Childsmile’s lesson of hope
Scotland’s oral health initiative for the young has been a major success.
The project’s director, Lorna Macpherson, explains why and offers Irish dentists support in their quest for a similar strategy
It’s critical that we get a hold on the scale of the problem, and that we provide solutions for children in Ireland. When you consider the effects that dental decay has upon a developing child, the need for adequate prevention and treatment is overwhelming.”
Writing this in the last edition of Ireland’s Dental, Dr Brett Duane and Dr Kirsten FitzGerald starkly underscored the profession’s continuing concern and frustration at the extent of the “tooth decay epidemic” afflicting the young and the lack of concerted action on children’s oral health.
In their article, Dr Duane, associate professor in dental public health at Dublin Dental University Hospital (DDUH), and Dr FitzGerald, consultant paediatric dental surgeon at Our Lady’s Children Hospital, Crumlin, highlighted, as they had at an Irish Dental Association seminar last year, the introduction of the Scottish Government-funded Childsmile scheme as an example of best practice that could and should be replicated in Ireland.
Having worked in Scotland earlier in his career, Dr Duane has first-hand knowledge of an initiative that has not only reduced the prevalence of decay by almost a third in a decade, but also saves the NHS up to £5 million a year.
The clamour for change in both the Republic and Northern Ireland was in the headlines again recently when the British Dental Association Northern Ireland threw its support behind calls from the NI Assembly for fundamental reform of an oral health strategy “well past its sell-by date”, as new analysis showed extractions of multiple teeth among under-18s could be costing the health service more than £9 million a year.
The BDA welcomed calls from MLA Roy Beggs for authorities to revisit the approach to oral health strategy across Northern Ireland, and to learn vital lessons from the Scottish Childsmile initiative and a dedicated programme in Wales.
It was against this backdrop of widespread concern that Professor Lorna Macpherson (pictured below), director of the Childsmile programme, was invited to address the Irish Society of Dentistry for Children annual scientific meeting in Portlaoise, Co Laois, and deliver an overview of the successful campaign, which started as a pilot in 2006 and has been delivered throughout Scotland since 2011.
Speaking to Ireland’s Dental, Prof Macpherson said Childsmile could hold valuable lessons for other countries, including the Republic and Northern Ireland.
Outlining her thinking, she said: “If any country is considering a programme like Childsmile, the first thing to do is make sure it is context specific. That means understanding what the problem is, what programmes are already in place and the infrastructure you can build on, which, naturally, will be different in every country. For example, parts of Ireland already have water fluoridation, so that would need to be taken into account from the start.”
In Scotland, she said, it had been decided to have a multi-agency approach, and preparations for Childsmile began with an assessment of how to utilise nurseries, schools, the health visiting system and community groups, as well as general dental practice.
Notably, Childsmile follows the “common risk factor” method recommended by the World Health Organisation. That puts the emphasis on integration and co-ordination across health issues. For example, sugar is not only a risk factor in oral health and multiple tooth decay, it has major implications in issues such as obesity. Accordingly, it’s important for agencies to work together on sugar control, for example, advocating for policies such as a sugar tax.
“This approach can make the biggest difference because it has the biggest reach,” she explained. “Plus, it means the cost of tackling the problems doesn’t simply come out of the dental health budget.”
She pointed out that success depends on long-term financial commitment from the government and that it’s vital to continually monitor progress.
“Our system of process evaluation is constant.
We regularly speak to people on the ground, such as nursery teachers and health visitors and ask them if the programme is working for them. If not, we try to find out why. We tweak the programme according to the information we receive and then monitor again once changes have been made.
“Childsmile is evolving and developing all the time. Learning from your mistakes is essential.”
The Childsmile programme to improve children’s oral health and reduce inequalities in dental health and access to dental services is funded by the Scottish Government. It started as a pilot in 2006 and has been delivered throughout Scotland since 2011.
As part of the programme, every child in Scotland should have:a tailored programme of preventive care within primary care dental servicesfree daily supervised toothbrushing at nurseryfree dental packs to support toothbrushing at home.
The programme also helps to develop national strategies and regulations relating to diet
Prof Macpherson believes this programme has encouraged new thinking among dentists and the dental team. In the past they might give advice on sugar, simply telling patients to cut down their intake. However, now they are aware that achieving a balanced diet can be a challenge for those who have restricted financial resources or no easy access to healthier foods. If dental teams understand what the issues are at an individual family level, they can tailor their support. Similarly, Childsmile has an advantage in that the NHS payments system allows the government to more directly influence the behaviour and priorities of general dental practice. In other countries, however, insurance companies have a greater role in the health system and they don’t always have the same aims as authorities and policymakers.
Prof Macpherson pointed out that, though it has helped to deliver some significant steps forward, Childsmile has yet to have a major impact among the country’s poorer communities. Indeed, the Scottish government has recently produced a new action plan for oral health that aims to address persistent issues.
“We recognise that we need to do a lot in the more disadvantaged areas,” she said. “Among other things, we will be asking people in communities for their views and working with local organisations to take forward oral health initiatives.
Childsmile has helped to reduce tooth decay significantly since it started as a pilot in 2006
Every newborn child in Scotland is linked to Childsmile. Health visitors see all children and their parents/carers regularly between birth and the age of five, providing advice and practical help on oral health, as well as making a referral to dental health support workers where appropriate.
There is a supervised toothbrushing programme for three and four-year-olds attending nursery, and for at least 20 per cent of five and six-year-olds in schools in areas of high deprivation.
To promote home brushing, up to the age of five, every child is regularly provided with a dental pack, containing a toothbrush and a tube of 1450 F toothpaste.
Children aged three to at least eight living in the most deprived areas are given an application of fluoride varnish.
Children are encouraged to attend primary care dental services and the dental team provides a tailored programme of preventive care. Extended duty dental nurses in dental practices are trained in oral health promotion and fluoride varnish application.
A compelling record of major improvements
Childsmile has been associated with major improvements in child dental health.
The National Dental Inspection Programme data show substantial improvements in dental health for both five- and 11-year-olds.
In 2016, more than two-thirds (69 per cent) of five-year-old children had no obvious decay experience in their primary teeth in 2016, compared with 45 per cent in 2003.
Similarly, the mean number of decayed, missing and filled primary teeth has gone from 2.76 in 2003 to 1.21 in 2016. For 11-year-olds the percentage of those showing no obvious tooth decay has risen from 53 per cent in 2005 to 77 per cent in 2017.
A recent study* has shown the estimated annual savings in dental costs to the NHS, which range from £1.2 million in 2003/04 to £4.7 million in 2009/10.
However, inequalities in child dental health remain – only 55 per cent of five-year-olds in the most deprived areas have no obvious decay compared with 82 per cent in the least deprived areas.
As a result, a new national Oral Health Improvement Plan was published by the Scottish Government in 2018, which sets the future direction for expansion of the programme.
*Anopa et al 2015
The case for special treatment
Ten years ago, the Irish Dental Association warned the government that three in four Irish children had experienced tooth decay by the time they reached the age of 15. Last year there were headlines that 50 per cent of children have tooth decay by the age of five. And that’s a figure that paediatric dentist Dr Rose-Marie Daly thinks is underestimated, as she is continuing to see dental decay in young children on a day-to-day basis, writes Tim Power.
In the years since she set up her first paediatric practice in Kerry in 2010, and now recently relocated to Dublin, she said that very little has changed: “I’m coming across very young children with dental decay every day of my working life so, in my experience, the incidence of children’s tooth decay is certainly not reducing.
“Unfortunately, Ireland’s Public Dental Service is not getting to children early enough, so by the time they are seen for the screening at around seven years old the damage is already done. It’s like closing the barn door after the horse has bolted.”
Dr Daly started her studies in dentistry at University College Cork and, after working in various dental health settings, completed her specialist training in paediatric dentistry at the Leeds Dental Institute in the UK.
She was awarded a fellowship in paediatric dentistry from the Royal College of Surgeons of Ireland and worked as a consultant in paediatric dentistry for more than seven years at the Bon Secours Hospital in Tralee, Co Kerry, before moving to Dublin to establish Northern Cross Dentistry for Children.
As a passionate advocate for children’s oral health, she said there was plenty of evidence
to support the need for a national programme on early intervention, such as the Childsmile initiative used in Scotland.
She said: “The Childsmile programme provides the evidence that shows it has reduced the dependency on general anaesthesia to remove teeth, so it clearly means that resources can be used in much more effective ways.
“But we have our own studies from Cork Dental Hospital to show that when you provide proper preventive care for children it’s eight times cheaper than waiting for a problem to develop and then having to send them to hospital to have their teeth taken out.
“We’ve got to see children at an early age, at least 12 months, and to support this intervention by giving parents appropriate preventive oral health advice about diet, fluoride and cleaning.”
To make this effective, Dr Daly argues for paediatric dentistry to be recognised as a specialism in Ireland by the Dental Council.
She said: “In Ireland, the case for treating children well can only be furthered by advocating for specialist recognition for paediatric dentistry.
“If you are going to see children early, you need to have dentists that not only have the specialist skills but the understanding of the best interests of children when it comes to their oral health planning. I believe you need specialists directing the care that children receive through the public dental system.
At the moment, it is not a specialist-led service, and that is to the detriment of the children in the service.
“We also need a national policy on what happens to children whose dentition is allowed to fall apart because extracting their teeth under general anaesthetic when they could be restored is not a modern and progressive way of approaching this problem.
It is certainly not consistent with best practice and scientific evidence-based work and also not in the interest of the child to wait until they become sick.”