Student Number: 81865730 School: Seymour Road Word Count:

Caries Prevention in School Children Prevention of the disease would benefit those affected and those at risk as its likely for the children to be affected by the negative effects of caries later in their adult life. Several measures to prevent caries have been employed at different scales in the past to varying effects so it is the job of this essay to assess the effectiveness of proposed tactics so that they can be employed to help benefit school children. The effectiveness will be based on: changes in caries figures and cost of the schemes including health/ethical concerns. To review and pinpoint an appropriate scheme, we must first understand what caries is and what factors are involved in its prevalence. Caries is a preventable sugar dependent infectious disease characterised by the demineralisation and remineralisation of tooth surfaces (Mitchell 2009). Its pathophysiology leads to a degradation of oral health and a reduced quality of life through pain via sensitivity or infection. Caries remains one of the most common chronic diseases of children across the world. The treatment of caries is expensive and for children (4-18) who are entitled to free dental care, it represents a burden on the NHS budget. In a study carried out by Public Health England1, 27.9% of five-year olds on average have experienced caries with those in the North-West having overall the poorest oral health: 34.8% (figure 1.). This is further seen to translate into a higher caries rate in twelve-year olds with on average 33.4% experiencing caries and again the NorthWest having a higher than average rate of 39.8% (figure 2.). (Davies G et al, 2013)

The study used methodology based on previous studies and results were taken using d 3tmft: visualonly examination for missing teeth (mt), filled teeth (ft) and teeth with obvious dentinal decay (d 3t) - a quantitative measure of caries and a subset of DMFT (DMFT = permanent dentition, dmft = primary).

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(Davies G et al 2013)
Figure 2: Percentage of 12 year old children with decay experience (D3MFT > 0) including 95% confidence limits. Strategic Health Authorities, 2008/09.

(Davies G et al 2013) Maintenance of oral hygiene is multi-factorial; blaming the individual on a poor dental regime is not enough to tackle the issue as various barriers exist that inhibit positive health behaviours. Several studies show a strong relationship between deprivation and (oral) health. The Marmot Review suggests that the more favoured an individual is socially and economically, the better their health (Marmot, 2010) - the review uses several components of the IMD2 (Department for Communities and Local Government, 2010) to compare the health of those with different socioeconomic statuses. In a
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The use of Indices of Multiple Deprivation as a composite index allows for a quantitative comparison of areas across multiple factors that contribute to deprivation including employment, education and crime

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comparison between IMD and d3fmt, a positive correlation was observed3 (figure 3.) (Davies G et al 2013).
Figure 3: 3: Correlation between number of dentinally decayed, missing (due to decay) and filled Figure

teeth (d3mft) among five-year-old children and Index of Multiple Deprivation (IMD 2010) score. Lower-tier local authorities in England, 2012.

(Davies G et al 2013)

Manchester as an average of all its LSAOs4 comes out at 3rd in the national ranking for most depraved with over 33,000 of its residents living in the 1% most deprived LSOA in the country. We focused on Seymour Road Primary School (M11 4PR) within LSAO Manchester 012B neighbourhood in Ancoats and Clayton Ward. The LSAO has an IMD of 50.36 (Office for National Statistics, 2011) which puts it within the 10% most deprived in the country (see figure 4 and 5 for examples of markers of deprivation); coupled with the proportion receiving FSM (figure 6) mean that the school contains a higher than average number of deprived pupils5, therefore making it a relevant case study to base our findings on.

samplingschool based and therefore not truly representativesample was treated as a stratified random sampleIMD-weighted estimates were produced to provide more robust estimates of overall prevalence 4 Lower-Level Super Output Area: theoretical areas of population 1000-3000 designed to improve the reporting of a small area statistics 5 Those eligible for free school meals and those living in areas of higher deprivation; generally considered for FSM > 40% to be deprived (ESARD, 2011)

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Markers of deprivation locally, regionally and nationally proportional to respective populations

Proportion of Population (%) 40 35 30 25 20 15 10 5 0 JSA claimers (16-24) Unauthorised school absences Markers of deprivation Individuals who claim that they have bad health or worse 1.5 1 1 10.7 6.8 4.2 36 31 Manchester 012B North West England

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Figure 4 (Office for National Statistics, 2011)

Total number/types of crimes within a 1 mile radius

141 crimes

336 crimes

Figure 5. Pie charts show the total number/types of crimes within a 1 mile radius of Seymour Road (M11 4PR) and Lancaster Lane Community Primary School (PR2 5TT) 6 in October 2013 (Office for National Statistics, 2011) (Crime-Statistics, 2013)

Deemed an appropriate point of comparison in the absence of available statistics for England as a whole. Reasoning: Lancaster is a state-funded school within the South Ribble 015A LSOA; the IMD for this area was one of 8 different LSOAs with the score 21.67 (representing the average deprived LSOA of the country). South Ribble 015A was the only LSOA out of the 8 in the same North-West region as Manchester 012B.

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National Average (%)

Seymour Road Junior School (%)

% of pupils taking FSM (free school meals) % of pupils known to be eligible for FSM Figure 6. (Find My School, 2008) 18.0% 60.4% 14.0% 54.1%

Higher than average school absences, JSA claimants and crime are just some of the numerous risk factors that may have negatively impacted their general health; collectively they represent a lack of guidance and control leading to the formation of barriers preventing better hygiene or accessing dental care. In an environment such as Manchester 012B, poor education and low incomes are likely to lead to an inadequate oral routine and hence an insufficient removal of plaque. This is because the reasons behind the consequences wouldnt be fully known or appreciated and the purchase of dental equipment wouldnt seem necessary. In addition, receiving regular dental care is hindered due to a combination of groups of barriers: dental anxiety, financial costs, perceptions of need and lack of access (Freeman, 1999). Freeman discusses how For example, even if persons receiving JSA are entitled to free care, other factors such as an anxiety coupled with unawareness of the importance of regular checkups will prevent care being taken - 22% of adults with extreme dental anxiety only access care when in pain rather than a regular check-up (Hill K. B. et al, 2013).

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A) Population level intervention Water fluoridation represents a holistic but controversial approach to tackling caries and involves raising the concentration of fluoride in water supplies to 1ppm optimum level to prevent caries whilst causing minimal aesthetic fluorosis. Population level interventions such as this remove socioeconomic status as a factor so are more likely to improve the oral health of everyone who drinks the water but only acts as an aid and wont ensure a vastly improved oral health on its own. Under the Water Act 2003, fluoridation of water supplies is done by water undertakers at the request of relevant authorities by adding either hexafluorosilicic acid or disodium hexafluorosilicate into the water. It is paid for by the health authority and does not come out of ones water bill. Several groups such as Fluoride Action Network protest fluoridation by claiming amongst other reasons that its a form of mass medication which has the potential to cause illness/death; despite evidence that the safely tolerated dose is 1mg/kg (1ppm unlikely to be toxic). In a systematic review (McDonagh M, et al 2000); the median difference at 1ppm in dmft/DMFT was observed at 2.25 less carious teeth, which implies a significantly beneficial result. However, at 1ppm an increased prevalence of aesthetically concerning fluorosis was observed estimated 12.5% (95% confidence level). There was no clear evidence of other adverse effects such as increased bone fracture or cancer incidence. The reviewer states that 214 studies of low to moderate quality were used and a fair amount of heterogeneity was observed between results of similar studies. In relation particularly to the negative impacts, its stated how enamel opacities, observer bias and external fluoride sources may have affected results. The review shows strong evidence for fluoride use in the prevention of caries, but it isnt of high enough quality to be completely conclusive. In terms of its implementation, part of the 2012 NHS reforms called for better public consultation to be obtained before the relevant authorities sanction fluoridation.

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B. Community level prevention (15 marks) Focusing on school-based prevention, the methods in this section set about to enforce schemes and improve the oral health across the pupils in school. Limitations of these schemes are costs, consent and whether behaviours are retained at home. A good scheme would be: cost-effective in improving oral health; not overly intrusive; and maintained at home. (a) Healthy eating:

In accordance with regular lunchtime meal provision, a change to a healthy menu offers a method that: shouldnt require written permission; is likely to improve the overall health of a child; and there is also no significant cost difference between a healthy and unhealthy diet. Diet follows the common risk-factor7 approach to oral health with factors such as obesity possibly leading to caries. So providing healthy meals in school time may help counter the effects of a poor diet and change the eating behaviour of a child at home. However, further research needs to be done on the long term benefits of diet on oral health to understand the efficacy. In addition, behavioural changes are hard to enforce and changing the diet at school is not guaranteed to change the diet at home. (b) Fluoride milk Heterogeneity between several studies across several factors including the concentration of fluoride used meant there was insufficient evidence to provide conclusive proof but the author concludes that for school children there is a benefit of milk provision. With higher quality evidence there is a possibility that the scheme may be more widely considered as early evidence is promising significant reduction in DMFT (78.4%) after 3 years between test and control groups in a randomised controlled trial. However, currently the costs and need for consent doesnt make this scheme a priority. (c) Oral health advice Delivered by oral health professionals (not necessarily dentists) and involves the teaching of better oral health to the school as well as the provision of toothbrushes/paste. The effectiveness of this scheme will be discussed in individual level prevention as it draws parallels with the advice given by the childs dentis t. The

Dictates how various diseases have multifactorial causations

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specific benefits of professionals giving seminars are that the knowledge acquired by the child may influence his oral health behaviour at home and the provision of a toothbrush/paste may encourage use. There is no guarantee however that any knowledge gained will be applied.

Individual level prevention At an individual level, caries prevention schemes rely on good dental education. . Education needs to be delivered to the: (a) children so they are aware of the reasons for maintaining a good oral regime; (b) parents as its necessary for them to brush the teeth of their children when young and supervise at later ages until the child is deemed to having a good oral regime these allow for good health routines and practices to be developed and maintained. Information should be delivered by the childs dentist and be based on the advice given in Delivering Better Oral Health. A governmental report written by experts designed for practicing dentists to give the best evident-based dental advice to their patients so to promote good oral health. All methods set out are tailored to the appropriate age and risk groups and were graded 1-5 using a system based on the level of evidence available on their efficacy (1 is highest quality evidence (systematic), 5 lowest (expert opinion)). Age groups represented are: <3, 3-6, 7-18 and >18. For the purpose of this essay We will focus on the 3-6 and 7-18 age groups and also factor in those with a higher risk of developing caries8. For both groups, the only grade 1 advice given is to brush last thing at night and on one other occasion and to use fluoridated toothpaste (1350+ ppm). Fluorides benefits to dental caries are well documented and reviewed in a number of systemic studies; the pre-eruptive benefits are through improving the crystal structure of teeth and hence decrease acid solubility and the post-eruptive benefits is mainly through the encouragement of enamel remineralisation and inhibit the action of cariogenic bacteria. The importance of brushing before sleeping is based on the concentration of fluoride in saliva and it was observed that after using 1500ppm fluoride toothpaste,
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Are considered to require further advice in addition to those given than normal individuals; some probably also need professional intervention. (including also those undergoing orthodontic treatments and those with special needs)

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the concentrations in saliva 12 hours later were similar to those 1-4 hours after brushing in the day. For the age group 3-6, it is recommended to use a pea amount of toothpaste. This distinction in quantity relates to the age of the child and their safe fluoride intake; it is suggested that a child may inadvertently swallow ~0.3-0.8mg of fluoride from 1g of toothpaste so to avoid an unsafe consumption an approximate 5mm of toothpaste should be used each time - which is another reason why adult supervision when brushing is important. For both groups, the application of fluoride varnish to teeth twice yearly (2.2% F-) is advised, (or 3-4 times for those at high risk); the ADA report suggests through grade 1 evidence the beneficial use of fluoride varnish at the proposed intervals. Fluoride varnish can be delivered by the hygienist or trained nurses. Taking a diet sheet has the same advantage and provides a cost-effective method in possibly preventing caries. Though the evidence for the efficacy of diet advice is not substantial (grade 3), benefits may still be observed. Stephans curve display how tooth surfaces go through 40-60 minute periods of net demineralisation after the consumption of food; hence decreasing the total periods of time in which teeth are being demineralised (limiting snacking) could arrest the state of caries, but unfortunately, no evidence is available to suggest it may decrease caries. For high risk groups of ages 7-18, several other professional methods have been suggested. Evidence provided was of grade 1 quality. These methods include: (a) daily fluoride mouthwash (0.05% NaF) at a different time to brushing (b) fissure sealant for permanent molars (c) 5000ppm F- toothpaste 16+ year olds with active caries. (a) Statistically significant reduction in caries observed with a 26% reduction in DMFS9 in children and little heterogeneity in results; the author concludes that the use is recommended but under supervision (b) Resin-based sealant significantly prevented caries in first permanent molars in high risk children aged 5 to 10 years for 2 years in comparison to no sealant (95% confidence) author concludes that sealants are effective in high risk children but evidence for benefits in other conditions are inconclusive
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Decayed, Missing, and Filled permanent tooth Surfaces a variation of DMFT

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(c) Statistically significant reduction of caries in the 5000ppm group - 38.2% of users had primary caries root lesions harden in comparison to 10.7% of 1100ppm users within the first 3 months. The evidence for the prescribed dentifrices display great impacts but would require the patient implementing this regime routinely; outside of a controlled trial, there is no guarantee for success due to perception of need. Sealants must be applied by a dentist and checked routinely so represent a burden to the NHS but the evidence within the report showed large reductions in caries.

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Bibliography
Crime-Statistics. (2013). PR25 5TT (141 crimes) & M11 4PR (336 crimes), October 2013 . Retrieved 12 01, 2013, from Crime-Statistics: http://www.crimestatistics.co.uk/compare/postcodes/PR255TT+M114PR Davies G., Neville J., et al (2013). National Dental Epidemiology Pogramme for England: oral health survey of five-year old children 2012. A report on the prevalence and severity of dental decay. England: Crown Copyright. Davies G., Neville J., et al (2013). National Dental Epidemiology Pogramme for England: oral health survey of twelve-year old children 2012. A report on the prevalence and severity of dental decay. England: Crown Copyright. Division, S. A. a. R. (2009). Deprivation and Education. S. a. F. Department for Children, Department for Children, Schools and Families. Department for Communities and Local Government. (2010). The English Indices of Deprivation 2010. Great Britain: Department for Communities and Local Government. ESARD. (2011). Underperforming schools and deprivation: A statistical profile of schools below the floor standards in 2010. England: Department for Education. Find My School. (2008). Retrieved December Sunday 1st, 2013, from http://www.findaschool.info/CompareSchools.php?Qry=131423,105453,105454,139078&hL oc=0&hLat=0 Freeman, R. (1999). Barriers to accessing dental care: patient factors. British Dental Journal, 187(3):141-4 Hatton, A. (2013). Schools, pupils and their characteristics. Department For Education. Hill, K. (2013). Adult Dental Health Survey 2009: relationships between dental attendance patterns, oral health behavious and the current barriers to dental care. British Dental Journal 2013; 214: 25-32 Marmot, M. (2010). Fair Society, Healthy Lives: The Marmot Review. http://www.instituteofhealthequity.org/ [accessed 01/12/2013] Mitchell, D. A. (2009). Oxford Handbook Of Clinical Dentistry. New York: Oxford Unversity Press Inc. Office for National Statistics. (2011). Neighbourhood Statistics. Retrieved December 01, 2013, from http://www.neighbourhood.statistics.gov.uk/dissemination/LeadSByASelectScotNI.do?a=7& c=012B&d=141&i=1001x1002&m=0&r=1&s=1386090342105&enc=1&areaId=6287517&OAA reaId=6342306

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