1.5.1 Oral health initiatives

Childsmile is the flagship national oral health improvement programme for Scotland. The overarching aims of Childsmile are to improve the oral health of children in Scotland and to reduce inequalities both in dental health and in access to dental services. There is also potential for other health impacts particularly with regard to diet and obesity. The Childsmile Programme is the main route to delivering the dental HEAT target.

The Programme has three main arms:

1. Childsmile Core is a Scotland-wide initiative involving universal supervised nursery school toothbrushing provision (extended to Primary 1 and 2 classes in most deprived areas); in addition to the free distribution of toothpaste and toothbrushes, oral health improvement packs are distributed to every child in Scotland on at least six occasions during their first five years.

2. Childsmile Practice targets children from birth and promotes oral health improvement and clinical caries prevention in dental practice, salaried primary care dental services and local community settings. This element has focused on reorientating dental practice to an anticipatory care and team approach to children’s dentistry, and integrating dental services with wider health services and community initiatives. There has been significant workforce development in creating Dental Health Support Worker roles within public health nursing teams, developing referral pathways, and training Dental Nurses ( DN) in clinical prevention including toothbrush demonstration, dietary advice and support, and as the child gets older the application of fluoride varnish.

3. Childsmile Nursery and School targets the most deprived 20% of nurseries and schools by identifying the 20% of establishments with the highest proportion of children living in the most deprived local quintile, as defined using SIMD. These nurseries and schools receive additional preventive initiatives in the form of twice yearly fluoride varnish applications to children’s teeth by Childsmile teams. These teams comprise DNs and DHSWs. The Childsmile teams also deliver oral health promotion advice to parents and carers. In addition, the Childsmile Nursery and School programme contributes to the creation of a health-promoting environment within nurseries and primary schools and provides additional pathways of referral into dental services for those who have not yet accessed dental care.

1.5.2 Priority groups

Oral health improvement initiatives are also being developed for a range of other priority groups including: older people, people with special needs, people with additional needs, homeless people, and prisoners. ²

1.6 Children’s oral health

There has been significant improvement in the oral health of 11-12-year-olds in Scotland in recent years, with the national target of 60% of children with no obvious dental decay by 2010 being reached in 2009. Figure 1 compares the mean number of permanent teeth that were decayed, missing or filled ( DMFT) in several European countries for which data were available and shows that in Scotland, in common with many other countries, there was a steep decline in the prevalence of dental caries among 11-12-year-olds between 1983 and 1989. This rapid improvement was followed by a more gradual improvement between 1989 and 2005. Since 2005 the rate of improvement has increased. This rate of improvement was faster than the only other country with comparable data during this period (Denmark).

Figure 1: Mean number of DMFT per child, 12-year-olds, by selected European country (1979-2009) ³

Surveys of 5-year-olds provide the most sensitive barometer of change in the oral health of the population. Figure 2 shows the trend in the percentage of 5-year-olds in Scotland with no obvious decay using data from the Scottish Health Boards’ Dental Epidemiological Programme and the National Dental Inspection Programme ( NDIP). The latest data on 5-year-old children from NDIP [5] show a continuation of the marked improvement in the oral health in this age group in Scotland as measured by the proportion of children with no obvious dental decay experience. The proportion with no obvious decay experience has risen from 44.6% in 2003, to 50.7% in 2004, to 54.1% in 2006, and to 57.7% in 2008. This trend is set to meet the national outcome indicator that 60% of school children in Primary 1 (P1) will have no signs of dental disease by 2010.

Figure 2: Proportion of 5-year-old children with no obvious dental decay experience in Scotland (1983-2009)

Figure 2 shows that the rate of improvement since 2003 is much faster than in the past.

The Care Index is a measure of the proportion of obvious decay which was treated with restorative fillings. For Scotland overall, only 10% of teeth with decay experience were filled in the school year 2007-08, and there are concerns that this high level of unrestored decay means that primary dental care provision is failing P1 children [5]. The registration rates for children aged 3-5 and 6-12 at the time of data collection were 68.9 and 76.6 in March 2007 and 82.4 and 88.8 in March 2008. Therefore some of this unrestored decay may reflect children who are not registered with dental practices.

1.6.1 Regional variations and inequalities

There is considerable variation in the level of dental caries between geographical areas within Scotland: the mean number of deciduous teeth that are decayed, missing or filled (dmft) of 5-year-olds varies from 1.24 in Orkney to 2.14 in Lanarkshire.

Figure 3, from the NDIP 2009 survey of Primary 7 (P7) children [6], shows that dental decay is more prevalent amongst children from the most deprived areas. This means that while the Scottish target for 2010 of 60% of 11-year-old children with no obvious decay has been met for the whole population, there remains a considerable challenge to improve the oral health of children in the most deprived communities. While there is considerable variation in the level of caries between children according to their socioeconomic status, NDIP 2009 [6] reports that the oral health of children in all deprivation categories has improved and the oral health of children in the most deprived deprivation category has improved most.

Figure 3: Percentage of P7 children with no obvious decay experience in permanent teeth by SIMD quintile (2006)

1.7 Adults’ oral health

The main source of data on the oral health status of adults in Scotland is from the series of UK Adult Dental Health Surveys ( ADHS), which were conducted in 1972, 1978, 1988, and last conducted in 1998 [7]. More recently the Scottish Health Survey ( SHeS) from 2008-09 has provided similar data at the national level. It is anticipated that oral health data will be available from the SHeS at the NHS board level from 2011 onwards. Furthermore, the potential to obtain oral health data in addition to treatment activity from the dental services in Scotland is also being explored by NHS National Services Scotland ( NSS).

The dental health of adults was poorer in Scotland than in the rest of the UK [8] but there has been considerable improvement since 1972. For example, only about 12% of adults in Scotland had no natural teeth ie, were edentate in 2008 compared with 44% in 1972 (Figure 4). Despite the improvement, the oral health of people in Scotland still lags behind western European norms [9].

Figure 4: Oral health status of adults in Scotland (1972-2008)

Although Figure 5 shows that as recently as 2008, more than 40% of all people aged over 65 had lost all their teeth, there has been a substantial improvement in the oral health of adults since 1972. Moreover, Figure 5 shows very strong cohort effects in the percentage of edentate people. In 1978, 27% of people aged 35-44 were edentate and by 2008, some 41% of people in the same cohort were edentate. This suggests that there is persistence in oral health over time and, therefore, that the improvements in oral health made during recent years should continue into the future.

Figure 5: Percentage edentate by age-group in Scotland (1972-2008)

While there has been a substantial improvement in adults’ oral health in Scotland since 1972, Figure 6 shows that people from the most deprived backgrounds are more likely to be edentate. There is limited evidence of the extent of any unmet oral health need for dental services by adults. Better information on the oral health of adults would allow more robust workforce planning.

Figure 6: Oral health of adults in Scotland (2008)

1.7.1 Projections

Data from the recent SHeS [10], in conjunction with previous work at the UK level using data from the ADHSs [7], indicates that the proportion of adults retaining their natural teeth is likely to continue to increase over time. The people most likely to become edentate in the future will generally be from more deprived socioeconomic backgrounds and from older age-groups and therefore the replacement of missing teeth with partial dentures will continue to be a common pattern of treatment for the foreseeable future.

Data currently available suggest that attitudes to dental care have changed significantly during the past 20 years, and an increasing number of people are retaining teeth into old age. More work is required to assess whether this changing oral health profile will impact on demand for dental services in the future.

Trends from SHeS and Scottish data from previous ADHSs can be applied alongside population projections to predict future numbers of adults with certain dental characteristics. This will provide some insight into the potential demand for dental services. Figure 7 shows that the percentage of edentate adults in each age group decreased between 1972 and 2008. It is projected that by 2028, levels of edentulousness in the under-55 age groups will have fallen to 1% or less.

Figure 7: Actual and projected percentage of edentate adults in Scotland by age group (1972-2028)

1.7.2 Oral cancer

The incidence of oral cancer in Scotland continues to rise in all age-groups, among men and women, and more rapidly among those from the most deprived communities [11],[12]. This disfiguring and debilitating disease requires major multidisciplinary planning and care across NHS healthcare services. Dentists’ roles along the care pathway include providing preventive services and early detection and referral in primary care. Consultants in restorative dentistry are involved in pre-treatment oral health assessment, treatment planning and comprehensive oral care and restoration following primary cancer treatment.

1.8 Summary

• Children’s oral health has improved during the period within which reliable data exist and the rate of improvement in children’s oral health in Scotland has increased since 2003 (Section 1.6).
• Poor oral health is strongly associated with socioeconomic deprivation and tackling the problem in the most deprived communities is at the core of the challenge of improving the population’s oral health and reducing oral health inequalities. The significant investment in, and the efforts of, the national oral health improvement programmes represent a unique and major effort to tackle this problem (Section 1.6).
• The oral health of children in all deprivation categories has improved but improving the oral health of the most deprived children remains a key challenge (Section 1.6).
• The oral health of adults in Scotland has improved markedly during the past 30 years. This improvement is expected to continue in the future such that there will be fewer adults with no natural teeth and more adults retaining more teeth into their older years (Section 1.7).
• There is limited evidence of the extent of any unmet oral health need for dental services by adults. Better information on the oral health of adults would allow more robust workforce planning (Section 1.7).
• The incidence of oral cancer in Scotland continues to rise in all age groups, among men and women, and more rapidly among people in the most deprived communities (Section 1.7).

*Original article from An Analysis of the Dental Workforce in Scotland: A Strategic Review 2010, online at http://www.gov.scot/Publications/2011/03/07154848/7

*Note from FAN:

For a further understanding of the Scottish Childsmile program, which was created because of the Scottish Executive’s decision not to fluoridate, go to http://fluoridealert.org/content/childsmile/