Geographic variation in oral health

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Geographic variation in oral health

• I.G. Chestnutt

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The United Kingdom

• England
• Wales
• Scotland
• Northern Ireland
• This presentation will review a selection of the
  previously presented data from a geographic
  perspective

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The United Kingdom - countries

• England
• Wales
• Over-sampled relative to England
• Northern Ireland
• Over-sampled relative to England
• Scotland
• No over-sampling as a separate analysis was not
  required by the Scottish Executive

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The United Kingdom - regions

• England
• 9 government office regions (GORs)
• Wales
• 3 regions
• Northern Ireland
• Scotland

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U.K. Regions
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U.K. Regions
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Caries experience
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Obvious decay experience in primary teeth
(d3cvmft) by country at age 5 and 8 years (2003)
children
Age (years) and country
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Mean number of primary teeth with obvious decay
experience (d3cvmft) by country at age 5 and 8
years (2003)
Mean d3cvmft
Age (years) and country
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Obvious decay experience (d3cvmft) in primary
teeth at age 5 by region (England 2003)
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Obvious decay experience (d3cvmft) in primary
teeth at age 5 by region (Wales 2003)
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Obvious decay experience (d3cvmft) in primary
teeth at age 5 by region (Wales 2003)
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Obvious decay experience in permanent teeth
(D3cvMFT) by country at age 8 and 15 years (2003)
children
Age (years) and country
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Mean number of permanent teeth with obvious decay
experience (D3cvMFT) at age 15 years (2003)
Mean D3cvMFT
Country
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Obvious decay experience (D3cvMFT) in permanent
teeth at age 15 by region (England 2003)
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Trends in mean number of permanent teeth with
obvious decay experience (D3cMFT) at age 15 years
(1983-2003)
Mean D3cMFT
Country
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Trends in mean number of primary teeth with
obvious decay experience (d3cmft) at age 5 years
(1983-2003)
Mean d3cmft
Country
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Trends in the proportion of children with fissure
sealants on permanent teeth at age 8 years
(1983-2003)
Proportion with sealants on permanent teeth
Country
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Orthodontics
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Orthodontic condition at age 15 by country
(United Kingdom 2003)
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Enamel opacities in 12 year-olds
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Diffuse enamel opacities by country at age 12
years (1993-2003)
Proportion with diffuse enamel opacities
Country
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Symmetry of diffuse enamel defects at age 12
years (2003)
Proportion diffuse enamel opacities which are
symmetrical
Country
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Accidental damage to the teeth
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Trends in the proportion of children with
accidental damage to the incisors at age 12
(1983-2003)
Proportion with accidental damage to incisors
Country
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Periodontal condition
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Proportion of children with unhealthy gums at age
12 and 15 years (2003)
Proportion with some gum inflammation
Country
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Reported oral pain
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Proportion of children reported as having
toothache or sore mouth in preceding 12 months
(2003)
Proportion reported
Country
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Patterns of care and service use
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Trends in proportion of 5 year-olds who have
never visited the dentist by country (1983-2003)
of children
Country
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Dental Services used at age 8 by country (2003)
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Proportion of 8 year-olds reported as having
difficulty finding an NHS dentist by country
(2003)
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Summary

• Variation persists in oral health across the U.K.
• The North / South divide in England is not as
  clear as perceived by many
• The majority of care is provided by the NHS
• Only minority having difficulty with access

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Childrens oral health social aspects

• Jimmy Steele

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Caries is a disease of deprivation

• Is there any truth in this statement?
• If there is, what about other oral conditions?
• If there is a relationship, why should that be?

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Caries is a disease of deprivation
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Previous evidence for a social gradient in
childrens oral health

• Empirical reporting
• Caries is a disease of deprivation
• Previous Data
• 1993 survey showed a clear gradient in the UK
• International evidence
• Flaws in the evidence
• Difficulties measuring social status
• Assumptions

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Measuring social factors

• There is no perfect measure all make
  assumptions
• Social class by occupation
• May not account for some aspects of environment
• Other SES measures
• Purely economic, though co-vary with education
  etc
• Area based deprivation measures (eg Townsend)
• Not individual
• Other proxy measures
• Not individual

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Measuring social factors for CDHS 2003

• A school level proxy measure
• Schools with 30 or more receiving free school
  meals
• Applied to all participants
• An occupation based Social Class (NS-SEC)
• Only applied to those interviewed
• Depends on a household reference person

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Measuring social factors for CDHS 2003

• Advantage of proxy measure
• Holistic and area based
• Can be applied to all
• Advantages of a personal measure
• Relative precision

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Theoretical problems with describing data
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What does this mean?

• Both groups regress towards the mean
• The true slope of the gradient from extreme to
  extreme - is underestimated
• Using the school deprivation measure there will
  be some dilution of the impact (if any) of social
  factors between deprived and non-deprived groups
  any effect will be greater than what you can
  see

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Comparison of children from deprived and
non-deprived schools for probability of decay
into dentine/obvious decay experience.
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School deprivation and probability of decay into
dentine/obvious experience

• At ALL ages and in BOTH dentitions the
  probability of finding obvious decay into dentine
  and obvious decay history was consistently much
  higher in deprived than in non-deprived schools
• BUT
• Between a quarter and a half of children from
  non-deprived backgrounds also had decay into
  dentine.
• What about the extent or severity of the disease?

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Comparison of affected children from deprived and
non-deprived schools for mean affected teeth.
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School deprivation and probability of decay into
dentine/obvious experience

• Generally speaking, even when matched for having
  disease, affected children attending deprived
  schools had more teeth affected by disease into
  dentine and more with a disease history
• The biggest difference was for obvious decay,
  suggesting fewer fillings/less treatment BUT
  there was also more disease history
• The proportion of DMFT that was a filled
  component was actually very similar in both
  groups for permanent teeth.

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Probability of decay into dentine by NS-SEC for 5
and 8 year olds (deciduous dentition)
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Probability of decay into dentine by NS-SEC for
12 and 15 year olds (permanent dentition)
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Mean number of teeth with obvious decay
experience amongst 12 and 15 year olds with decay
experience by NS-SEC
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Mean number of teeth with obvious decay
experience and number of filled teeth amongst 15
year olds with decay experience by NS-SEC
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Individual social position and caries

• What on earth is this lot telling us?
• There is something going on
• The pattern for deciduous teeth is possibly more
  straightforward a gradient for risk but not for
  teeth affected
• The pattern for 12 and 15 year olds is not
  straightforward and not linear.
• Patterns are difficult to interpret due to lower
  numbers for individual measures

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Probability of decay into dentine by NS-SEC for
12 and 15 year olds (permanent dentition)
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Mean number of teeth with obvious decay
experience amongst 12 and 15 year olds with decay
experience by NS-SEC
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Individual social position and caries

• A higher proportion of the total burden of dental
  disease is associated with deprivation and lower
  social position and all that this entails
• However, the children from fairly affluent and
  well educated backgrounds who are affected by
  obvious decay experience also have many teeth
  affected on average
• At least amongst teenagers, there is no clear
  evidence of large differences in access to and
  uptake of care.

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So why then?

• Access to care and treatment
• Dietary behaviour
• Environment
• Plaque and hygiene

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Comparison of children from deprived and
non-deprived schools for the proportion with
plaque and the number of affected sextants.
There is not a lot happening here!
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Is it changing?
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Probability of obvious decay experience (old
criteria) amongst 12 year olds, 1993 and 2003, by
social class
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Probability of obvious decay experience (old
criteria) amongst 15 year olds, 1993 and 2003, by
social class
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Trends 1993-2003

• Let us be REALLY careful here
• There is certainly no evidence for a WIDENING
  social gap for decay
• We cannot confidently say there is a reducing
  social gap either

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Other conditions

• Tooth surface loss
• Non significant, but consistently higher
  prevalence of lingual wear in children from
  deprived schools at all ages
• Orthodontic condition
• No difference in prevalence, but maybe a
  difference in uptake of treatment by 15 years

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CONCLUSION

• Is caries a disease of deprivation?
• This is much too simplistic
• There is a social gradient and large differences
  related to deprivation and social status
• School deprivation status was a good measure and
  may suggest the importance of an environment and
  a culture as well as straight economics
• There remains much to untangle