Towards Better Oral Health in Children
Additional Measures We Might Take
A lot is going on to help improve our children's oral health. But the pace needs to be accelerated. The unpalatable fact is that virtually no progress or sustained improvement in our youngest children's oral health has been achieved since 1991 when a target was first set. Radical steps are needed now if present and future generations of Scottish children are to avoid the legacy of poor teeth.
What more can be done? Certainly we need to maintain and build on current activity, through health education, toothbrushing schemes, dietary initiatives and preventive treatment services. No single approach will, on its own, deliver improvement to our oral health on the scale needed. Dietary change, in particular, is one of the key cornerstones on which we must build, but our deeply entrenched dietary habits will not be changed overnight, and it may need a whole generation of children to pass through current health promoting programmes. This will equip them, and parents themselves, to help and guide their own children to better health and oral health.
Urgent, effective concerted action now is required. A number of options follow which need not be mutually exclusive. Indeed, a cluster of approaches is required, if we are to realise, in the short and longer terms, lasting oral health gains.
We want to have your views on these options and any other suggestions you might have for improving our children's oral health.
Eating for oral health
Healthy eating will result in healthy mouths. Diet is therefore especially crucial from the earliest age. Baby foods, for example, often contain high sugar levels. The "sweet tooth" acquired at this young age can last into later life. We need, therefore, to work with manufacturers and major retailers to minimise the sugar content of baby foods to ensure our children's oral health gets off to a healthy start. Products also need to be clearly labelled to identify sugar content. Preventing "nursing" caries in young children aged as young as 18 months must be a priority.
As noted earlier, high-sugar fizzy drinks can damage teeth. Schools and pre-school organisations can exert considerable influence here in the products offered for sale in tuck shops, and with meals. Where fizzy drinks are sold, for example within public sector buildings, opportunity could be taken to display notices, warning of the potentially adverse consequences for oral health. Appropriate publicity materials could be provided for this purpose. Also, as described, the Food Standards Agency is taking forward work on the promotion and labelling of foods for childen. A separate international review of advertising to children noted that many European countries have introduced restrictions on advertising and promotions. Examples include Denmark, Finland, Norway and Sweden. Conversely, low sugar products should be encouraged and similarly identified, and milk and wholesome water supplies made available. Many excellent examples of this kind of approach exist: a number of Family Learning Centres in Glasgow provide a water cooler in the entrance to the building, where parents and children can get cups of water free of charge, thus reducing the need for soft drinks to be brought in. This simple measure has been very successful in cutting down on fizzy drinks.
Local authorities could also be encouraged to make water fountains and other wholesome water sources more widely available in leisure centres, sports grounds and facilities which are used by children. These centres should also be encouraged to promote semi-skimmed milk and low-sugar, non-acidic fruit drinks as an alternative to high-sugared acidic fizzy drinks.
The appointment of the Scottish Food and Health Co-ordinator will revitalise the push to improve diet. The Co-ordinator will be involved in activity to support primary producers, manufacturers and retailers to realise, to the full, their potential contribution towards improving health through diet. This will be taken forward by addressing a range of issues, such as reducing the sugar content of processed food.
Good oral health habits must start early. Special responsibilities devolve on parents: they themselves need to set positive examples in caring for their own teeth and must be equipped to instruct their children in the basic behavioural skills, which will stay with them throughout their lives. What needs to be imparted is:
- every encouragement should be given to the mother to attend dental services before the birth so that she can receive free dental treatment and advice. This would also give the dental team the opportunity to advise her about her own dental health as well as the importance of early registration and dental care of her child;
- the importance of preventive action as soon as possible after birth, focusing on the need to cut down on the intake of sugar in children's diets both in total quantity and frequency. It is especially important to ensure that parents are advised of the oral health dangers of using sugary juice in babies' bottles and of the benefits of receiving advice from the dental team when the child is still very young (3-6 months). Midwives and health visitors have a major role in giving such advice;
- mothers should be encouraged to breastfeed exclusively for the first six months, in line with World Health Organization recommendations and the UNICEF Baby Friendly Initiative in the UK;
- toothbrushing is important twice daily with a suitable fluoridated toothpaste to reduce levels of tooth decay and gum disease later in life;
- visiting the dentist, and encouraging parents and children to pay regular visits to get advice, care and treatment. Early intervention can prevent disease or facilitate less extensive treatment.
Health education is a crucial part of achieving change by providing guidance and information to enable parents and children to develop the habits necessary for good oral health and hygiene. The earliest impressions and influences are vital, a fact acknowledged in Nursing for Health which sets out proposals for developing the work of health visitors with young children and their families to ensure that parents are both well informed and enabled to make healthy choices about their own and children's health. The development of Family Health Plans will have this focus. And a shift towards community development approaches, in collaboration with initiatives like Sure Start Scotland, Social Inclusion Partnerships and New Community Schools, will support the development of more consistent approaches to oral health and hygiene within communities.
Information distributed from different sources is often contradictory. HEBS will continually review and develop material to this end, including:
- "Ready Steady Baby", a resource for new mothers in Scotland which, among other things, covers oral and dental health.
- A new information and training resource for carers of pre-5s which will include both nutritional and dental/oral health information, along with ideas for activities to promote key messages, among them, toothbrushing, enjoying fruit and vegetables.
Nurseries, playgroups and Family Centres all provide a suitable environment for the dissemination and discussion of oral health messages and for practical measures to encourage good habits, especially among the most disadvantaged children. There is wide scope for many varied and different initiatives on dental themes to provide an element of fun, combined with learning.
Toothbrushing schemes in nursery schools are being targeted at deprived communities although some NHS boards have already extended these schemes to cover the whole nursery school population. These settings, along with schools, offer scope for such schemes and linked initiatives to tackle the particularly acute problems in deprived areas.
The dental professions have a vital contribution to make; and significant increases in resources have already been announced in the Action Plan for Dental Services. Expansion of the whole dental workforce and, in particular, the professions complementary to dentistry for example hygienists, dental therapists and dental health educators, is planned.
Expansion of the workforce does not, in itself, improve health. Accompanying strategies are required, as Scotland, at present, has only 50% of the adult population registered with a dentist and only 65% of children. Often those not registered are the ones most likely to need dental treatment. Much of the current work done by the dental services is treatment-based. The Action Plan highlights the need to change to a more preventive approach with wider application of treatments like fissure sealants. With the appropriate workforce and incentives, a more prevention-oriented regime could be introduced. We are working to achieve this, but it will take time before the full benefits are realised.
Through joint planning between local authorities and NHS boards, and greater use of the professionals complementary to dentistry, scope exists to bring the dental workforce closer to people in nurseries, family centres, play groups and so on, both through visits and advice.
However, in order to ensure that all children receive appropriate and timely advice and treatment, we will ensure that by 2005 all children by the time they enter primary education at age 5 years will have received dietary advice and support to improve oral health and have accessed or been offered access to dental services.
The beneficial effects of fluoride in preventing dental decay have been apparent for many decades. It works by making the tooth more resistant to acid attack. Fluoride is present naturally in the environment and in some foods as are, for instance, calcium, sodium and potassium. Different foods contain different quantities. Most natural drinking water supplies contain minute quantities of fluoride, but only one public drinking water supply in Scotland is at present at a level to have an effect on dental decay (optimum concentration 1 part per million). Fluoride is also present naturally in tea, fish and sea water.
The safety of fluoride has been the subject of much discussion - indeed it is one of the most extensively researched health measures. What can be said is that the balance of evidence suggests that fluoride, where properly used, offers a safe and effective route to better oral health.
No one, of course, can ever say that a substance is completely harmless in all instances as it depends on how it is used. If used to excess, any supplement that can be of benefit to health, whether vitamin or mineral, can produce undesirable effects. Recommended supplement dosages are calculated to maximise positive outcomes and to minimise adverse effects. So, as with all substances, care would be needed to ensure that the use of fluoride from different sources did not exceed recommended optimal doses.
Child with fluorosis
A typical case of fluorosis observed in Scotland
It is the daily exposure of tooth surfaces to very low concentrations of fluoride that increases a tooth's ability to withstand the damage which results from the acid produced following sugar consumption. At present, in Scotland, many people's eating habits expose them to frequent consumption of sugar in foods and drinks with insufficient exposure to fluoride.
There has been much debate about the use of fluoride supplementation to prevent dental decay. One area of debate centres on the way in which fluoride is used. So, for example, freedom of choice is an issue if it is placed in the water supply but not if it is placed in milk, where choice would be available. Milk, salt and water are vehicles by which dietary fluoride supplements can be delivered. Fluoride tablets and drops are further sources.
Fluoride can be added to milk without changing its flavour and without diminishing its nutrient content. Milk has the benefit of itself being a healthy drink for children, particularly where it is semi-skimmed. Fluoridated milk programmes are being evaluated in England and have been undertaken previously in Scotland. The present use of milk as a healthy drink needs to be encouraged and expanded if fluoridated milk is to be introduced successfully. Fluoridated milk with appropriate labelling could be sold through retail outlets and therefore be available to all age groups and could preserve an element of choice. Alternatively, programmes could be developed in primary schools and nurseries where both fluoridated and non-fluoridated milk could be provided. The programme would have to offer fluoridated milk to children from pre-school until the end of primary education to secure a sustained and effective oral health effect.
Fluoride can also be added to salt. It is used widely in Europe. Salt producers or major retailers could be encouraged to import the product and to market it accordingly. Clearly a careful balance needs to be struck here, given the Executive's target of reducing salt consumption, but it could be marketed on the basis, not of encouraging salt intake but simply of ensuring that where salt is purchased, the product is available with or without fluoride and is clearly labelled. Benefits could be enhanced by use in commercial settings such as restaurants or by use in prepared foods and drinks. Appropriate labelling of products would ensure that choice is preserved.
Fluoride toothpaste was being used widely in developed countries by the 1970s and its effectiveness in reducing dental decay is well recognised. Unfortunately, not all children have teeth brushed regularly and are therefore less able to benefit from this method of delivering fluoride.
There is a reluctance in Scotland for children to take tablets and drops when they are well. It is just not done. Hence, compliance with daily fluoride tablet/drop regimens in the home setting is very limited over the long term. One option would therefore be to make tablets available to primary schools and nurseries for use, if desired. This has been piloted in some NHS boards but results, whilst showing improvement, did reveal operational and supervision difficulties as the number of schools and pupils in the scheme increased. Choice can be offered in these schemes.
The effectiveness of fluoride rinsing in reducing dental decay is acknowledged. However, the need for sustained use over a lengthy period of time reduces the potential effectiveness of this method of fluoride delivery.
There are strongly held views both in favour of, and against, fluoridation of the public water supply. Opponents of fluoridation claim that it amounts to mass medication. Supporters consider it to be the single most effective step that can be taken to secure lasting oral health benefits in the population, and particularly children. Clear significant benefits for children would be seen within three to four years of the initiation of water fluoridation.
Debate has continued over the years on both the efficacy and the health consequences of water fluoridation. There have been numerous reviews by health organisations throughout the world on water fluoridation. To help provide an objective view of the situation, the UK Government commissioned the Centre for Reviews and Dissemination at York University to carry out an expert scientific review of fluoride and health. This review, which was published in 2000, looked at thousands of papers and identified over 200 individual studies of fluoridation which were of an appropriate standard. The review concluded that:
- water fluoridation does reduce caries levels;
- additional benefits accrue from water fluoridation when fluoride toothpaste is also used;
- the prevalence of dental fluorosis of aesthetic concern may be increased;
- there is no evidence of other adverse effects on health.
The University of York Report recognised the fact that much of the research evidence concerning water fluoridation was conducted many years ago, and in response the Department of Health (England) commissioned the Medical Research Council (MRC) to provide advice on current scientific evidence and to consider what further research in this field is required. We will consider if further research on fluoride may be relevant to Scotland following this consultation.
Studies have shown that in fluoridated areas, children suffer fewer abscesses, there are less episodes of toothache, and a reduced need for general anaesthetics. By way of illustration, in 1987, the prevalence of dental abscesses was five times higher amongst 5 year olds in Northumberland, which is non-fluoridated, than Newcastle which was fluoridated. The number of tooth extractions in Newcastle among 5 year olds was also less than half the number in Northumberland. What is more, fluoridated water is beneficial to everyone with teeth, not just children.
There are at present no artificial fluoridation schemes in Scotland, although legislation exists to enable their introduction. On the other hand, under existing schemes in England, over 5 million people in the West Midlands and the North East receive artificially fluoridated water. Birmingham was fluoridated in 1964. Since then, the dental health of 5 year olds has been consistently and significantly better than the national targets in England and considerably better than Scotland.
Many other countries base their oral health improvement strategies on use of fluoride.
Regular reviews of health statistics have not identified any associated health issues. In the United States over 150,000,000 people receive fluoridated water daily. The Republic of Ireland has recently confirmed its commitment to water fluoridation although it has reassessed the recommended concentration in the water supply.
Fluoride occurs naturally in water, and is present at optimal concentration in the water supply to some communities in Moray, Scotland. A study there has shown that 87% of 5- to 6-year-old children were free of caries, compared with 32% in a socially matched group nearby. There are no recorded harmful effects to health in areas of natural fluoridation where levels match those recommended for artificial fluoridation i.e. one part of fluoride to a million parts of water.
Conclusion and consultation
We have set out the poor state of children's oral health in Scotland and described the action being taken to bring about improvements.
In order to guarantee further action on children's oral health we will ensure that by 2005, all children will have received dietary advice and support to improve oral health and have accessed or been offered access to dental services before entry to primary education at age 5 years.
But we want to have your comments on the measures you believe should be taken to accelerate progress. We would particularly like to have your views on:
- diet and health promotion programmes including:
- extension of fresh fruit initiatives
- enhanced dental services and preventive treatments including;
- strengthening current links between the primary care medical team and dental services
- encouraging greater use of professionals complementary to dentistry in the dental care of children.
- alternative ways of using fluoride, including:
- expanded toothbrushing with fluoride toothpaste in nurseries and schools
- use of fluoridated milk or salt in various settings
- fluoridation of the largest public water supplies in Scotland.
Your comments and requests for additional copies should be sent to:
Public Health Division
St Andrew's House
This document may also be viewed on the Scottish Executive website at www.scotland.gov.uk
To help inform debate on the issues set out in this consultation paper, the Scottish Executive intends to follow its normal practice of making available to the public, on request, copies of the responses received. The Executive will assume, therefore, that responses can be made publicly available in this way.
If respondents indicate that they wish all, or part, of their responses excluded from this arrangement, confidentiality will be strictly respected.