Children's oral health

The World health organisation (WHO) states that oral health is,

"A state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual's capacity in biting, chewing, smiling, speaking and psychosocial wellbeing."

Infants, preschool children, adolescents, older people and those with vulnerabilities are most at risk of tooth decay (Public Health England (PHE): West Yorkshire oral health needs assessment 2015 ). Nationally, 25% of children have dental decay, which can lead to pain and discomfort.

Cavities and periodontal disease are a major cause of tooth loss. There were 39,278 hospital episodes for tooth extractions due to decay in 0-19 year olds in 2015-16, making up 7% of all hospital procedures for this age group (PHE: Hospital episodes for teeth extraction of children aged 0-19 years, 2011-12 to 2015-16 ).

Risk factors for oral disease in children include an unhealthy diet and poor oral hygiene (WHO: Oral health factsheet , 2012). Dietary sugars which lead to tooth decay are present primarily in confectionery, biscuits and soft drinks, with most people in England consuming more sugar than the recommended levels (PHE: Scientific advisory committee on nutrition carbohydrates and health report 2015 ). Across England, 42% of children did not visit a dentist within the last year (NHS digital: NHS dental statistics for England 2015-16 ), despite the National institute for clinical excellence (NICE) recommendations that children would be seen by a dentist at least once a year, and in spite of all NHS dental treatment being free to everyone aged under 18 years old (NHS choices: Who is entitled to free NHS dental treatment in England , 2017).

The local picture

The proportion of children in Calderdale with tooth decay by the age of five years old is similar to the national average, and in 2014/15 it had fallen by 34% from a high of 45% in 2007/08. However in 2014/15, 29% of local children still exhibit signs of decay by the age of five years (PHE: Proportion of five year old children free from dental decay ), with a mean average number of decayed, missing or filled teeth of 1.08 (with a confidence interval of 0.83 to 1.34), compared to the England average of 0.84 (PHE: Decayed, missing or filled teeth in five year olds , 2014/15). In five year olds with decay, the average number of teeth affected is 3.7 in Calderdale, compared to 3.4 in England (PHE: Oral health survey of five year old children: 2014 to 2015 ).

By the age of three years old, almost 13% of children in Calderdale have experienced tooth decay compared with almost 12% nationally. By this age, 5.6% of children in Calderdale have early childhood caries, an aggressive form of decay affecting the upper front teeth. This is associated with consuming sweet drinks from a feeding bottle at night or for prolonged periods during the day (PHE: Oral health survey of five year old children: 2014 to 2015 ).

In 2015/16, there were 393 hospital episodes amongst 0-19 year olds in Calderdale for tooth extraction as a result of decay. Of these, the vast majority were aged 5-9 years old, reflective of regional and national trends.

  Age 0-4 years Age 5-9 years Age 10-14 years Age 15-19 years Total number
Calderdale 22.1% 61.1% 13.7% 3.1% 393
England 20.2% 57.3% 14.9% 7.6% 39,278

A local school pupil survey reports that 3.9% of secondary school aged children report serious problems with their teeth. While three quarters (76.3%) brush their teeth two or more times a day, 3.3% don't brush their teeth on a daily basis. Those reporting serious problems with their teeth were less likely to brush their teeth regularly. Around 7.4% of pupils have at least five unhealthy snacks / fizzy drinks per day ( electronic Health Needs Assessment (eHNA) survey: key findings , 2016).

Dental access statistics published by NHS Digital ( NHS dental statistics for England 2015-16 ) reveal that 65.7% of children in Calderdale had seen a dentist in the previous 12 months, compared to 62.9% in Yorkshire and the Humber and 58.0% in England.

 

Inequalities

Across England, levels of tooth decay are significantly higher in the most deprived areas than in the least deprived areas (PHE:  Proportion of five year old children free from dental decay , 2014/15), a picture that is reflected locally (Dyer T, Wyborn C, Godson J (2012): The dental health of five year old children in Yorkshire and the Humber 2007/08 ; PHE:   West Yorkshire oral health needs assessment 2015 ). Around 10,600 0-19 year olds in Calderdale (22.2%) live in low income families (PHE:  Children in low income families (all dependent children under 20) , 2006 to 2014).

Severity of tooth decay experience in five year olds by ward in Calderdale 2011/12

Severity of tooth decay experience in five year olds by ward in Calderdale

(dmft - decayed, missing or filled teeth)

Source: PHE: West Yorkshire oral health needs assessment 2015 ;

Map: PHE knowledge and intelligence team, Northern and Yorkshire © Crown copyright and database rights 2014, Ordnance survey 100016969 contains National statistics data © Crown copyright and database rights 2014.

Current provision

The 2012 Health and social care act conferred statutory responsibility for dental public health functions to local authorities. This responsibility includes the commissioning of oral health promotion programmes in order to improve local population oral health. As such, there are a number of evidence based initiatives delivered in Calderdale, which aim to promote good oral health. These follow a targeted population approach, focussing on high risk groups. They include advice to families, a dental award scheme for early years settings, resources for schools and a school based tooth brushing programme.

User views

Calderdale Council's Citizen panel feedback, from 2012, finds that 86% of respondents, who were parents / carers, reported that they did not have difficulties accessing dental care for their child, but 5% reported that they did experience difficulties (Calderdale Council, 2012). The vast majority (90.9%) of secondary school pupils report having an annual dental check-up (Calderdale Council, 2016: electronic Health Needs Assessment (eHNA) survey: key findings ).

Unmet need

A 2013 evaluation of the local tooth-brushing programme reported that 18 schools participated in the scheme (Woodall J, Woodward J, Witty K and McCulloch S (2013): An Evaluation of Calderdale’s tooth-brushing in schools scheme ), with children between the ages of three and five taking part. The evaluation found evidence of increased awareness of oral health, and positive behaviour change, but also that outcomes varied between schools, and that there was no evidence of impact on oral health outcomes.  Indeed, Cooper AM, O'Malley LA, Elison SN, et al (2011): Primary school-based behavioural interventions for preventing caries  note that the majority of school-based oral health programmes have failed to produce sustained behavioural change.

Current oral health interventions in Calderdale target only particular age groups and high risk subgroups, such as residents in deprived areas. Coverage therefore varies considerably across the district (South West Yorkshire Partnership NHS Foundation Trust, 2015: Oral health report). The current approach is further limited in that it relies on sustained individual behaviour change.

Projected future need

Despite overall improvements in children's oral health in Calderdale, inequalities in outcomes persist between children in deprived and less deprived areas. The proportion of children in Calderdale in low income families is significantly higher than the national average, and has increased in recent years (PHE:  Delivering better oral health: an evidence based toolkit for prevention , 2017). It is therefore particularly important going forward to ensure that oral health promotion is targeted at those at greatest risk. Furthermore, the child population in Calderdale is expected to increase (Office for National Statistics:  Population projections ), which will further increase demand for services.

Key considerations linked to the know evidence base (what works?)

PHE recommend that efforts to improve oral health should incorporate a suite of evidence based programmes adopting a life course approach and based on the principles of proportionate universalism. Such programmes should incorporate both population wide and targeted elements, with advice and actions for all, plus additional interventions aimed at those at higher risk of developing disease. For full details of evidence based recommendations, see:

Specifically for children and young people, these are recommended and implemented locally (PHE:  West Yorkshire oral health needs assessment 2015 :

  • Health visitor led programmes providing young children with dental packs, including fluoridated toothpaste, toothbrush and a dental information leaflet and advice;
  • supervised tooth brushing with fluoridated toothpaste delivered over a two year programme in targeted childhood settings;
  • targeted fluoride varnish schemes, where varnish is applied to children within a two year programme with at least twice yearly applications;
  • oral health training for professionals working with families and young children.

Furthermore, it is recommended that local authorities should consider the case for water fluoridation in the context of local needs and the range of oral health improvement programmes currently commissioned (PHE:  Delivering better oral health: an evidence based toolkit for prevention , 2017). A recently published online tool allows for the return on investment of various oral health interventions to be assessed at local authority level. Analysis using this tool suggests that nationally and locally, the implementation of a community water fluoridation scheme would be the most cost effective intervention at five and ten years when compared to local targeted interventions, including supervised brushing, fluoride varnish, provision of toothbrushes, and community promotion (PHE:  Hospital episodes for teeth extraction of children aged 0-19 years, 2011-12 to 2015-16 ). Though some commentators have argued that water fluoridation amounts to enforced medication and takes away freedom of choice (Nuffield Council on Bioethics: Public health: ethical issues , 2007), the strength of evidence in support of both the safety and effectiveness of water fluoridation suggests it represents the most advantageous balancing of costs and benefits, and thus the optimal policy solution.

Return on investment of oral health improvement programmes for 0-5 year olds

Source: PHE:  Return on investment of oral health improvement programmes for 0-5 year olds .

References and information

References

Information

More information about children and young people can be found in Further resources.

More information on children's oral health can be found in:

Always open first panel: 

Author

Naomi Marquis, Public health intelligence officer, Public health, Calderdale Council (23rd August 2017).