NHS Dental Epidemiology Programme for England

Oral Health Survey of
12 year old Children
2008 / 2009
Summary of caries prevalence and severity results
E Rooney, G Davies, J Neville,
M Robinson, C Perkins, M A Bellis
November 2010 Page 1
Introduction
This report gives details of the oral health of 12 year old children surveyed in the school
year 2008/9, the second national dental survey to take place under new arrangements for
the NHS Dental Epidemiology Programme (NHS DEP) for England.
Nationally coordinated surveys of child dental health have been undertaken across the
United Kingdom (UK) since 1985 which have produced robust, comparable information for
use at local, regional and national levels, with the first survey of 12 year olds being
undertaken in 1993. In England these surveys are now led by the North West Public
Health Observatory (NWPHO) and The Dental Observatory (TDO) working with the
Department of Health (DH) and the British Association for the Study of Community
Dentistry (BASCD). Each primary care trust (PCT) commissions its local providers to
undertake the fieldwork according to a national protocol and thereby fulfils its obligations
according to the Statutory Instrument 185 (2006) and the accompanying Directions (DH,
2008) made under the Functions of Primary Care Trusts (Dental Public Health) (England)
Regulations 2006 (OPSI, 2006).
The information produced from the nationally coordinated surveys of child dental health is
used by PCTs when conducting oral health needs assessments at local level and forms an
important component of the commissioning of local services.
The survey reported here provides information on the caries prevalence and severity of 12
year olds attending state schools. Additional reports will provide information about the
demand and need for orthodontic intervention in this age group, experience of oral
discomfort and the impact it has on quality of life, self-perception of enamel opacities1
of
front teeth and brushing habits.
Methods
The survey was undertaken during the school year 2008/9. The sampling frame was
children attending mainstream schools who were aged 12 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. In addition the need and demand for
orthodontic intervention were measured along with self perception of enamel opacities1
,
self reporting of oral symptoms and the impact they had on quality of life and brushing
frequency and the presence and absence of plaque.
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). 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.
Following guidance from the Deputy Chief Dental Officer in 2005, the protocol also set out
the methods to be used to gain consent from the pupils themselves. This involved

1 White marks that appear as fine bands or dots on some teeth in some individuals. There are many causes for these.
November 2010 Page 2
providing letters to the parents of all sampled pupils to inform them of the nature and
purpose of the survey and give them the opportunity to withdraw their child. All nonwithdrawn children received explanations of the nature and purpose of the survey, given
the opportunity to ask questions and asked for their consent. 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 weighting2
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 quintiles3
in the source
population.
Results
In total, 140 PCTs out of 152 took part in the survey covering 299 out of 326 local
authorities (configurations as of April 2009). A total of 89,442 clinical examinations were
included in the final analysis. This represented 15% of the population of this age cohort
attending mainstream state schools.
The overall response rate of pupils examined as a proportion of those sampled was 74%.
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 visually obvious dental decay into the dentine of the tooth and is indicated by D3.
Further detail relating to orthodontic need and demand, experience of oral discomfort and
its impact on quality of life, self perception of enamel opacities and brushing habits will be
reported within three months.
Experience of dental decay at age 12
At a national level 33.4% of pupils were found to have experience of caries, having one or
more teeth which were decayed to dentinal level, extracted or filled because of caries.
The remaining 66.6% were free from visually obvious dental decay. At a PCT level
however there are wide variations ranging from Southwark where only 12.9% have
experience in dental decay to Knowsley where 56.1% were affected. Figure 1 shows the
differences across the country at strategic health authority (SHA) level.

2 The sampling methodology utilised for this survey was school based and therefore not truly representative of the
population of twelve-year-old children by Index of Multiple Deprivation (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.
3 Deprivation quintiles divide populations into fifths according to the IMD, and are used to identify the range of deprived
and affluent sections of the population.
November 2010 Page 3
Figure 1 : Percentage of 12 year old children with decay experience (D3MFT > 0)
including 95% confidence limits. Strategic Health Authorities, 2008/09.
0 5 10 15 20 25 30 35 40 45 50
Yorkshire and the Humber
North West
North East
England
South West
East Midlands
West Midlands
South Central
London
East of England
South East Coast
Strategic Health Authority
Percentage
Severity of dental decay at age 12
Across the whole of the population examined the average number of dentinally decayed,
missing or filled teeth (D3MFT) per child is 0.74. Figure 2 shows the differences across the
country by SHA, whilst the distribution across PCTs is shown in Figure 3. This ranges
from 0.23 in Southwark to 1.48 in Ashton, Leigh and Wigan.
Figure 2 : Average number of dentinally Decayed, Missing (due to decay) and Filled
Teeth (D3MFT) in 12 year old children including 95% confidence limits.
Strategic Health Authorities, 2008/09.
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
Yorkshire and the Humber
North West
North East
England
East Midlands
South West
West Midlands
South Central
London
East of England
South East Coast
Strategic Health Authority
Average D3MFT
November 2010 Page 4
Figure 3 : Average number of dentinally Decayed, Missing (due to decay) and Filled
Teeth (D3MFT) in 12 year old children. Primary Care Trusts, 2008/09.
0.00 0.25 0.50 0.75 1.00 1.25 1.50
Average D3MFT
England = 0.74
Lowest = 0.23
Highest = 1.48
It is important to consider the average number of decayed, missing or filled teeth among
those children who were found to have obvious disease (i.e. children with a D3MFT > 0).
Of the 33.4% of children who have obvious dentinal decay, the average number of D, M, F
teeth is 2.21. This figure also varies widely from 1.55 teeth affected in Brighton and Hove
City to 2.91 in Calderdale.
November 2010 Page 5
The number of decayed teeth at age 12
The number of teeth with obvious, untreated dentinal decay contributes a significant
component of the D3MFT index (Fig 4) and, on average, 12 year old children in England
have 0.32 teeth decayed into dentine. Again there is wide variation from 0.04 in Brighton
and Hove City to 0.92 in Ashton, Leigh and Wigan.
The number of filled and missing teeth (due to dental decay) at age 12
The number of filled teeth makes a similar contribution to the total D3MFT index present in
12 year old children and missing teeth a far smaller portion. At a national level the
average number of filled teeth is 0.35 and the average number of missing teeth also 0.07.
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 12 year old children. Strategic Health Authorities,
2008/09.
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).
The care index is 47% across England as a whole and varies between SHAs from 42% in
the North East to 58% in London see Figure 5. There is considerable variation within
SHAs, for example within London SHA the index varies from 35% in Lewisham to 83% in
Richmond and Twickenham. The care index should be interpreted alongside other
intelligence such as levels of deprivation, disease prevalence and the provision of dental
services.
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
Yorkshire & The Humber
North West
North East
England
East Midlands
South West
West Midlands
South Central
London
East of England
South East Coast
Strategic Health Authority
Average D3MFT
Mean D3T
Mean MT
Mean FT
November 2010 Page 6
Figure 5 : Care index (FT/ D3MFT) in 12 year old children. Strategic Health
Authorities, 2008/09
0 10 20 30 40 50 60 70
London
South East Coast
East of England
South Central
West Midlands
East Midlands
England
South West
Yorkshire and the Humber
North West
North East
Strategic Health Authority
Percentage
There has been a trend for reducing prevalence and severity among 12 year olds for the
past 26 years and this survey suggests a further decline in the levels of disease. Figure 6
combines the caries severity and prevalence levels in National Child Health surveys over
the time period 1973 to 1993 and NHS DEP surveys over 1993 to the most recent survey.
Figure 6 : Results of caries surveys of 12 year olds in England from National Child
Health Surveys and NHS DEP surveys over 6 time periods.
0.00
1.00
2.00
3.00
4.00
5.00
6.00
1973 1983 1993 1993 1997 2001 2009
Average D MFT 3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage with decay experience
Average D3MFT
Percentage with decay experience
CHS surveys NHS DEP surveys
November 2010 Page 7
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 to conduct the surveys had remained constant. The
change in methods of gaining consent for this age group appears to have had very little
impact so the data can be used for comparison.
Approximately 12% of sampled schools declined to co-operate when asked by fieldwork
teams. Only a small proportion of parents (7.3%) actively withdrew their children and only
6.7% of pupils declined the request to take part. Absenteeism on the day of examination
accounted for loss of 11.8% of children. There was potential for any or all of these
reasons for non-participation to bias the results. This proved not to be the case as
weighting the results using quintiles of socio-economic deprivation had almost no effect on
the unweighted results and this suggests that the samples were representative of the
populations from which they were drawn, at a socio-economic level. This would suggest
that withdrawal of co-operation by schools, parents or pupils was not associated with
socio-economic measures.
In previous surveys the response rates of 75.0% and above have been achieved and
considered by BASCD to provide sufficient confidence to enable publication and
comparison with the results of previous surveys. In England during 2008/09, the response
rate was 74.1% and therefore national level comparisons with previous surveys can be
made with reasonable confidence.
Response rates vary at the SHA, PCT and LA level. Across SHAs the response varied
from 69.1% in East of England to 78.2% in London. On a PCT level it varied from 46.9 %
in Norfolk to 89.7% in Newham, therefore when looking at PCT/LA level data the response
rates need to be considered before making comparisons.
The results showing reducing levels of disease are in alignment with those found in
previous years. The geographic distribution of disease levels is also consistent with
previous surveys. The northern SHAs, Yorkshire and The Humber, North West and North
East show higher prevalence and severity of disease than SHAs in the Midlands and the
South West. The more southern and easterly SHAs, South Central, South East Coast and
London, along with East of England, have the lowest levels of disease.
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
Office of Public Sector Information (2006) The Functions of Primary Care Trusts (Dental
Public Health) (England) Regulations 2006. Statutory Instrument 2006 No. 185.
November 2010 Page 8
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 co-ordinated 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.
November 2010 Page 9
The Dental Observatory
C/o NHS Central Lancashire
Preston Business Centre
Watling Street Road
Fulwood
Preston
PR2 8DY
t: +44(0)1772 777035
e: Janet.Neville@centrallancashire.nhs.uk
www.nwph.net/dentalhealth
www.dental-observatory.nhs.uk
North West Public Health Observatory
Centre for Public Health
Research Directorate
Faculty of Health and Applied Social Sciences
Liverpool John Moores University
3rd Floor, Henry Cotton Campus
15/21 Webster Street
Liverpool
L3 2ET
t: +44(0)151 231 4535
f: +44(0)151 231 4552
e: nwpho-contact@ljmu.ac.uk
www.nwpho.org.uk
www.cph.org.uk
ISBN: 978-1-908029-02-7 (Web version)

NHS Dental Epidemiology Programme for England

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