Feature

Filling the gap in our dental health strategy

Tooth decay in young children has worsened in recent years. There’s an important element missing from our strategy for dental public health, says John Beal

In 1994 the Department of Health published its Oral Health Strategy for England.¹ In it, attention was drawn to the reductions in the level of tooth decay in children over the past two decades. Objectives were set for further improvements. These targets were that by 2003:

...70 per cent of 5-year-old children should have no experience of tooth decay;

...on average 5-year-old children should have no more than 1 decayed, missing or filled deciduous or baby tooth;

...on average 12-year-old children should have no more than 1 decayed, missing or filled permanent tooth.

But is dental health still improving? What is the likelihood of achieving these objectives? Three recent reports help to provide the answers.

The first is the latest of the national surveys of children’s dental health carried out by the Office of Population Censuses and Surveys.² In older children the reduction in dental decay is dramatic. In 1973 the average 12-year-old in England had 4.8 decayed, missing or filled permanent teeth (DMF). By 1983 this had reduced to 2.9 with a further improvement to 1.2 by 1993. So the government’s target for 12-year-olds would, at first sight, appear to be easily achievable.

The picture in the 5-year-olds was less encouraging. Between 1973 and 1983 there had been a reduction in the mean number of decayed, missing or filled baby teeth (dmf) from 4.0 to 1.8. But there was no further decrease in the 1993 survey. In 1983 52 per cent of 5-year-olds had no experience of tooth decay. This had improved only slightly to 56 per cent in 1993.

The second report contained the results of the most recent dental surveys of 5-year-olds carried out by local health authorities and co-ordinated by the British Association for the Study of Community Dentistry (BASCD).³ The studies were carried out in 1993-94 and the mean dmf in England was 1.74, virtually identical to the OPCS survey. In the BASCD surveys, samples of 5-year-olds are examined every two years so it is possible to discern the trend for the years between the OPCS 10-yearly studies. The BASCD surveys demonstrated that the downward trend in tooth decay continued until the late 1980s. Since then there has been a slow but steady increase in the level of decay. In other words, the improvement is now being followed by a worsening in dental health.

The third publication was the National Diet and Nutrition Survey, which included a dental examination of children aged 1½ to 4½ years.⁴ This is the first such survey and so no comparison can be made with previous findings. Only 4 per cent of children aged between 1½ and 2½ had any experience of tooth decay, the average dmf for children in that age group being 0.1. In the 2½ to 3½ year group the mean dmf was 0.5 and this rose to 1.3 in the 3½ to 4½ year group. These children already have more teeth affected by decay than the government’s target for 5-year-olds and if the current rate continues they will have more than 1.8 affected teeth by the time they are 5 years old, continuing the worsening trend in dental health.

These figures give averages for the country. But all of these surveys reported wide variations between sub-groups. For example, the pre-school study showed that children from households in which the head was a manual worker had up to three times as much decay as those from non-manual households. The OPCS survey of school children found that 5-year-olds who only visit the dentist when they have trouble with their teeth have over twice as much decay as those who go for regular check-ups. All of the studies demonstrated that children in the north of England have considerably more decay than those in the south. Detailed analysis of the BASCD survey results in a district such as Leeds shows that children living in socially deprived inner city wards have four times as much tooth decay as those in more affluent suburban wards.

The BASCD co-ordinated surveys also demonstrate the continuing effectiveness of water fluoridation. The table shows, for 5-year-olds, the five best and five worst health districts in England in 1993-94, together with their fluoridation status. All five of the best districts are fluoridated. In fact the West Midlands, which has fluoridation schemes supplying more than two-thirds of the population, now has the best level of dental health in the country standing out as a beacon against the north/south gradient.

So will the government’s objectives for the year 2003 be achieved? Those for 5-year-old children look increasingly unlikely — unless something dramatic is done to reverse the current deterioration in the dental health of young children. At first sight the objective for 12-year-olds looks possible. But will the improvement in this age group follow the pattern of the younger children? The maximum reduction in 5-year-olds was achieved in the late 1980s. Those children are now nearly 12. Will those who follow, who had more decay in their deciduous teeth, also have more decay in their permanent teeth?

In order to stand any chance of meeting the objectives we urgently need an overall strategy for improving dental health. Dental health education activities need to be targeted towards groups most at risk. These include those in the areas of greatest material deprivation and those from the Asian community, in which decay rates are particularly high in 5-year-olds. Any restructuring of dental services must ensure that young children are given the highest priority for care. But these actions alone cannot hope to result in meeting the objectives. While individual action in the form of dietary control, tooth-brushing, the use of fluoride toothpaste and visiting the dentist are all part of the strategy, it has to be recognised that messages relying on behaviour change will be least effective among those groups who are most at risk. A population-based strategy is essential. Only one measure can provide such a dramatic improvement in dental health on a community basis and that is fluoridation, which will benefit the whole population, not only children but also adults.

Despite the 1985 Water (Fluoridation) Act — subsequently incorporated into the Water Industry Act 1991 — progress in implementing new fluoridation programmes is lamentably slow. The Act clarified the legality of fluoridation and provided that water undertakers ‘may’ fluoridate at the request of health authorities, the latter having first to undertake widespread public consultation on such proposals.

HAs in much of northern England have carried out the statutory consultation but a number of the privatised water companies are refusing to comply with their requests. The intention of Parliament in using the word ‘may’ was to provide for those circumstances in which fluoridation would have presented technical problems related, for example, to water supplies which covered areas for which the HAs had not requested fluoridation. It was not intended to provide water companies with a veto on the principle of fluoridation.

Public opinion polls continue to show overwhelming support for fluoridation. It is to be hoped that water companies will recognise that they have a duty to respect the wishes of Parliament and the majority of their customers. If they continue to delay implementation of new fluoridation programmes Parliament should be asked to amend the legislation.

It is important that HAs meeting in public, after due consultation with local authorities, community health councils and the general public, make the final decision locally rather than leaving it to private companies meeting behind closed doors in distant board rooms. A simple change in the Act, indicating that when requested to do so the water company ‘shall’ fluoridate the water supply would ensure that the will of the community prevails rather than the blocking tactics of some parts of the water industry.

In summary, the government’s objectives to improve the dental health of children can only be achieved with a well-developed and targeted programme of health promotion activities. These must include fluoridation as well as health education and preventive oriented dental services. Failure to ensure that the water companies implement fluoridation schemes will inevitably lead to a failure to meet the government’s targets, and those who suffer will be the children in the most socially disadvantaged sections of our community. They do not have a voice in the corridors of power. We must use whatever influence we have to ensure that they are given the chance of a better dental future.