Shared learning database

Cardiff and Vale University Health Board
Published date:
August 2015

The Designed to Smile Programme is a key element of the National Oral Health Improvement Plan; the programme covers all of Wales, the focus is on applying fluoride to children’s teeth by means of supervised tooth brushing and/or the application of fluoride varnish and the application of fissure sealants, Cochrane reviews have demonstrated brushing with fluoride toothpaste to be consistently effective in reducing levels of decay.

The programme relates to NICE PH55 guidance recommendations 12 – 20, it is focused on targeting settings in areas of high need and is supplemented by raising awareness of the importance of oral health and encouraging a whole-school approach.

The programme is delivered by the Community Dental Service in close liaison with the pre-schools, schools and Local Education Authorities; this submission focuses on the Cardiff and Vale Local Health Board, CDS.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The overall aims of the programme relate to Recommendations 12-20 of the NICE Public Health Guidance in PH55.

Specifically Designed to Smile aims to reduce oral health inequalities for young children in Wales.

The objectives are to deliver a quality assured evidence based oral health promotion programme by the application of fluoride (either by supervised tooth-brushing, and/or the application of fissure sealants or fluoride varnish). A supplementary objective is to encourage partnership working to affect the wider determinants of health; partners includes: Healthy Schools, Flying Start, Health Visitors, Dietitians etc.

Reasons for implementing your project

Despite improvements, dental decay remains one of the most common diseases to affect children in Wales. The prevalence of disease in the least deprived communities is half that in the most deprived, where over 6 in 10 children have decay sufficient to require either a filling or extraction before they start school.

In the early 2000's, epidemiology surveys of 5 year olds in Wales revealed that the prevalence of disease had plateaued and started to lag behind other constituent countries of the UK.

At the time there was a localised initiative - The Fissure Sealant Programme - which was targeted to limited areas of high need.

In the 2006 Eradicating Child Poverty in Wales strategy, the Welsh Government set a target that by 2020 the dental health of 5 and 12 year olds in the most deprived fifth of the Welsh population will improve to that presently found in the middle fifth. Key to achieving this target is the Designed to Smile Programme. In line with the principles of Prudent Healthcare, this programme seeks to reduce inappropriate variation using evidence based practices consistently and transparently.

The benefits were to have a more holistic approach underpinned by NICE guidance; to reduce inequalities in oral health and to reduce the numbers of children having dental treatment.

How did you implement the project

Cochrane reviews (see reference 3 & 4 below) have demonstrated brushing with fluoride toothpaste to be consistently effective in reducing levels of decay.  In line with current thoughts on the best way to address health inequalities, the concept of proportionate universalism (see reference 5) has been utilised in selecting schools for participation.  Designed to Smile (based on the Scottish initiative – ChildSmile) incorporates a targeted population approach by focussing on nurseries and schools in the three most deprived quintiles of deprivation according to the Welsh Index of Multiple Deprivation. The core programme incorporates three elements: (i) supervised tooth brushing  in school or nursery for 3-5 year olds; (ii) oral health promotion for key groups of children, their parents and health and teaching professionals ; and (iii) promoting oral health from birth (0-3 year olds). The programme also incorporates the original Welsh Government Fissure Sealant programme, and a fluoride varnish application programme.

The CDS has been responsible for organising, coordinating and delivering the programme, including the production and translation of resources, the sourcing of materials and recruitment of new staff members to the project.  The scheme was originally piloted in two areas: in South East Wales and also in North Wales. In October 2009, the Welsh Government made the decision to expand and enhance the programme to all Health Boards in Wales.


1). Eradicating Child Poverty in Wales – Measuring Success, Welsh Assembly Government, October 2006. Web address: (Accessed 6th August 2015)

2). Welsh Government. Together for Health: A National Oral Health Plan for Wales 2013-18. (Accessed 6th August 2016)

3). Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002278. DOI: 10.1002/14651858.CD002278.

4). Walsh T, Worthington HV, Glenny AM, Appelbe P, Marinho VCC, Shi X. Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007868. DOI: 10.1002/14651858.CD007868.pub2

5). Marmot M. (2010) Fair Society, Healthy Lives The Marmot Review: London  ISBN 978–0–9564870–0–1

Key findings

Evaluation involves both process evaluation in the form of regular monitoring reports and also a more formal evaluation of the impacts and the outcomes. The monitoring reports are produced annually and there have been discrete pieces of work looking at impact and we are still awaiting the results of epidemiological surveillance information which will help determine the effects on children’s oral health in Wales. These results should be available in 2016/2017.

The monitoring reports highlight that the scheme is being targeted to children living in deprived areas, that setting participation, parent consent and child participation rates are very good. The scheme also is delivering from a quality assurance perspective. The most recent monitoring report highlights:

Currently, 1,389 settings are participating in the toothbrushing programme, with 92,948 children brushing daily. The average parental consent for their child’s participation is 95%. Population coverage represents 60% of all 3 to 6 year olds in Wales. To support the programme 230,744 oral health packs, which contain toothpaste, a toothbrush and parental information leaflet, have been distributed to support home brushing. In the year 2013-14, 10,119 parents and carers received either individual or group education on measures to prevent decay. This included messages of the reduction of the quantity and frequency of sugar consumption as well as how to access dental care.

Two evaluation reports have been drafted, the first focusses on the views of teaching staff at participating schools. It also presented data from a parent survey pertaining to the effect of participation in the Designed to Smile programme on children’s home brushing and attitudes towards toothbrushing in general.

The second report presents data as to how often parents brush their children’s teeth at home, and other family factors which may influence their decisions about oral hygiene. Specifically, to:

  • Establish the extent to which parents adhere to current guidelines about when to begin brushing their child’s teeth at home and whether or not they should supervise their child’s brushing
  • Establish parental and family factors which are associated with how often parents brush their children’s teeth at home, both in the morning and in the evening
  • Make suggestions about how this data might be used to inform future oral health education messages aimed at parents

Key learning points

This has been an evolutionary process and it is important not to underestimate the amount of project management involved in the implementation, monitoring and evaluation of the programme.

Contact details

Dinah Jones
Programme Lead for Designed to Smile
Cardiff and Vale University Health Board

Secondary care
Is the example industry-sponsored in any way?