Tooth decay: down in the mouth

06 April 2018

Tooth decay remains a persistent problem across the UK, especially among children, writes journalist John Windell, so what can put the sparkle back in the nation’s smile?

Dental Care

Public health programmes have energetically attempted to stem the rising tide of obesity across the UK in recent years. The cause of the problem is generally accepted to be a combination of lack of exercise and poor diet. In particular, the finger of blame is pointed in the direction of refined carbohydrates, in particular the added sugar in food and drink.

Besides obesity, an equally troubling – though less well-publicised – side effect of this excessive sugar consumption has been a high rate of tooth decay, particularly among children. The latest figures tell a startling story.

The 2013 Child Dental Health Survey of England, Wales and Northern Ireland found that almost half (46%) of 15-year-olds and more than a third (34%) of 12-year-olds had ‘obvious decay’ in their permanent teeth. In addition, 31% of five-year-olds and 46% of eight-year-olds had obvious decay in their primary teeth (NHS Digital, 2015).

More recently, the Local Government Association (LGA) analysed official 2016-17 data for England and found that the number of multiple teeth extractions among under-18s was 42,911. This represents a 17% increase on the 36,833 procedures in 2012-13 and a cost to the NHS of £36.2m. Since 2012, the overall cost of these operations, mostly carried out in hospital under general anaesthetic, has reached £165m (LGA, 2018).


The child dental health gap

These figures tell only half the story, though, because children who live in economically and socially deprived communities are far more likely to suffer from tooth decay than those in more affluent areas. Across England, the rate of five-year-olds with tooth decay shows massive variation, as Dr Jenny Godson, national lead for oral health improvement at Public Health England (PHE), explains: ‘The areas with poorer dental health tend to be in the north and in the more deprived local authority areas. When comparing the regions, the estimates of tooth decay ranged from 33% in the North West to 20% in the South East.’

According to PHE’s 2015 national dental epidemiology survey, the highest rate of tooth decay among five-year-olds was 56% in Blackburn with Darwen, while South Gloucestershire recorded the lowest level of just 14%. PHE claims that deprivation can explain 41% of the variation (PHE, 2015).

Part of that variation is also explained by fluoridation. It is a controversial issue, but in Manchester, for example, which has no fluoridated water, children are 23 times more likely to go into hospital for tooth extraction than children in Birmingham, which has had a fluoridated water supply since 1964 (Jeyanthi, 2011).

Poor dental health can compound deprived children’s problems: pain and infection can disrupt their sleep, upset their diet and impair their growth and development. It can restrict the way they socialise with other children, and they often have to miss school to get treatment. In effect, healthy teeth are a vital element of their overall wellbeing.

This brings us back to sugar. Eddie Crouch, vice-chairman of the British Dental Association (BDA), says: ‘Dental decay doesn’t happen without sugar.’ The National diet and nutrition survey shows that sugar accounts for 13% of children’s daily calorie intake, 15% for teenagers and 12% for adults – the official recommended limit is no more than 5% (PHE, 2016).

An overarching solution is needed, says Dr Godson: ‘Achieving good dental health for all children needs the support and commitment of a wide range of partners. The most effective way to improve dental health is to embed it in all children’s services at strategic and operational levels – this includes positive action from commissioners, healthcare practitioners, early years settings and consultants in dental public health.’

PHE believes health visitors have an important role in providing oral health advice and support, such as signposting parents to dental services within their child’s first year, and identifying families that need additional help, such as those that have already had one child suffer tooth decay.

But what – in everyday, practical terms – can be done to improve the dental health of children and adults? The BDA’s Eddie Crouch offers the following points of advice.


Baby teeth

‘They can still cause pain and suffering. The worst time to attend a dentist is when a child already has a problem. We want to see children from the moment they get their first teeth. Health workers who see new mothers should encourage them to take their children to the dentist before the teeth have arrived to get the best advice.’


‘Buy a small-headed brush for children and start brushing the gums when the teeth are just below the surface. This can help with teething, as many problems are related to plaque and bacterial build-up rather than the teeth themselves. Use a toothpaste recommended for small children. That will get fluoride on the teeth from an early age, giving the child the best chance of avoiding any problems.’  

Electric Toothbrushes  

‘Studies show that people who use electric toothbrushes tend to brush better. But the heads need replacing every three months, which can be expensive. An electric toothbrush with a poor head can cause more damage 
than a manual brush.’  


‘Plaque normally builds up around the margin between the teeth and gums. So angle the brush towards the join between the gum and the tooth, and use a circular, massaging motion rather than scrubbing, which can damage the gums. Work from tooth to tooth smoothly – don’t jump – to ensure you remove the plaque from all along the gumline. If you get some bleeding, gently massage that area more. Don’t avoid it as that could allow bacteria to cause more damage.’  


‘It is hard to avoid sugar, but apps are available where parents can scan barcodes and check the sugar content in the food they are buying. Try to limit sugar to mealtimes, when the mouth is producing more saliva, which can neutralise the acid. It’s better to brush before a sugary snack than after, as brushing when acid is 
on teeth can cause wear on the tooth surfaces.’    


‘The main benefit of flossing is in gum health (young adults can start by trying interdental brushes). In children, this is rarely an issue; it is far more important to brush well. However, during orthodontic treatment (braces), a tufted interspace brush can allow cleaning between brackets, wires and any spaces between the teeth as a result of extractions.’  mouthwash  ‘Do not rely on it as an alternative to good toothbrushing. Some washes offer another way of getting fluoride onto the surface of the teeth, and others can help with specific early problems. Otherwise, they will not make up for bad brushing.’  

Dentist visits  

‘Every six months for children. For high-risk children, it could be every three months. For adults it is more risk-based. If you have never had much dental work, your standard of cleaning is good, you don’t smoke, you don’t have a high-sugar diet, then you might not need to go for up to two years.’ 


Dental Infographic


Dental advice across the four nations

The Childsmile initiative offers free toothbrushes, toothpaste and supervised brushing in deprived areas. Access to NHS dentists has also improved: the rate of four- to seven-year-olds with no ‘obvious decay’ rose from 54% in 2006 
to 68% in 2014 (Scottish Government, 2016).


The Designed to Smile programme provides supervised brushing in schools and nurseries, and oral health education. Public Health Wales says that, as a result, the proportion of children with tooth decay is now 35.4%, falling from 47.6% in 2007-08 (Welsh Oral Health Information Unit, 2016).


England has no national oral health programme for children, and tooth decay remains the top reason 
for hospital admissions among children.  


The Children’s Dental Health Survey in 2013 found that 72% of 15-year-olds, 57% of 12-year-olds and 40% of five-year-olds have tooth decay. While these figures are down significantly from the 2003 survey, they still leave Northern Ireland with the worst rates of tooth decay among children (NHS Digital, 2015).




British Dental Association. (2017) Putting prevention first. See: bda.org/dentists/policy-campaigns/campaigns/Documents/bda-manifesto-2017.pdf (accessed 15 March 2018).

Jeyanthi J. (2011) Update on fluoridation: Portsmouth City Council health overview and scrutiny panel, September. See: democracy.portsmouth.gov.uk/Data/Health%20Overview%20&%20Scrutiny%20Panel/20110913/Agenda/hosp20110920_AI_5_ii.pdf (accessed 15 March 2018).

Local Government Association. (2018) 170 operations a day to remove rotten teeth in children. See: local.gov.uk/about/news/170-operations-day-remove-rotten-teeth-children (accessed 15 March 2018).

NHS Digital. (2016) NHS Dental statistics for England – 2015-16. See: digital.nhs.uk/catalogue/PUB21701 (accessed 15 March 2018). 

NHS Digital. (2015) Child Dental Health Survey 2013, England, Wales and Northern Ireland. See: digital.nhs.uk/catalogue/PUB17137 (accessed 15 March 2018).

Public Health England. (2016) Young children still exceeding sugar recommendation. See: www.gov.uk/government/news/young-children-still-exceeding-sugar-recommendation (accessed 15 March 2018).

Public Health England. (2015) National dental epidemiology programme for England: oral health survey of five-year-old children. See: www.nwph.net/dentalhealth/14_15_5yearold/14_15_16/DPHEP%20for%20England%20OH%20Survey%205yr%202015%20Report%20FINAL%20Gateway%20approved.pdf (accessed 15 March 2018).

Scottish Government. (2016) Record dental registrations. See: https://news.gov.scot/news/record-dental-registrations (accessed 15 March 2018).

Welsh Oral Health Unit. (2016) Picture of oral health. See: cardiff.ac.uk/__data/assets/pdf_file/0006/218589/Picture-of-Oral-Health-2016.pdf (accessed 15 March 2016).

Subscription Content

Click To Return To Homepage

Only current Unite/CPHVA members or Community Practitioner subscribers can access the Community Practitioner journals archive. Please provide your name and membership/subscriber number below to verify access:

Membership number

If you are not already a member of CPHVA and wish to join please click here to JOIN TODAY

Membership of Unite gives you:

  • legal and industrial support on all workplace issues 
  • professional guidance on clinical and professional issues 
  • online information, training and support 
  • advice and support for all health professionals and health support workers
  • access to our membership communities 
  • CPHVA contribution rate is the Unite contribution rate plus £1.25 per month 

Join here https://www.unitetheunion.org/join-unite/

If you are not a member of Unite/CPHVA but would like to purchase an annual print or digital access subscription, please click here