1
The need for dental survey data
Unlike medicine,
there is no data on the health of the population generated from the
interactions between patient and general dental practitioner. Thus
for monitoring of dental health and planning of dental services we
are dependent upon specially conducted surveys. These surveys
include the decennial Adult and Child Dental Health Surveys, funded
by the UK Governments and undertaken by the ONS in conjunction with
a number of Universities using local NHS community dental staff to
undertake some of the field data collection and the BASCD surveys.
Child Dental Health Surveys have been undertaken in 1973, 1983,
1993 and 2003. The position for 2013 is unclear. Adult Dental
Health Surveys were undertaken in 1968, 1978, 1988, 1998 and 2009.
In addition as a one-off the ONS undertook a National Diet and
Nutrition Survey of a range of age groups in the 1990’s which
included collection of some dental health data.
The BASCD surveys
are undertaken for the UK governments by local NHS staff in a
programme co-ordinated across the UK by the British Association for
the Study of Community Dentistry. They commenced in 1985/6 across
Wales and England (Dowell 1988). The use of BASCD standards and
co-ordination is intended to provide consistency and quality
assurance to ensure data is comparable from year to year and across
locations. While the ONS surveys examine a relatively small number
of individuals, once a decade and go into detail on oral health,
factors which influence dental health and use of dental services
(e.g. reporting at all-Wales level), the BASCD surveys generally
examine larger numbers of children, more frequently for a narrow
range of oral health indicators. Thus the BASCD surveys provide
more local detail at Unitary Authority level for key information
such as reported decay levels.
2
The survey programme
Until 2006 the
BASCD survey programme consisted of a 4 year cycle in which
children aged 5, 12, 5 and 14 years of age were examined
(technically in Wales we have examined a school year, e.g. school
year 1 for 5 year old data so some children will be age 6 by the
date of examination, but the mean age of children examined is about
5 ½ years). Problems with access to 14 year olds in many parts
of the UK led to decisions to change the programme from 2006. In
Scotland the cycle is now 5, 12, 5, 12 year olds examined. In Wales
we seek to examine 5 and 12 year olds at least once in each 4 year
cycle with 2 flexible years in the programme. This would allow us
to either see 5, or 12 year olds again, examine other child age
groups or to examine the oral health of adults.
In 2006/7 with the
support of the Office of the Chief Dental Officer we undertook a
survey of oral health policy and access to dentistry for registered
care homes in Wales which highlighted a number of issues. This was
followed up with a survey of the oral health of care home residents
from 2009/2010 which is intended to complement the recent Adult
Dental Health Survey. This care home data is about to be cleaned
and analysed and will be reported on in 2012.
3
Changes to consent arrangements
In 2006, shortly
after the decision to undertake a more flexible survey programme
was made, the traditional “opt-out” approach to consent
for these surveys (which relied upon the wording of the 1944
Education Act and then the 1996 Education Reform Act in relation to
a “dental inspection” in a school setting) was reviewed
by Department of Health lawyers in England and then Assembly legal
advisors in Wales. Guidance was issued to NHS Wales that in future
such examinations of teeth required either “Gillick
competent” consent of the 12 year old child or positive
consent of the parent for 5 year olds.
As it happened the
Education Act legislation and consent law for children generally
had been reviewed in the mid to late 1990’s and this possible
interpretation of the Education Acts had been forseen. As a result
in Wales the approach of using “Gillick competent”
consent for 14 year olds and then for 12 year olds had been piloted
in 2002/3 and 2004/5 respectively. Analysis of the findings in
Wales suggested that introduction of “Gillick
competent” consent would have negligible impact on the
reported caries indices (Morgan and Monaghan 2010).
For 5 year olds
the changed approach to inclusion of children has had an impact
upon the reported caries indices. Until 2005/6 we had data
collected every 2 years with data collected to a consistent
approach showing a trend in Wales which suggested mean caries in
Welsh 5 year olds was flat lining after a previous period of
reductions. In 2007/8 the introduction of changed consent method
appears to have resulted in a small drop in participation in the
surveys for children without caries, but with a huge drop in
participation in the surveys for children with caries (Monaghan,
Jones, Morgan 2011). These changes are present across the quintiles
of deprivation. These changes were also seen in England where
changed consent arrangements were also required (). Taken on face
value the reported “improvement” in decay levels in
England and Wales from 2005/6 to 2007/8 exceeded anything which
could be expected from a large scale decay prevention programme and
no such programmes were in place. Scotland did show smaller
improvement in decay levels in those years and they had already
implemented for a few years pilot child toothbrushing schemes in
the East of Scotland.
4
Caries trends in Wales
Data on trends in
caries data for 5, 12 and 14 year old BASCD co-ordinated surveys
are presented in Tables 1 to 3. There has been a steady trend of
reduced prevalence of decay in the permanent teeth (noted by
dentists as Decayed, Missing or Filled Teeth – DMFT) among
14- and 12-year-olds and a steady reduction of the average number
of teeth affected by decay (see tables 1 and 2) in these age
groups.
Table 1 Trends
in 14 year old caries in Wales 1986 Until 2003
Mean Decayed Missing Filled
Teeth Caries
free
1986/7
4.03
16%
1990/1
2.77
28%
1994/5
2.27
36%
1998/9
2.25
37%
2002/3
2.10
40%
[Sources: BASCD
and Welsh Oral Health Information Unit]
Table 2 Trends
in 12 year old caries in Wales 1988 Until 2009
Mean Decayed Missing Filled
Teeth Caries
free
1988/9
1.90
37%
1992/3
1.51
45%
1996/7
1.49
45%
2000/1
1.31
49%
2004/5
1.09
55%
2008/9
0.98
58%
[Sources: BASCD
and Welsh Oral Health Information Unit]
The steady
improvement of decay in teeth of older children contrasts with the
relatively steady state of the proportion of 5-year-old children
affected by decay of deciduous teeth (decayed, missing and filled
teeth – dmft) and of the mean number of teeth so affected per
child as shown in Table 3.
Table 3 Trends
in 5 year old caries in Wales 1985 until 2008
Mean decayed missing filled
teeth Caries
free
1985/6
2.52
43%
1987/8
2.27
46%
1989/90
2.65
43%
1991/2
2.74
41%
1993/4
2.52
46%
1995/6
2.36
47%
1997/8
2.50
43%
1999/2000
2.18
48%
2001/2
2.26
47%
2003/4
2.42
46%
2005/6
2.38
47%
2007/8
1.98*
52%*
(*New consent
arrangements in 2007/8 – data not comparable)
[Sources: BASCD
and Welsh Oral Health Information Unit]
The sudden
reported change in the prevalence and severity of decay in table 3
is related to changes in the consent arrangements and is in excess
of anything expected over a 2 year time scale which could be
expected from any new preventive programme. It also predates the
main roll-out of the Designed to Smile programme. The change was
seen across all quintiles of deprivation which would not be
expected if it was due to Designed to Smile which is targeted to
deprived communities.
The changed
consent arrangements represent a loss of trend data for Designed to
Smile and complicate target setting and evaluation. It is thought
to be unlikely that the consent changes will be reversed. Thus to
complement the 2007/8 data we are collecting data of 5 year olds
again in 2011/2012. This will give us a second data point and
therefore a feel as to the direction of travel.
5
Data collection and future surveys
Data is collected
by community dental staff during the school year. At any one time
there are three surveys creating work including planning for next
year’s survey, collection of data for this year’s
survey and data cleaning, analysis and reporting of last
year’s survey. Thus the 2011/2012 survey will be reported
upon in the first half of 2013. The forward programme for the BASCD
survey programme is co-ordinated across the UK such that training
and calibration can support the survey needs in each UK country and
generate data contemporaneously.
Table 4 Draft
survey programme as of September 2011
Year
Group
Possible surveys
2011/2012
5 year olds
2012/2013 12 year
olds
2013/2014
Flexible
5-yr-olds for 3rd +ve consent survey?
2014/2015 Flexible
Older people survey? or prison survey?
2015/2016 5 Year
olds
2016/2017 12 year
olds
2017/2018 Flexible
2018/2019 Flexible
2019/2020 5 year
olds
2020/2021 12 year
olds
Within Wales,
alongside providing routine data to support planning and evaluation
of dental health and care we seek to take advantage of
opportunities presented by ONS led surveys to explore areas of need
yet unexplored and to provide the data which Designed to Smile is
intended to impact upon. Looking forward the draft programme for
data collection is outlined in Table 4. Current plans are to use a
flexible survey year to collect 5-year-old data to assist in
evaluating Designed to Smile. This will limit the ability to use
these years to examine other areas of dental need in Wales.
6
References
Davies GM, Jones
CM, Monaghan N, Morgan MZ, Pine CM, Pitts NB, Neville JS, Rooney E
(2011) The caries experience of 5 year-old children in Scotland,
Wales and England in 2007-2008 and the impact of consent
arrangements. Reports of co-ordinated surveys using BASCD criteria.
Community Dental Health 28: 5-11
Dowell TB
(1998). The caries experience of 5-year-old children in England and
Wales. Community Dental health 5: 185-197
Monaghan NP,
Jones SJ, Morgan MZ. (2011) Do parents of children with caries
choose to opt out of positive consent dental surveys in Wales?
British Dental Journal 210: E1 DOI:
10.1038/sj.bdj.2011.26
Morgan MZ and
Monaghan N (2010). Trends in childrens’ ability to consent to
a dental examination and the potential impact on reported caries
indices. Community Dental Health 27: 200-205
