At the root of the problem

What can be done to tackle the persistent problem of dental decay in children? 

THE figures make for grim reading. Dental decay affects more than 40 per cent of UK children by the age of five and in some parts of the country 75 per cent of pre-school children have rotting teeth. The statistics have barely changed in 20 years and, to top it all, there is still no conclusive evidence for the most effective approach in managing decay.

The reasons why poor child dental health has persisted for two decades are many. One explanation may be that some parents struggle to find an NHS dentist to treat their children as more practitioners opt for private practice. In the last Dental Health Survey in 2003, a quarter of parents of 12 to 15-year-olds and a fifth of parents of five to eight year-olds claimed they had trouble finding a dentist for their child.

Professor Jimmy Steele, head of the school of dentistry at the University of Newcastle, told Summons that children’s oral health has “improved enormously in the last few decades, but there is still room for improvement.” He believes the reasons for poor oral health are “the same as they have always been: poor diet, a lack of awareness and perhaps an attitude that accepts that dental decay is a normal part of growing up.”

Damaging factors

The rise in tooth decay has also been blamed on changing dietary trends, as fizzy drinks, fast food and bottled water (which lacks fluoride) become increasingly popular. And sometimes a parent or carer’s own fear or mistrust of the dentist may prevent them seeking care for their child.

Janet Clarke, president of the British Dental Association, said some parents believe the health of their children’s milk teeth is not important. In an article in the Times, she said: “A lot of people think that baby teeth don't matter but they are hugely mistaken. Children can have severe pain in milk teeth, which then have to be removed. Because baby teeth hold a space open for adult teeth to come through, if they have decaying or removed teeth, that space gets smaller and there isn't enough room. This can lead to growth problems later, and mean that they have to wear a brace.”

Income level can also be a factor when seeking dental care for children. Figures published by the Audit Commission in February 2010 show that tooth decay is a greater problem in low income communities. Over 150,000 more children have decayed, missing and filled teeth in deprived areas compared with the rest of the country, a gap which has increased dramatically over the last ten years.

Lack of awareness is another factor. Chief Executive of the British Dental Health Foundation, Dr Nigel Carter, said: "Dental disease is the most common preventable childhood disease and good education at an early age can have a significant impact. Parents are very much responsible for helping their children to develop a good oral health routine and ensure regular visits to the dentist."

Future hope

Despite the gloomy figures, there have been concerted efforts in recent months to tackle the problem.

This includes recommendations made by Professor Jimmy Steele in his 2010 review of NHS dentistry in England – some of which are now being implemented. In April 2011, it was announced that a pilot project of a new dental contract is being launched across 62 practices in England that will reward practitioners according to the quality of care they deliver for patients rather than the number of treatments carried out. It is Professor Steele’s belief that NHS dentistry should be more about quality outcomes and disease prevention than simply measuring units of dental activity (UDAs).

He wants dentists to focus more on prevention than simply treating symptoms. Under his plans, dentists will be encouraged to identify patients at high risk of developing dental disease and spend more time giving them advice on brushing, flossing and diet. This will be combined with improved chairside IT systems that will help practitioners identify and manage high-risk patients.

Professor Steele said: “The existing system does need to change and we need to help dentists do what they want to do and look after the oral health of their patients. We are going in the right direction but there will be tough times ahead and we will need to keep our nerve to make the changes we need.” But he added: “Dentists can only do so much; parents and schools both have a role, as does wider society.”

There are also initiatives underway in Scotland to improve child dental health. Around 150 dentists in the Lothians have signed up to the Childsmile scheme aimed at helping under-fives. Under the scheme, children will have fluoride varnish applied to their teeth every six months and will be monitored during regular check-ups. Promoting the project, NHS Lothian’s Robert Naysmith said: “Encouraging the parents of very young children to register them with a dentist will bridge the gap between birth and nursery."

Managing decay

Meanwhile, new research commissioned by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme hopes to finally uncover conclusive evidence of the best way to manage child tooth decay. The £2.87million FiCTION study will assess three different methods. The multi-centre trial is taking place in Cardiff, Dundee, Glasgow, Leeds, London, Newcastle and Sheffield and the methods being assessed are:

1: Using only preventive techniques recommended in national guidance (better toothbrushing, less sugar in the diet, application of high fluoride varnish and fissure sealants).

2: Conventional fillings with preventive techniques.

3: Biological treatment of the decay (sealing the decay into teeth with filling materials or under crowns, generally without the need to use injections or dental drills) with preventive techniques.

Dr Nicola Innes, of the University of Dundee Dental School and one of the lead researchers for the trial, said: “Conventional clinical opinion is that baby teeth showing decay should be filled, yet the majority of cavities in young children are left unrestored. There is, as yet, no conclusive evidence for the most effective approach to managing decay in baby teeth. With this trial we are looking to provide that evidence.”

In the absence of such conclusive evidence, there are various pieces of clinical guidance available to dentists. One of the most recent is Prevention and Management of Dental Caries in Children published by the Scottish Dental Clinical Effectiveness Programme in April 2010.

Their list of priorities for dental teams includes:

• encouraging the parent/carer to take responsibility for their child’s oral health

• focussing on prevention of caries in the permanent dentition before management of caries in the primary dentition

• if caries in the permanent dentition does occur, diagnosing it early, and managing it appropriately

• managing caries in the primary dentition using an appropriate technique that maximises the chance of the tooth exfoliating without causing pain or sepsis, while minimising the risk of treatment-induced anxiety

• identifying as early as possible those children where there is doubt about a parent/carer’s ability to comply with dental health preventive advice, support or treatment uptake, and to contact and work collaboratively with other agencies, especially the child’s named health visitor, school nurse or general medical practitioner.

The aim should be to work with families and offer support, as well as taking a rigorous approach to follow-up appointments. For further information, read British Society of Paediatric Dentistry: a policy document on dental neglect in children at www.bspd.co.uk

Joanne Curran is associate editor of Summons

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