Adult Dental Health Survey 2009 Disease and Urgent Conditions Professor Nigel Pitts

1. Adult Dental Health Survey 2009Disease and Urgent ConditionsProfessor Nigel Pitts on behalf of the ADHS consortium

3. Outline 1: Disease • Data based on clinical dental examinations • Be clear on detection thresholds for all diseases and conditions: • Dental Caries • In crowns or roots • Social variation • Age variation • Primary coronal caries • Secondary coronal caries • Root caries • Periodontal Disease • Pocketing • Tooth Wear • Trends Conclusions

4. The Varying Stages of Tooth Decay and “Basic Reporting” Obvious Decay as assessed in many “Basic Methods” Surveys (D3MFT) and used in ADHSurveys….. lesions into the pulp Extensive decay clinically detectable lesions in dentine Moderate decay + hidden decay (in enamel and in dentine ) not seen by visual inspection clinically detectable ‘cavities’ limited to enamel Initial decay clinically detectable enamel lesions with ‘intact’ surfaces small lesions detectable only with additional diagnostic aids very early stage decay sub-clinical initial lesions in a dynamic state of progression / regression

5. Clarification of choices for caries reporting lesions into pulp More comprehensive clinical estimates include initial lesions in enamel, as used in increasingly in routine practice (D1MFT) + clinically detectable lesions in dentine + clinically detectable ‘cavities’ limited to enamel + clinically detectable enamel lesions with ‘intact’ surfaces + clinically detectable only with additional diagnostic aids ICDAS & PUFA Detection Codes (+/-) = activity status + sub-clinical initial lesions in a dynamic state of progression / regression

6. Just under one third of dentate adults (31 per cent) had obvious tooth decay in either the crowns or roots of their teeth. • For those adults who had some decay, the average number of teeth affected was 2.7, compared with an average of 0.8 among all dentate adults.

7. There are social variations in dental decay (in adults) • Adults from routine and manual occupation households being more likely to have decay than those from managerial and professional occupational households (37 per cent compared with 26 per cent )

8. The prevalence of decay in the crowns of the teeth varied with age, with the highest prevalence in adults aged 25 to 34 (36 per cent) compared with those aged 65 to 74 (22 per cent).

9. Primary dental decay (decay on the surface of a tooth that may or may not have evidence of restorations on another surface) affected almost a quarter (23 per cent) of all dentate adults and comprised the majority of decay in crowns. • (Secondary coronal dental caries prevalence was 7% overall)

10. Seven per cent of adults had active root decay and this proportion varied by age, • with 1 per cent of 16 to 24 year olds affected • with 11 per cent of 55 to 64 year olds affected and • with 20 per cent of 75 to 84 year olds affected

11. Periodontal assessment • Diagnosis made by examination of predetermined sites around the mouth with a periodontal probe. Sites were the same as those recorded in 1998. However, loss of periodontal attachment was only recorded in older adults 55+> • The periodontal examination is perhaps one of the more difficult parts of the examination for the examining dentists, particularly in the challenging field conditions of the survey. • False negatives are very much more likely than false positives. In other words a field survey is always likely to underestimate rather than overestimate the prevalence of the condition. • This difficulty in measurement may affect actual prevalence estimates and possibly geographical variation but should not affect the findings as they apply to other measures of the distribution of the disease across the population or the comparison with previous surveys.

12. Overall 45 per cent of adults had periodontal (gum) pocketing exceeding 4mm • Although, for the majority (37 per cent), disease was moderate with pocketing not exceeding 6mm.

13. Tooth Wear • The measurement of tooth wear was carried out for the first time in the 1998 ADHS and the same coding criteria were used in the 2009 survey. • Wear was recorded for the three surfaces of the six upper anterior teeth, buccal palatal and incisal. The worst affected surface of each of the six lower anterior teeth was also recorded. • Wear was assessed as: • no obvious wear or wear restricted only to the enamel of the tooth • loss of enamel just exposing dentine somewhere on the surface • more extensive exposure of dentine (more than one third of the buccal or palatal surface) or substantial loss of dentine (incisal surface) • complete enamel loss with exposure of dental pulp or secondary dentine. • In ADHS prevalence of wear is reported and outlined at three thresholds; • any wear, • wear that has exposed a large area of dentine on any surface (moderate wear) • wear that has exposed the pulp or secondary dentine (severe wear).

14. The prevalence of tooth wear in England has increased since the 1998 survey, when two thirds (66 per cent) of the dentate population showed signs of wear compared with over three quarters (76 per cent) in this survey. • Moderate tooth wear has increased from 11 per cent in 1998 to 15 per cent in 2009 • Although severe wear remains rare.

15. Conclusions………for “Disease” 1Several diseases and processes are a threat to the lifetime retention of natural teeth • Dental decay has traditionally been the greatest threat to natural teeth and is still prevalent in the population. Almost a third of the population showed decay and this represents many millions of people with decay. • Whilst the younger age groups have the most people with good oral health they also have the highest prevalence of decay and are substantially more likely to have multiple teeth with decay. • Despite the relative abundance of disease detected, and the clear history of previous disease in the form of fillings and other restorations, particularly for older age groups the trend is of a continued reduction over time.

16. Conclusions………for “Disease” 2Several diseases and processes are a threat to the lifetime retention of natural teeth • Periodontal disease remains common at a low level although overall there has been a reduction in mild disease associated, perhaps, with a general increase in cleanliness. • However, there has been a slight increase in the prevalence of more severe disease and the impacts of severe disease are concentrated in a relatively small proportion of the population. • The associations with a range of health behaviours (for example, smoking or infrequent tooth brushing) are perhaps expected but the social gradient is relatively minor. • Severe tooth wear remains rare, but there are signs of an increase since the last survey and there are a small but increasing proportion of younger adults with moderate wear which is likely to be clinically important.

18. Outline 2: Urgent Conditions • Data based on • Dentist-administered questions • interviewer-administered questionnaire • clinical dental examination • Two main themes: • Pain • At time of dental examination • Previous 12 months • Oral Sepsis / PUFA • P – U – F – A • Aross behaviours • Those with un-restorable teeth Conclusions

19. Open dental pulps and oral sepsis • PUFA is a recently developed index of clinical consequences of untreated dental caries. It provides a measure of badly diseased and broken down teeth which have been attacked by dental decay and are causing significant problems in need of early attention. • It is intended to complement more classical caries indices with relevant information for epidemiologists and health care planners. • The index was first validated on children within the Philippines National Oral Health Survey, 2006, and is being advocated for wider use by the FDI World Dental Federation. • This current survey is reporting nationally representative estimates of PUFA for a full range of adult age groups for the first time.

20. PUFA Index The index is expressed by the uppercase letters PUFA when used for the permanent dentition: • Pulp involvement is recorded when the opening of the pulp chamber is visible or when the coronal tooth structures have been destroyed by the carious process and only roots / root fragments are left. • Ulceration due to trauma is recorded when sharp edges of a dislocated tooth with pulp involvement or root fragments have caused traumatic ulceration of the surrounding soft tissues, e.g., tongue or buccal mucosa. • Fistula is scored when a pus-releasing sinus tract related to a tooth with pulp involvement is present • Abscess is scored when a pus-containing swelling related to a tooth with pulp involvement is present.

21. Nine per cent of dentate adults reported current pain related to their teeth in the clinical examination. • Older adults were less likely than younger adults to report current pain in their teeth, and • adults from professional and managerial households were less likely than adults from routine and manual occupation households to report current pain.

22. Eight per cent of dentate adults reported that they had experienced pain in their mouths fairly or very often in the previous 12 months. • Women were slightly more likely than men to report that they had experienced pain fairly or very often in the previous 12 months.

23. Seven per cent of dentate adults had one or more PUFA lesions (PUFA is the presence of open pulp, ulceration, fistula and abscesses in the mouth), • most commonly an open Pulp (4 per cent). • Ulceration related to decayed teeth was observed in 1 per cent of dentate adults and • Fistula or Abscess in permanent dentition was present in 2 per cent.

24. A positive PUFA score, that is having any element; • was more commonly recorded in men (8 per cent) than women (6 per cent), • was associated with socio-economic classification, • was much more common among those who reported that they only saw a dentist when they had trouble (13 per cent) and • was also related to the length of time since respondents had last seen a dentist.

25. There was a marked difference in the prevalence of PUFA according to: • the frequency of tooth brushing, • high levels of dental anxiety, • poor general and dental health, • PUFA was related to both current and long-term pain.

26. Eight per cent of dentate adults had one or more untreated teeth with unrestorable decay, • and • those who did, had an average of 2.2 teeth in this condition.

27. Untreated and unrestorable decay was present in: • 23 per cent of those who reported current dental pain and • 20 per cent of those who reported frequent pain or discomfort in the past 12 months.

28. Adults had an increased likelihood of both pain and serious decay or sepsis if: • they did not attend a dentist for regular check-ups, • brushed their teeth less than once a day, or • were smokers.

29. Conclusions: “Urgent Conditions” 1 Keeping a Balance • The very significant improvements in oral health reported in this survey need to be considered alongside urgent conditions. • Although these conditions affect a minority of people, even a minority reporting pain or problems amounts to many millions in need of immediate care within the total population. • The greater prevalence of pain in the youngest age groups as well as the high levels of people with the most severe levels of anxiety suggest that there are groups of people who may need special types of care in order to return them to a pain free condition.

30. Conclusions: “Urgent Conditions” 2 Implications for Services • Although an increasing proportion of people are enjoying improved oral health, these findings illustrate that this situation is not universal and for many, easy access to services for management of pain and discomfort remains relevant.

31. Adult Dental Health Survey 2009 The NHS Information Centre commissioned the survey, with funding provided by the Department of Health in England, the Welsh Assembly Government and the Department for Social Services and Public Safety in Northern Ireland. The Office for National Statistics (ONS) was the lead contractor working in partnership with the National Centre for Social Research, the Northern Ireland Statistic & Research Agency, and a team of academics from the Universities of Birmingham, Cardiff, Dundee, Newcastle and University College London