2012ScottishUniversitiesMedicalJournal, ElectronicallyPublishedSUMJ003

Dundee
Publishedonline:May2012 ChambersS(2012).PublicHealth&Dental
CariesinYoungChildreninDeprived
CommunitiesinScotland

PublicHealthandDentalCariesinYoungChildreninDeprived
CommunitiesinScotland

StephanieChambers(ResearchFellow,OralHealthandHealthResearchProgramme,
DentalHealthServicesandResearch)
Correspondenceto:StephanieChambers:s.a.chambers@dundee.ac.uk

ABSTRACT
Dental caries is the most prevalent disease worldwide, and is caused by a complex
interactionoftoothsusceptibility,nutritionandtheoralenvironment.Inyoungchildrenit
canhaveamajorimpactontheirqualityoflife,andisthemainreasonwhyScottishchildren
are admitted to hospital. There have been dramatic improvements in Scottish childrens
oralhealth.ThishasbeenenabledthroughtheintroductionofChildsmile,thenationaloral
health programme for Scottish children. Nevertheless, significant challenges exist in
reducing oral health inequalities. This paper calls for a greater emphasis on the social
determinants of health to ensure that all Scottish children have the benefit of good oral
health.

KeyWords:publichealth;dentistry;oralhealth

Introduction
Dentalcaries,alsoknownastoothdecay,affectsthevastmajorityofadultsand6090%of
childreninindustrializedcountries1.Ithasacomplexaetiologyasdemonstratedinfigure12,
whichshowsthatcariesoccursunderconditionsrelatingtothetoothitself,sugarspresent
in food and drinks, and the oral environment. This paper discusses dental caries in the
Scottish context, describing its aetiology, prevalence rates, policy, dental public health
programmesandfuturedirections.

Dental plaque forms continuously on tooth surfaces, and when exposed to fermentable
carbohydrates,bacteriaintheplaquecreateacid.AcidlowersthepHofthemouth,anda
processofdemineralisationoccursontheenameloftheteeth.Overtimeremineralisation
occursnaturally,however,ifdemineralisationovertakesremineralisation,thencavitiesform
in the teeth. Caries risk is associated with a wide range of factors including high levels of
mutans streptococci bacteria, previous caries experience, poor oral hygiene, sugar
consumption,lowfluorideexposure,reducedsalivaryflow,andsocialdeprivation3.

Sugar consumption has been identified as the major cause of dental caries4. Dramatic
increasesindentalcarieswereseenbetweenthe17thand19thcenturiesastheavailability
andconsumptionofsugarincreased57.Cariesprevalencehasbeenindeclineindeveloped
countries since the 1960s, but is increasing in developing countries as diets change and
sugar consumption increases1. The frequency of sugar consumption is particularly
important, with evidence suggesting that consumption on more than four occasions each
day is likely to result in caries8. The correlation between diet and health is not
straightforward9.Nevertheless,lowerlevelsofcariesarefoundincountrieswhereaverage
sugarconsumptionislessthan1520kgperyear,equatingto610%ofenergyintake8.

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Figure=1 Necessary conditions for caries development (adapted from Keyes and Jordan
(:;<
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1963 )
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Another
' key determinant includes access to fluoride, either through the water supply, or
fromanothersource,suchastoothpasteortopicalfluorideapplication.Systematicreviews
'
have suggested that water fluoridation can provide a preventive effect against decay1011.
Othereffectivemeansincludebrushingwithfluoridetoothpaste12,13,andfluoridevarnish1416
17
orfluoridegelapplication
' ,wherefluorideinahighlyconcentratedformisappliedtothe
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teeth.

Dental caries impacts on individuals in a number of ways. The most obvious is pain and
discomfort; however, the negative aesthetic appearance of caries can also have a huge
impact. Caries is related to lower oral health related quality of life in both adults and
children18, and has been shown to impact childrens growth19. Treatment of decay in
children can result in the extraction of teeth, and remains the most common reason for
Scottishchildrentobeadmittedtohospitalforanelectiveprocedure20.Thehealthofthe
primarydentitionisimportant,notonlytopreventpain,butalsotoensurethatadultteeth
grow into the appropriate space in the mouth. This can prevent costly orthodontic
treatmentinlateryears.

DentalCariesPrevalenceinScottishChildren
Scotland has excellent epidemiological data on caries prevalence in children through the
National Dental Inspection Programme (NDIP). NDIP originated in 2002, replacing the
Scottish Health Boards Dental Epidemiological Programme (SHBDEP), and gathers
anonymiseddataonoraldiseaseprevalenceinchildrenthroughschooldentalinspections.
NDIPprovidesinformationonthenumberofdecayed(d3),missing(mt)andfilled(ft)teeth
inchildrenacrossScotland.Primaryteetharerepresentedusinglowercaseletters(d3mft)
and permanent teeth by upper case (D3MFT). Only obvious decay is detailed, that is,
moderateorextensivedecaywherelesionsareintodentine(thelayerbelowtheenamel)or
pulp(figure2)21.

 ' !"#$%&'('!')*%"&+'",&-&%#'.*/*01&/'2%34'5"11+'(667(89'
Figure2Cariesiceberg(adaptedfromPitts200421)
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/7D:7'

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+1*#&'/&,*;'
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Basic' inspection data is collected annually for 5 year old and 11 year old children,
corresponding to the start and end of primary education. Detailed inspection data is
availableforeachagegroupinalternateyears.In2010,64%of5yearoldshadnoobvious
22
decayexperienceintheirprimaryteeth,exceedingthenationalHEATtargetof60%
! .The
targetfailedtobeachievedinonlytwooutoffourteenhealthboards(GreaterGlasgowand
Clyde and the Western Isles). This represented a rise of six percentage points from 2008,
andariseof23percentagepointsovera20yearperiod.Therearealsoimprovementsin
meand3mftoverthesameperiod(1.52in2010comparedwith3.2in1994).

TheproportionofPrimary7childrenwithnoobviousdecayexperienceinpermanentteeth
is69%,exceedingthenationaltargetof60%inallScottishhealthboardsforthefirsttimein
201123. The oral health of 11 year old children has improved greatly over the previous
decade, rising from 53% of children with no obvious decay experience in their permanent
teeth. A downward trend in decay prevalence was noted with D3MFT falling from 1.29 in
2005to0.70in2011.

UndoubtedlytheoralhealthofScottishchildrenisimproving;however,asocialgradientin
oral health persists, and decay experience is not shared evenly. Health statistics are
reportedusingtheScottishIndexofMultipleDeprivationwhichusesarealevelinformation
(includingemployment,income,andeducation)tostratifyScottishpostcodesintoquintiles,
where1representsthehighestlevelofdeprivationand5representsthelowestlevel.Inthe
least deprived areas (quintile 5) 79% of P1 children had no obvious decay compared with
only 47% of children in the most deprived areas (quintile 1)22. For P7 children, 81% in
quintile 5 had no obvious decay experience in their permanent teeth compared with only
54%inquintile123.

ItisnotonlyinrelationtodeprivationthatinequalitiesarenotedacrossScotland,butalso
between children living in urban and rural areas, and children from ethnic minorities.
Conwayetal.24reportedthatPakistanichildrenhadhigherd3mftlevelsthanwhitechildren,
and that only 25% of Pakistani children had no obvious decay experience compared with
48% of white children. These differences persisted after controlling for deprivation level.
Levin et al.25 found that children in remote and rural areas have lower d3mft and more
restorativecare.

OralHealthPolicyinScotland
Traditionallytherehasbeenafocusontreatmentratherthanprevention.However,more
recently this focus has shifted, and policies and programmes are oriented towards
prevention strategies. The key policy document that has influenced the direction of oral
healthcarewithinScotlandinrecentyearsistheActionPlanforImprovingOralHealthand
ModernisingDentalServicesinScotland26.WithintheActionPlanoneofitsmainprinciples
isforNHSdentistrytobedirectedtowardsprevention,particularlyinrelationtooralhealth
disparities.

Specific targets have also been created in relation to childrens oral health. Of particular
importancewerethefollowingtargets26:

ByMarch2008
1. Allchildrenwillhaveaccesstodentalcareonstartingnurseryschoolandtogether
withtheirparentsandcarerswillhaveaccesstodentaladvice
2. The number of children aged 02 years under dental care/supervision will increase
from35%to55%
3. The number of children aged 35 years under dental care/supervision will increase
from66%to80%
4. All preschool children in areas of greatest need will be offered dietary advice,
dental advice, support and preventive packs through community based
organisations
5. Allnurseryschoolswilloffersupervisedfluoridetoothbrushingschemesandsupport
healthyeatinganddrinkingwaterpolicies

By2010
1. 60%of5yearoldprimarychildren(Primary1)willhavenosignsofdentaldisease.
2. 60%of1112yearolds(Primary7)willhavenosignsofdentaldiseaseinpermanent
teeth.

ThecurrentHEATtargetisthat27:

At least 60% of 3 and 4 year old children in each SIMD quintile to receive at least
twoapplicationsoffluoridevarnish(FV)peryearbyMarch2014.

Toachievethesetargets,guidelineshavebeendrawnuptohelppolicymakers,programme
designers and practitioners. The prevention and management of caries in children in
Scotland is focused around two Scottish Intercollegiate Guidelines Network documents4,28.
These guidelines draw from the evidence base around the benefits of fluoride,
toothbrushingprogrammes,healthydiet,feedingpractices,andtheprovisionofservicesin
areas of high deprivation. In 2010 the Scottish Dental Clinical Effectiveness Programme
(SDCEP)29 published guidance on the prevention and treatment of dental caries in clinical
practice. The guidance provides recommendations on assessing children, delivering
preventivecare,managingcaries,andrecallfrequency.

Key public health messages to achieve the targets outlined above are focused around two
mainareas:toothbrushinganddiet29.Itisrecommendedthatchildrenbrushtwiceperday
for a period of two minutes using fluoride toothpaste (over and above toothbrushing in
nursery or school). Childrenaged 0to6shouldusetoothpastewith atleast 1000 ppmof
fluoride:childrenover7shouldusebetween1350and1500ppmfluoride.Childrenunder7
years should be helped to brush their teeth by a parent or carer, and children should be
encouraged to spit out their toothpaste without rising their mouths. This increases the
protectionprovidedbyfluoridetoothpaste.Toothbrushingshouldcommencewhenthefirst
tooth breaks through. Additional advice includes attending the dental practice for
preventivecarefromaged6months.

Dietaryrecommendationsarethatchildrenaregivensweetfoodordrinksonnomorethan
fouroccasionseachday,andthatsugarisconfinedtomealtimes.Sweeteneddrinksshould
not be provided in feeding bottles and children should not be left with bottles at night.
Salivaryflowreducesduringsleep,causingmilk(notnormallycariogenic)toraiseacidlevels
ininfantsmouths.Itisrecommendedthataddedsugarsberestrictedtolessthan10%of
dietaryintake8.Themostrecentnutritionalguidelinesavailableinrelationtooralhealthare
theOralHealthandNutritionGuidanceforProfessionals,whichprovideaccurate,uptodate
informationforprofessionalsworkingwithyoungfamiliesinScotland30.

As previously outlined, some of the targets set out above have been reached (i.e. 60% of
childrenwithnoobviousdecay).Inaddition,thenumberofdentalextractionproceduresin
hospital has reduced by 23% since 2006/7, when 9238 extraction procedures were carried
out,comparedtoonly7139in2010/1120.ThisnotonlysavestheNHScostlytreatment,but
alsoreducesanxietyandtraumainchildrenwhodonothavetoundergogeneralanaesthetic
inhospital.Dentalregistrationof35yearoldsisnowat89%;however,registrationof02
year olds remains low at only 41%31. This is of concern because evidence suggests that
whenchildrenareyoung,thosewhoattendregularlyhavelowerlevelsofdecaythanthose
whoattendforemergencycareonly32.Theadditionaltargetsoutlinedhavebeenreached
throughtheintroductionoftheChildsmileprogramme,whichisdescribedinthefollowing
section.

OralHealthProgrammesforScottishChildren
PilotprogrammestoimproveScottishchildrensoralhealthhaveinformedcurrentpractice.
NHSGreaterGlasgowandClydesetupafrombirthprogrammeintwoofthemostdeprived
areas of Glasgow City in 19971998 and 20032004. This scheme included free fluoride
toothpaste, a push for healthy food and drinks policies within nurseries, and promoting
attendanceatthedentalpracticeforpreventivecare.Thereweresubstantialreductionsin
d3mftanduntreatedcariesatatimewhenimprovementsinchildrensoralhealthwerenot
seeninotherareasofthehealthboard33.

In Dundee, a two year toothbrushing programme in schools and homes showed that the
beneficial effect of five year old children brushing twice per day was 50%34. By age 12 a
significant difference in caries prevalence between the intervention (D3MFT = 1.32) and
control(D3MFT=2.65)wasfoundforthechildrentakingpart.

Childsmile
Childsmile is the national oral health programme for all Scottish children35,36, and it has
developedfrompilotprogrammessuchasthoseoutlinedabove.Itisdesignedaroundthe
principles of the Ottawa Charter for Health Promotion, that is, the provision of education,
sustainable resources, social justice and equity33. Childsmile aims to reduce inequalities
through a universal and targeted approach. We know that health education tends to be
takenupbythosewhoarealreadyeducatedandwealthy37,therefore,programmeshavean
ethicaldutynottoincreaseinequality38.

Childsmiles demonstration programme ran between 20062009, with its Practice

programme in the west of Scotland (NHS Greater Glasgow and Clyde, Lanarkshire and
Ayrshire and Arran), and the nursery programme in the east (NHS Lothian, Tayside, Fife).
ThefullprogrammeisnowavailableacrossScotland.

TheCoreprogrammeisuniversal:everychildinScotlandissuppliedwithfluoridetoothpaste
andtoothbrushesonsixoccasionsuntilagefiveyears.TheCoreprogrammealsoincludes
toothbrushinginallnurseries,andP1andP2classroomsinthe20%mostdeprivedareasin
Scotland. Toothbrushing is carried out once every day, with each child having their own
toothbrushkeptwithintheclassroom.

Childsmile Practice is focused around childrens oral health from birth, where families are
riskassessedtodeterminewhetherachildshouldbereferredintotheprogramme.Therisk
assessmentisgenerallycarriedoutbyhealthvisitorswhenaninfantisaroundeightweeks
old,andisbasedonthedeprivationlevelofthearea(SIMD)inwhichafamilylives,whether
parentsareregularattendersatadentalpractice,ifoldersiblingshaveexperienceddental
decay, and the health visitors professional judgement of caries risk. Families within the
PracticeProgrammearehelpedtoregisterandattendalocaldentalpractice,andaregiven
adviceontoothbrushingandhealthyfoodsandsnacks.ChildsmilePracticeinvolvesthefull
dental team through a dental health support worker, dental nurse and general dental
practitioner. As children develop, they are able to receive fluoride varnish and fissure
sealantsatthedentalpractice.Fissuresealantssealoffthepitandfissuresurfacesofthe
teeththatareparticularlypronetocaries.Thecarryingoutofsuchpreventivemeasureshas
beenaidedbychangesindentalremuneration,wheredentalpracticesarenowpaidbythe
NHStoprovidethesepreventivetreatments39.

The Childsmile School and Nursery Programmes involve fluoride varnish application in
schools and nurseries in the 20% most deprived areas of Scotland (SIMD quintile 1).
Extendeddutydentalnursesanddentalhealthsupportworkersvisitschoolsandnurseries
toapplyfluoridevarnishto35yearolds.

TheimprovementinScottishchildrensoralhealthhasbeenattributedtotheintroduction
ofChildsmile.OfparticularnoteisthatalmostallnurseryschoolsinScotlandnowhavean
established toothbrushing programme. There remain concerns, however, that children
experiencingthegreatestdegreeofdisadvantagearenotengagedfullywithChildsmile,with
failuretoattendratesataround1/3rdforthePracticeProgramme40.

FutureImprovementsintheOralHealthofScottishChildren
Leading oral health academics have called for a common risk factor approach to address
poor general and oral health4143. They argue that the factors that affect health more
generally, are also those that contribute to poor oral health. This includes individual level
behaviourssuchaseatingapoordiet,smoking,alcoholconsumptionandpoorhygiene,but
also systemlevel factors such as low income, lack of education and poor access to health
care43. By focusing on particular diseases, repetition of programmes is more likely and
resourcesareusedinefficiently.Indeed,thesocialgradientinoralhealthisidenticaltothat
in general health42. This is seen particularly clearly in relation to sugar consumption in
Scottishchildren,whichaccountsfor17%ofdietaryintake,andcontributestobothdental
caries and excess weight44. Sugar intake is also highest among children living in the most
deprivedareas44.

Oral health promotion has been criticised for taking individualistic approaches42,45. These
areprogrammesandpoliciesthattendtodrawfrompsychologicalapproachesthatposition
behaviour as the outcome of rational decision making, and that theorise that increased
knowledge and education alone will affect positive outcomes. In reality, individual
behaviours are very difficult to change, particularly in high risk groups46. Sheiham and
Watt42 argue that instead the social determinants of health must be addressed to reduce
oralhealthandotherhealthinequalitiesintheUKandbeyond.

Newton and Bower45 put forward the view that dental public health must engage more
widelywiththesocialsciencecommunitytobetterunderstandthecomplexitysurrounding
disease experience. Childsmile has embraced this by incorporating an action research
model,usingaformativeandsummativeapproachtoimprovetheprogrammeandevaluate
its impact. Progress is monitored through its Central Evaluation and Research Team, and
additionalcommissionedresearch,whichinformstheprogrammeasitevolves.Childsmileis
alsofeedingintotheHealthPromotingSchoolsconcept,engagingwithschoolstoimprove
both oral and general health47. Nevertheless, major challenges remain, particularly in the
areaoforalhealthinequalitiesinScottishchildren.MarmotandBell48havenotedthatuntil
the causes of causes are addressed, i.e. social determinants of health, and social justice
issuesputatthecentreofpolicymaking,inequalitieswillpersist.Itisinthisdirectionthat
dental public health in Scotland must now turn to reduce oral health disparities in our
children.

Acknowledgements
IwouldliketothankmycolleaguesRuthFreeman,SteveTurnerandSucharitaNanjappafor
theirhelpfulcommentsonearlierdraftsofthispaper.

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