Keeping kids out of the dental chair

CHILD dental health in Scotland has seen a significant improvement which started before devolution in 1999. In 1994 only 38 per cent of primary 1 children were dentally healthy, that is free from obvious deciduous tooth decay. By 2014 this had risen to 68 per cent. For children aged about 11 years in primary 7, those free from decay in the permanent dentition rose from 52.9 per cent in 2005 to 72.8 per cent by 2013. This is typically credited to a national population-based initiative called Childsmile.

Art and science

Childsmile has a long history and is an excellent example of effective public health knowledge put into action. Dental public health has been defined as: “The science and the art of preventing oral disease, promoting oral health and improving the quality of life through the organised efforts of society”. By these criteria Childsmile can be judged a success: the science being the solid evidence-base behind the programme and the art being the incremental development of Childsmile through the political process, working both nationally and locally with education departments in local authorities.

It developed largely from two national demonstration programmes run between 2006 and 2008, which had been in the government Action Plan for Modernising Dental Services in Scotland, published in 2005. However, this action plan resulted from a 2002 consultation: Towards Better Oral Health in Children – A Consultation Document on Children’s Oral Health in Scotland.

Childsmile is funded by the Scottish Government and has four main elements which, when combined, provide a comprehensive pathway of dental care that is tailored to the needs of individual children: Childsmile Core, Childsmile Practice, Childsmile Nursery and Childsmile School. Since 2011 all four elements have been delivered in all health boards throughout Scotland, but the early development of these was incremental.

Childsmile Core

The consistent finding before the mid-1990s was that tooth decay could be found in almost two-thirds of primary 1 children in Scotland. Decay in deciduous teeth can take up to two years to develop, so to have a preventive effect, fluoride needs to reach the surface of these teeth before children are three years of age.

The Childsmile Core programme aims to provide topical fluoride to the teeth of every child in Scotland. It is available throughout the country, and every child (currently about 60,000 are born each year) is provided with a dental pack containing a toothbrush and a tube of fluoride toothpaste on at least six occasions by the age of five years.

In addition, every three and four-year-old child attending nursery (whether local authority, voluntary or private) is also offered free, daily, supervised toothbrushing. This comprehensive approach involving every child is one of the main reasons that Childsmile has been so successful. For children already brushing twice a day at home the benefit may be marginal but for those who do not brush regularly the preventive effect is huge.¹ Healthy snacks and drinks are also an important part of the programme.

Childsmile Practice

Childsmile Practice was successfully piloted among health boards in West of Scotland between 2006 and 2008. However, since October 2011 it has been integrated into the Scottish Statement of Dental Remuneration (SDR) and all practices delivering NHS care to children are expected to deliver Childsmile interventions.

Dietary advice that fosters good oral health behaviour – including information on nutrition and drinks (to prevent decay) – must be realistic and achievable. When it comes to toothbrushing, Childsmile highlights when to brush, the types of brushes and toothpaste to use, the amount of toothpaste, and methods and demonstrations where parents brush their child’s teeth to foster skill acquisition. The programme also provides fluoride varnish applications in all children over two years of age, twice a year. This is all in addition to routine dental check-ups.

The Childsmile Practice programme is designed to improve the oral health of children in Scotland from birth by working closely with dental practices. It is a universally accessible child-centred NHS dental service using a network of primary care dental service providers, both independent contractors and public dental services. Families are referred by a health visitor to a dental practice or to a dental health support worker (DHSW).

The DHSW will contact the family of children from the age of three months to make a first appointment for the child with a local Childsmile dentist and provide a link between dentists, the family and the health visitor. If required the DHSWs give additional dental health support to children and families most in need and try to get children who have been identified as not currently attending, to visit a dentist. Additional support is given to children and families most in need through home visits, community initiatives and primary care dental services.

Childsmile Nursery and School

Childsmile Nursery and Childsmile School were mainly piloted in East of Scotland health boards. The core programme includes universal toothbrushing in all nursery establishments. This is enhanced by targeting fluoride varnish applications to regions with the highest levels of socio-economic deprivation, which are the areas in Scotland where regular dental surveys have shown more children have tooth decay. Extended duty dental nurses (EDDNs) work in health boards or independent practices and provide preventive advice and regular fluoride varnish applications.

Childsmile School targets primary schools in areas with the highest levels of socio-economic deprivation and tooth decay among children. There is also daily supervised toothbrushing in primary 1 and 2 classes and regular fluoride varnish applications.

Tackling health inequalities

Childsmile follows what Geoffrey Rose called a population or universal preventive approach. There is no evidence to suggest that it has widened dental health inequalities, quite the opposite. This universal or structural approach to prevention, which does not rely on individual behaviour change, is one key lesson from the success of the Childsmile programme. The second lesson is very much simpler: the programme is properly funded.

Childsmile has succeeded but there is still a lot to do as one-third of five-year-old children still suffer tooth decay, even if less severe. This is a painful, miserable problem which can be entirely prevented. Childsmile has successfully evolved since it started and this learning approach involving all staff means the programme will continue to build, tweak and change a successful preventive formula for the benefit of the Scottish population.

What about the rest of the UK? The best advice to other countries is to first get universal nursery toothbrushing with fluoride toothpaste in place.

Dr Colwyn Jones is a consultant in dental public health and Head of the Evidence for Action Team at NHS Health Scotland

¹ Evidence supporting this approach can be found in The Cochrane Review: “Fluoride toothpastes for preventing dental caries in children and adolescents provides the evidence that supports the core programme” (Marinho VCC, Higgins JPT, Sheiham A & Logan S, 2013)