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Towards Better Oral Health in Children

Current Action

In 1991, the target was set that, by the year 2000, 60% of 5-year-old school entrants should have neither cavities nor have had fillings or extractions. Little progress was made and so the White Paper Towards a Healthier Scotland, published in 1999, revised the target, which is now to have 60% of 5 year olds with no experience of dental disease by 2010. To try to achieve it, we plan - and are carrying out - a wide range of actions. But will these be enough?

Diet

Diet is a crucial factor in oral health as recognised in the appointment of the Scottish Food and Health Co-ordinator. A broad spectrum of activity is being carried out, within the framework of the Scottish Diet Action Plan, to bring about improvements in the Scottish diet, with a particular focus on children.

We believe everyone should have the opportunity to enjoy eating more fruit, vegetables and starchy carbohydrates and less sugar, salt and fat. The plan encourages schools to ensure school meals, tuck shops and vending machines provide a range of healthy food and drink choices, and the aim is for all schools, both primary and secondary, to build on current good practice to provide high quality food and drinks, which are attractive to children and which result in consistent nutritious balanced meals and snacks, and healthy teeth. A number of schools have already implemented helpful initiatives, such as breakfast clubs, fruit projects, healthy eating vending machines, smart card systems for school meals, the "Smart Cooking" cookery course and School Nutrition Action Groups to encourage pupils to eat more healthily.

Two specific initiatives established as a direct result of the Scottish Diet Action Plan and which have a particular focus on improving diet, including oral health, are the Scottish Community Diet Project and Scottish Healthy Choices Award Scheme.

• The Scottish Community Diet Project was established in October 1996 to work with low income communities. This widely acclaimed project, which in 2000 was awarded the prestigious BBC Derek Cooper Award for the most outstanding contribution to improving diet in Great Britain, was developed by the Scottish Consumer Council and HEBS, and is supported by over half-a-million pounds of Scottish Executive funding. A particular focus of the project is its grant scheme to encourage the development of Community Food Initiatives. Many of these initiatives have a focus on improving oral health, including healthy food tasting sessions, breakfast clubs, and cooking skills classes.
• The Scottish Healthy Choices Award Scheme, developed by the Scottish Consumer Council and HEBS, and funded by the Scottish Executive, was established in 1998. The scheme encourages catering interests to provide and promote healthy food choices. Schools are showing increasing interest in the scheme and a number have already received this award for promoting healthy eating as part of their school meal provision.

Pre-school and school children

Schools are the key vehicle for the promotion of healthy lifestyles to children and young people, and a main focus of this activity is the promotion of good oral health. Education Authorities are increasingly on board with this concept and every school is being encouraged to become health promoting. To help schools promote good health, the Scottish Executive launched in May this year a Health Promoting Schools Unit in conjunction with HEBS, CoSLA and Learning and Teaching Scotland.

Dental health is a priority for a school's health education programme, and oral care is given attention throughout the curriculum from pre-5 through to S6, but with the most emphasis in pre-school and primary education. All NHS boards, through their primary care trusts and their health promotion departments, have a large and varied input into dental health education. Many schools and nurseries are supported by regular visits from dental health educators. Schools and groups benefit most when programmes are collaborative and involve a range of health professionals, parents and carers. New Community Schools, which focus on the provision of integrated services, provide a good opportunity for this collaborative work.

The Scottish Executive Expert Panel on School Meals published Hungry for Success: National Standards for School Meals, for consultation, in July 2002. In addition to producing nutritional standards, the panel reported on measures to eliminate stigma and improve the presentation of school meals. The report sets out a vision for a revitalised school meals service in Scotland and presents a number of far-reaching recommendations connecting school meals with the curriculum as a key aspect of health education and health promotion. For the first time in the UK, national nutrient-based standards for school lunches are proposed and detailed options for monitoring these standards are set out. The key agents of success in implementing these standards are Local Authorities working in partnership with catering professionals, schools and the school communities - teachers, parents and pupils themselves. The report is seen as a first step on a journey towards a whole-child, whole-school approach to food in all schools in Scotland.

A review of breakfast club provision in Scotland is underway. Once the review is complete (later this year), a breakfast club challenge fund will be used to sustain services or ensure that services are targeted at children who most need them. Breakfast clubs in schools can reduce in-between-meal snacking and provide an opportunity to re-enforce other healthy lifestyle habits including toothbrushing.

This report is currently out for public consultation ( July-October 2002) and is available at: www.scotland.gov.uk/education/schoolmeals

Health Education Board for Scotland (HEBS)

HEBS regularly support national oral health initiatives. In 1996, the Board produced the resource "Healthy Teeth in Healthy Mouths". The pack, which is still in use, was distributed free of charge to all primary schools in Scotland, with a particular focus on the 7- to 9-year-old age group.

Along with their work on healthy eating health education, HEBS are also involved in the development of materials for health professionals, voluntary organisations and the public on the prevention and early detection of dental and oral health problems, including oral cancer. The "Give Teeth a Chance" pack was part of a pharmacy initiative in 1996 in which key dental and oral health messages are promoted to the public. This initiative contributed to the publicity campaign for National Smile Week, which is supported annually by HEBS. Newer developments include a Child and Family Health initiative, for which dental health will be a priority topic, and production of support material for dental team members to use in the practice setting.

More recently HEBS, in liaison with the Executive produced material to support and promote the recently introduced caries prevention programme for 6 and 7 year olds. This is suitable for use with children of primary school age.

Food Standards Agency

The Food Standards Agency is looking to work with consumers, enforcement authorities and industry to develop a set of guidelines on best practice in labelling and promotion for foods aimed at children. This is to help parents choose more easily when trying to make healthy choices for their children.

Of particular concern are products such as those which are depicted as "healthy" when they may contain high levels of sugar, salt or fat.

The Agency is undertaking a series of activities which will help support parents who are trying to provide their children with a healthy, balanced diet. These activities include:

• commissioning a review of research concerning the effects of promotional activities on the eating behaviour of children;
• working with industry to tackle misleading "healthy" messages; and
• developing Agency advice on healthy eating aimed specifically at parents.

NHS boards

NHS boards have a responsibility for the dental health of children in their area. Specifically they are required to make arrangements for dental health education appropriate to local circumstances, and are presently recommended to inspect all children in local education authority schools at least three times in each child's school life.

In areas of poor dental health and where availability of general dental services is poor, inspection may be more frequent. This activity makes contact with thousands of children, and often their parents, annually, and can be used as a health education tool to promote change.

Community dental services and health promotion departments are involved in a wide variety of initiatives to improve oral health. Toothbrushing schemes, healthy eating activities, and encouraging parents to register their children with a dental practice are the core elements of these programmes.

Action Plan for Dental Services

The Action Plan for Dental Services in Scotland, published in August 2000, has a special focus on improving oral health in children. Particular initiatives include:

• Over 100,000 pre-school children have already received free toothbrushes and free fluoride toothpaste to encourage prevention of dental disease. In addition, locally co-ordinated community programmes, targeted at pre-school children and their parents, encourage registration with a dentist, regular toothbrushing and consumption of low sugar food and drink products. Many of these programmes are run in collaboration with initiatives on fruit and healthy eating, funded from the Health Improvement Fund.
• NHS boards are continuing to expand nursery toothbrushing schemes, with several areas, such as Ayrshire and Arran, Lanarkshire and Fife, already achieving comprehensive coverage of nurseries. Through these programmes additional steps are being taken to promote positive health practices in young children, linked to the provision of dental educational material and healthy eating initiatives.
• The strategic review of the dental workforce in Scotland is now delivering a workforce better structured to support the prevention of dental disease. Expansion of, and improved training for, the professions complementary to dentistry, has begun. This will result in an increased supply of these dental professionals from 2003 onwards. New post-registration training for these professions is enhancing the contribution dental nurses, therapists and hygienists can make to good oral health in children in Scotland.
• Enhanced payment schemes have been introduced, targeted at preventive treatments offered to children aged 6 and 7. This extensive programme, which includes fissure sealants (plastic coating to prevent dental decay) of the first adult molar (back) teeth as soon as they erupt into the mouth, is now being offered by hundreds of local family dentists. Over 50,000 children will benefit from this scheme every year, representing over half of all Scottish children, aged 6 and 7. The scheme will be extended to older children, if the results of this stage are positive. Early signs are encouraging. Caries reductions are expected to be similar to what has been achieved in Orkney and Shetland, where community dental service schemes involving the extensive use of sealants show considerable improvements in the oral health of 12 and 14 year olds.
• The Action Plan has encouraged NHS boards to look at how they can best use resources for programmes targeted at those in most need. For example, the Greater Glasgow Pre-5-year-old Oral Health Gain project is being extended, following successful assessment, to include a number of other areas of need in Glasgow and best practice is being shared and expanded throughout Scotland.

Health Improvement Fund

The National Health Improvement Fund, resourced from tobacco tax revenues to the tune of £26m per year, is also supporting oral health in Scotland through:

• fresh fruit for infants to improve their diet, delivered in every NHS board area in Scotland through local playgroups and other day care services according to local needs;
• free toothpaste and toothbrushes for over 100,000 pre-school children each year from 2001 onwards.

A mother brushes her baby's teeth

Toothbrushing programmes are now underway in nursery age and other young children in Scotland.

• additional resources have been made available to extend toothbrushing programmes in nursery age and other young children in Scotland;
• the expansion of the health service support offered through Sure Start Scotland;
• a major expansion of school breakfast clubs, beginning with schools in deprived areas and spreading across the country;
• the introduction of fruit and salad bars, building on work already started in new community schools.

Starting Well

The "Starting Well" project is being developed in two areas of socio-economic deprivation within Greater Glasgow. The project is providing intensive home-based education and support for families and has a significant oral health element. This is emulating elements of innovative programmes such as the Greater Glasgow Pre-5-year-old Oral Health Gain Project (the "Possilpark Initiative"). The multi-disciplinary Oral Health Action Team and Oral Health Promoter in each location are working closely with Starting Well's Health Visitors and health support workers. These staff are facilitating links between parents, nursery schools and dental practitioners in the General Dental Service and Community Dental Service. Starting Well is providing clear information on weaning and nutrition practice guidelines for Health Visitors and is encouraging dental practice registrations.

Conclusion

A significant programme of work is underway, supported by a wide range of organisations, which will impact on oral health. Research confirms that, where initiatives rely only on health education, change may be slow but where initiatives are combined with either preventive measures or with wider health programmes delivered in combination with other professionals, there is increased evidence of effectiveness in changing behaviours and health.

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