Child Dental Health
3rd February 2016
Child Dental Health
Sir Paul Beresford (Mole Valley) (Con): I have a well-known interest to declare as a very part-time, or occasional, dentist. I am a member of a number of dental organisations that have applied considerable pressure on me to seek this debate.
On 27 May, the Minister will give the opening address and take questions at the British Dental Association’s annual conference in Manchester. There are 39,000 dentists and 63,000 dental care professionals in the United Kingdom, spread over the four nations, with the majority of them in England. They will wish to hear about the national health service and contracts, but as professionals their biggest concern will probably be child dental health. Perhaps the Minister’s reply could be secret practice for opening the meeting, bearing in mind that, I suspect, very few dentists will be watching us.
Dentists feel that their small branch of general health is seen as a “Cinderella” service and a sideline within the national health service. Increasingly, the biggest problem they face is child dental health in the form of caries. This disease is almost entirely preventable, but it is not being prevented. As the Minister is aware, the biggest single factor in dental caries is sugar. The raw statistics on child dental health are pitiful. Deciduous teeth, or baby teeth, are particularly susceptible to decay as they have thinner enamel compared with permanent dentition, and this obviously contributes to children having dental decay. Dental decay is the No. 1 reason for children aged five to nine being admitted to hospital in the United Kingdom.
Jim Shannon (Strangford) (DUP): In Northern Ireland, tooth decay among under-15s has fallen consistently since 2000, and specific education has been done by our health and education Departments to make that happen. The hon. Gentleman referred to those aged between five and 10 consuming sugar. Every child will eat their weight in sugar in a year. Does he agree that we need a tax on sugar, because if we address this at the early stages, we will go a long way towards addressing the problem of tooth decay?
Sir Paul Beresford: I wish it were that simple. I personally believe that that would not make one iota of difference after a few months. One need only stand in the supermarket watching the kids pushing the mothers for sweets and the mothers feeding them to realise that, as I say, it will not make one iota of difference unless it is prohibited, in which case we would have other difficulties that I will not go into.
As I have said, the No. 1 reason for children aged five to nine being admitted to hospital in the United Kingdom is dental decay. The NHS spent £30 million on hospital-based extractions for children aged 18 and under in the year 2012-13. That is 900 children a week, who are being admitted primarily for tooth extraction—often under a general anaesthetic, which carries a slight risk in itself.
I am sure that the Minister is aware of the results of the 2013 child dental health survey. For the sake of those who have not read the statistics and who may glance tomorrow at the debate, I will touch on some of the figures. For example, 31% of five-year-olds had obvious decay in their primary teeth. That figure was higher in more deprived areas, where 41% of those eligible for free school meals had decayed primary teeth, in comparison with 29% of other children of the same age. Of five-year-olds who were eligible for free school meals, 21% had severe or extensive tooth decay, compared with only 11% of those who were not eligible.
By the age of 15, 46% of our children have tooth decay. Of the 15 year-olds, 59% of those eligible for free school meals had decay, compared with 43% of other children of the same age; 45% reported that their daily life had been affected by problems with their teeth and their mouth in the previous three months; and 28% reported being embarrassed to smile or laugh because of the condition of their teeth. Those are 15-year-olds, who are suddenly taking notice of the world and hoping to be taken notice of themselves.
Mr Graham Allen (Nottingham North) (Lab): I thank the hon. Gentleman for kindly taking an intervention, as we discussed beforehand; I also obtained the Minister’s permission to intervene. The hon. Gentleman knows more than anyone else in the House about the matter, and he is widely respected for what he does. He knows that I am the chair of a charity in Nottingham North that has three public health ideas, one of which is that every three-year-old should have the free NHS dental check. I am attempting to work with local dentists to make that happen, but without success; believe me, I have tried. Will the hon. Gentleman facilitate for me a meeting with the British Dental Association to discuss the matter? If I may, I will use this opportunity to ask the Minister to see me, at his convenience, to discuss how we can get dentists to help three-year-olds, who are entitled to that check.
Sir Paul Beresford: I would be more than happy to do so, because that has to be one the key ways forward. Sadly, the problems are not new, and people are looking at them. One of the areas that I have discovered to be a considerable problem is the dental care of disabled children. I draw the Minister’s attention to a recent report entitled “Open wide”, published by an organisation called Contact a Family. In addition, I know from my local government days that dental care for children in care is exceedingly poor.
The situation is not new; it has gone on for decades. I am not sure whether it is getting worse, but it is certainly not getting any better. I first practised dentistry in this country on the NHS in east London. The state of our child patients’ dental health, compared with that which I left behind in New Zealand, was staggering. Every Thursday, I or the principal of the practice ran general anaesthetic sessions with an anaesthetist. Fortunately, it is forbidden to do so now. Those sessions were packed with patients, predominantly little children, who had to have all or most of their teeth out. It was appalling, but not as appalling as seeing those children in pain when they came in, having had sleepless nights as a result of dental decay.
I will touch on the issue of sweet things. I went to the local supermarket, where there were huge long racks of biscuits, cakes, sweets and sweet drinks. However, the racks of fruit, vegetables and meat were infinitely shorter. Most of the children I dealt with did not have toothbrushes, and most of the parents were unaware that their children had such damaged teeth because of their diet.
Prevention, with progressively increasing reductions to NHS costs, can be achieved. If one realises that the UK population eats about 700 grams of sugar a week—an average of 140 teaspoons of sugar a week—it is obvious that a reduction is a necessity. That intake is not spread evenly; it is higher in the north of the country and lower in the south-east. Teenagers, as we would expect, have the highest intake of all age groups, consuming some 50% more sugar, on average, than is recommended.
The Scottish Government have a recent programme called Childsmile, and more than 90,000 nursery school children currently take part in supervised tooth-brushing. The Scottish Government have also directed the distribution of fluoride toothpaste and toothbrushes in the first year of life at nursery and in the first year of primary school. They are having great success: they reckon that, because of the reduced dental care required, they have managed to save the health service £6 million between 2001 and 2009. Wales has a similar programme with similar benefits. In England, we do not have one.
If I may be so bold, I will suggest to the Minister some possible solutions. We need to invest in a national oral health programme, possibly like the one in Scotland. It should particularly target areas with problems of poor oral health. This should be done in nurseries and schools, with the backing of local authorities, which would need a small amount of funding from the Minister’s Department. It would not be too much of a burden on schools to run a check system to ensure that every child in a primary school has visited the dentist once a year. From what the hon. Member for Nottingham North (Mr Allen) said, dentists will obviously have to be persuaded, if not bullied or forced, into such a system.
Not just dental healthcare professionals, but all healthcare professionals, such as midwives, health visitors and pharmacists, should be given the opportunity and training to apply oral health education, including in relation to persuasion on fluoride. The tax on sugar has been mentioned, but I am sceptical about it. Other ways, such as education, will have to be used. Perhaps—just perhaps—we can persuade the producers of such products to tone down the sugar content.
Far and away the biggest—the proven and most successful—way of reducing tooth decay among children, and ultimately adults, is of course fluoride. Fluoride in toothpastes has made a remarkable change. However, that surface application is nowhere near as effective as the fluoridation of water supplies. With fluoridated water supplies, the fluoride builds up in teeth as they develop. As part of a health professional programme, use of oral fluoride for children should be promoted to parents and children until such time as the water supply in the area in which the children live is fluoridated.
We have very few fluoridated areas in England. The marked difference in the incidence of tooth decay in UK fluoridated areas, compared with those in almost identical neighbouring but non-fluoridated areas, is stark and obvious. In the United Kingdom, approximately 330,000 people have naturally occurring fluoride at the right level in their water supply. In addition, some 5.8 million people in different parts of the country are supplied with fluoridation. That is about 6 million out of a total population of about 64 million, which is about 10%. The percentage of fluoridated water supplies in the United States is 74%, in Canada 44% and in Australia 80%. I believe that the percentage in New Zealand is not far behind that of Australia.
I have just come back from the southern hemisphere, so perhaps I can use New Zealand as an example. Early in the last century, the New Zealand Government set up a programme to train dental nurses, or what in this country we call dental auxiliaries. They provided dental care and oral hygiene instruction for every child in primary school. Those services were provided in clinics within the grounds of the bigger schools. As hon. Members can imagine, every child in the country called such clinics “the murder house”. These young ladies turned around the dental health of the children of New Zealand. They were trained at three schools in the country, and they predominantly provided dental health care by restoring decayed teeth, whether permanent or deciduous. Since 1954, water supplies in New Zealand have increasingly been fluoridated, and I understand that the demand for treatment in schools for such children has diminished dramatically. There is now one school, not three, and the dental nurses spend about 50% of their time on oral education, not on drilling and filling teeth.
In England, the decision to fluoridate the water supply is, in essence, in the hands of elected councillors. However, I believe it is important that the Government, along with the dental profession, apply pressure on local authority wellbeing boards to implement fluoridation. These boards will need support, professional guidance and scientific advice. They will need to be aware that they will be harangued with misinformation and false scientific facts, and that scaremongering will abound.
I will conclude with an example from a debate in this House on fluoride and fluoridation under the last Labour Government. A Welsh MP claimed that fluoridated water induced brittle bone disease. In fact, research has proved that fluoride in the water supply infinitesimally increases the strength of bones. As I pointed out to the Welsh MP, the All Blacks had recently trampled through the fields of Wales and every one of them had almost certainly been brought up in a fluoridated area. The only broken bones were Welsh.
The extent of dental caries among children in England is sad and it is a disgrace. It has been a disgrace for decades. It is preventable and, if we prevent it, we can make considerable savings to our health service and save the pain and suffering of England’s children. Minister, it is in your hands.
The Minister for Community and Social Care (Alistair Burt): It is a great pleasure to respond to my hon. Friend the Member for Mole Valley (Sir Paul Beresford) and his excellent speech. The House has been fortunate to benefit from his professional knowledge on a number of occasions. As a new Minister coming into office some nine months ago, I had an early meeting with him, from which I benefited hugely and continue to benefit. I am grateful for the way in which he put his case and for the heads-up in respect of what I might do and the speech that I might make to the British Dental Association in due course. I am grateful that the usual suspects have been here to listen because of their interest in these matters, namely the hon. Members for Strangford (Jim Shannon) and for Nottingham North (Mr Allen). I thank my hon. Friend the Member for Battersea (Jane Ellison), who is the public health Minister, for being here, together with the Whip and the Parliamentary Private Secretary. I also saw the hon. Member for Dewsbury (Paula Sherriff), who has been to see me to talk about dental matters and who clearly cares very much about these issues.
I congratulate my hon. Friend the Member for Mole Valley on securing this very important debate about children’s dental health. Poor oral health in children and young people can affect their ability to sleep, eat, speak, play and socialise with other children. Other impacts include pain, infections, poor diet and impaired nutrition and growth. When children are not healthy, it affects their ability to learn, thrive and develop. To benefit fully from education, children need to enter school ready to learn and to be healthy, and they must be prepared emotionally, behaviourally and socially. Poor oral health may also result in children being absent from school to seek treatment or because they are in pain. Parents may also have to take time off work to take their children to the dentist. This is not simply a health issue; it impacts on children’s development and the economy.
It is a fact that the two main dental diseases, dental decay and gum disease, can be almost eliminated by the combination of good diet and correct tooth brushing, backed up by regular examination by a dentist. Despite that, as my hon. Friend has set out, their prevalence rates in England are still too high. Dental epidemiological surveys have been carried out for the past 30 years in England and give a helpful picture of the prevalence and trends in oral health. Public Health England is due to report on the most recent five-year-olds survey in the late spring.
There is a mixture of news, as the House might expect. The good news is that the data we have at present show that oral health in five-year-olds is better than it has ever been, with 72% of five-year-old children in England decay free. Between 2008 and 2012, the number of five-year-old children who showed signs of decay fell by approximately 10%. The mean number of decayed, missing or filled teeth was less than one, at 0.94. Indeed, the data suggest that, notwithstanding the All Blacks’ rugby success and their bone-crushing efforts on the field, oral health in children is currently better in England than in New Zealand. New Zealand’s data for children aged five in 2013 showed that the proportion who were disease free was 57.5% and that the mean number of decayed, missing or filled teeth was 1.88.
Jim Shannon: We have had a marked reduction in dental decay in children since the year 2000, as I said earlier in an intervention. With respect, Minister, I would say that we are doing some good work in Northern Ireland. The Under-Secretary of State for Health, the hon. Member for Battersea (Jane Ellison) knows that I always say, “Let’s exchange ideas and information.” We are doing good work in Northern Ireland and we want to tell Ministers about it.
Alistair Burt: This is possibly the fourth or fifth invitation that I have received from my hon. Friend to come to see different things in Northern Ireland, and he is right about every one. He finds in me a willing ear, and we will make a visit because there are several different things to see. Where devolved Administrations and the Department can learn from each other, that matters, and I will certainly take up my hon. Friend’s offer.
In older children there are challenges when comparing different countries, because of how the surveys are carried out. The available data still show that we have among the lowest rates of dental decay in Europe, but despite that solid progress we must do more. There is disparity of experience between the majority of children who suffer little or no tooth decay, and the minority who suffer decay that is sometimes considerable and can start in early life. In this House, we know the children who I am talking about—it is a depressingly familiar case. We can picture those children as we speak, as my hon. Friend the Member for Mole Valley described in the sometimes horrific parts of what he told the House. The fact that we know that such decay affects children in particular circumstances makes us weep.
Public Health England’s 2013 dental survey of three-year-olds found that of the children in England whose parents gave consent for their participation in the survey, 12% had already experienced dental decay. On average, those children had three teeth that were decayed, missing or filled. Their primary, or baby, teeth will only have just developed at that age, so it is highly distressing for the child, parents, and dental teams who need to treat them. Dental decay is the top cause of childhood admissions to hospitals in seven to nine-year-olds. In 2013-14, the total number of children admitted to hospital for extraction of decayed teeth in England was 63,196. Of those, 10,001 were nought to four-year-olds, and so would start school with missing teeth.
From April 2016, a new oral health indicator will be published in the NHS outcome framework based on the extraction of teeth in hospital in children aged 10 and under. That indicator will allow us to monitor the level of extractions, with the aim of reducing the number of children who need to be referred for extractions in the medium term. Extractions are a symptom of poor oral health, and the key is to tackle the cause of that. Today I commit that my officials will work with NHS England, Public Health England and local authorities to identify ways to reach those children most in need, and to ensure that they are able and encouraged to access high-quality preventive advice and treatment.
The good news is that the transfer of public health responsibilities to local authorities provides new opportunities for the improvement of children’s oral health. Local authorities are now statutorily obliged to provide or commission oral health promotion programmes to improve the health of the local population, to an extent that they consider appropriate in their areas. In order to support local authorities in exercising those responsibilities, Public Health England published “Local Authorities improving oral health: commissioning better oral health for children” in 2014. That document gives local authorities the latest evidence on what works to improve children’s oral health.
The commitment of the hon. Member for Nottingham North to early intervention and the improvement of children’s chances is noteworthy and well recognised in this House and beyond, and of course he can come to see me. I would be happy to discuss with him what he wants to promote in Nottingham, which sounds just the sort of initiative we need.
Public Health England is also addressing oral health in children as a priority as part of its “Best Start in Life” programme. That includes working with and learning from others, such as the “Childsmile” initiative in Scotland, to which my hon. Friend the Member for Mole Valley referred. It is important that health visitors—I know that the Public Health Minister takes a particular interest in their work—midwives, and the wider early years workforce have access to evidence-based oral health improvement training to enable them to support families to improve oral health.
Public Health England and the Royal College of Surgeons Faculty of Dental Practice are working with the Royal College of Paediatrics and Child Health to review the dental content of the red book—the personal child health record—to provide the most up-to-date evidence-based advice and support for parents and carers. The National Institute for Health and Care Excellence has also produced recent oral health guidance that makes recommendations on undertaking oral health needs assessments, developing a local strategy on oral health, and delivering community-based interventions and activities for all age groups, including children. Community initiatives to improve oral health include supervised fluoride tooth-brushing schemes, fluoride varnish schemes and water fluoridation.
I agree with my hon. Friend that water fluoridation is an effective way of reducing dental decay. However, as the House knows, the matter is not in my hands. Decisions on water fluoridation are best taken locally and local authorities now have responsibility for making proposals regarding any new fluoridation schemes. I am personally in favour. I think I am the only Member in the Chamber who remembers Ivan Lawrence and the spectacular debates we had on fluoridation in the 1980s. He made one of the longest speeches ever. Fluoridation was bitterly and hard-fought-for and I do not think there is any prospect of pushing the matter through the House at present. I am perfectly convinced by the science and that is my personal view, but this is a matter that must be taken on locally.
Diet is also key to improving children’s teeth and Public Health England published “Sugar reduction: the evidence for action” in October 2015. Studies indicate that higher consumption of sugar and sugar-containing foods and drinks is associated with a greater risk of dental caries in children—no surprise there. Evidence from the report showed that a number of levers could be successful, although I agree with my hon. Friend that it is unlikely that a single action alone would be effective in reducing sugar intake.
The evidence suggests that a broad, structured approach involving restrictions on price promotions and marketing, product reformulation, portion size reduction and price increases on unhealthy products, implemented in parallel, is likely to have the biggest impact. Positive changes to the food environment, such as the public sector procuring, providing and selling healthier foods, as well as information and education, are also needed to help to support people in making healthier choices.
teams on preventative care and interventions that could be delivered in dental practice and school settings. Regular fluoride varnish is now advised by Public Health England for all children at risk of tooth decay.
For instance, the evidence shows that twice yearly application of fluoride varnish to children’s teeth—more often for children at risk—can have a positive impact on reducing dental decay. In 2014-15, for children, courses of treatment that included a fluoride varnish increased by 24.6% on the previous year to 3.4 million. Fluoride varnishes now equate to 30.9% of all child treatments, compared with 25.2% last year. This is encouraging progress.
There are many measures that can and should be taken in order to reduce the prevalence of decay in children, but we recognise it is unlikely that we will be able to eradicate entirely the causes or the effects of poor oral health in children. This means that the continued provision of high quality NHS primary dental services will continue to be an important part of ensuring that every child in England enjoys as high a standard of oral health as possible. NHS England has a duty to commission services to improve the health of the population and reduce inequalities—this is surely an issue of inequality—and also a statutory duty to commission primary dental services to meet local need. NHS England is committed to improving commissioning of primary care dentistry within the overall vision of the “Five Year Forward View”.
Mr Allen: The Prime Minister announced an excellent initiative on life chances less than two weeks ago. The cornerstone of that was improving parenting skills. Will the Minister’s Department ensure that feeding into that process there is, within the parenting programmes, stuff around health in general, but dental health in particular?
Alistair Burt: Yes. [Interruption.] Immediate information passed to me by the Minister with responsibility for public health indicates that that is a very positive initiative and we are indeed taking it up.
Overall, children’s access to NHS dentistry remains consistently high, with the number of children seen in the 24 months to September 2015 by an NHS dentist standing at 8 million, or 69.6% of the population. There are localised areas where children have access difficulties, but the more common problem is that the parents and carers of the children most at risk do not seek care until the child has developed some disease—this again emphasises the importance of health visitors and others in the process.
To help focus on prevention, the Government are committed to reforming the current system of primary care dentistry to improve access and oral health further. In line with the welcome improvements in oral health over the last 50 years, we need an approach in primary care dentistry that can provide a focus on prevention, while also incentivising treatment where needed.
That is why, following the piloting of the preventative clinical pathway, we are now prototyping a whole possible new system remunerated through a blend of quality, capitation and activity payments. The aim is to allow dentists to focus on prevention and, where appropriate, treatment, and how effective that could be for the children we are talking about. The new approach will be tested until at least 2017. We need to do a proper evaluation and, if successful, numbers will increase with a possibility of a national roll-out for 2018-19.
I hope I have been able to demonstrate the seriousness with which the Government take this subject—a seriousness that I know is accepted by the whole House. It comes back to some fundamental issues of inequality in health that are, as I said, depressingly familiar and which we are all absolutely dedicated to removing. The concept of total clearance for a child—I suspect that none of us has had to contemplate that in our personal lives, but it affects some of our constituents—is something that brings us all up short. I am grateful to my hon. Friend the Member for Mole Valley for raising this subject for debate.