Shared learning database

South West Yorkshire Partnership NHS Foundation Trust
Published date:
September 2014

The Calderdale tooth brushing scheme is an evidence-based daily brushing programme across 19 schools in Yorkshire. The scheme has also been introduced in children's centre settings. The individual child is involved for two school years; therefore the children are aged 3-5 years. The scheme is part of a wider package of initiatives that the team provides which includes a published children's book to facilitate early years patient experience and a locally awarded dental health award to venues that are meeting locally set criteria to promote oral health. Effective programmes involve health & local authority partnerships and are seen as an integral part of health promoting activity in early years and school settings. The NICE guidance on oral health recommends ensuring all early years services provide oral health information and advice and ensure early years services provide additional tailored information and advice for groups at high risk of poor oral health (Recommendation 13 & 14).

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 intervention aims to:
- introduce a life skill
- set an oral hygiene behaviour pattern for the future
- improve the oral health of young children

The intervention involves children aged between 3-5 years brushing their teeth during the school day, as research demonstrates that the application of fluoride toothpaste in a supervised school-based intervention can have a significant effect on children with high caries risk (Curnow et al., 2002). The actual time of brushing is not prescribed to the schools. This is to ensure that it fits best with the regime; however, it is advised that brushing is not undertaken at the start of the school day.

Reasons for implementing your project

The dental health of children in the Yorkshire and Humber region compares poorly to other parts of England. The mean number of decayed, missing or filled primary teeth (dmft) in five year old children in Yorkshire and the Humber is 1.51 which compares unfavourably to the South East Coast of England (0.72) and the average across England as a whole (1.11) (Robertson et al., 2011). It is acknowledged that the dental health of individuals from the lower end of the socioeconomic scale is markedly worse than that of individuals from the upper end (Locker, 2000). Indeed, the picture is reflected more locally where five year old children from the most deprived areas in Calderdale have higher dmft scores than those from less deprived (Dyer et al., 2012). However, within the Yorkshire and the Humber region the dmft of five year olds in Calderdale is higher than other parts, such as East Riding, Wakefield, Leeds and Sheffield. Only Doncaster, Hull, Kirklees and Bradford & Airedale show higher mean dmft scores (Robertson et al., 2011).

Good oral health is important for eating, speech, self-esteem and social confidence and is important in overall quality of life. However poor oral health can lead to pain, discomfort, sleepless nights, and difficulties with eating, which can lead to poor nutrition, and time off school. Many children still have teeth extracted due to dental caries, sometimes needing a general anaesthetic, a distressing experience and albeit small, risk to life.

Improving oral health is part of the Governments wider public health strategy and many of the key factors that lead to poor oral health are risk factors for other conditions or health related inequalities. The NICE guidance on oral health recommends ensuring all early years services provide oral health information and advice (Recommendation 13) and ensure early years services provide additional tailored information and advice for groups at high risk of poor oral health (Recommendation 14). It is a well-established fact that twice daily brushing with appropriate fluoride toothpaste is an effective means of helping to prevent tooth decay. Effective daily brushing becomes a routine for lifelong good oral hygiene thus preventing gum disease in later life and maintaining teeth for life. The second way to reduce tooth decay is to reduce the frequency and amount of in between meal sugars.

How did you implement the project

Initial buy-in from the local authority was sought by the dental public health consultant who approached the authority in order to initiate the pilot schemes. The pilots and subsequent wider tooth brushing scheme are targeted at schools and venues in the 30% IMD area. Successful pilots led to the establishment of the wider tooth brushing in schools scheme.

The scheme is an evidence-based intervention across 19 schools, the scheme also extends to a total of 32 venues which includes children and day care centres. To enable a two year continuous preventive measure it ideally needs to start at the beginning of the new school intake in the foundation unit or children?s centre venues.

Parent's buy-in is sought through an information session which they are invited to attend and sets out the aims of the scheme. The team met no organisational resistance to the scheme at the venues. Appropriate informed consent arrangements are in place for participating children. The intervention involves children aged between 3-5 years brushing their teeth during the school day. Schools are asked to exercise their own judgement in when best to schedule tooth brushing sessions during the course of the school day and the scheme provides flexibility in order to do this although schools are advised that tooth brushing should not be undertaken early in the morning.

Resources (e.g. brushes, toothpaste and the 'brush bus' - a storage facility for brushes (see Figure 1 in supporting material) are provided to schools and replenished regularly. Training is also given to school staff to ensure that hygiene standards are maintained and cross-contamination of brushes are avoided. Training cost is minimal as a member of the health improvement team will arrange to visit a school or venue outside of school hours or on a teacher training day. The training last 1.5 hours and consists of a presentation by the health improvement lead and the provision of materials and resources required to implement the scheme. There is no cost incurred to the school. The cost of set up materials initially in a venue is approximately £4.00 per child & just over £2.00 the following year. The only other cost is Health Improvement Service staff time to provide a training session for all Early Years staff who will be involved in the programme and the occasional ongoing support to aid the facilitation

Key findings

The South West Yorkshire Partnership NHS Foundation Trust commissioned the Institute for Health and Wellbeing at Leeds Metropolitan University to conduct an independent evaluation of Calderdale's tooth brushing in schools scheme. Data collection activities included: School case studies:
Case studies were conducted in three schools. In total data was gathered from:
- 21 children participating in a 'draw and write' activity
- 18 parents contributing to a focus group discussion
- 4 members of school staff directly involved with the programme
Programme/strategic level interviews:
Three interviews with oral health programme leads.
On-line survey: A small scale questionnaire based survey which was sent to the 18 schools participating in the intervention. The questionnaire was administered online and a total of 13 questionnaires were returned.
Key findings:

Children's engagement and increased knowledge:
Across the data collection activities, one recurring and clear theme was that children enjoyed participating in the tooth brushing scheme. Parents reported how their children enjoyed brushing their teeth and that the tooth brushing in school scheme had raised their interests: "Yes my son enjoys it and has started asking me, 'Mummy can I get a new tooth brush' he seems to enjoy brushing his teeth for lot longer, rather than it being taxing." (Parent) The survey data supported these assertions as responding schools either 'strongly agreed' or 'agreed' that children were engaged in the tooth brushing scheme: 10=strongly agree 3=Agree (n=13).
The importance of committed school staff:
The tooth brushing scheme was reported, primarily by the oral health co-ordinators, to be contingent on key staff within the schools. The head teacher was seen as being fundamental to enabling the scheme to be implemented; however, a stable and consistent day-to-day contact person within the schools was also regarded as being critical to success, with their commitment, motivation and personality often being key for the scheme to flourish.
Fulfilling learning objectives and the OFSTED agenda:
The survey data shows that the tooth brushing scheme is perceived to contribute to children's wider education and learning (7=strongly agree, 6=agree n=13). For a full copy of the programmes results, please refer to the supporting material.

Key learning points

On the whole the programme has been very well received as we can see from the evaluation that the individual staffs have been enthusiastic and see the need to promote the activity in their venue to increase the chances of good oral health for the children in their care.

- Gaining early buy-in from the local authority, headteachers and Children's centre managers is crucial for the success and sustainability of the scheme.
- It is important to gain the support of a motivated & competent member of staff at the start to be a named co-ordinator for the programme.
- Initially regular support is offered but staffs are soon able to facilitate the programme with little support once initial problems are overcome.
- A small number of venues have withdrawn from the programme and this tends to occur where staff have been reluctant to take on board the important role they can play in improving oral health The majority of staff and venues seem to incorporate things into their busy routine and look on it as a very positive contribution to improving health.
- We recently produced guidelines to enable us to provide support to establishments who wish to carry out TB in their venue but do not meet the criteria for us to support them in our programme with materials and resources. A copy of this will also go to all participating venues for their information.

The evaluation evidence suggests that the service is making a difference to the oral health of children in the Calderdale region, but needs to be considered as part of a wider work programme aimed at tackling inequalities in health.

Contact details

Kathryn Halstead
Health Improvement Lead (Oral Health)
South West Yorkshire Partnership NHS Foundation Trust

Is the example industry-sponsored in any way?

Initial funding for the pilot came from Sure Start West Central Halifax