The Burden of Dental disease in Children England, Wales and Northern Ireland Professor Jimmy Steele Newcastle University
Why report burden Changes in disease prevalence In 1973 caries was so abundant that the priority had to be to reduce prevalence A minority of children now affected by caries into dentine BUT number of teeth affected amongst those with disease remains unchanged.
Permanent teeth in 15 year olds Dentinal decay prevalence is less Is decay any more concentrated? 2003 2013 % mean % mean Obvious visual caries (Code 2V) Actual cavities (Code 2C) 32 21 13 11 Actual cavities here refers to cavitated dentinal lesions
Permanent teeth in 15 year olds Dentinal decay prevalence is less Is decay any more concentrated? 2003 2013 % mean % mean Obvious visual caries (Code 2V) Actual cavities (Code 2C) 32 2.5 21 2.4 13 1.5 11 1.8 Actual cavities here refers to cavitated dentinal lesions Is the picture in this 11% more neglected?
The implications of burden As opposed to simple caries presence Tooth tissue loss, lifetime implications Maintenance needs (permanent teeth) Restorative cycle (permanent teeth) Orthodontic impacts (age 5 and 15) Establishing a high risk environment (age 5) Immediate effects at 5 and 15 Family costs and inconvenience Service issues (GA, acute services, AB prescription) Quality of life impacts immediately and for life
The implications of burden SERVICE DESIGN COSTS QUALITY OF LIFE Take your pick
Defining burden Necessarily arbitrary 5+ teeth with obvious decay experience (dft at age 5 or DMFT at age 15) 3+ Visual caries lesions (into dentine) Any unrestorable teeth Any PUFA signs (sepsis related to caries) Any missing permanent teeth (age 15 only) Any of the above
Percentage of 5 year olds with severe or extensive dental decay, by country England, Wales and Northern Ireland, 2013 Children aged 5 England Wales Northern Ireland Total 5+ teeth with obvious decay experience 6 11 13 6 3+ teeth with decay into dentine 10 19 18 11 Any unrestorable teeth 5 7 5 5 Any PUFA signs 4 6 5 4 Any of these 13 22 19 13 Unweighted bases 1,526 493 530 2,549 What would Northern England look like here?
Percentage of 15 year olds with severe or extensive dental decay, by country England, Wales and Northern Ireland, 2013 Children aged 15 England Wales Northern Ireland Total 5+ teeth with obvious decay experience (high dmft) 8 14 28 9 3+ teeth with decay into dentine 5 11 10 6 Any unrestorable teeth 2 2 3 2 Any PUFA signs 2 2 3 2 Loss of any permanent teeth due to decay 6 11 13 6 Any of these 14 22 36 15 Unweighted bases 1,313 554 551 2,418
Children with a potential burden 13% of 5 year olds 15% of 15 year olds So about 1 in 7 children are in this group Who are the 1 in 7s?
Age 5 Total England Wales Northern Ireland Male Female Eligible for Free School Meals Not eligible Boys at 5 More deprived Age 15 Total 0 10 20 30 40 50 Percentage England Wales Northern Ireland Male Female NI fillings Girls at 15 Eligible for Not eligible 0 10 20 Percentage 30 40 50 More deprived
Behavioural factors linked with burden at age 15 Total Brushes at least twice a day Brushes less than twice a day Hygiene helps..a bit Dentist: check-ups Dentist: only with trouble Dentist: never Sugary drinks: less than once a day Sugary drinks: 1-3 times a day Sugary drinks: 4+ times a day 4+ Sugary drinks Water: less than once a day Water: 1-3 times a day <1 Water Water: 4+ times a day 0 10 20 30 40 50 Percentage with a caries burden
Area-based measures Output Area Classification (OAC) Index of Multiple Deprivation (IMD) Risk of caries burden by IMD quintile 25 20 15 10 Age 5 Age 15 5 0 Least deprived Most deprived
Multivariate analysis This gets a bit complicated Upstream and downstream influences difficult to separate (more complex modelling approaches can address this). Never cause and effect, all we can see is associations Nevertheless confounding can be addressed in a more straightforward model Two stage model used. First a model with all demographic variables inserted, then behavioural variables inserted.
Table 4.20 Characteristics significantly associated with severe or extensive dental decay (burden) among 15 year olds (odds ratios) Variable Country of residence (p<0.001) Odds ratio England 1 Wales 1.87 Northern Ireland 3.91 Eligibility for free school meals (p=0.002) Not eligible 1 Eligible 1.99 Pattern of dental attendance (p<0.001) Check-ups 1 Only with trouble 2.93 Consumption of sugary drinks (p<0.001) Less than once a day 1 Four times or more a day 2.13 Consumption of water (p=0.014) Less than once a day 1 One to three times a day 0.6 Four times or more a day 0.59
What does this say? Any child can have bad caries it is not just deprived children BUT deprivation is a major factor associated with risk Good health behaviours are associated with lower risks of disease, though not anywhere near completely protective It matters what a child drinks in a day
What do gradients now mean? Risk of caries burden by IMD quintile 25 20 Trend to reducing prevalence 15 10 Age 5 Age 15 5 0 Least deprived Most deprived
Other burdens Trauma not a lot (but deprivation effect?) Tooth surface loss very similar associations to caries; significant relationships with deprivation, brushing, attendance and preferred drinks Is it the same children?
Other burdens Orthodontic burden Malocclusion is not a disease There is not a lot you can do to avoid it Treatment is expensive and in demand Who gets it IOTN?
Orthodontic burden Percentage of 12 and 15 year olds undergoing orthodontic treatment, by country and age England, Wales and Northern Ireland, 2013 Children aged 12, 15 12 years 15 years Total England 8 18 13 Wales 8 16 12 Northern Ireland 17 19 18 Total 9 18 13
Orthodontic burden Percentage of 12 and 15 year olds with unmet orthodontic treatment need, by country and age England, Wales and Northern Ireland, 2013 12 years 15 years Unmet orthodontic treatment need (dental health component) Unmet orthodontic treatment need (aesthetic component score 8-10) Any unmet orthodontic treatment need (dental health component or aesthetic component score 8-10) 36 20 10 5 37 20
Orthodontic burden Percentage of 12 and 15 year olds with unmet orthodontic treatment need (dental health component), by eligibility for free school meals England, Wales and Northern Ireland, 2013 Children aged 12, 15, not undergoing orthodontic treatment 12 years 15 years Eligible 40 32 8% Not eligible 35 17 18% This suggests that a large majority of the children who may qualify for orthodontic care are not receiving it Why, and does this matter?
The burden is not fair 1 in 7 children have a large caries burden Important social and behavioural associations Associations suggest we will not treat our way out of this problem Distribution of orthodontic care asks some difficult questions
IOTN Aesthetic component.?