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Childsmile – the national child oral health improvement programme for Scotland

Lorna Macpherson, Yulia Anopa, Jennifer Rodgers, David Conway

Childsmile is a complex public health child oral health intervention delivered in partnership with multiple agencies in many settings, with sustained Governmental funding, and an integrated evaluation.

  • Dental Practices and Community Settings:
    • Referral pathways from Health Visitors to primary care dental practices
    • Preventive focus in dental practices
    • New workforce: community-based Dental Health Support Workers
  • Nursery (kindergarten) and Primary School Settings:
    • Universal National Supervised Toothbrushing programme in nursery schools and targeted to primary schools in the most deprived communities (delivered by school staff)
    • Targeted fluoride varnish programme in nursery and schools in the most deprived communities (by Extended Duty Dental Nurses and UK regulation change
Full project description: 


Lorna MD Macpherson, Yulia Anopa, Jennifer Rodgers, David I Conway, University of Glasgow / NHS Scotland correspondence:; tel. ++44(0)141 211 9750


Childsmile is a national programme designed to improve the oral health of children in Scotland and reduce inequalities both in dental health and access to dental services. It is funded by the Scottish Government (Macpherson et al 2010). It commenced as pilots in 2006, and since 2011 has been delivered as an integrated programme in all Health Board areas throughout Scotland. Childsmile is a complex public health intervention and aims to adopt a common risk factor approach, recognising the importance of multidisciplinary and multi-settings approaches – integrating oral health with other groups and agencies.  It combines targeted and universal elements, adopting a proportionate universalism approach, aiming to provide a comprehensive pathway of care, with the intensity of support related to needs at the individual and community level. Childsmile attempts to address the social determinants of health using a combination of upstream, midstream and downstream interventions.

The programme also follows the principles of the national approach in Scotland for supporting the wellbeing of children and young people and improving outcomes by offering the “right help at the right time from the right people.” This is known as Getting it Right for Every Child (GIRFEC) and supports young people and their families to work in partnership with the services that can help them (Scottish Government 2017). 


Dental caries is one of the most common diseases of childhood, impacting on quality of life through pain, infection, diet, and loss of sleep. Caries can to a large extent be prevented, substantially improving quality of life and child morbidity.

In the United Kingdom trends in children’s dental caries declined rapidly from the 1970s to the late 1980s, attributed to the introduction and widespread use of fluoride toothpaste during this period. However, by the 1990s, these improvements had begun to slow in Scotland, with children having among the worst rates of dental decay in the UK and Europe. Inequalities in dental decay were also becoming apparent, with those from the lowest socio-economic groups bearing the greatest burden.

The Scottish Government and National Health Service (NHS) Scotland are at the forefront of child oral health improvement. In response to the trends outlined above, the government commenced funding a nationwide universal supervised nursery toothbrushing programme in 2001. 

An action plan for improving oral health and modernising NHS dental services in Scotland was published by the government in 2005 and this formed the basis for the development of the wider Childsmile programme, incorporating the established supervised toothbrushing intervention. The action plan included new investment for improving child oral health, and successive government administrations have continued to provide this funding.


The programme was designed and is evaluated using a theory-based approach.  Logic models were developed following multi-stakeholder input. These identified the evidence-based health improvement activities which in theory were considered to be associated with long-term improved child oral health outcomes. Shorter-term service- and behaviour-change intermediate outcomes which would be required to achieve the health outcomes were also identified.

It is envisaged that every child in Scotland will, from birth, have access to Childsmile.

  • At a population level, every child will have access to:
  • A tailored programme of preventive care within Primary Care Dental Services
  • Free daily supervised toothbrushing in the nursery (kindergarten) setting (aged 3-4 years)
  • Free Dental Packs (toothbrush / 1450ppm fluoride toothpaste) to support toothbrushing at home.

Directed support targeting children and families in greatest need through:

  • Community interventions involving home visits and links to public health nurses and community agencies and third sector organisations via dental health support workers;
  • Clinical preventive programmes, involving fluoride varnish application, in priority* nursery and primary schools by extended duties dental nurses (age 3-8 years);  
  • Daily supervised toothbrushing in primary 1 and 2 classes (age 5-6 years) in priority* primary schools.

* priority nursery / school settings defined by children being from the most socioeconomically deprived communities.

Additionally, as part of a more upstream approach to health improvement, the programme is involved in advocacy for and involvement in development of national strategies and regulations relating to diet and nutrition.

Figure 1           Childsmile Oral Health Pathway - illustrates the Childsmile’s distinct but integrated components, which extend from birth to adolescence.

Project location

The project is a nationwide programme implemented in all health board areas in Scotland. It is delivered in multiple health, education, and community settings.

Evaluation type: self evaluation / external evaluation 

A strength of the programme is the integrated theory-based evaluation, led by the University of Glasgow, in collaboration with Childsmile stakeholders, and other academic partners, funded by the Scottish Government. This work is underpinned by a logic model and robust national data monitoring systems (including a bespoke Childsmile IT system developed by University of Dundee Health Informatics Centre (HIC)). The evaluation research includes: i) a pioneering big data linkage project – linking multiple routine administrative national health and education datasets to create a birth cohort to evaluate the complex multiple interventions of Childsmile with the range of service and health outcomes; ii) an in-depth multi-faceted process evaluation – assessing the barriers and facilitators to the delivery of Childsmile programme and its components; iii) an economic evaluation – investigating the cost effectiveness of the programme and its components; and iv) an embedded randomised control trial of the nursery fluoride varnish programme – Protecting Teeth @ 3 trial (Wright et al 2015).  


Child Oral Health Improvement: The National Dental Inspection Programme (NDIP) data show substantial improvements in dental health or both 5- and 11-year-olds over time (NDIP 2017). More than two thirds (69%) of 5-year-old children had no obvious decay experience in their primary teeth in 2016 (d3mft=0) (Figure 3). This is a large improvement in comparison with 45% back in 2003, when NDIP started. There has been a parallel continuing decline (improvement) in the mean number of decayed, missing and filled primary teeth from 2.76 in 2003 to 1.21 in 2016. Similar improvements are observed for 11 year olds – data from the latest survey demonstrates a decade of improvement from 53%with no obvious tooth decay in 2005 to 77% in 2017; and the mean D3MFT decreased from 1.29 in 2005 to 0.49 in 2017.

Figure 3           Trends in the proportion of 5 year olds with no obvious decay experience (dmft=0).

Nursery Toothbrushing:

A Scotland-wide population study aimed to assess the association between the roll-out of the Childsmile national nursery toothbrushing programme and a reduction in dental decay in five-year-old children (Macpherson et al 2013). Figure 4 shows that before the start of the nursery toothbrushing programme (time, t = 0) the mean d3mft was increasing, and only after the programme commenced, did the mean d3mft begin to decrease. The results of the same study also showed that the slope of the uptake in toothbrushing was correlated with the slope in the reduction of d3mft (correlation = -0.64; -0.86, -0.16; p = 0.011). Thus, the improvement in the dental health of 5-year-olds was associated with the uptake of nursery toothbrushing. 

Figure 4         Mean d3mft for 5-year-olds in Scotland in relation to commencement of nursery toothbrushing

Health Economics of Nursery Toothbrushing: 

A recent study compared the cost of providing the Scotland-wide nursery toothbrushing programme with associated National Health Service (NHS) cost savings from improvements in the dental health of 5-year-old children: through avoided dental extractions, fillings and potential treatments for decay (Anopa et al 2015).

The study showed that the estimated cost of the nursery toothbrushing programme in Scotland was around £1.8 million per year. The estimated cost of dental treatments in the baseline year 2001/02 was just under £8.8 million, while in 2009/10 it was around £4 million. In 2002/03 the costs of dental treatments increased by 2.4%. However, in the following years the costs decreased dramatically with the estimated annual savings ranging from £1.2 million in 2003/04 (14% of costs in 2001/02) to £4.7 million in 2009/10 (54%). The 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 (Figure 5).

Figure 5           Annual cost of nursery toothbrushing programme and costs / expected savings resulting from actual and anticipated dental treatments in comparison with 2001/02 dental treatment costs.

Ongoing Challenges:

Health inequalities remain a significant challenge. Figure 6 shows data from the NDIP report – the proportion of five-year-old children with no obvious decay experience by the Scottish Index of Multiple Deprivation (SIMD) quintiles (NDIP 2017). Quintile SIMD1 is the most deprived and quintile SIMD5 is the least deprived. Despite improvement in all groups, there are clear and persistent inequalities in child dental health over time, with only 55% of 5 year old children having no obvious decay experience in the most deprived areas compared with 82% in the least deprived areas. 

Figure 6           Proportion of Primary-1 children (five-year-old) with no obvious decay experience in Scotland by SIMD quintile



The Childsmile programme has had significant achievements and been associated with major improvements in child dental health over time. However, socioeconomic inequalities persist, with children from the most deprived backgrounds bearing the greatest disease burden. A new national Oral Health Improvement Plan has recently been published (Scottish Government 2018) and sets the future direction for the programme to expand.

The future direction of the Childsmile programme includes: i) optimising the delivery of the existing programme through lessons learned from the evaluation, this will include a focus on vulnerable groups (e.g. children looked after by the state; McMahon et al 2017); ii) further community development work, this will include further work with the third (NGO) sector, social prescribing / linking with ongoing community-based initiatives; iii) influencing policy and programmes (“upstream”), including common risk work as part of the Non-communicable Disease (NCD) agenda (e.g. obesity / sugar strategy).


Anopa Y, McMahon AD, Conway DI, Ball GE, McIntosh E, Macpherson LM (2015). Improving child oral health: cost analysis of a national nursery toothbrushing programme. PloS one, 10(8), p.e0136211.

Childsmile (2011). Incorporating Childsmile into the SDR. NHS Health Scotland (Accessed Feb 2018).

Childmile (2015). National Standards for Nursery and School Toothbrushing Programmes. NHS Health Scotland (Accessed Feb 2018).

Macpherson LM, Ball GE, Brewster L, Duane B, Hodges CL, Wright W, Gnich W, Rodgers J, McCall DR, Turner S, Conway DI (2010). Childsmile: the national child oral health improvement programme in Scotland. Part 1: Establishment and development. Br Dent J 209(2):73-8.

Macpherson LMD, Anopa Y, Conway DI, and McMahon AD (2013). National supervised toothbrushing program and dental decay in Scotland.  Journal of Dental Research 92(2):109-113.

McMahon AD, Elliott L, Macpherson LM, Sharpe KH, Connelly G, Milligan I, Wilson P, Clark D, King A, Wood R, Conway DI (2018). Inequalities in the dental health needs and access to dental services among looked after children in Scotland: a population data linkage study. Arch Dis Child 103(1):39-43.

National Dental Inspection Programme (2017). National Dental Inspection Programme NDIP. NHS Scotland (Accessed Feb 2018).

Scottish Government (2015) Universal Health Visiting Pathway in Scotland – Pre Birth to Pre School (Accessed Feb 2018).

Scottish Government (2016). Scottish Index of Multiple Deprivation. 2016 Scottish Government. (Accessed Feb 2018).

Scottish Government (2017) Getting it right for every child (GIRFEC) (Accessed Feb 2018).

Scottish Government (2018) Oral Health Improvement Plan (Accessed Feb 2018)

Wright W, Turner S, Anopa Y, McIntosh E, Wu O, Conway DI, Macpherson LM, McMahon AD (2015). Comparison of the caries-protective effect of fluoride varnish with treatment as usual in nursery school attendees receiving preventive oral health support through the Childsmile oral health improvement programme - the Protecting Teeth@3 Study: a randomised controlled trial. BMC Oral Health 15:160.

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