Neighbourhood school environment and dental care needs amongst 5-to-11-year-old children attending a local dental facility in South-East England

In the period 2019–2020, tooth extractions accounted for 14.3% of all clinical treatments provided to children within the primary dental care sector of the National Health Service (NHS) in England (NHS Digital 2020). Tooth extraction is an undesired treatment option for dental caries. Generally, preventive and restorative measures are preferred to maintain a natural dentition for as long as possible (Public Health England et al. 2021). Often, children who have extensive untreated tooth decay will require speciality care for extraction of single or multiple teeth under general anaesthesia (GA) or sedation within hospital services (National Health Service 2020). This is challenging for parents and children and costly to the NHS. In 2019–2020, a total of 55,137 completed consultant episodes were recorded for tooth extractions in children and adolescents aged 0 to 19 years in NHS secondary care hospitals in England (Public Health England 2020a). Approximately 64% of these extractions were related to untreated dental caries (Public Health England 2020a). Untreated dental caries is also associated with geographical inequalities. Despite the free dental care provision within the NHS (2021), the highest rates for tooth extractions have been consistently observed amongst children living in the most disadvantaged regions and localities within England (NHS Digital 2020; Public Health England 2020a).

Children living in deprived neighbourhoods are four times more likely to undergo tooth extractions as compared to those living in affluent communities (Public Health England 2020a, 2021). These patterns mirror the dental caries prevalence through routine national surveys and also with the patterns observed in the uptake of care (Wanyonyi et al. 2016; Wanyonyi et al. 2013; Public Health England 2018a, b, 2019, 2020b). Although, there is considerable evidence that verifies the link between where an individual lives and their dental health (Jamieson et al. 2013; Wanyonyi et al. 2016; Wanyonyi et al. 2017), exact mediators of this relationship remain underexplored. Authors suggest that the unequal distribution of mediating socio-environmental factors, including neighbourhood deprivation, level of urbanisation and distance from dental services, could explain these patterns (Pattussi et al. 2006; Cabral et al. 2015; Nobrega et al. 2017; Peres et al. 2019).

Schools are one of the social environments of interest and have been an important setting for promoting various oral health interventions such as the prevention of excessive sugar consumption, supervised tooth brushing with fluoridated toothpaste and routine dental check-ups (Public Health England et al. 2021). Children spend a large amount of time in schools, where they use facilities such as school canteens and snack centres accessing sugary foods, a risk factor for tooth decay (Sheiham and Watt 2000; Moynihan and Kelly 2014). To a lesser or greater extent, they are supervised by teachers and staff which may have an influence on their sugar consumption (World Health Organisation 2015; Moynihan 2016). This influence can be a result of various school-related factors such as quality of education, teachers’ support and involvement in pupils’ development, pupils’ academic attainment, school-based health policies and school governance.

A few studies have linked some aspects of the school environment to dental health. da Franca et al. (2020) suggested that a favourable school academic climate, as defined by higher educational aspirations of students, is linked to tooth loss prevalence amongst adolescents. These results are in line with other research suggesting a causal link between the duration of school education and tooth loss in later life (Matsuyama et al. 2019). Moysés et al. (2003) proposed that the comprehensiveness of the school curriculum and school support are associated with the percentage of caries-free children. Whilst food policies and interventions are endorsed by the school leadership and management, support offered by teachers have shown to shape children’s dietary behaviour, and therefore significantly influence their dental health (Maliderou et al. 2006; Freeman and Oliver 2009; Carvalho et al. 2014; Thornley et al. 2017; Marshman et al. 2019; Samuel et al. 2020). Although the individual impacts of various school-level determinants on child dental health have been explored previously, the collective influence of all these determinants on advanced treatment needs such as tooth extractions remains unexamined.

This study explores the hypothesis that the school environment extends to the geographical environment and contributes to the disparity in dental needs in small geographies, in this case, as demonstrated by the need for advanced dental treatment in the local dental facility. This assertion is supported by the understanding that in England, children live and attend schools within a 3-mile radius (Department for Education 2014). Therefore, it is highly likely that children living in deprived communities attend schools in deprived areas. Studies have shown that school location is important in relation to child dental health. Rajab et al. (2014), revealed that the children attending schools in disadvantaged areas of Jordan had higher dental caries prevalence than those going to schools in affluent areas. Edasseri et al. (2017) recorded a similar association in Quebec. With this in mind, the overall aim of this study was to investigate the relationship between school environment within neighbourhoods in a Local Authority (LA) in South-East England and the dental care needs of 5 to 11-year-old children attending a primary dental care facility in the area.

This research involved secondary analyses of cross-sectional and open-access data (Thyer 2009).

This is the first study to our knowledge, to determine the influence of neighbourhood school environment on small-area level inequalities in children’s tooth extraction rates using NHS patient management and Ofsted OES data. The findings suggest that tooth extractions are associated with patients’ age and neighbourhood level school overall effectiveness score derived from Ofsted scoring, but not with the patient’s gender or area-level deprivation scores. Whilst the predictive relationship between age and tooth extraction is representative of a national trend (Public Health England 2020a), the relationship between schools OES scores and dental extractions within a neighbourhood proposes a pervasive impact of a school on a child’s dental health right to the home environment.

This research has four important strengths. First, the study involves the use of validated and published data on patient management (Wanyonyi et al. 2017, 2019), which helps to avoid patient recall and selection biases (Hennekens et al. 1987). Similarly, Ofsted inspects all state-funded primary schools of various types (Office for Standards in Education 2020). Therefore, these data provide a complete picture of the primary educational environment within England and reduce selection bias (Hennekens et al. 1987). Second, the study has considered primary school-age children only. Exclusion of the secondary school-age population has allowed the investigators to minimise the confounding effects occurring due to other influencing factors such as peer pressure. Third, this study examines the overall school environment at the neighbourhood level rather than analysing individual school influence on dental health. This enhances the relevance of the study in understanding area-level inequalities in child dental health. Last, the use of weighted OES variable accounts for the different number of schools per MSOA and the different number of pupils per school (Buckley and King-Hele 2014).

However, we also acknowledge a few limitations. First, data were analysed based on an assumption that children attend a nearby school located within their MSOA of home residence. The UPDA data contains information on LSOA codes of patients’ residences, but no such data have been collected about paediatric patients’ schools. However, statutory walking distance regulations within England mean that children are more likely to attend the schools nearby their residence (Department for Education 2014). Second, data did not contain information on patients’ baseline oral health, their chief complaints, or history of previous dental treatments, which restricted a deeper understanding of causal pathways of tooth extraction. Even so, the UPDA data, representing patients’ expressed and normative needs, were proven valuable in understanding disparities in child dental health as they contained information on children’s area of residence contrary to the national data (Office of National Statistics 2015). Last, whilst this research did not investigate individual school influence, it is possible that schools of outstanding and inadequate rankings simultaneously exist within an area. However, the use of area-level variables can help recognise the average school environment within a particular area.

Interestingly, area deprivation was not a significant predictor of tooth extraction in this study. Whilst the previous study based on UPDA adult patient data revealed a significant relationship between tooth extraction and area deprivation (Wanyonyi et al. 2017), the present study involved paediatric patients aged 5 to 11 years. Additionally, the p-value could have been affected by the small sample size (Thiese et al. 2016). All IMD quintiles were not represented in the sample population. No patients belonged to quintile 2. Also, the proportion of patients belonging to the most deprived quintile was only 3.5%, whereas 48% of patients belonged to the least deprived quintile. However, this reflects the national pattern of dental attendance, where the proportion of the individuals from the most deprived quantiles (14.5%) attending the dental service is smaller compared to those from the less deprived areas (90%) (Wanyonyi et al. 2013). Such a pattern in healthcare access, described as the inverse care law, has been persistently observed across England (Gulliford and Morgan 2003; Petti and Polimeni 2011; West Sussex City Council 2018). It can be further argued that the poorest access levels of those belonging to the lowest quintiles could have been the result of children of these groups getting care in the local hospitals rather than in the primary care facilities such as the UPDA. This assumption indicates higher unmet dental needs and far more severe dental health conditions amongst children belonging to the lowest quintiles. This explanation is further reflected in the national data confirming the significant association between the IMD quintiles and hospital tooth extraction rates (Public Health England 2020a, 2021).

This research has several implications. First, it signifies the role of the neighbourhood school environment in understanding geographical inequalities in child dental health. Second, this study confirms the usefulness of the Ofsted OES in dental research. Third, it highlights the need to maximise the use of and enhance the quality of school performance and dental outcomes data to further understand and monitor dental health inequalities. Information on small area characteristics related to children’s homes as well as schools should be routinely collected and openly accessible to the researchers to enable further progress in this research area. Fourth, policymakers should consider promoting and facilitating equal opportunities across all schools to tackle inequalities in child dental health. Fifth and final, further research is required to test the efficacy of the school OES in predicting child dental outcomes at the national level.

A school overall effectiveness score, although a contextual measure, remained a significant predictor of tooth extraction in our study when controlling for individual predictors of dental health. The findings confirm the influence of the neighbourhood school environment on child dental health. Further research is required to assess the role of the neighbourhood school environment in predicting child dental health at the national level.