The Scottish Health Survey 2008

2 DENTAL HEALTH

Martine Miller

SUMMARY

• 88% of adults in 2008 had all or some of their own natural teeth (91% of men versus 86% of women). This is just below the 2010 target for 90% of adults to have some of their own teeth. Women are more likely than men to attend regular dental check-ups (and therefore to have treatment such as the fitting of dentures) which might explain why more women than men have no natural teeth.
• Fewer than 6% of men and women aged under 55 had no natural teeth, this then rose steadily with age to 43% of men and 57% of women aged 75 and over. The 2010 target for 65% of adults aged 55 to 74 to have some of their own teeth has already been exceeded: in 2008 81% of men and 75% of women (78% overall) had some natural teeth.
• 13% of men and 12% of women had experienced toothache, while 30% of men and 27% of women reported having bleeding gums within the last month. In most cases bleeding gums had happened only occasionally.
• 14% of men and 12% of women had experienced difficulty chewing or biting food often or occasionally in the past month.
• The age-standardised prevalence of toothache showed no clear pattern in relation to socio-economic group, equivalised income or area deprivation.
• Having no natural teeth was significantly associated with socio-demographic factors: for both men and women, the age-standardised prevalence of having no teeth was highest in the most deprived areas, among those in routine and semi-routine households and for those in the lowest income quintile. For example, 5% of men in the least deprived areas had no teeth compared with 13% in the most deprived areas. The equivalent figures for women were 8% and 20%.
• 35% of men and 31% of women thought that they would need dental treatment if they were to visit a dentist tomorrow. The differences between the age groups were significant with the proportions thinking they would need treatment being highest among those aged between 25 and 54. When people with no teeth were excluded from the analysis similar proportions across all age groups thought they would need treatment (39% of men and 35% of women).
• As might be expected, people who thought they needed treatment were more likely to report that they had experienced recent dental problems than those who didn't think it necessary.
• 61% of men who had recent toothache thought they needed treatment, as did 61% who reported chewing problems and 46% who had experienced bleeding gums. The corresponding figures for women were 69%, 58% and 41%, respectively.

2.1 INTRODUCTION

It is widely acknowledged that Scotland's oral health is poor in comparison with other European countries and that the many factors that lead to poor general health within Scotland's population, such as diet, poverty and tobacco use, contribute to this. ¹ Scotland's poor dental health is largely attributed to the high level of sugar in the nation's diet combined with less than adequate standards of oral care. ² There have not been any extensive studies of diet and dental health in adults. However, a study of sugar intake among children in Scotland in 2006 found that non-milk extrinsic sugar ³ intake was significantly higher among those who had been treated for decay than those who had not. ⁴

In an attempt to combat Scotland's poor oral health record and increase access to dental health services, the then Scottish Executive published An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland¹ in 2005. This laid out a series of national dental health and dental service targets. These aimed to achieve 60% of 5 year olds and 60% of 11 and 12 year olds having no sign of dental disease and 90% of all Scottish adults, and 65% of adults aged between 55 and 74 years, possessing some natural teeth by 2010. The targets also aimed to reverse declining trends in 5 year survival rates for men with oral cancer.

The Scottish Government has continued to ensure Scotland's dental health targets are met by implementing a variety of service improvement strategies. Since the last Scottish Health Survey was conducted in 2003 free dental check-ups for all adults have become available and numerous health promotion activities aimed at children have been rolled out. In 2007 the Scottish Government published Better Health, Better Care,⁵ its action plan for improving health and health care in Scotland. This confirmed plans for the opening of a new dental school in Aberdeen in autumn 2008 and initiatives to attract more dentists to work in Scotland. These plans build on the programmes established as a result of the 2005 Action Plan, such as bursaries for dentistry students who commit to five years of NHS practice after qualifying.

Young children within Scotland have higher levels of tooth decay than those in the rest of the UK and other European countries. In particular, children living within the most deprived areas of Scotland suffer from the highest levels of tooth decay. Evidence cited in the 2005 Action Plan suggests that by age 3, over 60% of children from deprived areas have dental disease, and by age 5 over 56% of all children within Scotland demonstrate dental disease. ¹ In light of this, strategies to improve dental health have been largely targeted at children. For example, the Childsmile national oral health improvement programme for children in Scotland seeks to provide every child with a dental pack containing a toothbrush, fluoride toothpaste and an information leaflet, on at least six occasions by the age of 5 years. Children also receive a free-flow feeder cup by the age of 1 year. Furthermore, every 3 and 4 year-old child attending nursery is eligible to be offered free, daily, supervised toothbrushing within nursery premises. Supervised toothbrushing is also available to primary 1 and 2 pupils of schools located within priority areas across Scotland.

In addition to child oral health improvement initiatives, the report of the 2008 Ministerial Task Force on Health Inequalities Equally Well recommended action be taken to improve the dental health of older people, prisoners and homeless people. ⁶

Scotland's oral health has certainly seen improvements over recent decades. The 2003 Scottish Health Survey found that 12% of men and 18% of women had no natural teeth. ⁷ In contrast, 44% of adults in 1972 had no natural teeth. ² However, Scotland's levels of tooth disease remain a major concern.

This chapter examines dental health in terms of the prevalence of natural teeth; problems with teeth such as pain, bleeding or difficulties chewing. It also explores people's perceptions of whether they currently need any dental treatment. As set out below, many of these questions are new for the 2008-11 Scottish Health Survey and represent a major enhancement to the information collected by the study about this important public health issue.

2.2 METHODS AND DEFINITIONS OF MEASUREMENT

The 1995, 1998 and 2003 Scottish Health Surveys included similar questions about the number of natural teeth people have, their brushing frequency, whether they use fluoride toothpaste and the frequency of their dental check-ups. In 2008 a wider set of questions were introduced to better meet the Scottish Government's information needs in relation to adult dental health. Two sets of questions were designed. The first, looking at dental health, will be asked in every year between 2008 and 2011. The second, about dentures and access to dental services, will be asked in 2009 and 2011. The dental health questions cover the following areas:

• Number of natural teeth
• Perceptions of teeth appearance
• Current experience of toothache or mouth pain
• Problems with biting or chewing food
• Bleeding gums
• Whether the respondent thinks any treatment is currently needed

2.3 DENTAL HEALTH

2.3.1 Prevalence of natural teeth and dental problems, by age and sex

Table 2.1 presents the proportions who had experienced toothache, gum bleeding after brushing or flossing, or difficulty chewing in the past month by age and sex; it also shows the proportions who have no natural teeth.

Natural teeth

As outlined above, the Scottish Executive's 2005 Action Plan set a target of 90% of adults to possess some natural teeth by 2010, and for 65% of those aged 55 to 74 to do so. ¹ In 2008, more men than women had some natural teeth (91% versus 86%). The figure for the whole adult population was 88% (data not shown), two percentage points below the 90% required for the 2010 target to be met. Among those aged 55 to 74, 81% of men and 75% of women (78% overall) had some natural teeth, meaning that the target (65%) for this particular group has already been met (data not shown). Fewer than 6% of men and women aged under 55 had no natural teeth, this then rose steadily with age to 43% of men and 57% of women aged 75 and over. The 2003 SHeS found that women are more likely than men to have regular dental check-ups. ⁷ It is possible that having more regular contact with dental care means that women might be more likely to receive treatment, such as the fitting of dentures or implants, which could account for them being less likely to have their own teeth than men. The fact that women live longer than men, and that people lose teeth as they age, might also explain some of the difference. Table 2.1

Toothache

Experience of toothache within the last month was relatively low among both men (13%) and women (12%), and across all age groups. Among men, those aged between 16 and 44 were the most likely to have experienced toothache within the last month (ranging between 16% and 19%), this then declined with age as the corresponding proportions with no teeth increased. For example, just 5% of men aged 75 and over complained of recent toothache. Similar patterns by age were seen among women; levels ranged between 14% and 19% among those aged between 16 and 54, and declined sharply after that to just 6% and 2% among women aged 65-74 and 75 and over, respectively. These declines in the experience of toothache as age increased correspond with the increase in the proportions with no teeth. Looking at the experience of toothache among only those with teeth, the overall proportions in the population were very similar (14% for both men and women). However, the proportions in the two older age groups (65-74 and 75 and over) were slightly higher (8% for men for both ages and 9% and 4% for women, respectively) (data not shown).

Bleeding Gums

Bleeding gums after brushing or flossing was more common than toothache; 30% of men and 27% of women reported that this had happened often or occasionally in the past month. It was more common for people to report this happening occasionally (25% of men and 23% of women) rather than often (5% and 4% respectively). The patterns by age were similar to those for toothache; bleeding was more common amongst men and women up to the age of 54 and declined thereafter as the proportion with no teeth increased.

Difficulty chewing

The proportions who reported difficulty chewing in the past month were similar to those for toothache, 14% of men and 12% of women had experienced this often or occasionally. As with bleeding gums, most said this was an occasional problem (11% of men, 9% of women) rather than something that happened often (3% of men and women). Difficulty chewing was similar for men across all age groups, indeed the figures for the youngest and oldest age groups were almost identical (13% and 12%). The pattern was slightly different for women as those aged 75 and over were less likely to report this than other age groups (8% compared with between 12% and 14% for those aged under 55). Table 2.1

2.3.2 Toothache and prevalence of natural teeth by socio-demographic characteristics

Tables 2.2 to 2.4 present the proportions who had experienced toothache in the past month by socio-economic classification ( NS-SEC of the household reference person), equivalised household income and the Scottish Index of Multiple Deprivation (descriptions of each of these measures are available in the Glossary at the end of this volume). The proportions with no teeth are also presented. To ensure that the comparisons presented in this section are not confounded by the different age profiles of the sub-groups, the data have been age-standardised (a description of age-standardisation is available in the Glossary). On the whole the differences between observed and age-standardised percentages are small. Therefore, the percentages presented in the text below are standardised. The tables report both the observed and the age-standardised figures.

Socio-economic classification ( NS-SEC)

Table 2.2 presents the prevalence of toothache within the last month by NS-SEC of the household reference person. The age-standardised prevalence of toothache within the last month was fairly uniform across each household type with no significant differences between them. However, the proportion with no natural teeth differed significantly according to NS-SEC. 6% of men in managerial and professional households had no natural teeth compared with 13% of men in semi-routine and routine households. The corresponding figures for women showed an even larger difference, 7% and 20%, respectively. Table 2.2

Equivalised household income quintile

The age-standardised prevalence of toothache within the last month by equivalised household income quintile is detailed in Table 2.3. Although there was a significant association between income group and prevalence of toothache, the patterns were not consistent. Men in the 4 ^th lowest income quintile were the most likely to have experienced toothache (20% compared with between 11% and 15% in the remaining four), with the highest and lowest income groups showing very similar figures (14% and 15% respectively). Among women, those in the highest income quintile stood out as least likely to have experienced toothache (9%), the figures for the remaining quintiles ranged from 11% to 14% with no obvious pattern. As with NS-SEC, the pattern is much clearer in relation to those with no teeth. For both sexes the proportion with no teeth increased as income decreased, with the difference between the highest and lowest quintiles being greater for women (6% and 20%, respectively) than for men (5% and 14% respectively). Table 2.3

Scottish Index of Multiple Deprivation

Two measures of SIMD are being used throughout this report. The first, which uses quintiles, enables comparisons to be drawn between the most and least deprived 20% of areas, and the intermediate three quintiles, and helps to assess the extent of any inequalities in behaviours or outcomes. The second contrasts the most deprived 15% of areas with the rest of Scotland (described in the tables as the "85% least deprived areas"). The most deprived 15% of areas have been identified as of particular concern by Scottish Government and are the subject of a number of policy initiatives. The Scottish Health Survey is designed to provide a large enough sample in the SIMD 15% areas after four years to enable robust detailed analysis at this level.

There was no clear pattern between the age-standardised prevalence of toothache among men and women across deprivation quintiles and the differences were not statistically significant. As with the two other socio-demographic measures, having no natural teeth was significantly associated with deprivation with the proportions highest in the most deprived areas. The scale of the difference between the most and least deprived areas was largely similar for men and women (5% versus 13% among men, 8% and 20% among women, respectively). These patterns are also evident when the 15% most deprived areas are compared with the rest of Scotland, though the nature of the gradient seen across the quintiles is less apparent when the comparison is restricted to these two groups. 15% of men and 20% of women in the 15% most deprived areas have no natural teeth compared with 8% and 13%, respectively, in the rest of Scotland. Table 2.4

2.4 DENTAL TREATMENT

2.4.1 Perceived need for dental treatment by age and sex

This final section turns its focus away from reported dental problems and looks at people's perceptions of whether they would require any treatment if they were to visit a dentist. Table 2.5 shows that 35% of men and 31% of women felt that dental treatment would be required if they were to visit a dentist. The differences between the age groups were significant with the proportions thinking they would need treatment being highest among those aged between 25 and 54 (around 4 in 10 men and a little below this rate among women). The equivalent proportions were lower among those aged 16-24 (29% for men, 33% for women), and much lower again in the oldest age group (22% of men and 15% of women aged 75 and over). As with the figures presented above, the decrease in the belief that dental treatment would be required corresponded with the increase in having no natural teeth. Based only on those with teeth, 39% of men and 35% of women thought they would need treatment. The figures for those with teeth in the younger age groups were similar to those in the whole population (as very few younger people have no teeth). However, once those with no teeth are excluded the proportions thinking they need treatment among the older groups are higher at 39% for men and 34% for women aged 75 and over; these figures are broadly similar to all other age groups. (Data not shown). Table 2.5

2.4.2 Perceived need for dental treatment and self-assessed dental health

Tables 2.6 and 2.7 bring together the data on the perceived likelihood of requiring dental treatment with the assessments of dental health presented above in relation to toothache, gum bleeding and chewing difficulties. Table 2.6 presents the proportions who said they thought they needed treatment by their recent experience of dental problems. As might be expected, people who thought they needed treatment were more likely to report that they had experienced dental problems than those who didn't think it necessary. 23% of men and 28% of women who thought they needed dental treatment had experienced toothache in the past month. The corresponding figures among those who thought they did not need dental treatment were lower, at 9% and 7% respectively. The differences in relation to bleeding gums were smaller; 38% of men and 37% of women needing treatment had experienced this compared with 28% (for both men and women) of those not needing treatment. The pattern for those experiencing difficulty chewing was similar to that for toothache; 24% of men and 22% of women needing treatment experienced this compared with 9% of men and women not needing it. Table 2.6

Table 2.7 looks at this from another perspective and reports the proportions of those with recent dental problems who also thought they needed dental treatment. In this table those experiencing bleeding gums or difficultly chewing often or occasionally have been combined. 61% of men who had recent toothache thought they needed treatment, as did 61% who reported chewing problems and 46% who had experienced bleeding gums. The corresponding figures for women were 69%, 58% and 41%, respectively. Table 2.7