Despite improvements, dental health problems among children are
still a reality. Meredith Jones Russell looks at what is being done.

There seems to be plenty to smile about in the UK when it comes to children's dental health, as overall figures show it is improving. According to the British Dental Health Foundation (BDHF), two in every three 12-year-olds are now free of visible dental decay, compared to fewer than one in ten in 1973. However, the BDHF also suggests that a third of all children starting school have tooth decay, and many adults remain poor role models for young children, with a quarter failing to brush their teeth twice a day and the average number of fillings in over-18s reaching seven.

Poor oral health is widely agreed to increase risk of serious health complications, including strokes, diabetes and heart disease. Meanwhile, the British Dental Association (BDA) has pointed out that in some parts of the country, as many as three-quarters of children under five have suffered tooth decay, missing teeth or fillings. There is a seven-fold difference between the populations of primary care trusts (PCTs) in England with the best dental health and those with the worst.

BDA spokesperson Dr Janet Clarke believes in the '80:20 rule', that 20 per cent of children have 80 per cent of the dental disease. She says, 'It makes no sense to work in schools and nurseries where you are trying to prevent something that will never happen. We should be concentrating on targeted prevention to groups which need it most.'

National dental health programmes such as Childsmile in Scotland (see case study) and Designed to Smile in Wales aim to tackle oral health inequalities by extending their universal provision to extra, targeted programmes in early years settings in deprived areas.

Since April 2013, local authorities have had responsibility for assessing the oral health needs of their local populations across England. Dr Clarke believes that the way that dental support is commissioned explains the lack of oral health programmes in England.

'Twenty-seven area teams from NHS England now control areas that were previously split into 152 PCTs,' she says. 'A national campaign is obviously much more difficult in England because of its size. We do provide an evidence-based toolkit for dentists, which is very helpful, but what it doesn't do is provide a way of getting to parents and carers, so it's not as systematic as what is in place in Scotland, for example.'

CAMPAIGNS

Promoting the importance of good oral hygiene often falls to charity organisations, many of which actively target young children.

The BDHF set up National Smile Month in 1977 to run through May and June annually to raise awareness of oral health, especially in deprived communities. The campaign is now the largest of its kind in the UK, with 3,000 organisations, including nurseries, schools and workplaces, taking part in fun days and sponsored events.

Action for Sick Children, which runs Dental Playbox in more than 300 playgroups, nurseries and schools across the UK (see case study), says that five-year-olds who have visited the dentist regularly have fewer fillings than children of the same age who have not.

Early years settings are well placed to promote good dental health among young children and their families, but toothbrushing campaigns should form only part of their strategy. 'From our point of view, educating parents and carers about oral health is more sustainable,' says Dr Clarke, 'but there is obviously a PR value to giving out brushes and toothpaste, and certainly a child running home excitedly with a new toothbrush is more effective than simply telling parents to clean their children's teeth. You need the two things together, but really prevention is the most important thing, not just in the early years but anywhere there is deprivation and inequality.

'We're in 2014, we have all this technology and progress, and we have this disease that is preventable - but we don't know how to do it. There isn't a silver bullet apart from fluoridating water, which protects all children universally, regardless of social background, but is not yet available in all areas. Complete prevention requires lifestyle change and that's much more difficult to crack. It's part of a wider political discussion. But a multi-factor problem needs a multi-factor solution.'

CASE STUDIES

National programme: Childsmile

smile1In 2005, the Scottish Government published an action plan for dental services which included the Childsmile programme. The initiative now provides all children with a toothbrush and toothpaste on at least six occasions by the age of five, and ensures daily supervised toothbrushing sessions in all nurseries at an annual cost of £1.87m.

Childsmile director Graham Ball says, 'We see toothbrushing as the foundation of Childsmile. That is how the programme hopes to establish good habits for life. Sessions follow national toothbrushing smile2standards, so the expectation is clear, and in that way it is quite a formalised programme. But at the same time we recognise it will be slightly different in all nurseries, and we are happy for them to approach it in their own ways.'

At least 20 per cent of children in the most deprived areas in Scotland receive ongoing support for at least the first two years of primary school in the form of twice-yearly fluoride varnish applications and opportunities to receive fissure sealant applications.

smile3Mr Ball adds, 'There is an almost linear relationship between deprivation and dental health, so this facet of the programme is particularly important. This is the first regulator-approved programme of its kind in the UK. Several aspects of Childsmile are therefore quite innovative and groundbreaking.

'We have been very lucky that Scottish ministers have been so good at supporting this very long-term project, which politically can be a difficult thing to do. But we are trying to get the idea that this kind of thing happens in nurseries into the national psyche, and as the programme develops and we see research demonstrating a clear link between improved oral health and the programme, we see that is happening.'

Charity project: Dental Playbox

Dental Playbox, run by charity Action for Sick Children, provides a box of play-based activities and a resource pack with links to the Early Years Foundation Stage to more than 300 early years settings in the UK.

The programme was set up in response to concerns about the number of young children having to undergo general anaesthetic procedures because of preventable oral health issues. Children under five are unlikely to be able to have teeth extracted under local anaesthetic.

Playbox, which is free for settings, is delivered by trained facilitators, usually with an early years rather than a dental background. Project development officer Holly Dolman says this was a conscious decision by the charity. 'I think having an early years background means our facilitators can differentiate the needs of the children very well,' she says. 'Education is absolutely the most important thing, and that's really such an easy thing to fix.

'We give the children an opportunity to be very hands-on in our sessions. We give them dentist's masks, latex gloves and mirrors. A fear of dentists is often passed down through parents and a lot of lights and someone standing over you with goggles and a mask and a handful of tools can certainly be quite intimidating for us, let alone for them. We like to show them the dentist can be smiling beneath the mask.'

Local initiative: Epsom Dental Centre

chigaminDr Chig Amin from Epsom Dental Centre is one of a growing number of dentists who is spreading the word about healthy teeth by visiting early years settings. Inpired by National Smile Month, Dr Amin and a dental nurse visit settings with goody bags for the children, including sand timers and reward charts for toothbrushing, and provide play-based activities such as small-world dentist toys and a large floor map of a dental surgery.

'It's important to go into a child's environment to make them feel comfortable. I always try to wear my dentist's tunic so they get used to it. There are usually a couple who look scared initially but they usually warm up because we're there on their terms.'

Dr Amin says the visits, which he provides free of charge, are having an effect. 'We've definitely had more people registering with us since we started the nursery visits, which can only be a good thing. It's very important to engage and educate the parents as well as the children; I make sure we do talks to parents at the nurseries.'

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