Childsmile is a complex, multi-sectoral intervention, using public health principles (World Health Organisation, 1986) such as the common risk factor approach, upstream, midstream and downstream initiatives and proportionate universalism. It also draws on evidence from systematic reviews (O'Mara-Eves et al., 2013; Brunton et al., 2014; Brunton et al., 2015) and clinical guidelines (Scottish Intercollegiate Guidelines Network, 2014).
There are four main components of Childsmile: the community-based
intervention involving Health Visitors, Dental Health Support Workers and other community-based groups; the dental primary care component, where members of the dental team provide preventive clinical treatment alongside tailored dietary and toothbrushing advice; the supervised toothbrushing programme where children are offered free daily supervised toothbrushing in nurseries and school; and the application of fluoride varnish to the teeth of children in
nurseries and schools, in establishments targeted by levels of socioeconomic deprivation (Macpherson et al., 2019b).
In 2006, two Childsmile demonstration projects, initially scheduled to be undertaken for three years, were launched in the East and West of Scotland (Macpherson et al., 2010a). At the end of the demonstration phase, a process to roll-out all of the Childsmile components across the whole of Scotland was undertaken and, by 2011, it was operating as a fully integrated programme within all fourteen health boards in Scotland (Macpherson et al., 2019b). The Childsmile oral health pathway (Figure 1-4) begins when the child is six to eight weeks old, with children being thereafter exposed to the different components at different stages of their pre-school years. A dental inspection occurs when the child is aged five, when they are in the first year of primary school (P1). For some children, supervised toothbrushing and fluoride varnish applications continue in targeted primary schools. Provision of advice and
clinical prevention in dental primary care should continue throughout childhood. Outwith the four main components, Childsmile also supports policy change at the upstream national level, for example, representatives of the programme formed part of a multidisciplinary group which was successful in developing healthy eating regulations for schools (Scottish Government, 2008). The formal incorporation of Childsmile into the universal child health surveillance system in Scotland (see 1.7.5.1) and the reorientation of the NHS primary care contract (see 1.7.5.2) also provide examples of more upstream activity.
1.7.5.1 Dental Health Support Workers
The benefits of utilising Health Visitors, specially trained nurses who universally visit parents with new born children throughout Scotland, in identifying children at increased risk of dental caries had previously been established (Ballantyne- MacRitchie, 2000). Training members of communities to provide oral health advice, toothbrushes and fluoride toothpaste within areas of high deprivation in Scotland has also shown positive outcomes (Blair et al., 2004; Blair et al., 2006) Capitalising on this research, within Childsmile, every child in Scotland is first linked to Childsmile via the child health surveillance programme as part of the Universal Health Visitor Early Years Pathway (Scottish Government, 2015b). Families are regularly contacted by Health Visitors from when the child is six- to eight-weeks-old, up until they are five years of age (Macpherson et al., 2019b). These contacts by the Health Visitor allow them to monitor the child’s health
and development, as well as offering health advice and signposting to an array of different services (Scottish Government, 2015b). Childsmile is formally
integrated into the child health surveillance programme, with specific guidance available to health visitors on appropriate dental advice, relative to the age of the child. There is the opportunity to dispense Dental Packs containing
toothbrushes and fluoride toothpaste, and to promote the attendance of children from a young age at a dental practice (Macpherson et al., 2019b). Health Visitors also identify families who they feel may require additional support in relation to the oral health of the child and refer these families to local community-based Dental Health Support Workers (Turner et al., 2010).
Figure 1-4: Childsmile Oral Health Pathway
Extracted from (Macpherson et al., 2015)
CHSP – Child Health Surveillance Programme; DHSW – Dental Health Support Worker; GIRFEC – Getting it Right for Every Child; P1 – Primary One; P7 Primary 7.
Dental Health Support Workers (DHSWs) are Childsmile-funded community-based lay workers (Hodgins et al., 2018). DHSWs are embedded within areas of high deprivation and offer peer support to families with young children within the family home as well as at community clinics (Macpherson et al., 2019b). DHSWs offer age-specific oral health interventions (dietary and toothbrushing advice and the distribution of dental packs containing toothbrushes and fluoride toothpaste) at the home of the family (and at community clinics), and help facilitate attendance at an NHS dental practice (‘High Street Dentist’) or Public Dental Services clinic (to be referred to collectively as a ‘dental practice’),
delivering Childsmile interventions (Kidd, 2012). DHSWs tailor the level of
support required for each child depending on the individual needs of the family. For example, a DHSW may deem it necessary to visit a family more than once before facilitating attendance at a dental practice. They may also assess the family / child as requiring additional support from them, to complement their attendance at a dental practice.
DHSWs should also interact with local community agencies and third sector organisations and can signpost and facilitate engagement with these local supportive organisations. DHSWs can work alongside these services to help embed oral health into their activities (Macpherson et al., 2019b).
1.7.5.2 Childsmile Dental Practice
From July 2006 to September 2009, dental practices participating in the
Childsmile demonstration programme in the West of Scotland were remunerated for their involvement in the programme directly from Childsmile. In October 2011, Childsmile was introduced into mainstream NHS Scotland dentistry, with remuneration payments undertaken via the Statement of Dental Remuneration, the contract by which NHS dentists are paid for their services (Scottish
Government, 2011b). This essentially meant that Childsmile was now available in every NHS dental practice in Scotland that offered paediatric services and led to the re-orientation of primary dental care to be more preventive focused.
Children, along with their parents or carers, are invited to attend a dental practice on a regular six-monthly basis, commencing during the child’s first year of life. Age-specific oral health interventions are offered which should be
tailored to the individual needs of the child. The specific interventions which now attract an NHS fee are fluoride varnish application from the age of two years, and toothbrushing and dietary advice. These interventions can be delivered by any member of the dental team who is considered trained and competent in relation to these activities. This includes Extended Duty Dental Nurses.
Emphasis is placed on moving away from the standardised ‘health education’ messages delivered in the practices and towards more individual focused and tailored messages instead. Action plans should be developed jointly by the dental team member and the family. The approach requires the dental team to
understand the social and commercial determinants that may act as barriers to families implementing the preventive approaches within their home, and to be aware of local organisations and groups that they can direct the families to when their needs lie outwith the scope of the care the dental team can provide (Watt et al., 2014).
1.7.5.3 Supervised Toothbrushing in Nursery and School
Towards the end of the 20th century, nursery toothbrushing programmes started
operating in various parts of Scotland. In 2001, a standardised national
toothbrushing programme was established with the toothbrushes and toothpaste provided by the Scottish Executive, via a national procurement contract. This programme was assimilated into the wider Childsmile programme in 2006 (Macpherson et al., 2013a). National standards have been produced and local dental teams train nursery staff to adhere to these standards (Scottish Dental Clinical Effectiveness Programme, 2010). This midstream activity is universally available to every three- and four-year-old child attending nursery (both local authority and private). By 2007, 95% of nurseries in Scotland were participating (Anopa et al., 2015). Supervised toothbrushing is also available in targeted primary schools using the same method of targeting as the fluoride varnish programme (see below) (Macpherson et al., 2019b). In both nurseries and participating primary schools, children are given the opportunity to brush their teeth, under the supervision of nursery or school staff, for a minimum of two minutes per day with 1,000 ppm fluoride toothpaste (1,450 ppm since Autumn 2016). Children are also provided with a home pack containing a toothbrush and fluoride toothpaste on at least four occasions while at nursery, with the aim of encouraging toothbrushing in the home (Macpherson et al., 2019b).
1.7.5.4 Fluoride Varnish Applications in Nursery and School
Initially trialled in the East of Scotland, fluoride varnish applications are
targeted towards children aged three- to eight-years-old attending nurseries and schools within the most deprived areas of each of the fourteen Scottish health boards (Humphris and Zhou, 2014). At least 20% of children living in each of the health boards are targeted for this intervention (Macpherson et al., 2019b). Nurseries and schools are targeted in order of those with the highest proportion of children living in the most deprived SIMD quintile within each health board.
Evaluation of the efficiency of targeting of the programme by Brewster et al. (2013) showed that to ensure that children from the most (20%) deprived SIMD areas are included in the programme, nursery schools located in the three most (60%) deprived SIMD fifths needed to be included in the programme. The
intervention involves the application of fluoride varnish to the teeth twice per year by Extended Duty Dental Nurses trained in the application of fluoride
varnish (Macpherson et al., 2019b). This process also allows for the identification of children who need further dental care within a dental practice.
The Extended Duty Dental Nurses, functioning in both primary dental care and the nursery / school setting all receive formal training from NHS Education for Scotland.