We hope our latest edition of Health Matters – on the subject of “Child dental health”– will help you and other health professionals by compiling key facts, figures and evidence of effective interventions.
Where we can, we’re also committed to answering your questions and taking on your feedback. In this blog we’ve published the answers to a number of Health Matters child dental health questions we received from professionals across the UK at the recent launch teleconference.
We’d love to hear from you at healthmatters@phe.gov.uk.
Question 1 (Oral health and central and eastern European families)
Our latest data suggests that we’ve got a deterioration in oral health in one particular district. Although one has to be a bit cautious about it given the numbers, the evidence suggests that the drop in oral health appears to be related to eastern and central European families. I have spoken to various areas in the Midlands who say similar things, but I’m struggling to find areas that can share information, translated information, information that would be useful for us to use in early years settings with parents who come from Central and Eastern Europe. I’m wondering if this forum can help?
Answer
The last dental survey of 5-year olds looked in detail for ethnicity as one of the factors and we are actually doing some more detailed multi-variant analysis on our 5-year old data, in terms of ethnicity, social deprivation and a number of other factors. Across the country, we have got consultants in dental public health in Public Health England (PHE) who might know of any of the resources that you’re talking about. We will take that forward as an action to ask our colleagues out there and we will highlight any resources that are available
Additional comment
In Sheffield we’ve got a large population of young families, particularly of Roma origin, and we have developed resources in Slovakian, particularly a fairly simple leaflet about ways to improve children’s oral health. So, we’d be very, very happy to share that leaflet, and the advice in that was all based on delivering better oral health.
Question 2 (Resources for school nursing and health visiting)
Quite a few of our commissioned services around school nursing and health visiting have raised with me that the resources they have to promote dental health in schools and children’s centres are really outdated. I was just wondering if there were any plans to create any promotional resources or information films, because I know they’ve been using an information film that has been around 20 years and we don’t have the budget on a local level to develop these?
Answer
We have some national resources that have been launched recently and we do have an information sheet that captures all of the resources. In fact, most of them are linked through the Health Matters pages but specifically relating to your query, we have launched a Delivering Better Oral Health fact sheet for children and we have the e-learning resource for Health Visitors which is housed on Health Education England’s e-learning for healthcare. The training is an oral health module which is part of the training for the Healthy Child programme. With regard to the early years workforce, we know of several local authority areas that are currently looking at developing training resources to support the early years workforce.
You may be familiar with the Baby Buddy app, which was developed by Best Beginnings. It has some oral health content and we’re hoping to work with them to review and build on that this year.
Question 3 (Fluoride varnishing by dentists)
As a professional development lead for school nursing and health visiting, I’ve recently been looking at the Delivering better oral health (DBOH) toolkit and extracting from there what we can actually embed into practice so that we’re giving consistent messages. We need to be assured that this will be completed by dentists before recommending it. Are all dentists going to be able to comply with the recommendations, such as offering the required varnishing, and also the additional services to children with additional needs?
Answer
We promote the application of fluoride varnish very strongly with dentists professionally. Also, we know from the British Dental Association that is it the most commonly prescribed item for children. This year there was a 20% increase in the number of courses of treatment for children that included the application of fluoride varnish. So, we know that progress is being made but we know that it varies considerably across the country. The dental commissioners are very supportive of the dental practices within their patch using fluoride varnish and it’s important to have the local profession involved in any programmes that you were going to take part in to promote the application of fluoride varnish. Our PHE consultants in dental public health on the ground locally would be able to advise and support that work.
Dentists can choose to offer it or choose not to offer it, but the DBOH guidance is very clear about the evidence for a child population over 3 years old having fluoride varnish twice a year, and for those at higher risk at all ages to have it 2 or more times per year. The way the payment works for dental practices at the moment, is that they’re not paid extra for putting it on, all of the care comes under banding within dental practices. This comes within band one, along with x-rays and other items, so it is a part of their contract.
Question 4 (Dental Check by One)
My question relates to a campaign that the British Society of Paediatric Dentistry (BSPD) is running, which is called Dental Check by One, and this was raised at the British Dental Association Conference, and at another dental conference. So it seems to have gained traction among the dentists. Is this is something that Public Health England would be able to support?
Answer
As you mentioned, Dental Check by One is currently being led through NHS England, the Office of the Chief Dental Officer and the British Society of Paediatric Dentistry (BSPD), as part of the work that is in the delivery plan of the Child Oral Health Improvement Programme Board, where PHE brings together the stakeholder organisations for oral health improvement for children. So PHE would be supporting it through the board, and also particularly around what intervention happens when those children go to the dentist, because going to the dentist per se won’t necessarily improve oral health. It’s what happens once you get to the dentist and how important it is that when appropriate, fluoride varnish is being applied, and also that oral health advice is being given – not just by the dentist, but we’re also talking about the wider team. Dental nurses, dental hygienists and dental therapists all have a part to play in improving the oral health of young children.
Question 5 (Engaging schools in targeted supervised tooth brushing)
I’m a project officer for children and young people. I administer the Keep Suffolk Smiling project, where we hand out dental packs via health visitors to the 8 to 12 month checks. We’re trying to go on from there and start a targeted tooth-brushing scheme within primary schools, but we’re really struggling to get schools to engage with this. We approached 7 schools, we only got 3 to sign up, and I just recently yesterday had a school pull out. The main reason for schools not engaging with it is because they say that they don’t have enough resource within the school day to commit to daily brushing, and they have too much on their curriculum as it is, and they don’t seem to get the message that if they work on this, it can improve children’s health and attendance in school. I just wondered whether there was any advice on how to engage schools, or whether anyone else had any advice on – or a better way of trying to engage them?
Answer
Frequently, commencing some of these programmes can be very difficult. Once you have got several schools, then others tend to come along. A couple of things that may be useful - in the latest edition of Health Matters, it talks about the days gained in school from running a targeted supervised tooth-brushing programme. After 5 years, targeted supervised tooth brushing can result in an extra 2,666 school days gained per 5,000 children. Also it is very helpful is to link up with where they’re already running a successful scheme. There are lots of schemes that are running and they often have hints and tips about how this works. Sometimes the time of year can be difficult. Some provide supervised targeted tooth brushing in early years settings rather than schools.
Question 6 (Funding to support delivery of oral health messages by dentists in schools)
I’m a dentist based in Norfolk. We’re currently voluntarily going into local primary schools to deliver better oral health messages, and that’s in collaboration with Healthy Knowledge, which is an initiative between Norwich CCG, Norfolk County Council and Norfolk City Council. We’ve voluntarily gone to a few schools but we’re wondering whether there are any national resources such as dental clawback money, that could finance this kind of project throughout the whole of Norfolk or indeed nationally as well?
Answer
The system around oral health improvement puts responsibilities in different parts of the system and the statutory responsibility to improve oral health lies with the local authority. You mentioned that you already linked with them in the programme. So that’s one avenue that you have. You mentioned dental clawback, and of course that’s in another part of the system in terms of NHS England. Often the place that these organisations are brought together locally is through an oral health advisory group (OHAG), or it may be the health and wellbeing board for you locally, or via your sustainability and transformation plan. Another thing that might be useful is the return on investment tool. If the programmes that you’re considering developing mirror those in the ROI tool, you can begin to see what the savings would be, and that often helps to build a business case locally, where perhaps the savings are being made in the NHS, and it helps to make a case to invest to save.
Question 7 (Working collaboratively on child dental health across the system)
I work for NHS England in the finance department and deal with the dental contracts and commissioning. I know there is a project that we’re running as well, but are we collaborating with each other on this child health, or are we running two different projects? I’m sorry to ask what might be a basic question, but I’ve only just come into this whole new project that’s going on.
Answer
It’s a very good question because what we can’t afford in this present financial climate is to be duplicating work across the system. We mentioned earlier the Child Oral Health Improvement Programme Board, and that is really about system leadership. We had a workshop in London 2 years ago now, which brought together all of the people who had a key role or responsibility in their organisations around child oral health improvement. We spent a really productive day looking at what we felt we should do, agreeing an ambition that every child should grow up free from tooth decay, and we looked at what were the drivers for poor oral health and what should we do to improve oral health. That was the whole basis of the establishment of the board, and the board membership consists of partners across the system, from health, education, voluntary and community sectors. So NHSE commissioners are represented there through Janet Clark, who has a joint role on leading for the office of the Chief Dental Officer as well as for NHSE commissioners. We have partnerships across policy through the Department of Health, Department for Education, representatives from the British Dental Association. We have specialist societies and the Royal College. We have cross-PHE colleagues in diet and obesity, and children and young people and families. We have really good representation across the system.
Question 8 (Parent responsibilities in taking their children for dental check-ups)
I’m a dental practitioner in Coventry, and I’m very concerned about the children who have very poor dental health, particularly the toddlers. And there has been, I believe, a poor response from the dental public health side in trying to increase the uptake of dental treatment or dental assessment in the practices by these parents, because there is a behavioural problem. Coventry has been water-fluoridated for many years now, but still we are seeing a large number of children with decayed teeth, some requiring extraction, and this is traumatic for both the parents and the children. So I think we need a behavioural change within the parents, as well, so that they bring their children for regular check-ups.
Answer
Although we have consultants in dental public health and the public health teams, the responsibility really for services and encouraging attendance is with the NHS. They have helplines to try and encourage people to access the dentist and find out where they are and where there are spaces. We’ve already heard about the planned initiative Dental Check by One. This aims to encourage children to attend the dentist as early as possible, so that prevention can go on as early as the dentist sees somebody, and can talk about diet and can make sure that the fluoride varnish is on the teeth. There’s quite a difference across the country around children seeing the dentist. For 0 to 4-year olds in England, the rate varies across the country from 15% in the City of London seeing the dentist, to 58% in the High Peak in Derbyshire, so there’s a big difference across the country.
Question 9 (Supervised tooth brushing with child minders and at after-school clubs)
I’m a dental nurse from Sheffield and I wanted to give a bit of information about what we’re doing in my area. I’m working with Public Health England to advance the Red Book, and we’re working alongside health visitors when people go to the weigh-in clinics and start asking their health visitors about what is best dental health-wise for their children. What we want to do really is get people to bring their children under 1 to the dentist, and then for that to be verified by the dentist by signing it in the Red Book similar to what you have when you take a child for immunisation. You'd have a dentist, authorise that they've been seen and the Health Visitor can keep an eye on safeguarding as well, making sure that the child has been looked after properly health wise.
I'm a school governess at my daughter's school, and just basing it on that school, they're under a lot of pressure with trying to squeeze in more time in sports and PE activities, they’re not looking to or having tooth brushing clubs, so it might be worthwhile, either if somebody can volunteer to go in and do that, or looking at child minders and after-school clubs and introducing tooth brushing clubs into those settings rather than the school setting, where they've possibly got a bit more time.
Answer
We are really pleased to hear about the work that you're doing locally, and the Red Book is a good tool in terms of making that link between parents and dental practices. Thank you for your suggestions around child minders and after-school clubs and tooth brushing programmes. Recently, 4Children looked at the feasibility of doing supervised brushing with very young children, 2-year olds, and they piloted it with child minders, and they found that it was easily deliverable by them. So, I'm delighted to say, there has been a pilot study, and that's available through the Health Matters pages.
Question 10 (Water fluoridation coverage)
Statistics relating to water fluoridation around the country show both increased dental health and also cost effectiveness. I am struck at how little of the map of England is currently covered, and I was wondering, is anyone aware of plans to increase the coverage of water fluoridation within England, or if you look at this map in 5 years' time, will it look very similar?
Answer
Water fluoridation is one of those interventions where people don't have to change their behaviour to get the benefit, and we know that there is a proven benefit over decades, not just in this country, but for millions and millions of people all over the world. If we look at countries like the USA and Australia, where 70% to 75% of the population are covered by fluoridation schemes, it does look quite sparse when we look at our own maps. The responsibility for making a decision about water fluoridation was changed in 2013, so now local authorities have the responsibility to consult locally and ask water companies to alter the fluoride content in the water. There are 2 or 3 local authorities that are actively looking at this, and that is to be congratulated. In the past there have been some people who are opposed to water fluoridation who have had very strong voices about what they consider are the negative aspects of water fluoridation, but our evidence base including Cochrane reviews wouldn't support that. There are reports from other countries that have looked at the scientific evidence and concluded that it is a safe and effective way to improve oral health, and from Public Health England, we have a toolkit that we published that is a sort of step-by-step guide for local authorities. Some local authorities have found it very useful and are actively taking things forward, and we would like to thank our dental professionals across the country, who have also been supporting our local authorities and promoting good dental health at local levels. We've also had a monitoring report that shows that it's a good idea. So, it would be lovely to have greater coverage of water fluoridation across the country, and we're trying to support it.
Question 11 (Water fluoridation return on investment)
We have some local authorities who are interested in starting to look at water fluoridation, and I just wondered how much of the return on investment information shows the breakdown on where that return on investment falls? Because I think a lot of the challenge in local authorities with current austerity is how would they fund it, and, actually, what benefit would they get back, and I know that there is challenge that a lot of return on investment comes to the NHS, and how do we get a local partnership to fund it rather than it being all local authority funding? And I just wondered if the return on investment breaks down the savings to local authority, NHS, social care, et cetera, and how that might help?
Answer
It is understandable that local authorities in these austere times would be worried about money spent by the local authority, when it's just making savings for the NHS in terms of primary and secondary care. PHE’s return on investment tool will give you more information than is summarised in the infographic. The monetised savings consist of savings from primary care and secondary care to the NHS but also fewer days lost at work, and so all of those are monetised within the ROI figure, but when you fit the information from the local area into the tool, it will actually give you those amounts monetised separately, and it also will give you, of course, the days that have been gained at school. Once you've fed your local information in it will be printed off quite nicely on a summarised PDF. Dental public health isn't the only area of public health where spend happens in one part of the system and the savings are in the other, but the ROI tool facilitates those discussions and reinforces the case to be made and why to invest.
Additional questions received by email
Question 12 (Educating birth parents of looked after children)
Public Health Worcestershire has recently been talking to foster carers about dental health in looked after children (LAC). The foster carers we spoke to are very vigilant in promoting healthy diets and supervised tooth brushing, but the children often come to them with existing tooth decay and the carers say that when they go back to the birth parent they are given sugary food and drink and good tooth cleaning practice goes by the wayside. I am aware that this is a very difficult area to tackle. Can you suggest evidence based effective ways in which we can reach birth mothers of LAC and educate them in healthy diet and good oral hygiene?
Answer
As you have mentioned we know what works to improve oral health, which is brushing at least twice a day with fluoride toothpaste and reducing the amount and frequency of consumption of foods and drinks containing free sugars. It is challenging to support parents and families especially when perhaps they are trying to cope with multiple issues and leading chaotic lives. In supporting birth mothers of LAC it is important to provide not only consistent evidence based information but to discuss what might be an achievable goal. Then what the barriers to achieving this may be and how they think they could overcome them. Having these healthy conversations and providing motivational support is important in supporting and facilitating behaviour change. Further information on how dental teams can help patients to change behaviour can be found in recent NICE guidance.
In addition the Local Government Association (LGA) has recently published a document Healthy Futures – Supporting and promoting the health needs of looked after children and this includes a dental health project case study - “Let’s Talk about Teeth” which you may find useful.
Question 13 (Delivering oral health to Looked after children)
I have recently looked in to a project for delivering oral health to Looked after children (LAC) and in our area in particular we have a higher than average number of LAC. I wondered what measures are in place or accessible to this vulnerable group. Many of the challenges appear to be around placements, re-placement, and the number of people who come and go in their lives. I have spoken to the local authority and they themselves feel challenged around this group. I appreciate that this is perhaps a mid-stream issue that has various levels of complexity.
Answer
As you will know there is Statutory Guidance for promoting the health and well-being of LAC, which says that local authorities are responsible for making sure a health assessment of physical, emotional and mental health needs is carried out for every child they look after. This includes a statutory health assessment of dental care appropriate to their needs and treatment. Some areas have made local arrangements with regard to dental care pathways for LAC involving commissioners and provider dental services.
In addition the Local Government Association (LGA) has recently published a document Healthy Futures – Supporting and promoting the health needs of looked after children and this includes a dental health project case study - “Let’s Talk about Teeth” which you may find useful.
Question 14 (Dental care for children with significant medical problems)
I am a consultant in paediatric dentistry at Birmingham Children’s Hospital (CH). My question or point which I would like to raise is targeting those children with significant medical problems who fall between the primary care and secondary care, especially the children with congenital cardiac disease. As you are aware the surgical care for these children is being narrowed down to specific centres. The plan will be Birmingham CH will be taking on the surgical care of children from Leicestershire and given their complex medical needs, general dental practitioners are not happy to see and treat and neither are the community dental service in surrounding areas. How do we target these children and get them access to dental preventive care? There are many other areas that I work with including children with haemophilia and cleft craniofacial anomalies who also are not receiving the appropriate dental care, as there are not enough paediatric specialists to support in secondary care especially in our area. I would be grateful for the panel’s thoughts
Answer
It is really important that all children and particularly those with special needs receive appropriate and timely dental care. Preventive care is particularly important as for many of these children dental care can be complex and have inherent risks. All dental services as you know are commissioned by NHS England and care pathways are locally designed. Therefore these issues are best raised locally through the Local Dental Network and NHSE local office. If the pathways are over larger areas this may involve several LDNs and local NHSE offices. A useful first contact would be your own LDN Chair and (if established in your area) the chair of the paediatric dentistry managed clinical network.
Question 15 (Oral health and the red book)
Is there already information on oral health included in the parent held child record (red book)? And if not could this be included to highlight the key health messages?
Answer
Yes, PHE have recently worked with the Royal College of Paediatrics and Child Health to revise and update the oral health information in the parent held child record (PCHR). This includes key evidence based messages such as ‘start brushing as soon as the first teeth erupt, brushing with fluoride toothpaste at least twice a day’ form example. It also includes a section for parents and dental teams to record details of dental visits, links to NHS Choices for more information on children’s teeth and information on access to NHS dental treatment for mothers and children. The PCHR was updated in 2016 and it is appearing in all new orders of the printed copies of the PCHR. However, in some areas current copies will be used up before the updated versions are available. It should also be available in the e-PCHR but this is limited to some areas in London at the moment.
Question 16 (Oral health in children needing special support)
Do we have data regarding the oral health of children with additional needs, specifically at a local/national level?
Answer
In 2014 the PHE national dental epidemiology programme for England published a report of a survey of 5 and 12 year old children attending special support schools (2014). Data is provided at national, regional, public health centre level and upper-tier local authority level.
Question 17 (Educating potential future parents)
What work is currently being done to educate children and young people leaving school, who may become parents, to educate them regarding good oral hygiene messages?
Answer
The Children’s Oral Health Improvement Programme Board (COHIPB) is focused on improving the oral health of children aged 0 to 5 years. Whilst the COHIPB continues to focus on this age range, PHE also engages across the life course 0 to 24 years regarding oral health improvement. Oral health is included in the PHE 6 High Impact areas documents which support local authorities and providers in commissioning and delivering children’s public health services aged 0-19 years. For example, oral health is mentioned in Early Years High Impact Area 1: Transition to parenthood. It is also included in an oral health infographic which is aimed at public health nurses (health visitors, midwives and general practice nurses) based on the 4-5-6 model for health visiting. Links to these products are also included in the longer version of Health Matters.
Question 18 (Early years apps)
Locally in Nottingham there is the pocket midwife app and you mentioned the use of the baby buddy app for improving health in early years. Would it be worth some liaison between these two groups?
Answer
It may be useful to collaborate locally with the Nottingham University Hospitals pocket midwife app to review existing oral health content, ensuring it is in line with Delivering better oral health and adding to the oral health content.
Best Beginnings is a charity focusing on the period between conception and a child’s third birthday. They have developed a Baby Buddy app which is freely accessible and aims to provide support through pregnancy and the first 6 months of life. This year PHE will be providing specialist input to review and add new oral health content to their app, based on the evidence based messages in Delivering better oral health. There is also a Start 4Life Information Service for Parents (ISP) which gives NHS information during pregnancy, birth and parenthood.
Question 19 (Sugar free medicines)
Is there any incentive for pharmacies in supplying sugar free medications as a standard practice for all children (particularly for those children with disabilities on multiple medications who are not orally fed)?
Answer
Advice in Delivering better oral health is that sugar free medicines should be recommended for children.
The majority of liquid medicines are sugar free and although there are no incentives for pharmacists to supply sugar free medicines, the British National Formulary (BNF) and the Children’s BNF (cBNF), that is used by most clinicians who prescribe and supply medicines, advises that sugar-free medicines should be provided whenever possible, especially for long-term treatment. Advice should be given on dental hygiene to those receiving medicines containing cariogenic sugars for long-term treatment.
Many children are able to swallow tablets or capsules and may prefer a solid dose form. Involving children and parents in choosing the formulation would be helpful.
Question 20 (Strength of fluoride toothpaste)
Can you please clarify if 1350-1500 ppm fluoride toothpaste is to be used with all children (0-6 years old) replacing the Delivering better oral health message of “no less that 1000ppm” for 0-3 year olds?
Answer
No both of these statements are supported by DBOH v3 and this is still the evidence based messaging that should be followed for oral health improvement. In Health Matters the infographic is focused on maximising caries control (as in DBOH for 0-6 year olds) and emphasising using 1350-1500ppm, using small amounts - a smear for 0-3 year olds and a pea for 3-6 year olds and under supervision.
Question 21 (Oral health in 0-19 contracts)
I work on 0-19 contracts in Hull and I am looking for some guidance / advice or to see what other areas are doing (if anything). I would like to do some work with schools around obvious tooth decay in children, and look at the possibility of members of staff who have contact with children to be able to recognise obvious tooth decay and look to work with the parents to ensure the child is seeing a dentist and are getting sound advice / guidance around good oral health.
Answer
Integrating oral health within 0-19 commissioning is a great way of ensuring sustainable universal and targeted interventions. Suggestions of how it can be integrated can be found in supporting toolkits such as the 0-19 commissioning guides and the early years and school aged years high impact areas.
Locally based consultants in dental public health can be a great source of advice as to what local programmes are currently in place and can make links through their dental networks, sourcing examples of good practice. Your local consultant will be based in Yorkshire and the Humber PHE centre.
Summary
If you have any further questions, the team here at Public Health England will be very pleased to answer them. Please send your questions via email to healthmatters@phe.gov.uk.
Do please keep on sharing your stories about how you have used the Health Matters materials to communicate your messages and to get things done, or if you have ideas for improvements. Just send an email to healthmatters@phe.gov.uk.
Health Matters
Health Matters is a resource for professionals which brings together the latest data and evidence, makes the case for effective public health interventions and highlights tools and resources that can facilitate local or national action. Visit the Health Matters area of GOV.UK or sign up to receive the latest updates through our e-bulletin. If you found this blog helpful, please view other Health Matters blogs.