A randomised control trial of oral health education provided by a health visitor to parents of pre-school children.

OBJECTIVES: To determine the effect of oral health education carried out by a specially trained health visitor on the dental health of young children. DESIGN AND SETTING: Children, who were recruited during their 8-month distraction-hearing test, were randomly allocated to intervention and control groups. A home visit by the health visitor was arranged to parents in the intervention group who were given dental health advice. A second home visit, when the child was about 20 months old, focused on a completed diet record sheet and discussions about what and when the child was eating and drinking. Children in the intervention group received a toothbrush and toothpaste containing 440 ppm fluoride at both visits while those in the control group received the level of care usually provided by health visitors in the area. The children's teeth were examined when they were three years old and two years later as part of a census survey of 5-year-old children in the area. MAIN OUTCOME MEASURES: The numbers of decayed, missing and filled tooth surfaces. RESULTS: 251 children were recruited to the control group and 250 to the intervention group. At age three, they were examined; the mean dmfs scores were 2.19 (95% Confidence Interval: 1.41-2.97) in the control group (n = 171) and 2.03 (CI: 1.39-2.67) in the intervention group (n = 181). During the census survey 276 of the children in the study were examined at school. At this age the mean dmfs scores were 4.84 (CI: 3.39-6.29) in the control group (n = 129) and 3.99 (CI: 2.54-5.04) in the intervention group (n = 147). However, the mean dmfs of the remaining 2,253 children who were examined was 5.94 (CI: 5.55-6.33). CONCLUSIONS: No statistically significant differences in mean dmfs scores were found between the control and intervention groups of children, although, as the children grew older, the gap between them widened. However, the mean dmfs score of other 5-year-olds in the area was significantly worse than that of children in the intervention group. Asking the control parents to take part in the study and examining their children at three years may have had an effect on their dental health status and have made it more difficult to detect any differences achieved by the programme.

The relationship between socio-demographic characteristics and dental health knowledge and attitudes of parents with young children.

OBJECTIVE: To determine if parental socio-demographic characteristics are associated with dental knowledge and attitude. DESIGN: A questionnaire survey of 500 consecutive parents with children aged approximately 8-months, attending clinics in 1999/2000, in Burnley, Pendle and Rossendale, for health visitor distraction-hearing tests. OUTCOME MEASURES: Scores were obtained for dental knowledge and attitudes. The socio-demographic variables of parental ethnicity, age, education and area of residence were used to determine any associations. RESULTS: Parental age ranged between 16-46 years. Child age ranged between 7-11 months. Significant differences were detected for parental dental knowledge according to ethnicity (P = 0.003), educational status (P = 0.000), and area of residence (P = 0.016). Significant differences were also found in dental attitudes; ethnicity (P = 0.000), educational status (P = 0.004) and area of residence (P = 0.005). Parental age was not significant for either knowledge or attitude. CONCLUSIONS: Lack of further education, being Asian and living in a deprived area means parents have less chances of high dental knowledge and positive dental attitudes.

Management information failings and future requirements for dental commissioning groups.

OBJECTIVE: To examine existing secondary care management information systems for dental specialities, and to determine their completeness and suitability for supporting effective primary care led purchasing decisions. DESIGN: An observational cross-sectional study of current information systems in selected secondary care provider units and the applicability of their data for contracting dental services. A comparative study of two information systems in two settings (primary and secondary care) and the utility of the data gathered for contracting for dental services. SUBJECTS: Secondary care activity data was sought from the key secondary dental care providers (hospitals) in two dental total purchasing localities. Referral data were also collected directly from general dental practitioners. MAIN OUTCOME MEASURES: The integrity, quality and accuracy of current secondary care activity data in dental specialities, in comparison to data supplied from primary dental care. RESULTS: The secondary care activity data was found to be incomplete, inadequate and inaccurate. It was found that due to data retrieval insufficiency, indicative budgets for secondary providers may be reduced to less than half of their actual entitlement. The data inflated individual dental outpatient attendance by 3.3 times between 1995/6 and by 2.5 times between 1996/7. CONCLUSION: Existing management information systems within secondary care providers are not structured in a way which will adequately inform future commissioning by the dental profession. Communication between primary and secondary care must be increased and data inputting methods in secondary care provider units must be substantially improved.

The provision of primary care dental general anaesthesia and sedation in the north west region of England, 1996-1999.

AIM: To investigate trends in the provision of primary care dental general anaesthesia (DGA) and sedation following the new guidance from the General Dental Council. DESIGN: Cross-sectional analysis of data about the provision of DGA in the General Dental Service and Community Dental Service from 1996/97 to 1998/99. SETTING: The North West Health Region of England. METHOD: The numbers of DGAs in the General Dental Service (GDS) and Community Dental Service (CDS) for the three financial years, 1996/97, 1997/98 and 1998/99 were examined. In addition General Dental Service quarterly information about the numbers of general anaesthetics, sedations requiring another dentist or doctor, and claims for conscious sedation or inhalation sedation from April 1997 to December 1999 was requested from the Dental Practice Board. RESULTS: The numbers of DGAs declined by 24 per cent between 1996/97 and 1998/99. Those in the GDS fell from 14,550 in the first quarter of 1997/98 to 3,527 in the first quarter of 1999/2000. The number of claims for sedation, which required another dentist or doctor, increased from 712 in the first quarter of 1997/98 to 2,989 in the same quarter of 1999/2000, while the number of claims for conscious sedation and inhalation sedation increased slightly from 2,847 to 2,963 over the same period. CONCLUSIONS: The revised General Dental Council guidance has reduced the numbers of DGAs being carried out in both GDS and CDS. The number of sedations involving another dentist or doctor has increased considerably but the new guidance seems to have had little effect on the numbers of patients receiving operated administered conscious sedation and inhalation sedation.

Maintaining good dental practice: the East Lancashire approach to dentists whose performance gives cause for concern.

The Consultant in Dental Public Health and the Local Dental Committee in East Lancashire have developed a local system, similar to that being set up for general medical practitioners, to help general dental practitioners whose performance is causing concern. GDPs approved it at an open meeting of practitioners. A Dental Performance and Assessment Group has been set up and one problem has already been resolved to everyone's satisfaction. The model is recommended to dentists in other areas.

The ability to successfully include primary dental care practitioners in commissioning groups.

OBJECTIVES: To evaluate two total purchasing (TP) sites and ascertain whether general dental practitioners (GDPs) could be successfully included in the total purchasing model of health care commissioning. Another objective was to examine the role GDPs may play in future primary care commissioning groups and trusts. DESIGN: An observational cross-sectional study of two dental purchasing pilots in the North West Region. SUBJECTS: Two TP sites were studied, one in South Cheshire, the other East Lancashire. Each TP organisation had a dental subgroup which had a formal structure and was given an active role in dental healthcare service decision making. MAIN OUTCOME MEASURES: General dental practitioners' ability to manage dental health care provision in the selected sites and the suitability and effectiveness of the services managed by them. RESULTS: GDPs were willing and able to form cohesive primary care commissioning organisations but attitudes in secondary care prevented the implementation of their decisions. CONCLUSIONS: Structural, organisational and psychological changes would be necessary if GDP led purchasing were to be successfully implemented. Such changes are vital if GDPs and the dental profession are to have an effective role in the newly formed primary care groups and trusts.

Past and present attempts to control health service expenditure and its effects on National Health dentistry.

OBJECTIVE: To examine the methods used by policy makers to try to reduce or limit expenditure within the National Health Service. METHOD: A chronological examination of cost related health care policy and its wider impact on society. Comparison of past developments in the NHS with new methods of health care organisation in the United Kingdom (UK). The experiences of two dental Total Purchasing Pilots are used to describe where the dental profession now stands in relation to current NHS developments. RESULTS: The introduction of Primary Care Groups (PCGs) constitutes part of a continued effort by health care policy makers to control expenditure on health services. In the PCG system, as in Total Purchasing (TP), a group of primary care practitioners control a finite budget. These groups therefore must decide which health care services should be available to the population they represent. Inevitably such systems result in the rationing of health care, but the decisions are instigated by primary health care professionals rather than by government edict. CONCLUSION: Unless GDPs are allowed, willing and able, to participate in and influence the newly emerging Primary Care Groups and Trusts, dental services may once again be pushed to the fringe of NHS care provision. Without adequate representation, the value of dental care may not be recognised and PCGs may decide to make use of traditional dental resources, to fund other services.

A model framework comparing resources required for activities in the Community Dental Service validated using the Delphi technique.

OBJECTIVE: To validate a model framework comparing resources required for activities in the Community Dental Service. The framework consisted of five levels of care of increasing complexity for six groups of patients. The patient groups were: children with behavioural problems, mentally disabled patients, anxious adults, paedodontic patients, medically compromised and physically disabled patients. DESIGN: Delphi study using two sequential questionnaires. Participants were asked to rate the difficulty of 29 different treatments on a scale from 1 to 100. PARTICIPANTS: Six clinical directors and eleven senior dental officers working in the Community Dental Service in the North West of England. RESULTS: Seventeen of the 29 treatments were rated at the level of care predicted by the model. Nine were rated lower and three higher. Within the patient groups the order of increasing complexity, predicted by the model, was verified with only one exception. CONCLUSIONS: The research confirmed that it is possible to measure CDS activity in a rational way. Consensus was reached on a suitable framework which was simpler than the original model in having only four levels of care. The use of the modified model is now being tested in the Community Dental Service.

Dental caries in 12-year-old children and the effectiveness of dental services in Salford, UK in 1960, 1988 and 1997.

OBJECTIVE: To investigate the dental health of 12-year-old children and the effectiveness of dental services in 1997 and compare the results with studies carried out in 1960 and 1988. BASIC RESEARCH DESIGN: Analytical survey using a one in five random sample of children in all seven secondary schools in Salford UK. Standard clinical criteria were used. SETTING: Clinical examinations were carried out in school. PARTICIPANTS: 65 boys and 49 girls were examined. OUTCOME MEASURES: Caries experience expressed as DMFT, Restorative Index and Care Index. RESULTS: The boys and girls both had a mean DMFT of 1.65. (95% confidence intervals were 1.18-2.12 for the boys and 1.16-2.14 for the girls.) This compared with means of 2.34 (1.85-2.83) for boys and 3.40 (2.63-4.17) for girls in 1988, and 6.04 (5.65-6.43) and 6.54 (6.09-7.00), respectively in 1960. The prevalence of caries fell least in first permanent molar teeth. The Care Index for the boys was 22.0 in 1960, 51.4 in 1988 and 31.5 in 1997. The pattern was similar for the girls for whom the values were 19.5, 48.6 and 32.2 respectively. The boys' Restorative Index scores (modified to include fissure sealants) were 25.7 in 1960, 58.5 in 1988 and 57.1 in 1997. The girls' scores were 23.9, 53.7 and 58.0. CONCLUSIONS: Caries has declined considerably in Salford since 1960. More of the total disease was concentrated in first permanent molar teeth in 1997. Indices, which measure the effectiveness of dental services, show that a greater proportion of overall disease was being treated in 1988 than in 1960 or 1997.

Trends in the provision of primary care dental general anaesthesia in the north of England, 1991/92 to 1994/95.

AIM: To investigate trends in the provision of primary care dental general anaesthesia (PCDGA) and any association with dental caries. DESIGN: Cross-sectional analysis of data about the provision of PCDGA in the general dental service and community dental service from 1991/92 to 1994/95. SETTING: The former North Western, Mersey, Northern and Yorkshire regions. METHOD: The combined rates of PCDGAs in the general dental service and community dental service, from 1991/92 to 1994/95 were calculated and compared with the levels of caries from the NHS dental epidemiology programme. RESULTS: All regions except the North Western had a lower rate at the end of the 1991 study but only the Northern region had a lower rate in 1994/95 than in 1993/94. Only weak correlations were found between the PCDGA rate in a health authority and the level of dental caries. CONCLUSIONS: PCDGA rates did not continue to decline during the period of this study. One of the principal recommendations of the Poswillo report was that the use of general anaesthesia should be avoided wherever possible. Other initiatives, perhaps the development of criteria for selection of patients, may be necessary if further reductions in PCDGA rates are to be achieved.

Household income in relation to dental health and dental health behaviours: the use of Super Profiles.

OBJECTIVE: To investigate the relationship between household income defined by Super Profiles, a socio-economic indicator, and dental health and dental health behaviours. BASIC RESEARCH DESIGN: Analytical survey involving a clinical examination and a questionnaire to parents. SETTING: Primary schools in Salford, UK. PARTICIPANTS: Two thousand five hundred and seventy eight 5-year-old children were examined; 1938 (75%) returned questionnaires. MAIN OUTCOME MEASURES: Mean caries experience and ages at first visit to dentist and when toothbrushing commenced. RESULTS: Children in the highest income group had a mean dmft of 1.83 compared with 2.56 in the middle group and 3.43 in the lowest income group. The proportions who had visited a dentist by their second birthday were 71%, 64% and 62% respectively. The corresponding proportions having their teeth brushed by their first birthday were 69%, 58% and 57%. CONCLUSIONS: The study showed a relationship between Super Profiles, and the dental health and dental health behaviours of 5-year-old children.

Water fluoridation, tooth decay in 5 year olds, and social deprivation measured by the Jarman score: analysis of data from British dental surveys.

OBJECTIVE: To examine the effect of water fluoridation, both artificial and natural, on dental decay, after socioeconomic deprivation was controlled for. DESIGN: Ecological study based on results from the NHS dental surveys in 5 year olds in 1991-2 and 1993-4 and Jarman underprivileged area scores from the 1991 census. SETTING: Electoral wards in three areas: Hartlepool (naturally fluoridated), Newcastle and North Tyneside (fluoridated), and Salford and Trafford (non-fluoridated). SUBJECTS: 5 year old children (n = 10,004). INTERVENTION: Water fluoridation (artificial and occurring naturally). MAIN OUTCOME MEASURE: Ward tooth decay score (score on the "decayed, missing, and filled tooth index" for each electoral ward). RESULTS: Multiple linear regression showed a significant interaction between Jarman score for ward, mean number of teeth affected by decay, and both types of water fluoridation. This confirms that the more deprived an area, the greater benefit derived from fluoridation, whether natural or artificial (R2 = 0.84, P < 0.001). At a Jarman score of zero (national mean score) there was a predicted 44% reduction in decay in fluoridated areas, increasing to a 54% reduction in wards with a Jarman score of 40 (very deprived). The area with natural fluoridation (at a level of 1.2 parts per million-higher than levels in artificially fluoridated areas) had a 66% reduction in decay, with a 74% reduction in wards with a Jarman score of 40. CONCLUSION: Tooth decay is confirmed as a disease associated with social deprivation, and the more socially deprived areas benefit more from fluoridation. Widespread water fluoridation is urgently needed to reduce the "dental health divide" by improving the dental health of the poorer people in Britain.

Five-year-old children: changes in their decay experience and dental health related behaviours over four years.

At the time of the 1989-90 survey of 5-year-old children, co-ordinated by the British Association for the Study of Community Dentistry, a questionnaire about dental health behaviour was sent home to 2,390 parents in Salford and 2,098 in Trafford. The response rates were 78 per cent and 81 per cent respectively. The questionnaire was repeated for the 5-year-old survey in 1993-94 with the aim of finding out if there had been any changes: 2,794 parents were contacted in Salford and 2,343 in Trafford. The response rates were 75 per cent and 73 per cent. The percentage of children who were having their teeth brushed before they were aged one and who had visited a dentist by their second birthday rose in both districts. Campaigns at regional and district levels are thought to have influenced these improvements. The percentage of children who had experienced toothache and the proportion who had received a general anaesthetic for tooth extraction were similar in both years.

The views and expectations regarding dental care of the parents of children with special dental needs: a survey in the County of Cheshire, England.

A postal questionnaire of multiple-choice design was sent to 122 parents of children with special dental needs in the county of Cheshire, England, with the aim of determining parents' views and expectations of dental care. Replies were received from 85 (70%). Eighty respondents (94%) were in favour of preventive dental advice being given to their children and 83 (98%) felt that an explanation should be given of the risk to general health posed by dental disease or its treatment. A high proportion of parents felt that simple dietary and oral hygiene advice was necessary, that the benefits of fluoride supplementation should be explained and that free fluoride supplements should be issued. The 'family dentist' was most favoured as the source of advice, closely followed by a community dental officer. Likewise the dental surgery was the most popular location for receiving advice, and doctors' surgeries were the least favoured. Parental support for regular school dental screening examinations of all children was extremely high and parents thought that special-needs children should be examined more frequently.

An open-access dental practice.

The DoH funded a drop-in dental practice in inner-city Salford for 12 months. Its aim was to increase accessibility and availability of dental services to people not registered with a dentist. It operated on a no-appointment basis and priority was given to those in pain and/or on their initial visit.

Attendance patterns and dental health of parents and children.

Questionnaires were posted to the parents of 293 5-year-old children who had been dentally examined at school in Stretford, Manchester, UK. Replies were received from 195 addresses and consisted of 182 mothers and 149 fathers. The mothers who replied were divided into three groups; 99 who reported that they attended the dentist for regular check-ups, 38 who went for occasional check-ups and 45 who only went when having trouble. The mean numbers of decayed teeth of their children were 0.92, 1.50 and 2.00 respectively (p < 0.05) and the mean dmft scores were 1.36, 2.05 and 2.69 (p < 0.05). Fifty children whose mothers reported having 25 teeth or less had a mean of 2.12 decayed teeth compared with 1.06 for 125 children whose mothers had 26 teeth or more (p < 0.01). The mean dmft scores for the two groups were 2.68 and 1.59 respectively (p < 0.05). In contrast, dividing the children into groups based on reported attendance patterns and numbers of natural teeth of their fathers did not show any significant differences in decayed teeth or dmft scores. It is concluded that the dental attendance pattern and dental health of the mother, but not of the father, are important influences on the dental health of 5-year-old children.

A classification of residential neighbourhoods (ACORN) in relation to dental health and dental health behaviours.

Five-year-old children in two district health authorities in the North Western Region of England were examined during 1989-90. Questionnaires were issued to parents to determine whether dental health and related behaviours were associated with socio-economic status. Parents of 1858 children in Salford (response rate = 78 per cent) and 1691 in Trafford (response rate = 81 per cent) returned the questionnaires. Their replies were analysed by dividing the children into a hierarchy according to a classification of residential neighbourhood (ACORN). Significantly fewer in the highest of three Divisions in both districts had suffered from toothache and had undergone a general anaesthetic to have teeth extracted. They were also more likely to have had their teeth brushed with toothpaste by their first birthday and to have visited the dentist by their second. Because ACORN had detected these differences in dental health related behaviour it was possible to identify localities towards which dental health promotion activities can be directed.

Dental caries in 12-year-old children in Salford, UK: changes over 28 years.

A sample of 111 12-year-old children in Salford, UK was examined in 1988, and the findings compared with those of a survey carried out in 1960 of 12-year-old children in the same city. Between 1960 and 1988, the mean DMFT of the boys fell from 6.04 to 2.34 and that of the girls from 6.54 to 3.40. All types of teeth were affected by caries in 1960 but in 1988 none of the canines and mandibular lateral incisors were affected. In 1960 the permanent first molars contributed 57% of the boys' and 54% of the girls' total DMFT while in 1988 they contributed 87% of the boys' and 73% of the girls' DMFT. Jackson's Treatment Index showed that the dental services were making a greater impact in 1988; for the boys it rose from 29.5 to 63.2 and for the girls from 27.8 to 62.3.