Written evidence submitted by Teeth Team Limited Charity (COH0001)

 

 

The

Teeth Team

Programme

 

A collaborative working partnership on a school based supervised tooth brushing programme, incorporating clinical dental assessments, applications of fluoride varnish and signposting for accessing primary and secondary dental care.

 

Teeth Team Limited

Progress Update

 

Executive Summary

 

  1. Teeth Team is a local child dental health improvement programme.In 2010, three local dental practices and a dental supplies company were concerned about the high incidence of dental decay (caries) in local children and decided to join forces to create a partnership.

 

  1. Additional partners have come on board and now consist of:

 

 

  1. Together, the partners support over 12,000 local children at primary and nursery schools in East Yorkshire. The aim is to reduce the inequalities in child oral health. When you look at the determinants of oral health inequalities, Teeth Team addresses many of the issues and targets of those in greatest need, i.e. the most deprived wards where you will find the highest proportion of disparities in health.

 

  1. A recent survey by PHE indicated 27.9% of 5-year-olds in England have tooth decay, Department of Health (2012). It also revealed:

 

•                     Children with decay have on average between 3 and 4 teeth affected by decay, treated or untreated.

•         24.5% of children have untreated decay.

•         1.7% of children have infection in their mouths.

 

  1. This national survey concluded 43.4% of five-year-olds in Hull have tooth decay, compared with the national average of 27.9%, there clearly is a local problem. The survey also revealed 39.2% in Hull and 20.1% for the East Riding suffered from untreated decay. Figures for the Yorkshire and Humber region show 29.3% were not undergoing treatment to tackle the decay.

 

  1. Encouraging parents to access dental treatment for their children should be a priority, as should raising the awareness of the importance of regular toothbrushing with a fluoride toothpaste and dietary advice.

 

  1. From October 2012 to December 2013, 693 children experienced a General Anaesthetic (GA) for dental extractions in the area, with the highest cohort (131 children) being five years old.

 

  1. Unfortunately, 21 children from the youngest cohort were only two years old.

 

  1. Increasing the number of nurseries in the programme, will ensure good oral health care starts early, reducing the prevalence of GA experience in infants and young children.

 

  1. Treatment of dental caries in children, particularly at the younger cohort, often results in GA for multiple extractions. This is an expensive treatment, (estimate of £719 per secondary care episode) NICE (2010), with high levels of emotional and physical distress and is not without risk.

 

  1. Based on NICE (2010) guidelines, that a GA session costs £719, we can assume the expense of providing these sessions locally would exceed the annual running costs of the programme.

 

  1. Even in the older cohort, management in primary care can be difficult, especially for those who may present late in the caries process. They may require extraction with local anaesthetic or sedation, or even GA where anxiety or treatment complexity indicates. Within this population group, a strategy for prevention is paramount to reduce the caries risk and the inequalities in oral health.

 

  1. The aim of Teeth Team is to reduce the inequalities in child oral health. This is addressed by facilitating a supervised toothbrushing programme, annual dental assessments at school and applications of fluoride varnish. Children are offered treatment at the dental practices that support the schools in the programme.

 

  1. Unfortunately for many children taking part in the programme, the only time they do brush their teeth is when they are at school.

 

  1. 5,110 children received a dental assessment which were carried out in the time period from October 2013-January 2014.

 

  1. Our records indicate an increase in the number of children now accessing dental care as a direct result of the programme. 470 children who required dental treatment previously have not accessed dental treatment which is cause for concern.

 

  1. Fluoride varnish applications are included in the dental assessment process and those children whose parents have consented, will have topical fluoride applied to their teeth, if appropriate.

 

  1. Fluoride varnish has been clinically proven to reduce the incidence of tooth decay in children by up to 50%. Children who do not receive routine primary dental care will at least benefit from the preventive action of the topical fluoride.

 

  1. The Department of Health (2009) also recommends the application of fluoride varnish bi-annually, and up to four times a year for those children giving concern in their “Delivering Better Oral Health Toolkit”.

 

  1. Numerous studies have evaluated the effect of fluoride varnish in preventing caries in children, including 46% reduction in caries, (Watt 2005), Peyron et al (1992), Seppa (2004), (Clark et al, Malmo study, Zimmer et al and Autio-Gold et al).

 

  1. Limited or inconsistent evidence is available regarding monetary benefits of fluoride varnish preventive programmes. Niessen (1984), Klock (1980), Davies and Horowitz & Heifetz, Kallista et al (2003), Lindhe (1973). (Weintraub, 2003).

 

  1. The Child Smile in Scotland released data to show the cost effectiveness of their programme which is not dissimilar to Teeth Team. Macpherson, L.M., et al (2013).

 

  1. Accurate records of clinical data collated at each of the dental assessments have been maintained. This data details the level of treatment need, be it primary or secondary care, dmft levels and the numbers of children who have accessed dental care. 

 

  1. Our findings support Weintraub’s theory. The cost effectiveness of fluoride varnish applications within a prevention programme, compared to the cost of providing dental treatment is undoubtedly more favourable.

 

  1. There has been significant cost saving when comparing the original level of treatment need in these children in relation to primary dental care and the present level of treatment need.

 

  1. In 2012 the programme was awarded the Patron’s Prize for Innovation from the National Oral Health Promotion Group.

 

  1. In 2013, Dr. Nigel Carter, OBE BDS LDS (RCS), Chief Executive of the British Dental Health Foundation, fully endorsed the programme.

 

  1. Our local MP’s have all pledged their support to enable more children to participate.

 

  1. The programme was awarded the national prize for the “Best Child Dental Health Initiative” at the Dental Hygiene and Therapy Awards in January 2014.

 

  1. The partners in the programme have formed a limited company which is registered at Companies House and HMRC as a charity.

 

Supervised Tooth Brushing Programme with Clinical Dental Assessments & Applications of Fluoride Varnish

 

  1. The annual dental assessments prove very popular with over 5,545 parents giving consent for their children to be included. Parents whose children require dental treatment were notified and information is given on where to access local dental treatment. This element of the programme encourages children and their parents to bring about a positive attitude to oral health, the subsequent establishment of good oral hygiene habits and regular dental attendance.

 

Background Information

 

  1. From October 2012 to December 2013, 693 children between the ages of two and 16 years, experienced a GA for dental extractions in the East Yorkshire, with the highest cohort (131 children) being five years old.

 

  1. 48% (335) of children who experienced a GA within this period were between the ages of five and seven years old.

 

  1. On average, 46 children attend the Day Care Unit at Hull Royal Infirmary for dental extractions each month.

 

  1. The highest proportion of children who experienced a GA reside within some of the most socially deprived electoral wards in Hull.

 

  1. It is well documented that the main cause of dental caries is sugar in the diet.  Fluoride is the only factor that has been shown beyond doubt to decrease susceptibility to decay and that the single most important oral hygiene measure is toothbrushing (Scottish Health Education Group1986).

 

  1. Previous studies involving teacher supervised toothbrushing programmes, aimed at primary school children, have shown a significant reduction in dental caries especially among caries-susceptible children (Jackson RJ and Newman HN et al 2005).

 

  1. The Rt. Hon. Alan Johnson endorsed the programme. He said: “This is a superb, marvelous programme. Fluoride is key for children and their teeth, so this programme added with water fluoridation will give poor kids rich kids’ teeth.”

 

  1. The application of Fluoride Varnish was piloted in November 2012 and has gradually been introduced into further schools since.

 

  1. Highlighting the benefits of having fluoride varnish applied to children’s teeth is paramount to obtaining maximum consent rates from parents.

 

  1. In total 69% (2666) parents consented to the fluoride varnish applications. 1,900 children subsequently received an application of fluoride varnish at the time of the dental assessments.

 

Objectives

 

 

Methodology

 

  1. An initial sample group was made up of 12 schools. As the programme progressed, additional schools have joined the programme, some of which have been included in the pilot study.

 

  1. The clinical data from the additional schools has been collated and are recorded separately from the 12 original schools.

 

Data Collection

 

  1. Dental assessments were carried out by a Dental Practitioner and the clinical data detailing the dmft was recorded by a Dental Nurse on a database.

 

  1. The children were then asked to complete a short questionnaire.The purpose of the questionnaire was to determine both the toothbrushing habits of the child and their views regarding the programme.

 

  1. Children, for whom parental consent had been obtained for the application of fluoride varnish, had Duraphat VarnishTM applied by a dental nurse, if the examining dentist considered it to be clinically necessary and if there were no contra-indications. Verbal and written post-operative instructions were given to the child to take home.

 

  1. Parents of children who required dental treatment received a letter encouraging them to access dental care for their child. Contact details were included of where treatment could be accessed locally for their child if they did not already have a family dentist.

 

Target Population and Sample Size

 

  1. The target population was identified as 5,545 primary school children from Foundation Stage (aged 4) up to Year 6 children (aged 11) attending 24 primary schools in Hull.

 

  1. 5,110 children composed 92.2% of the sample size. The difference in the target population and the sample size is due to some children being absent from school.

 

Results

 

Children’s Questionnaire Data

 

  1. 4,201 children’s questionnaires were completed. The children were asked if they liked brushing their teeth at school, 4,070 answered “Yes” and also if they brushed their teeth at home. 2,518 answered “Yes”, 1,637 “Sometimes” and 176 “No”. Of the children who answered “sometimes” this was usually less than three times a week.

 

  1. The final question was asked to determine how many children had visited the dentist since they were last seen at school. 3,408 said “Yes”, 709 said “No.”

 

Clinical Data

 

  1. In total 5,110 children received a dental assessment. A record of all decayed, missing, filled and sound teeth was collated for each child.

 

Data collated from the original sample group of 12 schools

 

  1. 1,315 of these children were from of the original sample group.

 

  1. The assessments concluded 280 (69%) of these children were identified as requiring treatment previously and had still not received dental treatment.

 

  1. The mean dmft has been recorded for the original schools for each of the dental assessments carried out between March 2012 and January 2014.

 

  1. Below is a table detailing the mean dmft from each of the schools for the first and last dental assessments from the 12 original schools.

 

 

School

Mean dmft March

2012

Mean dmft January 2014

Bude Park

1.72

2.24

Francis Askew

2.81

2.11

Greenway Academy

2.36

2.82

Griffin

1.14

1.31

Highlands

2.34

1.68

Longhill

2.00

1.43

Maybury

1.85

2.07

St. Georges

1.81

1.66

St. Mary Queen of Martyrs

1.34

1.17

Stockwell

1.99

1.89

Thanet

1.89

N/A

Thoresby

1.35

1.18

 

  1. In March 2012, 485 children from this group required primary dental care in the way of restorations and prevention treatment. Under the current dental contract, each episode of care would attract three units of dental activity (UDA).

 

  1. Taking into consideration the average UDA value in the UK is £24.00, we can assume the cost of providing treatment for these children will be approximately £34,920. 3 x UDA= £72.00 - £72.00 x 485= £34,920.

 

  1. In January 2014, 338 children from this group required primary dental care. We can again assume the cost of providing treatment for these children will be approximately £24,336. 3 x UDA= £72.00 - £72.00 x 338= £24,336. This means there has been a cost saving on primary dental care of £10,584.

 

  1. We must also consider the cost of applying fluoride varnish at the dental assessments. 62 tubes of Duraphat TM were used therefore, we can conclude the applications of fluoride varnish will cost approximately £523.90 per annum. 62 x £8.45 = £523.90.

 

  1. Unfortunately, the number of children requiring secondary dental care has increased. In March 2012, five children required extractions under GA, but in January 2014, that figure has risen to 59. We can clearly identify why this figure has increased.

 

  1. 280 children previously requiring dental treatment had not accessed dental care. Many of these originally small lesions have, over time, increased in size and are now further down the line in the decay process and require extraction.The potential cost implications for this treatment is significant, in comparison to providing primary care at the appropriate time.

 

  1. Based on NICE guidelines (2010), where the suggested fee for undertaking dental extractions under GA is £719, we can assume the cost of providing secondary care for the original five children would be £3,595. 5 x £719.00 = £3,595.

 

  1. However, the cost of providing secondary care to the 59 children who now require a GA will be £42,421. 59 x £719.00 = £42,421.

 

  1. Taking into consideration the data collated for GA in Hull, we can identify where the highest area of need exists. 693 children experienced a GA for dental extractions between October 2012 and December 2013.

 

  1. We can also identify the ages of the children who have experienced a GA in this time period.

 

  1. We have to acknowledge there is an issue of child dental neglect locally which is predominantly present in areas of severe social deprivation where you will find the most vulnerable children.

 

  1. The introduction of fluoride varnish applications has seen an increase in the number of children assessed at each school.

 

  1. Schools have worked extremely hard to increase the level of parental consent for both the dental assessments and applications of fluoride varnish.

 

  1. Policies are now in place to ensure all children new to a school are signed up to the programme.

 

  1. At the dental assessments carried out in July 2013, 4,131 children were examined. That figure has now risen to 5,110. An additional 979 children are now benefitting from the dental assessments.

 

  1. From the most recent assessments carried out at all of the schools from October 2013-January 2014, evidence suggests 470 children who required treatment six months ago had not accessed treatment.

 

  1. However, it was also evident some children had accessed treatment, but had not completed treatment.

 

  1. 3,408 children stated they had seen a dentist since the last assessment, with 709 children indicating they had not. This information suggests some are accessing care, but many are not.

 

Current position

 

  1. Since the introduction of fluoride varnish, the number of children now included in the study has increased from 2,113 to 5,545.

 

  1. Fluoride varnish applications have enabled more children to benefit from the programme, not only from the preventive action of the fluoride itself, but also the opportunity to identify more children who are at risk.

 

  1. There has been a slight increase in the overall percentage of treatment need from 23% in July 2013 to 25% in January 2014. Given the increase of new children to the study, this is not a cause for concern.

 

Recommendations

 

  1. The results have enabled us to make the following recommendations:-

 

 

Conclusion

 

  1. By continuing to work closely with schools we have further succeeded in breaking down some of the barriers to accessing routine dental care and in the process improving oral health.

 

  1. The reduction in the mean dmft of the original pilot schools confirms the effectiveness of the programme and the potential cost saving.

 

  1. The increased requirement for secondary dental care is a cause for concern, not only the cost implications, but also the psychological effects on the children in question.

 

  1. The provision of mobile dental units would ensure that those vulnerable children who have not accessed dental care and who are at risk of dental neglect will receive the primary dental care they obviously need.

 

  1. The applications of fluoride varnish enhance the programme making it one which provides prevention, early intervention and equal access.

 

  1. Teeth Team aims to follow some of Marmot's principles - giving every child a healthy start. By working closely with parents, providers of education and wrap around care providers we can help the most vulnerable children in our society.

 

  1. The trustees of Teeth Team Limited are very proud of our achievements which include:

 

 

  1. Only by continuing along this path with our evidence based programme will we see the inequalities in oral health amongst the children of Hull and East Yorkshire reduce.

 

 

References

 

Department of Health(2012) http://www.nwph.net/dentalhealth/Oral%20Health%205yr%20old%20children%202012%20final%20report%20gateway%20approved.pdf

 

Department of Health (2009)

http://www.oralhealthplatform.eu/sites/default/files/field/document/NHS_Delivering%20Better%20Oral%20health.pdf

 

Holm, AK., (1979). ‘Effect of a fluoride varnish [Duraphat®) in preschool children’, Community Dentistry and Oral Epidemiology, vol. 7, pp 241-245.

 

Kallestal et al (2003) ‘ Economic evaluation of dental caries prevention : a systematic review’, Acta Odonto Scandinavia, Vol 61, pp 341-345.

 

Klock, B. (1980) ‘Economic aspects of a caries preventive program’, Community Dentistry and Oral Epidemiology, Vol 8, pp 97-102.

 

Lindhe, J., and Axelsson, P., (1973).   ‘The effect of controlled oral hygiene and topical fluoride application on caries and gingivitis in Swedish schoolchildren,’ Commnuity Dentistry and Oral Epidemiology, vol. 1, pp 9-16.

 

Macpherson, L.M., et al., National supervised toothbrushing program and dental decay in Scotland. J Dent Res, 2013. 92(2): p. 109-13.

 

Marmot, M. (2008) Closing the gap in a generation: health equity through

action on the social determinants of health, Lancet 2008; 372: 1661–69

 

NICE Costing Report: Sedation in children and young people: costing report, p17 www.nice.org.uk/nicemedia/live/13296/52185/52185.pdf‎

 

Niessen, L.C. and Douglass, C.W. (1984) ‘Theoretical Considerations in Applying Benefit -Cost and Cost -Effectiveness Analyses to Preventive Dental Programs’, Journal of Public Health Dentistry, Vol 44, No 4, pp 156-167.

 

Petersen et al. The global burden of oral diseases and risks to oral health. Bulletin of the World Health Organization September 2005; 8(9): 661-68

 

Peyron, M., Matsson, L., Birkhed, D., (1992). ‘Progression of approximal caries in primary molars and the effect in vitro’, Scandinavian journal of Dental Research’ vol.96, pp 523-535.

 

Seppa, L., (2004). ’Fluoride Varnishes in Caries Prevention’, Medical Principles and Practice, vol.13, pp 307-311.

 

Simons, D., Pearson, N., Evans, P (2013) ‘A pilot of a school-based dental treatment programme for vulnerable children with possible dental neglect: the Back2School programme’,  British Dental Journal 2013; 215: E15 pages 1-6. Available online: http://www.nature.com/bdj/journal/v215/n8/pdf/sj.bdj.2013.998.pdf

 

Steele, J (2013) NHS dental contract pilots –“Learning after first two years of piloting-The second report from the dental contract pilots evidence and learning reference group”

 

Watt, R.G. (2005) ‘Strategies and approaches in oral disease prevention and health promotion’, Bulletin of World Health Organization, Vol 83, No 9, pp 711-716.

 

Weintraub, J.A., (2003). ‘Fluoride varnish for caries prevention: comparisons with other preventive agents and recommendations for a community-based protocol’, Special Care Dentistry, vol. 23, issue 5, pp 180-186.

 

 

5 February 2015

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