Transcript Disease and Urgent Conditions, Professor Nigel Pitts

Adult Dental Health Survey 2009
Disease and Urgent Conditions
Professor Nigel Pitts
on behalf of the ADHS consortium
Outline 1: Disease
•
•
Data based on clinical dental
examinations
Be clear on detection thresholds for
all diseases and conditions:
1. Dental Caries
o
o
o
o
o
o
In crowns or roots
Social variation
Age variation
Primary coronal caries
Secondary coronal caries
Root caries
2. Periodontal Disease
o Pocketing
3. Tooth Wear
o Trends
Conclusions
The Varying Stages of Tooth Decay and
“Basic Reporting”
Extensive
decay
Moderate
decay
Initial
decay
very early
stage decay
Obvious Decay as
assessed in many “Basic
Methods” Surveys (D3MFT)
and used in ADHSurveys…..
lesions into
the pulp
clinically detectable
lesions in dentine
clinically detectable
‘cavities’ limited to enamel
clinically detectable enamel
lesions with ‘intact’ surfaces
+
hidden
decay
(in enamel
and in
dentine )
not seen
by visual
inspection
small lesions detectable only with
additional diagnostic aids
sub-clinical initial lesions
in a dynamic state of progression / regression
Clarification of choices for caries
reporting
lesions into
pulp
+ 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
More comprehensive
clinical estimates include
initial lesions in enamel, as
used in increasingly in
routine practice (D1MFT)
• 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.
• 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 )
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).
• 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)
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
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.
• 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.
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).
• 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.
Conclusions………for “Disease” 1
Several 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.
Conclusions………for “Disease” 2
Several 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.
Outline 2: Urgent Conditions
•
•
Data based on
– Dentist-administered questions
– interviewer-administered
questionnaire
– clinical dental examination
Two main themes:
1. Pain
o At time of dental examination
o Previous 12 months
2. Oral Sepsis / PUFA
o P–U–F–A
o Aross behaviours
o Those with un-restorable teeth
Conclusions
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.
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.
• 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.
• 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.
• 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.
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.
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.
• 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.
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.
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.
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.
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.
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