Secondary analysis of child hospital admission data for dental caries in London, UK: what the data tells us about oral health inequalities

Abstract

Objectives

Dental caries is the most common reason for hospital admissions for children aged 6–10 years in England. The prevalence in the experience of hospital admission is not uniform across all populations. This paper reports on the analysis of secondary data on dental hospital episodes for children residing in London, and its association with oral health inequalities.

Design, setting and participants

Retrospective, non-identifiable patient data sourced from the Hospital Episode Statistics dataset was analysed. Finished consultant episodes (FCEs) were extracted for children aged 1–19 years, residing in London and admitted with a primary diagnosis of caries between 2015/2016 and 2020/2021.

Outcome measures

The number and rates of FCEs with a primary diagnosis of dental caries for children aged 1–19 years old was analysed for six consecutive financial years (2015/2016 to 2020/2021). To assess oral health inequalities in children experiencing hospital admission due to dental caries, several demographic variables were analysed: deprivation, age, and sex.

Results

Between the financial years of 2015–2016 and 2020–2021, there were a total of 57 055 hospital admissions for dental caries for children aged 1–19 years (average rate of admission was 465.1 per 100 000 of children). A year-on-year decline was noted between 2015–2016 and 2020–2021. Regression analysis demonstrated clear social gradients with significant oral health inequalities; those from the most deprived areas experienced over two times the number of hospital admissions (58%). Children aged 4–9 years accounted for 68.9% (39 325) for the total dental hospital episodes from 2015–2016 to 2020–2021.

Conclusion

London’s year-on-year reduction in hospital admission for dental caries is due to various factors including effective prevention interventions and an effective paediatric clinical care pathway. Sociodemographic factors remain to act as key predictors for hospital admission for child with dental caries. While health service level changes may reduce the number of hospital admissions, persistent child oral health inequalities continue to exist.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Regression analysis was conducted to determine the magnitude of demographic variables on the rate of hospital admission due to dental caries.

• Analysis was conducted over six consecutive financial years (2015/2016 to 2020/2021) to better understand factors and patterns in the utilisation of secondary care services for child populations with dental caries.

• The data analysed did not include unique patient episodes and it is therefore not possible to calculate the number of children requiring repeat admissions due to dental caries.

• Due to a lack of robust and reliable data, exploration of ethnicity data could not be conducted.

Introduction

Despite improvements in the prevalence of dental caries among children in the UK over the past 30 years, it continues to be a public health burden with significant oral health inequalities.¹ Dental caries remains the most common reason for hospital admission for children aged 6–10 years old to receive dental care under general anaesthetic (GA).²

The consequences of dental caries can impact on children’s health and social well-being including school attendance, sleeping, speaking, eating and socialising.^3–6 Poor child oral health can result in significant economic constraints on families and communities, with parents and carers needing to take time off work to care for their children.^{7 8} There are clear social gradients in child oral health and those residing in certain areas are disproportionately affected.⁹ The consequence for many children admitted due to dental caries with multiple extractions under GA. There is evidence to show that deprivation and socioeconomic status act as key predictors for higher rates for using GA services for children diagnosed with dental caries.⁷

There are certain circumstances whereby dental care needs to be provided under GA and considerations need to be factored in. These include:

• Cooperation of the patient.

• The perceived level of anxiety and previous response to similar procedures.

• Degree of surgical intervention.

• Complexity of the procedure.

• Medical status of the child.¹⁰

Clinical, parental, organisational and funding mechanisms have been known to influence the usage of GA for dental procedures. These factors include: high caries experience, low health literacy of parents, family circumstances and limited experience and training of dental clinicians and remuneration.⁷

While a GA is sometimes a required and necessary method to provide dental care, particularly for the very young child, there are risks associated with it.⁸ The potential negative impact on a child experiencing a GA must be considered in the decision-making process. General anaesthesia has been associated with increased risk of anxiety postprocedure.¹¹ Furthermore, dental procedures under GA create an economic burden on the National Health Service (NHS). In 2019/2020, hospital admissions for extractions due to dental caries were estimated to cause a financial burden to NHS England of £33 million.²

London includes some of the most affluent and most deprived areas in England. There is wide variation in caries experience among children residing in London’s 33 local authorities.⁹ In London, as in other regions of the UK, the community dental services (CDS) and hospital (secondary care services) provide specialist paediatric dental care including treatment of caries under a GA. These services can be accessed by referral from general dental practitioners (GDPs) in primary care.

In 2016, CDS services were re-commissioned in London. This created an opportunity to address the high prevalence of child hospital admissions due to dental caries. A seamless, consistent commissioning model for vulnerable children and adults was implemented across London. The CDS became the ‘gatekeeper’ of onward referrals into hospital dental services as an intermediary service providing specialist dental care before referring children. Consequently, a significant number of children were managed by the CDS using inhalation sedation or other behavioural management techniques before considering treatment under GA. This new pathway was established to facilitate appropriate, timely and efficient care for all children ensuring high quality and equitable care. Prior to this new clinical care pathway, GDPs in primary care were able to directly refer children into secondary care services (hospital) for dental treatment.

We therefore evaluated the impact of the newly established paediatric clinical care pathway on dental care provision in secondary care and its association with oral health inequalities. This intended to inform future commissioning decisions and help us understand patterns and factors in usage of GA and reasons for dental hospital admission among children and young people. As part of this evaluation, analysis of secondary data on hospital episodes for children aged 1–19 years old, residing in London and admitted with a primary diagnosis of caries was conducted.

Methods

Retrospective, non-identifiable patient data sourced from England’s NHS Digital HES dataset was analysed for London, UK. This database details all hospital admissions, A and E attendances and outpatient appointments at NHS hospitals in England. Finished consultant episodes (FCEs) were extracted from this dataset for those children admitted with a primary diagnosis of caries between 2015/2016 and 2020/2021. The number and rates of FCEs with a primary diagnosis of dental caries for children aged 1–19 years old was analysed for six consecutive financial years (2015/2016 to 2020/2021) from this data source. An FCE is the time a patient spends in continuous care of one consultant within an NHS hospital in England. Primary diagnosis of dental caries was extracted from the dataset using the International Classification of Diseases 10th edition (ICD-10), code K02.

To assess oral health inequalities in children experiencing hospital admission due to dental caries, several demographic variables were considered: deprivation, age, sex and ethnic group. Area deprivation was defined by the Index of Multiple Deprivation 2019 (IMD). IMD was grouped in five quintiles. To determine the magnitude of the impact of these variables, regression analysis was completed, grouped by lower tier local authority. Regression analysis was used to understand if IMD was an independent predictor to dental hospital admissions. Single age groups were analysed as a continuous variable to highlight the distribution of hospital admissions across the child population in London.

To analyse the crude rate of dental caries, FCEs per 1000 population, the Office of National Statistics mid-year population averaged estimate between 2015 and 2020 was used.

Exclusion criteria included removal of teeth under GA for non-caries related diagnoses, regular day patients and residential postcodes outside of London. To protect patient’s confidentiality, values were not included for all sub-national breakdowns where it was possible to calculate a value between 1 and 7 from the data gathered.

The data analysis assessing the impact of ethnicity on admissions due to dental caries could not be completed. This was due to a lack of reliable population level data for ethnicity, which if used could lead to invalid findings.

The data was analysed by the London Local Knowledge and Intelligence Service team from the Office of Health Improvement and Disparities in July 2022. Data was analysed using the software package RStudio V.2022.02.03 and R V.4.0.5.

Patient and public involvement

None.

Results

Hospital admission rates

Between the financial years of 2015–2016 and 2020–2021, there were a total of 57 055 hospital admissions for dental caries in London for children aged between 1 and 19 years. This equated to an average hospital admission rate of 465.1 per 100 000 of children aged between 1 and 19 years across the six financial years. Since 2015/2016 up to and including 2020/2021 there was a year-on-year decline in the rate of admissions. In 2015/2016, the rate of hospital admission was 580.0 per 100 000, 570.4 per 100 000 in 2016, 518.8 in 2017, 502.6 in 2018, 433.9 in 2019 and 184.8 in 2020/2021, respectively.

Results show a clear trend with a reduction in the number of episodes of dental caries related admissions among 1–19 years old from 2015/2016 to 2020/2021, as shown in figure 1.

Figure 1.

Hospital admissions rates (per 100 000) for dental caries by financial year, 2015/2016 to 2020/2021 (based on data from National Health Service Digital).

The number and rate of child hospital admissions due to dental caries significantly dropped in 2020. Which is likely to be attributed to a reduction in services due to the COVID-19 pandemic. When excluding year 2020–2021, to account for disruptions to service due to the pandemic, the average admission rate was 521.1 per 100 000.

Hospital admissions by IMD quintile

When investigating hospital admissions due to dental caries by IMD quintile, a clear stepwise social gradient was evident. The most deprived quintile (quintile one) had the highest numbers of hospital admissions (16 840) and the highest rates of admissions (588.1 of children aged 1–19 years). There was an association between the number and rate of hospital admissions due to dental caries for children aged 1–19 years with increasing levels of deprivation. IMD quintile five (least deprived) was found to have a 58% lower admission rate per 100 000 compared with IMD quintile one, as shown in figure 2.

Figure 2.

Hospital admissions rates (per 100 000) for dental caries by Index of Multiple Deprivation (IMD) quintile, 2015/2016 to 2020/2021 (based on data from National Health Service Digital).

Hospital admissions by age

Hospital admission by single years of age were analysed across the 6 years, as shown in figure 3. Children aged 5 years old were found to experience the highest rates of hospital admissions due to dental caries. Those children aged 4–9 years old made up a significant proportion of the total number of child hospital admissions in London. Of the 57 055 total admissions for children aged 1–19 years, those children in the 4–9 years old age group accounted for 68.9% (39 325) for dental caries between 2015/2016 and 2020/2021.

Figure 3.

Hospital admission rates (per 100 000) for dental caries by single years of age between financial years 2015/2016 and 2020/2021 (based on data from National Health Service Digital).

Hospital admission rates by sex

There were no significant differences in the number and rates of hospital admissions for dental caries for 1–19 years old by sex. The GA rates of admission for male children was higher (467.6 per 100 000) compared with the rates for female children (459.2 per 100 000).

Regression analysis

A series of regression analyses using the extracted hospital admissions data for dental caries for 1–19 years old was conducted to determine the significance of the relationships with demographic variables.

Age groups and mean IMD were significantly associated with increased rates of hospital admissions among children in London, but not sex (table 1). For IMD, the beta value indicated a positive relationship, with a higher impact noted for the 4–9 years age group. R² calculations showed that the IMD predicted 1% of the variation in results for the 1–19 years age group and 7% for the 4–9 years age group. The predicted variation in hospital admissions was found to be slightly higher for age than the IMD. Further exploration of the data found IMD scores to be evenly distributed across all age groups.

Table 1.

Univariate regression analysis results of age (including singular years), Index of Multiple Deprivation (IMD) and sex on rate of dental caries admissions (per 100 000) (based on data from National Health Service Digital)

Characteristic (age)	Beta	95% CI	P value	R2
Age group (1–19)	180.36	211.28 to 149.45	<0.001	0.18
Age group (4–9)	355.97	518.30 to 193.63	<0.001	0.09
Mean IMD (1–19)	40.02	9.46 to 70.58	<0.01	0.01
Mean IMD (4–9)	86.80	40.53 to 133.07	<0.001	0.07
Sex	60.00	500.00 to 370.00	0.8	<0.01
IMD by single age
Mean IMD (4)	130.15	46.51 to 213.78	<0.01	0.24
Mean IMD (5)	128.10	18.99 to 237.19	<0.01	0.16
Mean IMD (6)	83.61	32.06 to 199.28	0.15	0.07
Mean IMD (7)	83.10	39.08 to 205.29	0.18	0.06
Mean IMD (8)	56.82	49.57 to 163.19	0.29	0.04
Mean IMD (9)	38.24	37.69 to 114.16	0.31	0.03

Further analysis for IMD by single years of age from the 4–9 years old group was conducted. Only ages of 4 and 5 years were statistically significant, with the R² predicting 24% and 16% variance, respectively, as shown in table 1.

To determine the combined impact of IMD scores and age on dental caries hospital admission rates, a multivariate regression analysis was conducted for the 4–9 years old age group. The results found a cumulative effect of age and mean IMD score on predicting the rate of dental caries admissions, as shown in table 2.

Table 2.

Multivariate regression analysis results of Index of Multiple Deprivation (IMD) and age for 4–9 years old on dental caries admissions rate (per 100 000) (based on data from National Health Service Digital)

Characteristic (age)	Beta	95% Cl	P value	Adjusted R2
Age (4–9)	360	510 to 200	<0.001	0.1469
Mean IMD (4–9)	87	40 to 130	<0.001	0.1469

Discussion

This study aimed to analyse secondary data relating to child hospital admissions with demographic variables.

The results from these analyses indicate a year-on-year decline in hospital admission rates for dental caries in those residing in London aged 1–19 years from 2015/2016 to 2020/2021. Regression analysis demonstrated clear social gradients with significant oral health inequalities; those from the most deprived areas experienced over two times the number of hospital admissions due to dental caries compared with the least deprived.

Deprivation and child age were significantly associated with hospital admissions due to dental caries in London. This association is aligned to what is experienced in other regions across England. Current literature and a national report produced by the Office of Health Improvement and Disparities found significant oral health inequalities for hospital admission rates for tooth extractions impacting children living in most deprived areas in England.¹² The report found the rates of tooth extraction for children and young people residing in the most deprived communities was three times more than those residing in the most affluent communities.¹² A study conducted by Moles and Ashley in 2009, retrospectively analysed HES data in England from 1997 to 2006. The study found children from the most deprived quintile experienced two times as many episodes than those children from the most affluent communities.

For the age group of 4–9 years old, age had a greater impact on admissions than deprivation. Regression analysis revealed that deprivation to be more predictive than age when the data was analysed in single years of age. Data indicates ages 4 and 5 may be especially sensitive to differences in IMD, as those in more deprived areas experience a greater chance of being admitted to hospital for dental caries admissions. Authors of this study hypothesise the main reason for children with a primary diagnosis of dental caries admitted to hospital was for dental care (mainly extractions) under a GA. This hypothesis aligns to other studies conducted related to this field.¹³ Research has found those under 5 years were more likely to receive a GA for dental care, and age to be an important variable to predict the use of anaesthetic type.^{7 14} Reasons for this include: difficulties to perform dental treatment under local anaesthetic due to behaviour challenges, missed opportunities for early intervention and prevention, inadequate remuneration of GDPs to provide care to infants and young children. Parental attitudes have been found to be contributory factors with some supporting the provision of a dental GA to reduce child stress and placing less importance on primary teeth.⁷

Tackling oral health inequalities

Results found a clear stepwise social gradient with hospital admissions. Children in the more deprived areas are not only experiencing higher rates of admissions, but evidence has shown this population experience a higher prevalence of dental caries.¹⁵ Results found that age (4–9 years old) had a greater impact on hospital admission than IMD, suggesting that younger children are more likely to be admitted. Younger children may experience more dental GAs due to their age making treatment planning under local anaesthetic more challenging.⁷

The significant decline noted in year 2020/2021 could be mainly attributed to the disruptions caused by the COVID-19 pandemic. However, the data presented in this paper shows a year-on-year decline in admissions in the preceding years before the pandemic.

There are several factors that occurred in the region that may have contributed to this decline in the numbers and rates of child dental admissions. Introduction of a regional, effective clinical care pathway allowed for established and consistent acceptance criteria for intermediate and specialist paediatric services. This enabled appropriate and timely referral into these services. Authors hypothesise that the behaviour of referring GDPs may have changed. Introduction of appropriate referral criteria may have provided opportunities for more paediatric oral and dental care to be provided by GDPs. This allows for resources to be re-oriented to those children in most of need of specialist care.

Commissioning of a variety of oral health preventative programmes and initiatives at a local level may have contributed to the reduction in dental hospital episodes and prevalence of child dental caries. These programmes include targeted fluoride varnish schemes, supervised toothbrushing programmes in early years, training of the wider healthcare workforce and targeted provision of oral hygiene aids. Given the complex context of preventative programmes and the multi-factorial causes of tooth decay, it can be difficult to estimate the potential effectiveness of each intervention (dietary interventions, fluoride interventions, etc) on the reduction in dental hospital admissions. Another potential explanation is the impact of the ‘Soft Drinks Industry Levy’ or ‘Sugar Tax’ that was launched in 2018, which may have had a preventive effect on child population’s oral health. It is evident that there is a positive association and dose–response gradient between the consumption of sugar sweetened beverages and dental caries.¹⁶

The predicted variation in hospital admissions could be partially explained by IMD and age, highlighting that dental caries is determined by wider social and economic factors as well as access to health services. There are additional factors that need to be considered when understanding this variation. A rapid review of variation in the use of dental GAs in children conducted was by Broomhead et al in 2020, which found variations in standards of service provision and sociodemographic factors as key predictors to dental GAs, including age, ethnicity and culture, level of deprivation and geographical location.⁷

Implications

This study has highlighted the importance of tackling health inequalities in the context of wider social determinants. General anaesthesia is the end point of poor oral health and when dental diseases are largely preventable.

Efforts around prevention need to be focused on the early years as emphasised by the Marmot Review by giving every child the best start in life.¹⁷ The first 1000 days of life from conception to year two is a critical period which will impact on children’s development and health outcomes into adulthood.¹⁸ Interventions during the early years increase opportunities for children and families to lead healthier and prosperous lives. Riskier health behaviours such as high sugar diets and poor oral hygiene practices, resulting in poorer health outcomes, are largely influenced by social environments and structural determinants of health (eg, living conditions, wealth distribution and employment).¹⁹ To address child oral health inequalities, a range of public health actions are needed by integrating oral health into public health initiatives using principles of proportionate universalism.²⁰ Achievements in good oral health cannot be achieved by working in silos but working in collaboration with multiple sectors (health, education, social care) focusing on prevention.¹⁹

Equitable access to care

Everyone should be able to access dental care that should be delivered proportionate to the level of need. To better understand the experience of current services, engagement is needed with the patients, service users and providers. Future service development needs to consider how to prioritise and facilitate access to care for those child populations experiencing the highest burden of disease.

Study limitations

The data charts have all been produced using HES data collected from NHS Digital. It only captures children who had a hospital admission due to dental caries and does not account for the care that has been provided. Assumptions have been made after discussions with paediatric dental specialists that children admitted to hospital due to dental caries were likely to have had single or multiple dental extractions under GA (rather than restorative treatment). It was not possible to analyse unique patient episodes from the data presented. It is therefore not possible to calculate the number of children requiring repeat admissions due to dental caries. Those children having a previous dental GA have been found to be at higher risk of subsequent dental procedures under GA. One study from Northern Ireland found 23%–31% of these children requiring further GA, those aged 4 years and below were at the highest risk.^{21 22}

A proportion of children treated under GA is provided by CDS. This data is not always captured on HES due to differing commissioning structures and data arrangements. Data presented in this paper therefore may be an under-representation of the burden dental caries on secondary are NHS services, particularly for procedures under GA.

No data was reported on the correlation or influence of ethnic group on child hospital admissions. This was due to the absence of reliable data on ethnicity.

This paper did not analyse other confounding factors for child dental hospital admissions such as patient relating behaviours, parent related factors and clinical related behaviours. Furthermore, the data analysis focused on the London region alone and geographical factors such as commissioning structures and population demography may impact on the generalisability of findings.

Conclusion

London has experienced a year-on-year reduction in hospital admission due to dental caries. This is likely due to various factors including effective prevention interventions, an effective paediatric care pathway, increased inhalation sedation provision and changes in referral behaviours. Children residing in deprived areas are disproportionately experiencing higher rates of hospital admissions due to dental caries.

While there has been a reduction in total numbers of children, those from the most deprived areas are still experiencing an unfair, disproportionate burden of both higher prevalence of dental disease and higher hospital admissions. Sociodemographic factors are key predictors for hospital admission for children with dental caries. While health service level changes may reduce the number of hospital admissions, persistent child oral health inequalities continue to exist.

Data availability statement

No data are available. The raw data is not in the public domain. Access was granted by the Office for Health Improvement and Disparities in DHSC.

Ethics statements

Patient consent for publication

Not applicable.