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Our team has decided to investigate the epidemiology of dental caries in Scottish children, below the age of 16 inclusively from the 1970’s to present. Scotland has the highest prevalence of tooth decay in Europe.1 This is evident from the numerous data sources ascertained. There are associated inequalities found in geographic and socio-economic subgroups which are at the forefront of dental caries prevalence in Scotland.
The combination of bacteria with small food particles and saliva creates a sticky film on the tooth which is commonly known as plaque. 2 Over consumption of sugary food and drink, which is high in carbohydrate, provides the bacteria with the energy it needs, whilst producing acid simultaneously. 2 If this plaque is neglected, it will erode the tooth causing dental caries.2 In Scotland there is a ‘sweetie culture’,3 where sugary snacks are too readily available and so consumption levels are damaging children’s teeth. As a result the Scottish government are making efforts to assess the problem and subsequently trying to resolve it.
Assessment of Caries And Prevelence Measurement
The classification of dental caries is done by several sets of criteria, the primary one being the DMFT (decayed/missing/filled teeth) which divides the population into two groups and gathers the mean from each of decayed missing and filled teeth. It’s measured from 0 to 32 in terms of affected teeth for people over the age of 12 and from 0 to 20 in children.4 The prevalence portrayed by this measurement has seen a marked decrease in caries in children from 2.16 in 2006 to 1.86 in 2008.5 It’s been of paramount importance to the Scottish Government in assessing the levels of caries in children and giving them direction in terms of policy making and goal setting. This is evident from the Graph 15 portrayed in the appendix, which displays the decrease in caries, which in this instance displays decay that goes in to the dentine (d3mt) since the 1980s, with the mean age of children being 5.54 years old.3 This marked decrease has allowed the government to target specific areas of Scottish society to enable an even further reduction in prevalence in caries and employment of even more defined classification models.
Another method used for assessing dental caries in preschool children in Scotland is the DCRAM (Dundee Caries Risk Assessment Model). This statistical analysis tool provides an appropriate risk assessment model to determine incidence in a community setting. The DCRAM collects data from one year olds, and uses this data to predict caries incidence over a three year timeframe, to when they are at the age of four. Data is collected following a dental and microbiological examination and from information received via parental questionnaires.6 This type of model makes it easier to differentiate people into different sub-groups so as to investigate the differing incidence levels of oral ill-health within these sub-groups, for example urban and rural differences in dental caries of five year old children in Scotland.7 Here Scotland was split into six different geographies, namely the four ‘big’ cities (Glasgow, Edinburgh, Dundee and Aberdeen) to the smaller ‘rural areas’. The findings of this study were that the children in rural areas had a better level of dental health than those living in urban areas (mean DMFT of 1.87 for all of Scotland, the four cities 2.16, other urban 1.81, accessible towns 1.88, remote towns 1.86, accessible rural 1.31, remote rural 1.34).5
Socioeconomic factors have been attributed to the cause of caries in Scotland, where deprivation is positively and significantly associated with having d3mft.8 In a three year follow up study undertaken it was obvious that a serious level of DMFT imbalances between the upper class (SEG1) of society and the lower class (SEG2) existed. As noted the percentage improvements found in SEG1 were up to three times larger than those in SEG2.9 This study undertaken in the 1980’s led to the development of further classification tools to give greater transparency. The DepCat scale divided communities into socioeconomic groups from 1 (most affluent) to 7 (most deprived). In doing so it applied the DMFT to reveal high levels of inequality with “findings in this study ranging from 62.4% (DepCat 1) to 19.8% (DepCat 7)”.10 Although this looks ominous there is evidence to portray a 13 point improvement between 2006 and 2008 in the most deprived areas (DepCat 7).5 Further evidence of a decreased DMFT can be seen on Graph 25 in the appendix. With this the employment of a newer scale The Scottish Index of Multiple Deprivation1 will ensure further study and reduction of caries in the deprived.
“Epidemiological principles, methods, tools and information are applied in every aspect of public health from policy setting at macro level to decision making at individual level”,11 therefore making the collection and cohesion of information highly important. The result of this work by the Scottish government and health officials has given us tangible trends to decipher the level of dental caries in the country. Graphs 312 and 412 in the appendix clearly portray the level and improvement in dental caries in Scotland. It is given expectation and focus to the government in their implementation of preventive measures for the future.
Evidence-based Population-based Prevention Strategies
Pit and fissure configuration on tooth can harbour bacteria and lead to dental caries. Prevention of dental caries would be most efficient when the interaction between the host, causative agent and favouring environmental factors is inhibited. Fissure sealant is a primary prevention approach as it diminishes the risk of getting dental caries by enhancing resistance against the bacteria.
A systematic health review published by NHS Health Scotland outlines fissure sealants as one of the early childhood caries prevention measures. Three studies were carried out on children under five years old to prove sealants are effective against occlusal dental caries depending on the retention rate, type of sealant and method of application.13 Rather than treating sequel of dental caries, preventive sealants are considered cost-effective compared to expensive restorative procedures. However, an article by Department of Paediatric Dentistry, University of Glasgow, Scotland addressed the efficiency of sealants depends on several factors. Caries are more susceptible in molar tooth, at highest risk during post-eruption period and whether resin-based or glass ionomer fissure sealants were to be chosen is influenced by moisture control.14 If sealants are used for all cases and risk assessment is neglected, this will reduce the cost-effectiveness.
On the contrary, fissure sealants are effective against dental caries only if retained. Sealants require vigilant management that they must be replaced over time. Glasgow Dental Hospital and School reported out of 7000 sealants applied by private practitioners in Scotland, 23% of failed sealants end up carious after 4 years. This study concludes that maintenance of originally sealed fissures is vital for success sealants in long run.15 The study concluded that dental caries are bacterial, regardless of age and the process of wearing sealants would be of the same in any age group.
The use of fluorides, on the other hand, in either topical (mouth rinsing solutions, tablets, toothpastes) or systemic (fluoridated water, milk or salt) forms, has shown to have a positive effect on the prevention and reduction of dental caries experience among children and adolescents, globally.16 Although fluoridation of water is considered one of the ten main achievements of public health interventions,17 its real advantages to public health remain controversial.18 Scotland rejected artificial water fluoridation amidst public complaints of its harmful side effects, namely fluorosis or “mottled teeth.”19
Over the past 50 years in the UK, fluoridated toothpastes have played a crucial role in the declining trends of dental caries in children (in terms of reduced DMFT scores and overall oral health.) 20,21 There is also consensus about 1000ppm Fluoride concentration per toothpaste as optimal for ensuring protection from dental caries, and has proved to be 25% more beneficial in preventing tooth decay.22 Systematic review carried out by the University of Dundee reinforces the superior preventive effect of fluoride toothpastes compared to placebos (addition PF, 24.9%.)23 Researchers and public health authorities have unanimously placed fluoride toothpaste as “the method of choice for preventing caries, as it is convenient and culturally approved, widespread, and it is commonly linked to the decline in caries prevalence in many countries.”20
One of the chief concerns associated with consumption of fluorides is the incidence of fluorosis. Systematic reviews of studies carried out across the UK indicate a positive correlation between the concentrations of fluoride and dental fluorosis.24 Moreover, there are two major concerns associated solely with topical fluoride use- a) noncompliance with tooth brushing regimens and b) chronic overconsumption of toothpaste among children leading to increased risk of fluorosis.20 While some studies claim that fluoridated water is associated with higher incidence of diseases like bone fractures, senile dementia or cancer; no conclusive evidence has been reported.24 Other concerns of fluoridation like its effects on immunity, reproductive health and GI effects have also not shown to be clinically significant.25
A third prevention strategy called Childsmile was fully running since 2011. It is a children orientated, oral health promotion programme driven by the NHS. The aim is to improve the overall oral health of all children across Scotland and reduce inequalities in dental public health and access to related services.26
Childsmile has three components, the Core, which is applied to all Scottish children, provides fluoridated toothpaste and toothbrushes till five years of age and advocates supervised tooth brushing. 26 The Practice component allows new parents to register easily with local dental practices and is educated on oral health, such as tooth brushing methods and diet. Risk assessments are used to identify children at high risk, who are then provided with varnish and fissure sealants. 26 The third component, Nursery and School, provides twice per annum fluoride varnish applications to those living in the most deprived local quintile of Scotland under the Scottish Index of Multiple Deprivation (SMID). 26
In 1996, the Greater Glasgow Health Board introduced a community-based oral health promotion for five year olds in the most socially deprived areas in Glasgow, comparable to Childsmile, which involved establishing Oral Health Action Teams (OHATs). 27 OHAT’s main goals are very similar to Childsmile’s, including supervised tooth brushing, providing information to parents and supporting local dentists to further promote oral health. A follow-up study was done and the D3MFT values has shown to decrease from 5.5 to 3.6 and from 6.0 to 3.6 respective to DepCat 1 and 2 communities and the mean D3MFT values of 5 year olds was reduced in all DepCat 7 communities from 4.9 to 4.1. “This change was of sufficient magnitude to impact upon area-wide statistics for Glasgow”. 28 This suggests that oral health education interventions do give a positive impact on the population if it is implemented rigorously.
Even though dental treatments are now relatively more advanced and effective, it is difficult for the whole population to benefit from these treatments, due to cost and access, as a prevention strategy for further tooth decay. Hence, it would be wiser to put into place public health strategies to get the knowledge to the general public and to promote the idea from young that ‘prevention is better than treatment’ for oral health.
But even with these health promotion programmes, there is evidence that shows how it is not a sustainable way to stop poor oral health because they do not tackle the main underlying cause. This leads to an ethical dilemma; creating a bigger inequality gap of access to oral healthcare, with those being in higher SES groups actually benefitting more than those who are in much more need of these service in the most deprived population.
Discussion / Conclusion
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Search Strategy
For our project we began with a general search of dental caries on PubMed. There were numerous articles published from around the world so we narrowed it down to UK and Ireland and South America, as there were plenty of relevant articles for these regions. It was later decided that the following electronic databases: MEDLINE, PubMed and Cochrane library provided a number of articles for Scotland and Brazil. Using certain parameters like age (0-16 years old) it was decided that our project would be focussed on the dental caries of children in Scotland and articles produced between 1973 and present day. Keywords used to refine the search included ‘children’, ‘fluoridation’,’ fissure sealants’ and ‘government studies’ amongst others. We used the “advanced search option” on PubMed with a combination of keywords such as “Government Interventions” AND “Dental caries Scotland” to review steps taken by the Scottish Government in recognising dental caries in children and also treating the problem.
For the epidemiology section of the project we found articles using keywords “epidemiology”, “dental caries”, “Scottish children”. We found 107 relevant articles that were eventually narrowed to give us the most pertinent approaches taken in Scotland to diagnose dental caries, such as DCRAM (Dundee Caries Risk Assessment Model) and the NDIP (National Dental Inspection Plan). Searches based on individual interventional approaches were then carried out, yielding 17 results for DCRAM on PubMed and 16000 results for NDIP on Google Scholar. The studies were reviewed and chosen only if they met the criteria we wished to discuss throughout project, such as, age (0-16 years old), social background and residence i.e. Rural v Urban setting. We also did not include articles and studies published before 1973.We also used articles produced by the NHS and took these as official and accurate.
For review of prevention strategies, we decided to use fissure sealants, fluoridation and the public health strategy of ‘Childsmile’ as our main areas of discussion in terms of intervention. After comprehensive research using our chosen electronic databases- MEDLINE, PubMed, Cochrane Library and Google Scholar, we narrowed the expansive intervention of “Fluoridation” to “the use of Fluoridated Toothpastes” as we realized that artificial fluoridation was rejected by the Scottish government and that toothpastes were hence the most ubiquitous form of fluroide intake in Scottish children. A search on pubmed with keywords “Fluoridated Toothpastes” initially yielded 125 results, which were then narrowed using additional limits of “Full Free Text” and “English Language”. Similar limits were applied to searches of Fissure Sealants and ChildSmile, yielding 33 and 4 results, respectively.
For reviews evaluating the efficacy of these interventions, we depended mostly upon PubMed and Cochrane Library. A seach with the advanced limits of “English Language”, “Free Full Text Available” and type of article-“Systematic Review” yielded only 1 result on Pubmed for Fissure Sealants, 3 for ChildSmile and 15 for fluoridated tootpastes. We feel our results provide an accurate review of dental caries in children in Scotland between the ages of (0-16).
References
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What did dr beisma say about long url?
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