08
0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 1.10 1.20 1.30 1.40 1.50 1.60
North West
Yorkshire and the Humber
North East
London
England
South West
East Midlands
South Central
West Midlands
East of England
South East Coast
Strategic Health Authority
Average d3mft
Mean d3t
Mean mt
Mean ft
The Care index
The care index is the proportion of teeth with caries experience which have
been filled, derived by taking the number of filled teeth and dividing by the total
number of dentinally decayed, missing and filled teeth and converting to a
percentage (ft/d3mft). There are different schools of thought regarding the
appropriateness and benefit of filling decayed deciduous teeth and a lack of
definitive evidence based guidance on this. In using this Care Index data, care
October 2009 Page 5
should be taken in making assumptions about the extent or the quality of care
available.
The care index is 14% across England as a whole and varies considerably
from 4% in Hull to 33% in South Gloucestershire.
Children with sepsis at the time of the examination
Sepsis was defined as the presence of a dental abscess or sinus which was
recorded by visual examination of the soft tissues. Across England 2.3% of 5
year old children showed signs of sepsis and as expected the level was
generally higher in those areas where there were higher levels of decay. For
example the highest levels occurred in London (3.4%) and the lowest in the
South East Coast and West Midlands SHAs (both 1.6%) Figure 5.
Figure 5 : Percentage of 5 year old children with evidence of Sepsis.
Strategic Health Authorities, 2007/08.
0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5% 4.0%
London
North East
Yorkshire and the Humber
North West
East Midlands
England
South Central
South West
East of England
South East Coast
West Midlands
Strategic Health Authority
Percentage
Discussion
One of the benefits of the nationally coordinated programme using
standardised BASCD criteria has been the ability to look at trend data over
time. This had been possible because the methodology used in the conduct of
the surveys had remained constant. As described in the introduction this is the
first survey to be carried out following a number of methodology changes. A
thorough investigation of the likely impacts of these changes has been
undertaken and, whilst most are felt to have had limited impact on the results
October 2009 Page 6
of the 2007/8 survey, it has not been possible to quantify the effect of the
introduction of positive consent. The requirement for parents to give positive
consent for the examination has introduced possible bias.
Only a small proportion of parents actively stated that they did not want their
child included in the survey. Simple non-response to the request for consent
was far more common. The non responders in the survey tend to be from the
more deprived areas and there is an established relationship between
deprivation and dental decay whereby children from more deprived areas tend
to have higher levels of dental decay (Mellor, 2000 : ONS, 2003). Although the
data has been weighted to model the underlying deprivation profile of the
population, it is possible that the non responders have different levels of dental
decay, over and above that explained by deprivation alone. No clinical data
exists on this missing part of the sample and therefore it is not possible to
model or measure the impact that this has had.
In previous surveys the response rates of 75.0% and above have been readily
achieved and considered by BASCD to provide sufficient confidence to enable
publication and comparison with the results of previous surveys. In England
during 2007/08, only 66.8% of the drawn sample were included in the final
analysis therefore national level comparisons with previous surveys cannot be
made with confidence.
At other geographic levels response rates vary widely. Across SHAs the
response varied from 58.4% in London to 75.1% in South Central. On a PCT
level it varied from 24.3% in Bournemouth and Poole to 90.3% in Tameside &
Glossop. Again, it is recommended that comparisons with other surveys are
not made without first carefully examining the response rate.
Whilst the results of this survey are not directly comparable with those of the
previous series for the reasons outlined, the ranking of the SHAs and the
geography of the inequality in disease levels is broadly consistent with
previous surveys.
Methods of improving response rates and the representativeness of the
children examined are currently under consideration
References
Department of Health (2008) Directions to Primary Care Trusts concerning the
exercise of Dental Public Health Functions 2008. Gateway No. 10639.
Available from:
www.dh.gov.uk/en/publicationsandstatistics/legislation/dh_090515
Mellor, A.C (2000) Tooth decay and deprivation in young children. British
Dental Journal 189, 372
Office for National Statistics (2003) Children’s Dental Health Survey [Online].
Available from: www.statistics.gov.uk/cci/nugget.asp?id=1000
October 2009 Page 7
Office of Public Sector Information (2006) The Functions of Primary Care
Trusts (Dental Public Health) (England) Regulations 2006. Statutory
Instrument 2006 No. 185.
Available from: www.opsi.gov.uk/si/si2006/20060185.htm
Pine, C.M., Pitts, N.B., Nugent, Z.J. (1997a) British Association for the Study of
Community Dentistry (BASCD) guidance on the statistical aspects of training
and calibration of examiners for surveys of child dental health. A BASCD coordinated dental epidemiology programme quality standard. Community Dental
Health: 14, (Supplement 1), 18-29.
Pine, C.M., Pitts, N.B., Nugent, Z.J. (1997b) British Association for the Study of
Community Dentistry (BASCD) guidance on sampling for surveys of child
dental health. A BASCD coordinated dental epidemiology programme quality
standard. Community Dental Health: 14, (Supplement 1), 10-17.
Pitts, N.B., Evans, D.J., Pine, C.M. (1997) British Association for the Study of
Community Dentistry (BASCD) diagnostic criteria for caries prevalence
surveys – 1996/97. Community Dental Health: 14, (Supplement 1), 6-9.
October 2009 Page 8

Dental Epidemiology Programme for England

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