Plenty to smile about
It is nearly a decade since the Dental Action Plan laid the foundations of what has become the hugely successful Childsmile programme in Scotland.
Since that time, there has been a dramatic improvement in the oral health of primary school children in Scotland, with the latest figures showing 68 per cent of P1 pupils with no obvious decay experience, up from 51 per cent in 2004.
Graham Ball, Childsmile director and chair of the national dental epidemiology co-ordinating committee, which co-ordinates the National Dental Inspection Programme (NDIP), welcomed the latest results for the dental health of five-year-old children and emphasised the substantial progress seen since the programme began in 1988.
He said: “We still have more work to do – a substantial proportion of children still start school having experience of dental caries.”
Speaking during the recent Childsmile Symposium at the Beardmore Hotel in Clydebank, Childsmile director Professor Lorna Macpherson insisted that those within the programme were not getting complacent.
She said: “If you look at where we have got to with regards to the NDIP stats over the last 10 years, I think the health improvement we have seen has been wonderful.
“But, as with any programme, you don’t want to rest on your laurels and think you can’t do anything differently. We now need to look at the fact that the improvements are maybe slightly tailing off, so we need to look back and reflect on what more we perhaps could do to continue this improvement of our children’s oral health in Scotland.”
Professor Macpherson explained that, while oral health is improving, inequalities still persist and the programme aims to tackle this in the future.
She said: “We are still not seeing as much of a reduction in inequalities as we had hoped. It is maybe quite early days yet, but that is very much the direction of travel required in terms of the strategic direction of the programme as a whole.”
She said that this focus on inequalities was one of the reasons Professor Richard Watt was invited to give the keynote address at the symposium. “His area of expertise is in approaches to tackling inequalities and understanding the social determinants of health. We feel that the guidance and the information he has given us can help with regard to developing our strategies for Childsmile into the future.”
Professor Watt graduated from Edinburgh in 1984 and is currently a professor of dental public health at University College London. His professional focus is on health inequalities in general and how oral health fits into that.
He said: “For me, as an observer of the programme, the biggest challenge for Childsmile is this notion of how to really tackle health inequalities within Scotland.
“The overall levels of disease are improving, and that is important, but inequalities by deprivation are still a major problem. To achieve an improvement in that means different things need to be done, and that is really the message that needs to get across.”
David Conway, senior lecturer in dental public health at the University of Glasgow Dental School, took up the theme of tackling inequalities: “The gradient is not shifting – those from the poorest backgrounds have the most decay and we need to make sure we have our eye on that ball and are focused on targeting that.
“We are looking at all the levers that are at our disposal in terms of policy, regulation, food in schools, even fine-tuning the dental contract to make sure that has been addressed and making sure clinical prevention can be fully implemented in practices – that fluoride varnish applications in nurseries and schools are as effective, targeted and resourced as possible.
“We need to look at all the components and make sure they are delivering and tailored towards those who have the greatest need.”
In terms of the future direction of Childsmile, the team is looking to move towards a more ‘upstream’ approach. Professor Macpherson explained: “In the past, I think there has been a tendency for us to concentrate more on the downstream, clinical preventive types of approaches, the one-to-one approaches. I think we need to move more upstream now, which is doing more with regards to advocacy and influencing policy development at national and local levels.”
Rather than focusing solely on dental specific policy areas, Professor Macpherson said they have identified areas such as sugar policy and the work the Government has been doing on school meals as areas they could have an ongoing influence.
But, as well as the upstream elements, the community – or midstream – approach will always be fundamental to how Childsmile works and how it develops into the future.
Professor Macpherson explained that the plan is to improve engagement with local communities and involve them more in the decision-making process. “Rather than a top-down approach, with professionals saying ‘this is what you should be doing’, it should be more about understanding the environments in which people are living and helping to support them with regards to environmental change. It shouldn’t just be education. If we can help them through community engagement and development, I think it will be more sustainable into the future,” she said.
Another key element that plays into the long-term planning of the Childsmile programme is that it is now actually showing economic benefits on a national scale. A cost analysis carried out by the University of Glasgow on the national nursery toothbrushing programme has shown that it is now saving money. David Conway said: “Not only is the toothbrushing programme improving health, there is also a big economic preventive spend associated with that.
“So, yes it costs money – it costs just under £2 million a year, every year, to do the toothbrushing programme – but we have savings now of more than £4m per year. We have done a detailed analysis with health economic experts and we are due to publish that in a peer-reviewed journal.”
However, Scotland’s Chief Dental Officer Margie Taylor, while being very impressed with the economic benefits, insists the advantages to the children are more important.
She said: “The economic evaluation showed that we not only save money, we also save the children having to go through all the treatment that would otherwise have been required and along with that, the inconvenience, time off school and all that sort of thing, so there is a wider benefit than saving money – it is the benefit to the child.”
View from the front line
Following the news that there has been a dramatic improvement in the oral health of children since the launch of Childsmile, we contacted two dentists to ask what they think.
Childsmile was launched almost a decade ago and the latest figures show that 68 per cent of primary 1 pupils have no obvious decay experience.
Gavin Balfour, from King Street Dental Practice in Aberdeen, said: “When it was first launched, it was quite confusing. It was over-complicated in the way it was broken down and there was a hurdle to get over in terms of training the staff and understanding it all.
“However, it has worked and made a difference and it’s especially good that it’s been rolled out in nurseries and primary schools. It’s quick and easy to do and it has definitely raised awareness. Parents and children come in now and when I’m putting the Duraphat on, they recognise it from school.
“I still think the people who need it most are missing out – there’s a lack of awareness in disadvantaged families and there’s still an area of the community that it’s not reaching, perhaps even the ones we’re tryin
g to target the most. It’s not a magic bullet. It has helped, but there is still work to do in providing the public with more knowledge. It’s a step in the right direction.”
Agnes Swinfen, from D.L. Swinfen Dental Practice in Blantyre, said: “I think Childsmile has been very successful. Previously, especially in this area, people left it until age five to bring their children to the dentist and quite often their first visit was because they were in pain.
“The attitude used to be that it was only the deciduous teeth, but because of Childsmile, parents are now more aware that it’s important to keep the deciduous teeth in place for the adult teeth to come in in the right position.
“Childsmile has made such a difference in the more deprived areas, too. This is down to the nurses. Before Childsmile, if families failed appointments, they wouldn’t get seen again, but now I can report that to the Childsmile co-ordinator and she’ll look into it. There are some people whose health visitors are still having to chase them up and if it wasn’t for the Childsmile programme, I think these children would be missed.
“A lot of people think that Childsmile was a waste of money, but it’s not, because without the back-up of these people, the patients wouldn’t be coming into the practice with their children.”