Keep children smiling: making it happen together

Middlesbrough Council and NHS England Cumbria and the North East have launched a joint programme “Starting Well” to develop closer links between dental team members and the wider health and social care workforce to increase uptake of both school and dental practice prevention programmes to prevent dental decay in our youngest children. This case study forms part of our oral health resource.

Getting dental teams out of the surgery, reaching out to parents within the community, to bring their children into dental practices as early as possible, is hoped will turn the tide of high decay rates.

The challenge

  • Middlesbrough has been identified by Public Health England (PHE) as the tenth worst area in England for both dental disease rates and poor dental attendance.
  • In Middlesbrough, 17 per cent of three year olds already have decayed teeth (PHE, 2013). These rates are 40 per cent higher than the national average (England rate 12 per cent). Dental prevention needs to start early: as soon as teeth appear in the mouth at about 8 months. However, getting children into dental surgeries early enough has proved to be a challenge.
  • A particular challenge in Middlesbrough is dental health inequalities: the most deprived wards have the highest rates of dental disease and the  lowest attendance, making prevention more difficult.
  • Another issue for dentistry in Middlesbrough is the variation in rates of advice and interventions delivered by dental practices to prevent dental decay.
  • Local providers are informing local teams that General Anaesthetic (GA) referrals are increasing year on year. This is contributing to overarching cost pressures.

The solution

The solution to improving dental decay rates has seen a multifaceted, coordinated, systems based, approach being developed:

  1. Community dental programmes have been commissioned by Middlesbrough following NICE and PHE commissioning guidance:
  • Pre-school supervised tooth brushing programmes: 26 settings involved with over 1500 children brushing their teeth daily (1-3yr olds)
  • School supervised tooth brushing programmes: universal offer to all schools (3-6yr olds). 32 schools are involved with over 4000 children brushing their teeth daily.
  • School based fluoride varnish programmes: 10  schools have implemented the programme(3-11yr olds)
  • All special educational needs schools (primary and secondary) are offered resources to implement a tooth brushing programme.
  • Oral health training offer for appropriate education and health and social care partners describing the key messages in “Delivering Better Oral Health: an evidence based toolkit for prevention” (PHE, 2014). 
  1. Improved joint working between dental and health professionals to improve uptake of preventive dentistry:
  • Health Visitors encourage and assist parents of  0-3 year olds to take their child to the dentist as soon as their teeth appear by helping book appointments if needed.
  • Dental practices commissioned to provide fluoride varnish programmes in schools also offer dental care to children that report not having a family dentist. Joint working has been established between dental teams, school nurses, public health practitioners, and school pastoral care leads to optimise take up of this preventive programme and take up of dental care.
  • Follow up of access information contained in the school entry questionnaire to facilitate access to dental services at an early stage.
  1. Starting Well outreach community engagement commissioned by NHS England
  • NHS England Cumbria and the North East has commissioned dental practices to deliver an outreach programme  in partnership with the wider health and social care sector including: health visitors, schools, children’s centres, early intervention hubs, safeguarding teams etc to increase dental attendance.
  • In order to reduce dental health inequalities” Dental Practice Champions” working with a prevention network will seek to engage with high risk groups in the community, and establish personal contact with parents to encourage dental attendance.
  1. Starting Well: implementation of an evidence-based prevention pathway to optimise prevention advice and treatment  in dental practice
  • To reduce variation in the approach to dental disease prevention, practices have been asked to implement an evidence based prevention pathway. This  will be audited against specified criteria to ensure prevention activity and advice is optimized.
  • Practices have been asked to sign up to the Council breastfeeding friendly scheme, contributing to the wider health agenda.
  • To evaluate the efficacy of this approach, NHS England will monitor participating practices to assess any increases in dental attendance rates in the 0-4 year old age group.

The impact 

  • Increase in the attendance rate for under 5 year olds, with particular focus on 0-2 year olds.
  • Significant  improvements in the levels of prevention activity, particularly in those areas of greatest need.
  • Increase in rates of fluoride varnish applications in the under fives.
  • Improved follow-up care of children undergoing extractions in hospital to prevent repeat general anaesthetics (GA).
  • Reduced pressure on GA waiting lists in the medium/long term. Costs will reduce as local teams will not have to commission as many additional waiting list initiatives to meet 18 week “referral to treatment” targets.
  • Reduced GA waiting times for young children who are currently having to wait unacceptably long periods to address acute infections.
  • A contribution to the evidence base through the evaluation of the Starting Well programme
  • Improved cost efficiencies to the system. The PHE return on investment tool for oral health improvement programmes for  0-5 year olds reports the following:

Targeted supervised tooth brushing programmes

After 5 years for every pound spent £1= £3.06 saving
After 10 years for every pound spent £1= £3.66 saving

Targeted fluoride varnish programmes

After 5 years for every pound spent £1= £2.29 saving
After 10 years for every pound spent £1= £2.74 saving

How is the new approach being sustained?

  • Evaluation results of the “Starting Well” programme will determine the efficacy of the programme and its sustainability.
  • Raising the profile of oral health programmes by inclusion in the Joint Strategic Needs Assessment (JSNA).
  • Supporting oral health functions have been included in service specifications for the Council’s early years workforce .

Lessons learned

  • We will record any issues and opportunities that emerge in delivery so that they can be accounted for in future work.


Links to relevant documents

Delivering better oral health: an evidence-based toolkit for prevention (updated 2017) this is an evidence based toolkit to support dental teams in improving their patient’s oral and general health

Oral health: local authorities and partners (PH55) makes recommendations on undertaking oral health needs assessments, developing a local strategy on oral health and delivering community-based interventions and activities

Improving oral health: an evidence-informed toolkit for local authorities

Commissioning better oral health for children and young people.

Infographic which summarises the ROI of the 5 interventions using modelling data.

Local Government Association (LGA)

Tackling poor oral health of children – updated April 2016