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The Scottish Health Survey: Volume 1: Main Report

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2 DENTAL HEALTH

Fiona Dobbie

SUMMARY

  • The percentage of men aged 16-64 with all false teeth fell from 9% in 1995 to 8% in 1998 and to 5% in 2003. In both 2008 and 2009 4% of men aged 16-64 had no natural teeth.
  • The corresponding figures for women aged 16-64 were 13% in 1995, 11% in 1998, 7% in 2003 and 5% in both 2008 and 2009.
  • In 2009, 88% of all adults aged 16 and over had some natural teeth (91% of men and 86% of women). This is just below the 2010 target for 90% of adults to have some of their own teeth.
  • Almost all adults with teeth (97%) say they brush them daily with fluoride toothpaste. 39% of adults with teeth use a mouth wash daily, 25% use dental floss, and 26% say they restrict their sugar intake to help improve their dental health.
  • Women were twice as likely as men to report using dental floss every day (34% versus 17%), and were also more likely to say that they restrict their sugar intake (29% versus 22%).
  • 61% of adults with dentures clean them daily and 31% leave them out at night. Women with dentures were more likely than men with dentures to clean them daily (65% versus 56%) or leave them out at night (34% versus 26%).
  • Women were more likely than men to have been to the dentist in past year (73% versus 65%). The biggest difference between men and women was among those aged 25 to 54, with men much less likely to have been to the dentist in the past year than women of this age.
  • Men using a private dentist were more likely to have attended within the last year than men using NHS dentists (71% compared with 65%). In contrast, there was no significant difference in attendance between women who used private (75%) or NHS dentists (73%).
  • Adults whose last visit to a dentist was more than 5 years ago were more likely to have had NHS treatment than private (14% versus 6%).
  • 62% of adults said they did not feel nervous about visiting the dentist. Women were less likely than men to say this (53% versus 72%). Around six in ten adults aged 16 to 64 said they were not nervous, compared with 74% of those aged 65-74 and 78% of those aged 75 and over.
  • 65% of adults who had ever been to a dentist said they did not face any difficulties when they visited the dentist. The most commonly mentioned problems were with: the expense (13%), getting suitable appointment times (10%), and accessing NHS treatment (9%).

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 A study based on the 1995, 1998 and 2003 Scottish Health Surveys has also suggested that poor dental health might be associated with cardiovascular disease, one of the leading causes of mortality and morbidity in Scotland (see Chapter 9 in this report). 2

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. 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, there are two NHS Scotland HEAT targets 3 relating to child dental health:

80 per cent of all three to five year old children to be registered with an NHS dentist by 2010/11

At least 60% of 3 and 4 year old children in each Scottish Index of Multiple Deprivation ( SIMD) quintile to receive at least two applications of fluoride varnish ( FV) per year by March 2014

The dental health chapter in the 2008 Report 4 highlighted inequalities in adult dental health, with the proportion of adults with no natural teeth highest among those in semi-routine and routine households, in the lowest income households and in the most deprived areas. 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%. A more detailed overview of the actions being taken by the Government and NHS Scotland to improve oral health can be found in the introduction to the dental health chapter in the 2008 Report.

The focus of this chapter is to explore two key areas: dental health and dental treatment. The section on dental health presents data on the number of natural teeth adults in Scotland have and compares this with previous years (1995, 1998, 2003 and 2008). It also discusses actions people take to improve their dental health. The remainder of the chapter then explores dental treatment in terms of: time since last visit and whether treatment was provided by the NHS or a private dentist; anxiety about dentist visits; and difficulties experienced when attending the dentist. 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, but has been a notable change to the wording that affects the data presented here. The three surveys conducted before 2008 asked participants whether they had their own teeth. From 2008 onwards people are asked how many natural teeth they have. Consequently, it is only possible to compare the people in 1995-2003 who said they had all false teeth with the proportion from 2008 onwards who said they had no natural teeth. In addition, the definition of false teeth used in 1995 was not the same as in 1998 and 2003. In 1998 and 2003 participants were asked to count caps and crowns as natural teeth but there was no such instruction in 1995. Although the question format from 2008 onwards is very different, it attempts to measure the same underlying concept (having no teeth) and might therefore be functionally equivalent. However, as there is no way of quantifying this, the comparison over time between 1995-2003 and 2008 onwards needs to be treated with caution.

In 2008 additional 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, access to dental services and actions to improve dental health, will be asked in 2009 and 2011. This chapter reports on some of the dental treatment questions first asked in 2009. These dental treatment questions cover the following areas:

  • Length of time since last visit to a dentist
  • Whether treatment was NHS or private
  • Difficulties or barriers faced when attending a dentist
  • Level of anxiety about dentist visits
  • Daily actions taken to improve dental health

2.3 DENTAL HEALTH

2.3.1 Trends in natural teeth by age and sex, 1995, 1988, 2003, 2008 and 2009

This section looks at trends in the number of natural teeth since 1995. Changes to the sample composition in the first three surveys mean that the 1995-2009 figures presented here are based only on those aged 16 to 64. Figures from 2003 onwards based on adults aged 16 and over are also presented in Table 2.1.

As noted above, some of the data reported in this section are based on previous surveys where questions about natural teeth were slightly different. Table 2.1 and Figure 2A present the proportion of adults aged 16-64 with all false teeth in 1995, 1998 and 2003, and the proportion with no natural teeth in 2008 and 2009. This suggests that the decline previously noted between 1995 and 2003 may have slowed in recent years. For example, among men aged 16-64, 9% in 1995 and 8% in 1998 had all false teeth compared with 5% in 2003. In both 2008 and 2009, 4% of men aged 16-64 had no natural teeth. The corresponding figures for women aged 16-64 were 13% in 1995, 11%, in 1998, 7% in 2003 and 5% in both 2008 and 2009. Figure 2A, Table 2.1

Figure 2A

The 2005 Action Plan set a target for 90% of all adults in Scotland, and 65% of adults aged between 55 and 74 years, to possess some natural teeth by 2010. 1 The dental health chapter in the 2008 report noted that the target for adults in the 55-74 age group had already been met while the figure for all adults stood at 88%, just shy of the 90% target. Table 2.1 shows that the proportions of men (91%), women (86%) and all adults (88%) aged 16 and over with some natural teeth were the same in 2008 and 2009. Table 2.1

2.3.2 Actions taken to improve dental health

This section reports various actions people said they took daily to improve their dental health. Table 2.2 presents the figures based on all adults with some natural teeth while Table 2.3 is based on all adults with dentures. Note that these two categories overlap as some people have a combination of natural teeth and dentures. The tables report the proportions who reported each of the actions asked about, however the text below about adults with some teeth does not comment on denture care, while the commentary about people with dentures does not mention actions to protect teeth.

Not surprisingly, brushing teeth with fluoride toothpaste was the most common action mentioned by people with teeth, with almost all (97%) adults doing this (96% of men and 98% of women). Using a mouth rinse was the next most common action reported, but this lagged behind fluoride toothpaste use with around 4 in 10 (39%) adults with teeth doing this (37% of men and 42% of women). Around 1 in 4 adults with teeth said they used dental floss daily (25%) or restricted their intake of sugary foods and drinks (26%).

Some of the actions reported were equally common among men and women with teeth, such as brushing with fluoride toothpaste or using mouth wash. In contrast, women were twice as likely as men to report using dental floss every day (34% versus 17%). Women were also more likely than men to restrict sugar intake (29% versus 22%).

There were some variations by age in the actions reported by adults with teeth, but the patterns were not wholly consistent. For example, rates of daily tooth brushing were similar for all age groups (96%-98%) with the exception of a dip among those aged 65-74 to 90%. Dental floss use was highest among those aged 35 to 54, while mouth wash use declined from the age of 55 onwards. Adults with teeth aged 16-24 and 65 and over were less likely to report restricting sugar intake than those aged 25 to 64. Table 2.2

Now looking at adults with dentures (some of whom also have natural teeth), Table 2.3 shows that 61% clean their dentures daily while half as many (31%) leave them out at night. Women with dentures were more likely than men with dentures to clean them daily (65% versus 56%) or leave them out at night (34% versus 26%). 12% of people with dentures said they restricted their sugar intake. This was half the rate reported by adults with some teeth (26%, Table 2.2). This could be because older people are less likely to take this kind of action, or it could be that people with dentures (who also tend to be older on average), are less likely to do this. Cleaning dentures daily or taking them out at night increased with age; this could be because older people have more extensive dentures (full dentures rather partial ones). Table 2.3

2.4 DENTAL TREATMENT

The focus of this section is dental treatment, looking specifically at people's most recent visit to a dentist, feelings of anxiety attending the dentist, and any difficulties people reported when attending the dentist.

2.4.1 Last visit to the dentist

Women were more likely than men to have been to the dentist in past year (73% versus 65%). Recent visits to the dentist also varied with age but the patterns were different for men and women. Around 8 in 10 women aged 16 to 54 had been in the last year, this dropped to 66% of those aged 55-64, and declined further to 52% of those aged 75 and over. The figures for men and women aged 65 and over were almost identical, however men aged 25 to 54 were much less likely to have been to the dentist in the past year than women of this age. This variation accounts for the overall difference between men and women and highlights an important group in the population who might require further targeting to encourage dental visits. Very few people had never been to a dentist and this did not vary by age or sex. Visits of more than 5 years ago were much more common among older people. Table 2.4

To investigate whether the time elapsed since the last visit was related to the type of dentist people saw, Table 2.5 compares people who had received private treatment with NHS dental patients. The proportions of all adults visiting the dentist in the last year were similar for those who had been to a private dentist (73%) and those visiting an NHS dentist (69%). However, men using a private dentist were more likely to have attended within the last year than men using NHS dentists (71% compared with 65%). This was not the case for women where there was no significant difference between those receiving private treatment (75%) and those receiving NHS treatment (73%). Women were more likely than men to have been to a dentist in the past year. However, the difference between the sexes was greatest among NHS patients (73% of women versus 65% of men had been in the last year). In contrast, women and men who were private dental patients had very similar rates of recent attendance (75% versus 71%).

Adults whose last visit to a dentist was more than 5 years ago were more likely to have had NHS treatment than private (14% versus 6%). This is most likely to be a reflection of change over time in dental provision. We know from Table 2.4 that people aged 65 and over were the most likely to have been to a dentist more than 5 years ago, it is possible that their last visit was at a time when private dentists were less common than they are now. Table 2.5

2.4.2 Dental anxiety

All those who had ever attended a dentist were asked how nervous they felt about such visits. Overall, 62% of adults said they did not feel nervous about visiting the dentist, however women were less likely than men to say this (53% versus 72%). Similarly, 20% of women said they were very nervous compared with 11% of men. Table 2.4 showed that more women than men had attended a dentist in the past year. It is possible that men report lower levels of anxiety because they attend the dentist less often than women. Further analysis of the association between anxiety, gender and how often people visit dentists might therefore be useful when the 2009 and 2011 data can be combined to provide a larger sample.

Although anxiety levels differed by sex, there was little variation by age. Between 58% and 64% of adults aged 16 to 64 said they were not nervous, and this increased markedly to 74% of those aged 65-74 and 78% of the 75 and over age group. This might be caused by the lower level of dental visits in this age group, or because people of this age group are less anxious than younger people about medical checks in general. Table 2.6

2.4.3 Difficulties experienced visiting a dentist

Table 2.7 presents some difficulties people might experience when visiting a dentist. All participants who had ever been to a dentist were asked whether any applied to them. As Table 2.4 showed, two-thirds of men and three-quarters of women had been to a dentist within the previous 12 months so had recent experience to draw on. Based on this analysis, it is not possible to say whether any of these difficulties affect how often people visit the dentist, but when the 2011 data are available it might be possible to look at this further by comparing the experiences of people with more and less recent visits.

As the figures in Table 2.7 show, two-thirds (65%) of adults who had ever been to a dentist said they did not face any difficulties when they visited the dentist. The most commonly mentioned problems were associated with cost (13% said it was too expensive), getting suitable appointment times (10%) and accessing NHS treatment (9%). There were no significant differences between the types of problems reported by men and women.

As might be expected, problems with suitable appointment times or time off work for dentist visits were much less common for people aged 65 and above. Whereas, concerns about costs or access to an NHS dentist varied by age with no obvious patterns. Problems with physical access barriers were more common among the oldest age groups, 9% of those aged 75 and over mentioned this compared with around 1% of all other age groups. Table 2.7