Learning from 25 years of preventative interventions in Scotland
Within Scotland, there has been a long standing interest in preventative approaches. This report includes 15 case studies of successful preventative interventions introduced in Scotland since devolution and draws together overarching observations.
4. Childsmile
Childsmile: Improving Scotland’s Oral Health and Reducing Healthcare Costs
Childsmile is a national, system wide programme to improve oral health amongst children. It was introduced in Scotland in 2006. Childsmile has been evaluated and shown to have led to large measurable improvements in children’s oral health and generated significant cost savings for NHS Health Boards.
Introduction
Childsmile is an example of a downstream primary preventative intervention which involves healthcare, education, community and voluntary sector professionals working together to deliver a universal programme of advice, treatment and support with additional targeted measures.
Context
Childsmile has played a key role in the story of Scotland’s improved oral health. The change in Scotland’s oral health has come about as a result of sustained and targeted interventions that have been maintained over several Parliamentary terms.
In the early 2000s, almost 60% of 5 year olds in Scotland had visually obvious signs of tooth decay[94] and this figure had remained broadly unchanged over the previous decade. Scotland’s oral health was poorer than in many other European countries and it was widely acknowledged that, in the words of the then Deputy Minister for Health and Social Care ‘Our children have some of the worst teeth in Europe.’[95]
Scotland’s poor oral health resulted in significant short term costs for the NHS in relation to dental extractions, fillings and treatments for decay.
There were also pronounced and concerning socio-economic inequalities, with children from the most disadvantaged communities commonly demonstrating the highest levels of tooth decay.
The problem was compounded due to issues over access to NHS dental services in many parts of Scotland, with only around half of all Scottish adults and two thirds of children registered with an NHS dentist.
Response
In 2005, a Scottish Government Action Plan[96] identified the need to improve Scotland’s dental health. The plan recognised the need for early preventative intervention and the need to:
‘Ensure that children from all communities in Scotland access care regimes which emphasise the importance of good dental health and healthy eating habits from early childhood’. This required a partnership between a range of professionals and the parents of young children’.
Intervention
Childsmile developed largely from two national demonstration programmes in 2006-2008 set up in the East and West of Scotland. In 2008 these programmes were expanded into a national evidence informed Scottish Childsmile programme. The Childsmile programme continues to run across all NHS Boards in Scotland.
Childsmile is a complex public health intervention involving a large number of stakeholders with a shared goal to improve the oral health of young children and reduce socio-economic inequalities. Figure 1 below sets out the key stakeholders involved in Childsmile.[97]
A diagram which shows the full range of stakeholders involved in the design and delivery of the Childsmile intervention. The stakeholders include: NHS Boards; Primary care dental teams; Hospital dental services; Community health partnerships; Public health nursing/health visiting; Dental public health specialists; Public health nutritionists; Public Health Scotland; Community and voluntary sector; Information technology experts; Academic community; Educational professionals; Local authorities; NHS Education Scotland; Children and families; Scottish Government.
The Childsmile programme has evolved over time and is currently based around three key elements.[98]
1. Delivering a universal and targeted programme of supervised toothbrushing in nurseries and schools
The Childsmile Toothbrushing Programme is available throughout Scotland. As part of this programme toothbrushing advice and instruction is provided at all nurseries and targeted toward schools in areas of higher deprivation. The programme is designed to instil good toothbrushing habits from an early age. The programme also includes the distribution of toothbrush and fluoride toothpaste packs for home use.
2. Working with disadvantaged communities to offer oral health support to families
The Childsmile Community and Practice Programme is designed to address oral health inequalities, through embedding support workers within the more disadvantaged communities and offering oral health support to families with young children, in the family home. This involves working closely with health visitors, dental teams, Education, community groups and other partners (and includes helping families to attend dental practices).
3. Applying fluoride varnishes to children’s teeth to slow decay
Fluoride varnishes have been shown to be effective in reducing tooth decay in children.[99]
The Childsmile Community Fluoride Varnishing programme is targeted to children from disadvantaged communities. Fluoride varnishes are applied by Childsmile dental teams. Children are able to join the programme when they start nursery (from two-years-of-age) and remain in the programme, receiving six-monthly fluoride varnish applications for the duration of their time at nursery, often continuing in school.
In addition all children from the age of two are eligible to receive fluoride varnish treatments from their registered dentist and this also forms part of the Childsmile programme.
The delivery of the programme has been informed by behavioural science which has been used to introduce changes to incentivise dentists to apply fluoride varnishes and improve training and guidance for people working with disadvantaged families.
Monitoring and Evaluation
The Childsmile programme has been extensively and robustly evaluated since its outset by academics at the University of Glasgow, School of Medicine, Dentistry and Nursing[100] with funding provided by the Scottish Government.
The on-going evaluation is guided by a theory based model and includes elements of process, economic and impact evaluation. Outcomes from the programme are being investigated via a pioneering data linkage project. This involves linking multiple routine administrative national health and education datasets to evaluate the effectiveness of Childsmile in relation to short term health and educational outcomes.
There has also been a randomised control trial of the effectiveness of the nursery fluoride varnish programme.
Emerging evidence from the evaluation has been used to inform the development of the programme through, for example, better targeting interventions and improving guidance for working with seldom heard families.
Key Findings
a) Improved outcomes
The research team at Glasgow University have demonstrated via the longitudinal data linkage study that nursery toothbrushing and regular dental practice visits (two key universal elements of the Childsmile programme) were independently and most strongly associated with reduced likelihood of tooth decay.[101] Data from the National Dental Inspection Programme shows a sustained improvement in the percentage of primary school children with no obvious decay experience in the period since the Childsmile programme was implemented.
b) Cost savings
The economic evaluation of Childsmile compared the cost of providing toothbrushing in nurseries with the expected savings resulting from actual and anticipated dental treatments. The study[102] found NHS costs associated with the dental treatments for five-year-old children decreased over time. In the eighth year of the toothbrushing programme the expected savings were more than two and a half times the costs of the programme implementation.
c) Reduced inequalities
The Childsmile programme has supported a reduction in socio-economic health inequalities. Oral health inequalities are reducing and the gap between the most and least deprived quintiles of P1 children decreased from 32.2 percentage points in 2010 to 23.6 in 2024.
However, in 2024, P1 children living in the most deprived areas were still considerably less likely to have no obvious decay experience compared to those in the least deprived areas. The challenge of reducing health inequalities was acknowledged in the 2018 Scottish Government Oral Health Improvement Plan[103] which stated ‘Despite the considerable success of the Childsmile programme in improving the oral health of young children through intervention by health visitors, education staff and dental teams, it remains particularly difficult to achieve good oral health in some of our most deprived communities in Scotland’.
Learning and Next Steps
The Childsmile programme is a complex intervention involving many partners. The programme involves a mix of universal and targeted provision. It is an example of a preventative cost effective intervention that has been scaled up to be introduced across all of Scotland’s NHS Boards. Over the last 20 years the programme has continued to evolve. The Childsmile programme has resulted in considerable cost savings with the Public Health Minister claiming in 2015 that Childsmile was saving the NHS almost £5m per year in treatment costs.[104] Childsmile has contributed to an increase in the percentage of P1 children reported to be free from obvious decay experience, which has risen from 45% in 2003 to 73% in 2024.[105]
The Scottish Childsmile approach has been internationally recognised. In 2019, Childsmile was awarded a certificate of best practice by the European Commission for progress in achieving Sustainable Development Goal 3.4 “by 2030 reduce by one-third pre-mature mortality from non-communicable diseases (NCDs) through prevention and treatment, and promote mental health and wellbeing”.[106]
A 2020 a report by the Royal College of Paediatrics and Child Health, stated that oral health progress in Scotland ‘markedly’ outstripped that of England and put this down to the introduction of Childsmile. The report recommended that England should introduce a ‘preventative support programme for children and families to enable them to take up positive oral health habits’ learning from the Childsmile programme in Scotland. Since August 2013, the Scottish Childsmile approach has been adopted by a range of countries.[107]
Whilst the programme has successfully improved health outcomes the latest data from the National Dental Inspection Programme has shown a slowdown in improvements in oral health amongst children – this is likely to be related to access to nurseries and schools being reduced during the Covid-19 pandemic. In 2022, as part of the national payment reform programme the Scottish Government took the opportunity to extend the scheme to older children in an attempt to address the increase in oral health inequalities that may have arisen in children and young people during the pandemic.[108]
Looking ahead, the Childsmile programme will continue to be refined over the course of this Parliamentary term in order to maximise its preventative impact and to further address inequalities. This will involve taking an intersectional approach particularly focusing on those children and their families who will most benefit from the programme.’
Contact
Email: Tom.Lamplugh@gov.scot