The Oral Health of Three- Four-Year-Old Children in Inner North East London in 2007

The Oral Health of Three- Four-Year-Old Children in Inner North East London in 2007 A survey carried out in inner north east London by the Institute of Dentistry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London on behalf of Hackney PCT, Tower Hamlets PCT, Newham PCT. Wagner Marcenes Desmond Wright Sian Murray Penny Redshaw Ursula Bennett

Contents Acknowledgements v Summary of Main Findings vi 1: Background 1 2: Aims and Objectives of the Study 2 3: Setting and Study Population 3 4: Ethical Issues 4 5: Methods 5 5.1: Study Design 5 5.2: Sample Size 5 5.3: Sampling Strategy 5 5.3: Data Collection Procedure 5 5.4:Demographic Information 6 5.5: Data Analysis 7 6: Results 10 6.1: Sample Description 10 6.1.1: Response Rate 10 6.1.2: Sample Socio-Demographic Characteristics 12 6.2: The Oral Health of Three-Four-Year-Old Children in Inner North East London: Dental Caries (Decay) Experience 14 6.3: The Oral Health of Three-Four-Year-Old Children in Inner North East London: Oral Sepsis 19 6.4: The Oral Health of Three-Four-Year-Old Children in Inner North East London: Traumatic dental injuries 21 6.5: The Oral Health of Three-Four-Year-Old Children in Hackney in 2007 23 6.6: The Oral Health of Three-Four-Year-Old Children living in Tower Hamlets in 2007: 26 6.7: The Oral Health of Three-Four-Year-Old Children living in Newham in 2007 29 Appendix 1: BASCD Diagnostic Criteria 32 Appendix 2: Child Data Collection Form 34 References 35 i

Tables Table 5.5.1: Number (%) of three-four-year-old children in Inner North East London by borough of residence in the sample and the population in 2007 Table 6.1.1.1: Response rate for all stages of the oral health survey of three-four-year-old children living in Inner North East London in 2007 Table 6.1.2.1: Frequency distribution of three-four-year-old children living in Inner North East London in 2007 by gender (weighted data, n = 1297). Table 6.1.2.2: Frequency distribution of Index of Multiple Deprivation (2004) quartiles in England and in the sample of three-four-year-old children living in Inner North East London in 2007 (weighted data, n = 1297) Table 6.1.2.3: Average Index of Multiple Deprivation (IMD) scores by borough in sample of three-four-year-old children living in Inner North East London in 2007 (weighted data, n = 1297) Table 6.2.1: Mean number of untreated primary decayed teeth into dentine and the percentage of children with one or more untreated decayed teeth in the sample of three-four-year old children living in Inner North East London in 2007 (weighted data, n = 1297), 3½-4½year old children in the UK in 1992/93 and five year old children in the UK in 2003. Table 6.2.2: Mean number of untreated primary decayed teeth into dentine and the percentage of children with one or more untreated decayed teeth by gender and borough in the sample of three-four-year old children living in Inner North East London in 2007 (weighted data, n = 1297). Table 6.2.3: Mean number of missing teeth and the percentage of children with one or more missing tooth by gender and borough in the sample of three-four-year old children living in Inner North East London in 2007 (weighted data, n = 1297). Table 6.2.4: Mean number of filled teeth and the percentage of children with one or more filled tooth by gender and borough in the sample of three-four-year old children living in Inner North East London in 2007 (weighted data, n = 1297). Table 6.2.5: Mean number of teeth with obvious decay experience and the percentage of children with obvious decay experience by gender and borough in the sample of three-four-year old children living in Inner North East London in 2007 (weighted data, n = 1297). Table 6.3.1: Percentage of children with oral sepsis by gender and borough in the sample of three-four-year old children living in Inner North East London in 2007 (weighted data, n = 1297). Table 6.4.1: Percentage of children with a traumatic dental injury (TDI) by gender and borough in the sample of three-four-year-old children living in Inner North East London in 2007 (weighted data, n = 1297). 9 11 13 13 13 16 16 17 17 18 20 22 ii

Table 6.5.1: Number (%) of children living in Hackney by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 243). Table 6.5.2: Mean number of untreated decayed teeth into dentine and the percentage of children living in Hackney with one or more untreated decayed tooth into dentine by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 243). Table 6.5.3: Mean number of missing teeth and the percentage of children living in Hackney with one or more missing teeth tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 243). Table 6.5.4: Mean number of filled teeth and the percentage of children living in Hackney with one or more filled tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 243). Table 6.5.5: Mean number of teeth with obvious decay experience and the percentage of children living in Hackney with teeth with obvious decay experience by gender in the sample of three-fouryear old children living in Inner North East London in 2007 (n = 243). Table 6.6.1: Number (%) of children living in Tower Hamlets by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 333). Table 6.6.2: Mean number of untreated decayed teeth into dentine and the percentage of children living in Tower Hamlets with one or more untreated decayed tooth into dentine by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 333) Table 6.6.3: Mean number of missing teeth and the percentage of children living in Tower Hamlets with one or more missing teeth tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 333) Table 6.6.4: Mean number of filled teeth and the percentage of children living in Tower Hamlets with one or more filled tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 333) Table 6.6.5: Mean number of teeth with obvious decay experience and the percentage of children living in Tower Hamlets with teeth with obvious decay experience by gender in the sample of threefour-year old children living in Inner North East London in 2007 (n = 333) Table 6.7.1: Number (%) of children living in Newham by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 709). Table 6.7.2: Mean number of untreated decayed teeth into dentine and the percentage of children living in Newham with one or more untreated decayed tooth into dentine by gender in the sample of 24 24 24 25 25 27 27 27 28 28 30 iii

three-four-year old children living in Inner North East London in 2007 (n = 709) 30 Table 6.7.3: Mean number of missing teeth and the percentage of children living in Newham with one or more missing teeth tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 709) 30 Table 6.7.4: Mean number of filled teeth and the percentage of children living in Newham with one or more filled tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 709) 31 Table 6.7.5: Mean number of teeth with obvious decay experience and the percentage of children living in Newham with teeth with obvious decay experience by gender in the sample of three-fouryear old children living in Inner North East London in 2007 (n = 709) 31 iv

Acknowledgements We thank those who assisted with the organization and execution of this survey and the children who participated in this survey. We specifically thank: Reanna Yhap and Surjahan Bib who helped to recruit participants, coordinated the clinical examinations in Hackney and Tower Hamlets, and worked as recorders for the clinical examinations Seema Vaghela, Jackie Harrison and Alex Baciu who worked as recorders for the clinical examinations in Hackney and Tower Hamlets Beatrice Kivengea and Jenny Waters who helped to recruit participants and coordinated the clinical examinations in Newham Jo Murphy and Chris Urwin who worked as recorders for the clinical examinations in Newham Val Graves, the Director of services in Newham. Head teachers, secretaries and nursery staff in the participating schools v

Summary of Main Findings This oral health survey of three-four year-old children attending nurseries in Inner North East London was carried out in 2007. It was the first study of preschool children conducted on behalf of Hackney Primary Care Trust (PCT), Tower Hamlets PCT, Newham PCT and the Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London. This survey found that three-four-year-old children in Inner North East London had better oral health than 3½-4½ year old children in the UK in 1992/93 and five-year old children in the UK in 2003. Twenty-three percent of children in Inner North East London had previous decay experience compared to 30% of 3½-4½ year old children in the UK in 1992/93 and 43% of five-year-old children in the UK in 2003. Three-four-year-old children in Inner North East London also had fewer teeth (mean=0.92 teeth) with decay experience than 3½-4½ year old children in the UK in 1992/93 (mean=1.3 teeth) and five year old children in the UK in 2003 (mean=1.6 teeth). There were significant differences between decay experience among children living in different boroughs. A significantly lower percentage of children living in Hackney (14.8%) had one or more untreated decayed tooth than children living in Tower Hamlets (23.4%) and children living in Newham (27.5%). Children living in Newham had fewer missing teeth (mean=0.04 teeth) than children living in Tower Hamlets (mean=0.13 teeth) and Hackney (mean=0.09 teeth). Children living in Hackney (16.1%) were less likely to have had decay experience than children living in Tower Hamlets (24.9%) and in Newham (28.6%). There were no statistical differences in decay experience in boys and girls. This survey found that levels of deprivation were not related to decay experience because most (99.2%) children resided in highly deprived areas. We were unable to demonstrate an statistical association because of the lack of variation in levels of deprivation in this sample of three-four-year-old children in Inner North East London. vi

Less than two percent (1.5%) of three-four-year-old children in Inner North East London had oral sepsis (i.e., dental abscess). The difference between the percentage of children with oral sepsis living in Tower Hamlets (1.2%), Hackney (0.0%) and Newham (3.0%) was not statistically significant because of the small number of children who had oral sepsis. Four percent of three-four-year-old children in Inner North East London had a Traumatic Dental Injury (TDI). As expected, a higher percentage of boys (5.5%) had a TDI than girls (23.0%). Children living in Newham (8.2%) were also more likely to have a TDI than children living in Tower Hamlets (1.8%) and Hackney (1.7%). vii

1: Background The mouth is an integral and important part of the gastro-intestinal system. Oral diseases are prevalent and often irreversible. The sequelae of oral diseases include abscesses, pain and tooth loss [1]. The consequences or poor oral health accumulate over a lifetime and impact people s quality of life from childhood to adulthood [2]. Oral diseases in children cause sleep disturbances and impair masticatory (chewing) function, which impacts dietary intakes leading to poor nutritional status and inadequate body mass index [3]. Oral diseases are preventable and treatable. Good quality treatment restores function and prevents the undesirable consequences of oral diseases. Joint Strategic Needs Assessments (JSNAs) have been an statutory requirement for Primary Care Trusts (PCTs) since 2007, specifically aimed at identifying the current and future health needs of local populations [4]. Even though oral health surveys are an essential part of JSNAs, no surveys have been conducted to assess the oral health needs and behaviours of preschool children in Inner North East London. This oral health survey of three-four-year-old children addressed this shortfall. It provided information to support commissioning, treatment demand and health promotion strategies targeting relevant groups in Inner North East London based on sound epidemiological data 1

2: Aims and Objectives of the Study 1. To identify a population of three-four-year-old children in Hackney, Tower Hamlets and Newham (Inner North East London) 2. To select a sample of pre-school three-four-year-old in Hackney, Tower Hamlets and Newham using the criteria described by the British Association for the Study of Community Dentistry (BASCD) 3. To conduct a local survey assessing dental caries (decay), sepsis, and traumatic dental injuries involving the deciduous teeth of selected children 4. To report the oral health of three-four-year-old children in Inner North East London related to dental caries (decay), sepsis, and traumatic dental injuries by borough, gender and levels of deprivation 5. To report the oral health of three-four-year-old children living in Hackney in relation to dental caries (decay), 6. To report the oral health of three-four-year-old children living in Tower Hamlets in relation to dental caries (decay) 7. To report the oral health of three-four-year-old children living in Newham in relation to dental caries (decay) 2

3: Setting and Study Population This survey was conducted in Hackney, Tower Hamlets, and Newham located in Inner North East London in 2007. The study population included three-four year old children attending local authority-run nurseries located in Inner North East London. The age distribution of residents in Inner North East London differs from the rest of London with the percentage of children projected to increase [5-7]. Newham has the highest percentage of young people aged below 20 years (31%), followed by Hackney (27%). Moreover, Hackney, Newham and Tower Hamlets all have birth rates three times the death rates [5-7]. Inner North East London includes areas with high levels of social and material deprivation [5-7]. The 2004 Index of Multiple Deprivation (IMD) showed that 10% of the most deprived areas in England were concentrated in Tower Hamlets, Newham and Hackney [8]. Inner North East London areas is characterized by high unemployment rates, low levels of education, poor housing and high child poverty rates Tower Hamlets (74%), Hackney (62%) and Newham (59%) [5-7]. Inner North East London is also culturally diverse, home to a variety of people from different ethnic, religious and linguistic backgrounds [5-7]. The area has historically attracted immigrants and remains one of the most ethnically diverse regions the UK [5-7]. Newham is the most ethnically diverse borough in UK with over 60% of people from Black and Minority Ethnic Groups (BME), predominantly Black and Asian residents. Four in ten residents were born outside of the UK originating from 47 different countries [5-7]. Tower Hamlets is ranked third nationally in terms of ethnic diversity; the most prominent ethnic groups are Asian Bangladeshis [5-7]. 3

4: Ethical Issues Positive consent was obtained from the parents or guardians of all children in adherence with Department of Health guidance. Parents/guardians received a specifically developed letter and an information sheet explaining the reasons for the study and the dental examination process. All parents or carers signed a consent form at the time of the dental examination visit. 4

5: Methods 5.1: Study Design This oral health survey adopted a cross-sectional study design and followed the methodology described by the British Association for the Study of Community Dentistry (BASCD) [9]. 5.2: Sample Size BASCD suggest that a minimum sample size should include at least 250-300 subjects in each Primary Care Trust (PCT). Therefore, this study included 243, 333, and 709 threefour-year old children living in Hackney, Tower Hamlets and Newham respectively. 5.3: Sampling Strategy The sampling framework described by BASCD was used in this study to select three independent random samples of three-four-year-old children living in Hackney, Tower Hamlets, and Newham in 2007. We adopted a cluster sampling approach. The first stage unit was nurseries; all local authority-run nurseries located in three Inner North East London were included in the sampling frame. The list of nursery schools in each borough was obtained from local education authorities. BASCD protocol suggests that a minimum of 15 first stage units (e.g., nurseries) is acceptable with 20 first stage units being preferable. Hence, we selected 20 nursery schools. All pupils in the sample drawn who were present in school on the selected day were examined. There were no substitutions for selected children who could not be examined. We identified at least 400 children in each borough to assure that we would obtain the minimum number (N=250) required. We purposively oversampled assuming that we would obtain a low response rate. 5.3: Data Collection Procedure Data collection included a clinical examination and a questionnaire to collect demographic information. Data collection teams consisted of a BASCD-trained and experienced community dental officer and a formally trained scribe. The dentist carried out all clinical oral examinations and the scribe recorded the clinical information. The 5

data collection team participated in a training exercise prior to starting data collection covering the procedures and the criteria used to identify dental caries experience. All children were examined at nurseries in a medical room or in a suitable alternative venue. Clinical examinations followed strict infection control procedures. Each examination kit included an autoclaved set of instruments including a Number Four plane mouth mirror, a CPITN probe (or a blunt probe with a 0.5mm tip) and fresh cotton wool rolls or buds to dry the teeth. Disposable plastic cups were available for rinsing. The examiners wore uncontaminated disposable latex-free gloves during the clinical examination. Examiners sat behind the child who lay in a supine position on a table or in a reclined chair. All children rinsed their teeth prior to clinical examination but they did not brush their teeth. Radiographs were not taken in this survey. The examinations used the BASCD diagnostic criteria for dental caries, oral sepsis, and traumatic dental injuries (Appendix 1). A Daray "Versatile" light provided standardised illumination. Tooth surfaces were examined in a standard order: upper left, upper right, lower right and lower left. Examiner recorded all surfaces starting from the distal, occlusal, mesial, buccal, and lingual surfaces. The examiners removed debris and moisture using cotton wool rolls or buds. The probe was also used to remove debris. Clinical data was recorded at the tooth level at the time of the examination on paper or directly onto a laptop. Appendix 2 shows that record forms.. 5.4:Demographic Information Demographic information obtained for children included the child s name, date of birth, ethnicity and home postcode. Children s home postcodes were used to generate an areabased measure of deprivation- the Index of Multiple Deprivation (2004) [8]. This information was confirmed from school records. 6

5.5: Data Analysis The data was first entered into an Excel spreadsheet and then. transferred For into the Statistical Package for Social Sciences (SPSS for Windows, version 15.0) for data analysis. The data were then checked for entry errors and missing information and weighted to reflect the population ratios and proportional representation of children living in the three boroughs. Weighting the data was required because children in Hackney and Tower Hamlets were under-represented, while children in Newham were overrepresented in the sample. Weights were produced and applied producing similar weighted and unweighted sample sizes. Further weighting was unnecessary because non-respondents did not affect the representativeness of the sample (See 6.1.2: Sample Sociodemographic Characteristics). This study estimated caries experience by summing the total number of teeth with untreated decay into dentine, missing teeth due to decay and filled teeth, which represented the dmft score. We assumed that missing teeth were missing due to decay or trauma. We also dichotomised caries experience into caries free (dmft=0) and caries experience (dmft>0). We used four continuous oral health outcomes assessed caries experience ( i.e., the mean number of untreated decayed teeth, missing teeth, filled teeth and number of teeth with caries experience) and one categorical variable (i.e., caries free/ caries experience)., Sepsis was recorded and analysed as present or absent. Traumatic dental injuries were recorded when there was evidence of a treated or untreated fracture exposing dentine, if the tooth was discoloured or missing due to trauma. Traumatic dental injuries were recorded and analysed at the tooth level as present or absent. The response rate is defined as the percentage of all sample members who are eligible to participate in a study from whom a complete and usable set of data is collected. We calculated the response rate for this study by dividing the number of completed successful clinical examinations (numerator) by the number of eligible children invited to participate in the study (denominator). 7

Data analysis calculated the prevalence (percentage) of dental caries, oral sepsis, and traumatic dental injuries and the mean number of teeth with untreated decayed teeth, missing teeth, filled teeth and teeth with caries experience. Further data analyses compared the oral health of children in different genders and boroughs by calculating odds ratios, prevalence rate ratio (for count variables) and their confidence intervals,. The level of significance was set at five percent. Although, we originally planned to compare the oral health of children living in neighbourhoods with different levels of deprivation, this was not possible because nearly all children (99.2%) resided in the 25% most deprived postcodes in the UK. No postcodes fell in the 25% or 50% more affluent neighbourhoods and only nine children resided in this survey resided in neighbourhoods with moderate levels of deprivation. It is impossible to assess associations when there is no variation. Unsurprisingly, levels of deprivation were not related to dental disease in this survey. Therefore, we have not presented these associations in this report to avoid redundancy. 8

Table 5.5.1: Number (%) of three-four-year-old children in Inner North East London by borough of residence in the sample and the population in 2007 Variable Number (% ) in the unweighted sample Number (% in the population in 2001 Number (%) in weighted sample (%) Tower Hamlets 333 (26%) 6135 (29%) 372 (29%) Hackney 243 (19%) 6620 (32.3%) 415 (32%) Newham 709 (55%) 8387 (39.7%) 510 (39%) Total 1285 (100%) 21142 (100%) 1297 (100%) 9

6: Results 6.1: Sample Description 6.1.1: Response Rate All local education authorities gave their permission to approach the selected 20 nurseries in each of the three boroughs in Inner North East London. All 60 nurseries allowed us to invite children attending their nurseries to participate in this survey. Two thousand, four hundred and thirty-four children were sampled in the final stage and 1285 were successfully examined in all three boroughs, producing a response rate of 52.8%. Table 6.1.1 shows the response rates for the different stages and boroughs. There were no significant differences between the response rates in the three boroughs (Table 6.1.1.1). 10

Table 6.1.1.1: Response rate for all stages of the oral health survey of three-four-year-old children living in Inner North East London in 2007 Hackney Tower Hamlets Newham Inner North East London Number of schools selected Number of schools who agreed to participate Number of children sampled Number of children successfully examined 20 20 20 60 20 20 20 60 469 603 1362 2434 243 333 709 1285 Response rate (%) 51.8 55.2 52.1 52.8 11

6.1.2: Sample Socio-Demographic Characteristics The sample was composed of 651 girls (50.2%) and 646 (49.8%) boys (Table 6.1.2.1) aged three-four-years of age (Table 6.1.2.1). Most children in the survey resided in deprived neighbourhoods; 1,162 postcodes out of a total number of 1,171 postcode addresses were among the 25% most deprived neighbourhoods in the UK (Table 6.1.2.2). This finding was not surprising given than Hackney, Tower Hamlets and Newham are the second, third and sixth most deprived boroughs in the UK. Data analysis demonstrated that non-respondents did not affect the representativeness of the sample. There was no significant difference between the percentage of boys and girls in the sample population and the percentage of boys in the population reported in the 2001 UK census. Similarly, the average Index of Multiple Deprivation (IMD) obtained for the sample for Hackney (mean=46.3) and Newham (mean=43.8) were comparable to those reported in the UK 2001 census. The mean IMD score in Tower Hamlets (mean=51.1) was marginally higher than the average score reported in the 2001 census (mean=44.6) (Table 6.1.2.3). 12

Table 6.1.2.1: Frequency distribution of three-four-year-old children living in Inner North East London in 2007 by gender (weighted data, n = 1297). Variable Number Percentage Boys 646 49.8 Girls 651 50.2 Total 1297 100.00 Table 6.1.2.2: Frequency distribution of Index of Multiple Deprivation (2004) quartiles in England and in the sample of three-four-year-old children living in Inner North East London in 2007 (weighted data, n = 1297) IMD quartiles in England (2004) Range of average IMD scores in England (2004) Number (%) in sample 1 st quartile (least deprived scores) 4.13-11.78 0 (0.00) 2 nd quartile (middle range less deprived scores) 4.13-11.78 0 (0.00) 3 rd quartile (middle range more deprived scores) 4.13-11.78 9 (0.8) 4 th quartile (most deprived scores) 4.13-11.78 1162 (99.2%) Missing information 125 (9.6) Table 6.1.2.3: Average Index of Multiple Deprivation (IMD) scores by borough in sample of three-fouryear-old children living in Inner North East London in 2007 (weighted data, n = 1297) Variable Mean Index of Multiple Deprivation (IMD) 2004 score in the sample Hackney 46.3 46.10 Tower Hamlets 51.1 44.64 Newham 43.8 42.95 Mean Index of Multiple Deprivation (IMD) 2004 score in the population census (2001) 13

6.2: The Oral Health of Three-Four-Year-Old Children in Inner North East London: Dental Caries (Decay) Experience The study adhered to the methodology and caries diagnostic criteria used in the 1992/93 National Diet and Nutrition Survey of 1½ to 4½ year old children and the UK Children s Dental Health survey in 2003, which allowed us to compare our findings with national data [10, 11]. Although one should be cautious about comparing this local oral health survey conducted in 2007 with national oral health surveys carried out in 1992-3 and 2003, this survey found that three-four-year-old children in Inner North East London had better oral health than 3½-4½ year old children in the UK in 1992/93 and five-year old children in the UK in 2003 (Table 6.2.1). Twenty-three percent of children in Inner North East London had previous decay experience compared to 30% of 3½-4½ year old children in the UK in 1992/93 and 43% of five year old children in the UK in 2003. Three-four-year-old children in Inner North East London also had fewer teeth (mean=0.92 teeth) with decay experience than 3½-4½ year old children in the UK in 1992/93 (mean=1.3 teeth) and five year old children in the UK in 2003 (mean=1.6 teeth) (Table 6.2.1). The majority of children with decay experience had untreated decayed teeth; few children had missing or filled teeth due to decay. Twenty-two percent of children in Inner North East London had one or more untreated decayed tooth (Table 6.2.2). Children in Inner North East London had a mean number of 0.80 untreated decayed teeth (Table 6.2.2). There were no difference between the number of untreated decayed teeth in boys and girls and the percentage of boys and girls with untreated decayed teeth but there were borough differences (Table 6.2.2). A significantly lower percentage of children living in Hackney (14.8%) had one or more untreated decayed teeth than children living in Tower Hamlets (23.4%) and children living in Newham (27.5%) (Table 6.2.2). Three-four-year-old children in Inner North East London had a mean number of 0.08 missing teeth with only 1.7% of children having a missing tooth (Table 6.2.3). Children living in Newham had fewer missing teeth (mean=0.04 teeth) than children living in Tower Hamlets (mean=0.13 teeth) and Hackney (mean=0.09 teeth) (Table 6.2.3). There was no gender difference related to missing teeth (Table 6.2.3). 14

Only two percent of three-four-year-old children had a filled tooth (mean filled teeth=0.04) (Table 6.2.4). There were no gender or borough differences related to filled teeth (Table 6.2.4). Twenty-three percent of three-four-year-old children in Inner North East London had a obvious decay experience with a mean number of 0.92 teeth with obvious decay experience (Table 6.2.5). Children living in Hackney (16.1%) were less likely to have had decay experience than children living in Tower Hamlets (24.9%) and in Newham (28.6%) (Table 6.2.5). 15

Table 6.2.1: Mean number of untreated primary decayed teeth into dentine and the percentage of children with one or more untreated decayed teeth in the sample of three-four-year old children living in Inner North East London in 2007 (weighted data, n = 1297), 3½-4½year old children in the UK in 1992/93 and five year old children in the UK in 2003. Three-Four-Year olds in Inner North East London 3.½-4½ year-olds in the UK (1992/3) Mean number of teeth with decay experience 0.92 23.5 1.30 30.0 Five-year-olds in the UK (2003) 1.60 43.0 Percentage of children with decay eexperience Table 6.2.2: Mean number of untreated primary decayed teeth into dentine and the percentage of children with one or more untreated decayed teeth by gender and borough in the sample of three-four-year old children living in Inner North East London in 2007 (weighted data, n = 1297). Mean number of teeth with decay into dentine Prevalence Rate Ratio (95% C.I) Percentage of children with decayed teeth into dentine Odds Ratio (95% C.I) Gender Boys 0.81 1 23.12 1 Girls 0.79 0.98 (0.73,.1.33) 0.92 21.43 0.91 (0.67, 1.23) 0.52 Borough Tower Hamlets 0.89 1 23.42 1 Hackney 0.52 0.58 (0.33, 1.03) 0.06 14.81 0.57 (0.35, 0.92) 0.02 Newham 0.96 1.08 (0.72, 1.62) 0.26 27.50 1.24 (0.85, 1.80) 0.25 Inner North East London 0.80-22.27 16

Table 6.2.3: Mean number of missing teeth and the percentage of children with one or more missing tooth by gender and borough in the sample of three-four-year old children living in Inner North East London in 2007 (weighted data, n = 1297). Mean number of missing teeth Prevalence Rate Ratio (95% C.I) P value Percentage of children with missing teeth Odds Ratio (95% C.I) Gender Boys 0.06 1 1.32 1 Girls 0.11 1.95 (0.65, 5.81) 0.22 2.00 1.52 (0.57, 4.07) 0.40 Borough Tower Hamlets 0.13 1 2.40 1 Hackney 0.09 0.65 (0.18, 2.42) 0.54 1.65 0.68 (0.20, 2.36) 0.54 Newham 0.04 0.31(0.11, 0.87) 0.03 1.13 0.46 (0.17, 1.30) 0.14 Inner North East London 0.08 1.66 Table 6.2.4: Mean number of filled teeth and the percentage of children with one or more filled tooth by gender and borough in the sample of three-four-year old children living in Inner North East London in 2007 (weighted data, n = 1297). Mean number of filled teeth Prevalence Rate Ratio (95% C.I) Percentage of children with filled teeth Odds Ratio (95% C.I) Gender Boys 0.04 1 1.13 1 Girls 0.03 0.83 (0.33, 2.08) 0.69 0.94 0.83 (0.36, 1.90) 0.66 Borough Tower Hamlets 0.03 1 1.80 1 Hackney 0.02 0.91 (0.16, 5.09) 0.92 1.24 0.68 (0.18, 2.55) 0.56 Newham 0.05 1.93 (0.56, 6.62) 0.30 2.96 1.66 (0.63, 4.38) 0.30 Inner North East London 0.04-2.08 17

Table 6.2.5: Mean number of teeth with obvious decay experience and the percentage of children with obvious decay experience by gender and borough in the sample of three-four-year old children living in Inner North East London in 2007 (weighted data, n = 1297). Gender Mean number of teeth with obvious decay experience Prevalence Rate Ratio (95% C.I) Percentage of children with obvious decay experience Boys 0.90 1 24.01 1 Odds Ratio (95% C.I) Girls 0.94 1.04 (0.78, 1.37) 0.79 23.07 0.94 (0.71, 1.27) Borough Tower Hamlets 1.04 1 24.92 1 Hackney 0.63 0.60 (0.35, 1.03) 0.07 16.05 0.58 (0.36, 0.93) 0.03 Newham 1.05 1.01 (0.68, 1.50) 0.96 28.63 1.21 (0.83, 1.75) 0.31 Inner North East London 0.92-23.54 18

6.3: The Oral Health of Three-Four-Year-Old Children in Inner North East London: Oral Sepsis Less than two percent (1.5%) of three-four-year-old children in Inner North East London showed evidence of oral sepsis (i.e., dental abscess) (Table 6.3.1). The difference between the percentage of children with oral sepsis living in Tower Hamlets (1.2%), Hackney (0.0%) and Newham (3.0%) was not statistically significant because of the small number of children who had oral sepsis (Table 6.3.1).. There were no statistical difference between the presence of sepsis in boys and girls (Table 6.3.1). 19

Table 6.3.1: Percentage of children with oral sepsis by gender and borough in the sample of three-fouryear old children living in Inner North East London in 2007 (weighted data, n = 1297). Gender Percentage of children with oral sepsis Boys 1.97 1 Odds Ratio (95% C.l) Girls 1.06 0.53 (0.26, 1.11) 0.09 Borough Tower Hamlets 1.20 1 Hackney 0.00 - Newham 2.96 2.51 (0.69, 9.13) 0.16 Inner North East London 1.51 20

6.4: The Oral Health of Three-Four-Year-Old Children in Inner North East London: Traumatic dental injuries This survey used the BASCD criteria for Traumatic Dental Injuries (TDI) including few signs and symptoms, which can underestimate the actual prevalence of TDI. Four percent of three-four-year-old children in Inner North East London had a Traumatic Dental Injury (TDI) (Table 6.4.1). As expected, a higher percentage of boys (5.5%) and had a TDI than girls (23.0%) (Table 6.4.1). Children living in Newham (8.2%) were also more likely to have a TDI than children living in Tower Hamlets (1.8%) and Hackney (1.7%) (Table 6.4.1). 21

Table 6.4.1: Percentage of children with a traumatic dental injury (TDI) by gender and borough in the sample of three-four-year-old children living in Inner North East London in 2007 (weighted data, n = 1297). Gender Percentage of children with a TDI Boys 5.54 1 Odds Ratio (95% C.I) Girls 2.99 0.52(0.29, 0.96) 0.04 Borough Tower Hamlets 1.80 1 Hackney 1.65 0.91 (0.28, 2.98) 0.88 Newham 8.18 4.86 (2.21, 10.64) <0.001 Inner North East London 4.26 22

6.5: The Oral Health of Three-Four-Year-Old Children in Hackney in 2007 The sample of three -four-year-old children in Hackney was composed of 119 boys (49%) and 124 girls (51%) (Table 6.5.1). Fifteen percent of children in Hackney had one or more untreated decayed tooth (mean number of untreated decayed teeth=0.52 teeth) (Table 6.5.2). There was no gender difference related to untreated decayed teeth in children in Hackney (Table 6.5.2). Approximately two percent (1.7%) of three -four-year-old children in Hackney had a missing tooth (mean=0.09 missing teeth) (Table 6.5.3). There was no gender difference related to missing teeth in children in Hackney (Table 6.5.3). Approximately one percent (1.2%) of three -four-year-old children in Hackney had a filled tooth (mean=0.02 filled teeth) (Table 6.5.4). There was no gender difference related to filled teeth in children in Hackney (Table 6.5.4). Sixteen percent of three-four-year-old children living in Hackney had obvious decay experience (Table 6.5.5). Children had a mean number of 0.63 teeth with decay experience. There was no gender difference related to obvious decay experience (Table 6.5.5). 23

Table 6.5.1: Number (%) of children living in Hackney by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 243). Variable Number Percentage Boys 119 49.0 Girls 124 51.0 Total 243 100.0 Table 6.5.2: Mean number of untreated decayed teeth into dentine and the percentage of children living in Hackney with one or more untreated decayed tooth into dentine by gender in the sample of three-fouryear old children living in Inner North East London in 2007 (n = 243). Mean number of teeth with decay into dentine Prevalence Rate Ratio (95% C.I) Percentage of children with decayed teeth into dentine Odds Ratio (95% C.I) Gender Boys 0.57 1 16.81 1 Girls 0.47 0.82 (0.27, 2.52) 0.71 12.90 0.73 (0.31, 1.74) 0.46 Hackney 0.52 14.81 Table 6.5.3: Mean number of missing teeth and the percentage of children living in Hackney with one or more missing teeth tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 243). Mean number of missing teeth Prevalence Rate Ratio (95% C.I) P value Percentage of children with missing teeth Odds Ratio (95% C.I) Gender Boys 0.07 1 1.68 1 Girls 0.10 1.55 (0.16, 15.13) 0.68 1.61 0.95 (0.11, 8.67) 0.97 Hackney 0.09 1.65 24

Table 6.5.4: Mean number of filled teeth and the percentage of children living in Hackney with one or more filled tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 243). Mean number of filled teeth Prevalence Rate Ratio (95% C.I) P value Percentage of children with filled teeth Odds Ratio (95% C.I) Gender Boys 0.05 1 2.52 1 Girls 0.00 -) 0.00 - - Hackney 0.02 1.24 Table 6.5.5: Mean number of teeth with obvious decay experience and the percentage of children living in Hackney with teeth with obvious decay experience by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 243). Mean number of teeth with decay experience Prevalence Rate Ratio (95% C.I) P value Percentage of children with teeth with decay experience Odds Ratio (95% C.I) Gender Boys 0.69 1 17.65 1 Girls 0.57 0.83 (0.31, 2.19) 0.69 14.52 0.79 (0.35, 1.79) 0.56 Hackney 0.63 16.05 25

6.6: The Oral Health of Three-Four-Year-Old Children living in Tower Hamlets in 2007 The sample of three -four-year-old children in Tower Hamlets was composed of 169 boys (50.8%) and 164 girls (49.2%) (Table 6.6.1). Twenty-three percent of children in Tower Hamlets had one or more untreated decayed tooth (mean number of untreated decayed teeth=0.89 teeth) (Table 6.6.2). There was no gender difference related to untreated decayed teeth in children in Tower Hamlets (Table 6.6.2). Two percent of three -four-year-old children in Tower Hamlets had a missing tooth (mean=0.13 missing teeth) (Table 6.6.3). There was no gender difference related to missing teeth in children in Tower Hamlets (Table 6.6.3). Approximately two percent (1.8%) of three -four-year-old children in Tower Hamlets had a filled tooth (mean=0.03 filled teeth) (Table 6.6.4). There was no gender difference related to filled teeth in children in Tower Hamlets (Table 6.6.4). Twenty-five percent of three-four-year-old children living in Tower Hamlets had obvious decay experience (Table 6.6.5). Children had a mean number of 1.05 teeth with decay experience. There was no gender difference related to obvious decay experience (Table 6.6.5). 26

Table 6.6.1: Number (%) of children living in Tower Hamlets by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 333). Variable Number Percent Boys 169 50.75 Girls 164 49.25 Total 333 100.0 Table 6.6.2: Mean number of untreated decayed teeth into dentine and the percentage of children living in Tower Hamlets with one or more untreated decayed tooth into dentine by gender in the sample of threefour-year old children living in Inner North East London in 2007 (n = 333) Mean number of teeth with decay into dentine Prevalence Rate Ratio (95% C.I) Percentage of children with decayed teeth into dentine Odds Ratio (95% C.I) Gender Boys 0.88 1 23.67 1 Girls 0.90 1.02 (0.60, 1.73) 0.95 23.17 0.97 (0.53, 1.77) 0.92 Tower Hamlets 0.89 23.42 Table 6.6.3: Mean number of missing teeth and the percentage of children living in Tower Hamlets with one or more missing teeth tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 333) Mean number of missing teeth Prevalence Rate Ratio (95% C.I) P value Percentage of children with missing teeth Odds Ratio (95% C.I) Gender Boys 0.06 1 1.18 1 Girls 0.21 3.50 (0.54, 22.68) 0.18 3.66 3.17 (0.72, 13.80) 0.12 Tower Hamlets 0.13 2.40 27

Table 6.6.4: Mean number of filled teeth and the percentage of children living in Tower Hamlets with one or more filled tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 333) Mean number of filled teeth Prevalence Rate Ratio (95% C.I) P value Percentage of children with filled teeth Odds Ratio (95% C.I) Gender Boys 0.02 1 2.37 1 Girls 0.03 1.29 (0.15, 10.51) 0.80 1.22 0.51 (0.07, 3.55) 0.48 Tower Hamlets 0.03 1.80 Table 6.6.5: Mean number of teeth with obvious decay experience and the percentage of children living in Tower Hamlets with teeth with obvious decay experience by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 333) Mean number of teeth with decay experience Prevalence Rate Ratio (95% C.I) P value Percentage of children with teeth with decay experience Odds Ratio (95% C.I) Gender Boys 0.96 1 25.44 1 Girls 1.13 1.18 (0.74, 1.86) 0.47 24..39 0.95 (0.55, 1.64) 0.83 Tower Hamlets 1.05 24.92 28

6.7: The Oral Health of Three-Four-Year-Old Children living in Newham in 2007 The sample of three -four-year-old children in Newham was composed of 353 boys (49.8%) and 356 girls (50.2%) (Table 6.7.1). Twenty-seven percent of children in Newham had one or more untreated decayed tooth (mean number of untreated decayed teeth=0.96 teeth) (Table 6.7.2). There was no gender difference related to untreated decayed teeth in children in Newham (Table 6.7.2). Approximately one percent (1.1%) of three -four-year-old children in Newham had a missing tooth (mean=0.04 missing teeth) (Table 6.7.3). There was no gender difference related to missing teeth in children in Newham (Table 6.7.3). Three percent of three -four-year-old children in Newham had a filled tooth (mean=0.05 filled teeth) (Table 6.7.4). There was no gender difference related to filled teeth in children in Newham (Table 6.7.4). Twenty-nine percent of three-four-year-old children living in Newham had obvious decay experience (Table 6.7.5). Children had a mean number of 1.06 teeth with decay experience. There was no gender difference related to obvious decay experience (Table 6.7.5). 29

Table 6.7.1: Number (%) of children living in Newham by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 709). Variable Number Percent Boys 353 49.79 Girls 356 50.21 Total 709 100.0 Table 6.7.2: Mean number of untreated decayed teeth into dentine and the percentage of children living in Newham with one or more untreated decayed tooth into dentine by gender in the sample of three-fouryear old children living in Inner North East London in 2007 (n = 709) Mean number of teeth with decay into dentine Prevalence Rate Ratio (95% C.I) Percentage of children with decayed teeth into dentine Odds Ratio (95% C.I) Gender Boys 0.94 1 27.76 1 Girls 0.99 1.05 (0.80, 1.41) 0.68 27.25 0.97 (0.67, 1.41) Newham 0.96 27.50 Table 6.7.3: Mean number of missing teeth and the percentage of children living in Newham with one or more missing teeth tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 709) Mean number of missing teeth Prevalence Rate Ratio (95% C.I) P value Percentage of children with missing teeth Odds Ratio (95% C.I) Gender Boys 0.04 1 1.13 1 Girls 0.04 0.93 (0.15, 5.67) 0.93 1.12 0.99 (0.18, 5.41) 0.99 Newham 0.04 1.13 30

Table 6.7.4: Mean number of filled teeth and the percentage of children living in Newham with one or more filled tooth by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 709) Mean number of filled teeth Prevalence Rate Ratio (95% C.I) Percentage of children with filled teeth Odds Ratio (95% C.I) Gender Boys 0.04 1 1.98 1 Girls 0.06 1.45 (0.56, 3.74) 0.83 3.93 2.02 (0.92, 4.47) 0.08 Newham 0.05 2.96 Table 6.7.5: Mean number of teeth with obvious decay experience and the percentage of children living in Newham with teeth with obvious decay experience by gender in the sample of three-four-year old children living in Inner North East London in 2007 (n = 709) Mean number of teeth with decay experience Prevalence Rate Ratio (95% C.I) Percentage of children with teeth with decay experience Odds Ratio (95% C.I) Gender Boys 1.02 1 28.05 1 Girls 1.09 1.07 (0.83, 1.38) 0.60 29.21 1.06 (0.74, 1.52) 0.75 Newham 1.06 28.63 31

Appendix 1: BASCD Diagnostic Criteria Dental caries The diagnosis of the condition of tooth surfaces will be visual and the ball-ended probe will be used only for the removal of debris. Present and sound surface - CODE 0 A surface is recorded as "sound" if it shows no evidence of treatment or untreated clinical caries at the "caries into dentine" diagnostic threshold. The early stages of caries, as well as other similar conditions, are excluded. Thus surfaces with the following defects, in the absence of other positive criteria, should be coded as present and "sound": white or chalky spots discoloured or rough spots stained fissure in the enamel that are not associated with a carious lesion dark, shiny, hard, pitted areas of enamel in a tooth showing signs of moderate to severe fluorosis. All questionable lesions should be coded as "sound". Arrested dentinal decay - CODE 1 Surfaces are recorded as falling into this category if, in the opinion of the trained examiner, there is arrested caries into dentine. Decayed surface - CODE 2 Surfaces are recorded in this category if, in the opinion of the trained examiner, after visual inspection, there is a carious cavity into dentine. Hard arrested caries into dentine is separated as CODE 1 above. Decay with pulpal involvement - CODE 3 Surfaces are recorded in this category if, in the opinion of the trained examiner there is a carious lesion that involves the pulp, necessitating an extraction or pulp treatment. Code 3 includes retained roots requiring extraction. Filled and decayed surfaces - CODE 4 A surface that has a filling and a carious lesion [whether or not the lesion(s) are in physical association with the restoration(s)] will fall into this category unless the decay is so extensive as to be classified as Code 3. Fillings which have deficient margins but show no evidence of fresh decay are recorded as Code R - filled needs replacing (not carious) - below. Filled surfaces with no decay - CODE 5 Surfaces containing a satisfactory permanent restoration (excluding crowns - Code C) of any material will be coded under this category. Filled, needs replacing (not carious) - CODE R A filled surface is regarded as falling into this category if, in the opinion of the examiner it is chipped or cracked and needs replacing, but there is no "caries into dentine" present in the same surface. 32

Lesions or cavities containing a temporary dressing, or cavities from which a restoration has been lost, will be regarded as "filled, needs replacing" unless there is also evidence of caries into dentine, in which case they will be coded in the appropriate category of "decayed". Extracted due to caries - CODE 6 Surfaces are regarded as missing if the tooth, of which they were a part, has been extracted because it was carious. Surfaces that are absent for ANY other reasons are NOT included in this category. NB - Deciduous molars and canines only will be recorded in this category, not deciduous incisors. Missing deciduous incisors should be excluded. Unerupted tooth - CODE 8 If a deciduous incisor is missing and the permanent whole tooth is unerupted it will be recorded as the permanent successor unerupted - Code 8. Obscured surfaces All obscured surfaces are assumed sound unless there is evidence of disease experience on the remaining exposed part of the tooth, in which case the tooth should be coded according to its classification for those exposed surfaces. (NB: Code 9 is no longer used.) Traumatic Dental Injury Traumatised surfaces - CODE T Incisor surfaces will fall into this category if, in the opinion of the examiner, the tooth/surface has been subject to a traumatic blow and as a result: the whole tooth missing - Code T all surfaces (avulsed tooth), or is fractured so as to expose dentine - Code T each surface affected (repaired or not) discoloured due trauma Sepsis Following examination of the mouth for caries, if, in the opinion of the trained examiner, the presence of an acute abscess or sinus has been noted - circle YES in the appropriate section on the chart. If no abscess or sinus present circle NO 33

Appendix 2: Child Data Collection Form Plaque measurement 0- Teeth appear clean 1- Little plaque visible 2 -Substantial amount of plaque visible 9 - Assessment could not be made Abscess / Sepsis measurement 0 - absent 1 - present Caries (Ca) and trauma (Tr) measurement Right UPPER Left E D C B A A B C D E Ca Tr Right LOWER Left E D C B A A B C D E Ca Tr 34