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Caries Prevention in School Children
For school children, prevention of the disease would benefit those affected and those
at risk as its likely for the negative effects of caries to be experience later in 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. 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 the most common chronic
diseases of children across the world (Guido et al, 2011). 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 e.g. observed for amalgam fillings to be ~1,024-
2,224 per year for 1000 children (6-18) taking into consideration the 7% failure rate
of amalgam (Yee & Sheiman 2002). In addition, for those experiencing extensive
anxiety, general anaesthetic may be used which adds a further cost and has an
increased risk of safety attached.
In a study carried out by Public Health England using d
3
mft
1
, 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% (Davies G et al, 2013a). This translates into a higher
caries rate in twelve-year olds with 33.4% and the North-West 39.8%. (Davies G et
al, 2013b)
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.

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visual-only examination for missing teeth (mt), filled teeth (ft) and teeth with obvious dentinal decay
(d
3
t) - a quantitative measure of caries and a subset of DMFT (DMFT = permanent dentition, dmft =
primary). (Davies et al, 2013)
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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 IMD
2
(Department for Communities and Local Government,
2010) to compare the health of those with different socioeconomic statuses. In a
comparison between IMD and d
3
fmt, a positive correlation was observed (figure 1.)
(Davies G et al 2013).


Manchester as an average of its LSAOs
3
comes out at 3
rd
in the national ranking for
most depraved with over 33,000 of its residents living in the 1% most deprived LSOA
in the country (Department for Communities and Local Government, 2010). 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 (figure 2); coupled with the proportion receiving FSM (figure 3) mean that the

2
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
3
Lower-Level Super Output Area: theoretical areas of population 1000-3000 designed to improve the
reporting of a small area statistics (Office for National Statistics, 2011)
Figure 3:
(Davies G et al 2013)
Figure 1: Correlation between number of dentinally decayed, missing (due to decay) and filled
teeth (d3mft) among five-year-old children and Index of Multiple Deprivation (IMD 2010)
score. Lower-tier local authorities in England, 2012.
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school contains a higher than average number of deprived pupils
4
- therefore making
it a relevant case study to base our findings on.

Figure 2 (Office for National Statistics, 2011)







Higher than average school absences, JSA claimants and crime 336 crimes in
October 2013 within a 1 mile radius of M11 4PR (Crime-Statistics, 2013) 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

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Those eligible for free school meals and those living in areas of higher deprivation; generally
considered for FSM > 40% to be deprived (ESARD, 2011)

36
1.5
10.7
31
1 6.8
28
1 4.2
0
5
10
15
20
25
30
35
40
JSA claimers (16-24) Unauthorised school
absences
Individuals who claim
that they have bad
health or worse
P
r
o
p
o
r
t
i
o
n

o
f

P
o
p
u
l
a
t
i
o
n

(
%
)

Markers of deprivation
Markers of deprivation locally, regionally and nationally
proportional to respective populations
Manchester 012B
North West
England
National Average (%) Seymour Road Junior
School (%)
% of pupils taking FSM
(free school meals)

14.0%

54.1%
% of pupils known to be
eligible for FSM

18.0%

60.4%
Figure 3. (Anon., 2008)
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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. The
reasons behind the consequences are likely to be a lack of knowledge/appreciation
and the purchase of dental equipment seeming unnecessary. 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).
The barriers are not individually causal. For example, persons receiving JSA are
entitled to free care, so other reasons such as anxiety and lack of knowledge may
hinder care being sought - 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).
Preventative schemes would therefore be important to improve the overall oral
health of communities across the country as they would help remove some of the
barriers that have been built up through various socioeconomic and environmental
factors. We can group schemes based on the proportion of the population that will
benefit, for the purposes of this essay well focus on population, community and
individual levels. We shall conclude with a discussion of efficacy and likelihood of
implementation. The effectiveness will be based on: changes in caries figures and
cost of the schemes - including health/ethical concerns.

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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.
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 and is paid for by Strategic health authority revised now to Local
authorities in an effort to achieve better public consultation (Department for
Environment, Food and Rural affairs 2003; Department of Health 2012 cited by
Department of Health 2013). 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 (Mitchell, 2009)).
In a systematic review, the median difference at 1ppm in dmft/DMFT was observed
at 2.25 less carious teeth, a significant result. However, at 1ppm a significant
increased prevalence of aesthetically concerning fluorosis was observed estimated
12.5%. 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 (McDonagh M, et al 2000).

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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 (M. Rao, et al. 2013). Diet follows the common risk-factor
approach to oral health with factors such as obesity possibly leading to caries
(Sheiham A and Watts RG 2000). 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 (Yeung et al, 2010). 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 dentist. The
specific benefits of professionals giving seminars are that the knowledge acquired by
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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, 5 lowest).
We will focus on the 3-6 and 7-18 age groups and also factor in those with a higher
risk of developing caries
5
(Department of Health 2009).
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) (Marinho et al
2003). 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 (J. J Murray 2003 cited by Mitchell, 2009). 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, the
concentrations in saliva 12 hours later were similar to those 1-4 hours after brushing

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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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in the day (Duckworth RM et al 2001 cited by Davies R. M. et al 2003). 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); a systematic review found significant
reductions in dmfs/DMFS (37%/43%) with little significant homogeneity (Marinho et
al 2007). Fluoride varnish can be delivered by the hygienist or trained nurses in
addition to a dentist. Dietary advice can also be given by other trained members of
the dental team and provides a cost-effective method in possibly preventing caries.
Evidence of efficacy is not substantial (grade 3), but the action of fluoride to increase
resistance to caries in other preventative schemes does not offset the primary cause:
dietary sugars, meaning limiting sugar intake is still important for prevention
(Moynihan P. et al 2001). The aim of dietary advice is to decrease time for which
teeth are at risk of demineralisation and increase the potential remineralisation
periods; teeth go through demineralisation upon consumption of any food type but
the effects of erosion are worse from high sugar or acidic food/drink.
For high risk groups of ages 7-18, several other professional methods have been
suggested, including: (a) daily fluoride mouthwash (0.05% NaF) at a different time to
brushing (b) fissure sealant for permanent molars (c) 2,800ppm F
-
toothpaste 10+
year olds with active caries. Evidence provided was of grade 1 quality.
(a) Significant reduction in caries observed with a 26% reduction in DMFS
6
in
children and little heterogeneity in results; the author concludes that the use is
recommended but under supervision (Marinho et al 2009).
(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

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Decayed, Missing, and Filled permanent tooth Surfaces a variation of DMFT
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evidence for benefits in other conditions are inconclusive (Ahovuo-Saloranta A et al
2007).
(c) Significant reduction of caries in the 2,800ppm group 0.83 fall in mean DMFS
compared to 1100ppm users over two years (Stookey GK et al 2004).
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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Cochrane Database of Systematic Reviews 11