AGENDA ITEM

REPORT TO CHILDREN AND YOUNG PEOPLE’S PARTNERSHIP

17 JUNE 2015

DIRECTOR OF PUBLIC HEALTH

ORAL HEALTH PROGRAMME

SUMMARY

This paper provides an update to the CYPP on the oral health programme in schools.

RECOMMENDATIONS

The CYPP is asked to consider the update.

DETAIL

1. The previous Children and Young People’s Health and Wellbeing Commissioning Group supported an oral health programme in schools prior to the formation of the revised CYPHWJCG in September 2014. The original paper is attached to this report for information.

2. The initiative has been commissioned and funded by Public Health. The Public Health team is working in partnership with Public Health England (PHE) to develop and deliver the project. PHE is responsible for providing specialist dental Public Health advice and support and has implemented elements of the programme in other areas.

3. The initiative is overseen by a multi-agency Oral Health Programme steering group, which is chaired by Public Health England.

4. The programme originally commissioned constituted three elements and an update on progress is given in this report.

Tooth brushing programme5. The tooth brushing programme is being offered to nursery and reception

years in all primary schools. An evaluation of 166 Teesside schools implementing the tooth brushing programme showed a reduction in dental decay that was twice as great in schools with the programme, than schools where the programme was not implemented (Figure 1 below).

6. Presentations have been given to Chairs of Governors and also to Primary Heads (at the SBC Education Matters session) to introduce the programme and encourage engagement. The programme had a positive reception and some Heads signed up for meetings with the Oral Health Promotion team following the presentation.

7. A letter has been sent out to all Heads, together with an information poster to raise awareness in schools.

8. An engagement event was held on 4th February 2015 for Heads and Foundation Years leads. The event presented examples of how tooth brushing is already working in some schools and gave the opportunity for discussion on the practicalities of roll-out and to respond to any concerns. An example of the experience of one Head in adopting the programme is given in Box 1. The event was very positively received by schools and a number of schools have signed up to the programme since.

9. The tooth brushing programme was designed to be rolled out in the schools with the poorest dental health first (quintiles 4 and 5). The programme is now in 18 out of 24 quintile 4 and 5 schools, with plans in place for roll-out by end of June in 2 of the remaining 6 Q4 and 5 schools. Work is ongoing with the remaining schools to address any concerns they may have about adopting the programme; a small number of schools have expressed they are not ready to adopt the programme at present.

10. Offering the programme in the rest of the schools in the Borough (Q1-Q3) is planned by Christmas 2015. The programme has already been rolled out in 8 Q3 and 2 schools. All schools will have different practical considerations to enable roll-out e.g. access to enough sinks; and size of the school. The Oral Health Promotion Team discusses these considerations with the school and work is underway to ‘buddy’ schools with those already on the programme.

11. From the new academic year (2015/16), the programme will also be offered to all year 1 children in schools visited by the Oral Health Promotion Team, in-line with new NICE guidance. A ‘catch-up’ programme will then be implemented to offer to year 1 in the schools already implementing tooth brushing in nursery and reception.

12. Five schools in Q5 have been identified as pilot sites for roll-out in the whole school. The programme will be rolled out in nursery and reception first, but the whole school approach has been discussed in initial meetings with Heads and Heads have expressed their support.

13. A newsletter is being produced for all primary schools, outlining the progress-to-date and including a frequently asked questions document, to further support recruitment to the programme.

Box 1

“Since implementing the tooth brushing scheme in school, children’s oral hygiene has improved. Parents have a heightened awareness about the importance of oral care – not just brushing teeth but the continued use of dummies and bottles into Nursery. The scheme has empowered childrento be able to develop their self-care skills at home. The scheme has provided the children with the resources they need to use at home and equipped them with the necessary skills. Last but not least – the children enjoy it!”

Charlotte Hardiman, Early Years Foundation Stage Lead, Bowesfield Primary School

14. The programme is being quality assured through a QA checklist, which schools are asked to complete themselves following conversation with the Oral Health Promotion Team. The Team also visits schools participating in the programme 2 or 3 times a year to support schools and check there are no issues with implementation.

15. From September, in-line with new NICE guidance, participating schools will be asked to include the tooth brushing programme in the list of activities the school undertakes, for which they seek parental consent at the start of the school year.

16. Participating schools will be offered packs for children to take home at the end of the Summer term 2015, to support ongoing tooth brushing in the school holidays.

17. Packs (toothbrushes, paste and racks) are provided for preschools feeding into Q4 and 5 schools. In addition, packs have been funded for health visitors to distribute at the 2 year development checks they carry out.

Fluoride varnish programme18. The fluoride varnish element of the programme is currently being planned for

the 20% of schools with the poorest dental health. The fluoride varnish programme is delivered by dental practices, in schools, through three applications of the varnish. The programme also offers an opportunity to engage children in attending a dental practice, where they do not already.

19. Schools have been identified to participate, based on those schools currently implementing the tooth brushing programme and being in Q4 or Q5. If schools have a Parent Support Advisor (PSA) in place to support the programme, this is also considered a positive factor. The fluoride varnish programme will be implemented in these schools first.

20. Evaluation of the fluoride varnish programme in Middlesbrough (carried out by CHASE at Teesside University) showed that an inherent risk to the programme is drop-off between the rounds of varnish application (application every six months for three years). This is largely due to the need to update the child’s medical history every sixth months and obtain the corresponding signed forms from parents. An important element to ensuring the success of the programme is therefore ensuring schools have sufficient support for this administrative task and work is underway to look at this.

21. A Service Level Agreement has been drafted and expressions of interest will be sought from dental practices who would like to deliver the fluoride varnish programme. A timetable for the implementing the fluoride varnish programme is attached (Figure 2).

Fissure sealant programme22. The fissure sealant programme is delivered through a mobile dental van.

Options are being sought for the hosting of the van (historically hosted by North Tees and Hartlepool NHS Foundation Trust) and the future of this element of the programme. The fissure sealant programme has not yet been implemented, due to these logistical issues. Any slippage in the funding will be used to support the implementation of the rest of the programme.

FINANCIAL AND LEGAL IMPLICATIONS23. There are no further specific financial / legal implications of this update.

RISK ASSESSMENT24. This work will help to improve the dental health of children and young people

and to reduce inequalities. Risk will be considered as part of implementation and of any options for future commissioning or service development.

COMMUNITY STRATEGY IMPLICATIONS25. Implementation of the work will have a positive impact on both the

Sustainable Community Strategy and Joint Health and Wellbeing Strategy themes through positive outcomes the health and wellbeing of children.

CONSULTATION26. Consultation on the project is ongoing through stakeholder events for a range

of relevant parties.

Name of Contact Officer: Sarah Bowman (Consultant in Public Health, SBC)Telephone No: 01642 524296Email Address: sarah.bowman2@stockton.gov.uk

Figure 1

Figure 2: Timetable for implementation of dental fluoride programme in Stockton

Action Date Action will be completedContact dentists regarding expression of interest and ask for feedback

Send letter by 24/4/15Responses required by14/5/15

Identification of schools eligible to take part in scheme 18/5/15Visit to eligible schools to confirm participants 17/7/15Collective meeting of dentists who have expressed an interest in taking part in scheme

31/7/15

Collective meeting of schools that have confirmed participation

30/9/15

Collective working session between all schools and all dental practices

20/11/15

Joint operational implementation meetings between individual schools and individual dental practices

31/12/15

Scheme commencement January 2016

AGENDA ITEM

REPORT TO CHILDREN AND YOUNG PEOPLE HEALTH

AND WELLBEING COMMISSIONING GROUP

27TH NOVEMBER 2013REPORT OF DIRECTOR OF

PUBLIC HEALTH

CHILDREN AND YOUNG PEOPLE’S DENTAL HEALTH

SUMMARY

Children and young people in some areas of Stockton Borough have poor dental health and significant inequalities exist between areas in the Borough. This briefing outlines the plans to help address this situation.

RECOMMENDATIONS

1. The Children’s Health and Wellbeing Commissioning Group is asked to endorse the plans.

DETAIL

1. Dental health is important to help giving children the best start in life – one of the strategic priorities in the Joint Health and Wellbeing Strategy 2012-18. Poor dental health in children and young people can cause significant pain and can impact upon a child’s self-esteem, general wellbeing and education due to potential impacts on school attendance.

2. If good dental health is not maintained, this may have longer-term impacts on health - if dental caries leads to infection, this may impact on the emergence of healthy adult teeth. Ongoing treatment can be unpleasant for the young person and costs to the health system may be significant. There is evidence that gum disease in adulthood can have complications including stroke, diabetes and heart disease.

3. Dental health among children is a good indicator of deprivation and health. The dmft score (% of 5-year old children with decayed, missing or filled teeth) is a well-used and valid method of measuring dental health. Figure 1 shows there is a good correlation between deprivation and dental disease in Stockton Borough.

4. Stockton Borough has a lower average dmft score than the other Tees Local Authority areas but higher than Hartlepool and many other areas across the North East (Figure 2). Average dmft is particularly low in Hartlepool, North Tyneside,

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Northumberland and Gateshead as the water is naturally fluoridated across Hartlepool and across parts of the other areas.

5. There is significant inequality between Stockton Borough schools regarding dmft (Figure 3). Layfield school has a score of 0% and St. Mary’s 6.67% (partly due to low numbers of children surveyed); whereas in High Clarence school, 72.73% of 5-year old children have decayed, missing or filled teeth by 5 years old and the score in Fred Natrass school is 69.23%.

Figure 1: Deprivation and dental disease in 5-year olds in Stockton Borough (Tees JSNA)

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Figure 2: Children’s dental decay across the North East (Source: BASCD 2005)

Figure 3: Dmft across Stockton Borough primary schools (Source: Dental health survey of 5-years olds, 2011/12)

01020304050607080

Disease prevalence (dmft>0, %) in Stockton Borough schools

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Schools

% dmft

St. Mary’s 6.67%

Fred Natrass 69.23%

High Clarence 72.73%

6. Dental disease is preventable. Dmft is a good indicator of diet and nutrition in both the child and their family; the diet of younger children will be greatly influenced by their main care-giver. A high dmft score in young children is most likely due to sugary drinks and / or high-sugar foods.

7. The evidence shows that the best ways of protecting children against poor dental health is a diet low in sugar, promotion of good dental health (regular, effective brushing of teeth) and on a population level, fluoridation of water supplies (Appendix 1). Health promotion messages alone have a limited effect.

8. To address the poor dental health among children and young people in Stockton Borough, Stockton Borough Council Public Health is working with Public Health England to plan a package of three types of intervention (Table 1). The package is based on Marmot’s (2010) principle of proportionate universalism: universal provision, supported by targeted intervention for those with the greatest need. It is supplemented by health promotion messages on adopting a healthy diet, through other Public Health commissioned services such as MoreLife (weight management service for children and young people).

Table 1: Local Action – evidence-based programmes

Intervention Where?

Provision of toothbrushes and fluoride toothpaste

Nursery and reception, all primary schools

Application of fluoride varnish In all quintile 5 primary schools (based on dmft prevalence) i.e. the 20% with worst dental health

Fissure sealant programme in year 6 (as adult teeth emerge)

In all children needing this in quintile 4 and 5 primary schools (based on dmft prevalence) i.e. the 40% with worst dental health

9. Dental Public Health sits within Public Health England (PHE) and Local Authorities are responsible for dental health promotion. Pilot work carried out by PHE in Middlesbrough showed a significant improvement in the dental health of children where a tooth brushing scheme was introduced in primary schools (Appendix 2). This involved provision of a toothbrush and toothpaste to children and the support of schools to encourage toothbrushing once a day while children were at school.

10. Fluoride varnish is a widely-used fluoride preparation, applied directly to the surface of the teeth. Its effectiveness has been established - a Cochrane review (2002) showed that application twice a year was associated with 46% reduction in decayed surfaces in both primary and permanent teeth of children. This was irrespective of their baseline decay severity or their background exposure to other sources of

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fluoridation. As well as preventing tooth decay, fluoride varnish also slows down the progression of established decay.

11. The fissure sealant programme involves the sealing of cracks and fissures in teeth by the application of a safe plastic coating, painted onto the chewing surfaces of back teeth. This has a longer term effect if applied as adult teeth begin to emerge, so the programme will focus on year 6 children in the 40% of schools with the worst dental health.

12. The total estimated cost of the programme is £75,000 and is to be met through the Public Health ring-fenced grant. Exact costs are being calculated based on the most recent data and approximate breakdown is as follows:

Toothbrushing scheme: £10,000Fluoride varnish: £37,500Fissure sealant: £27,500

13. Operational planning will take place in close partnership with schools, using the pilot studies as examples.

FINANCIAL IMPLICATIONS

10. The approximate cost of the work is £75,000, which is to be funded from the Public Health ring-fenced grant.

LEGAL IMPLICATIONS

11. There are no specific legal implications of this proposal.

RISK ASSESSMENT

12. Services delivering the interventions have their own risk management processes in place. Communications plans will be inherent in the implementation of the interventions.

SUSTAINABLE COMMUNITY STRATEGY IMPLICATIONS

13. The work will support implementation of both the Sustainable Community Strategy and the Joint Health and Wellbeing Strategy.

CONSULTATION

14. Consultation is an integral part of the Joint Strategic Needs Assessment process on which these plans are based. Consultation with schools will be an integral part of the implementation of the plans.

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Name of Contact Officer: Sarah BowmanPost Title: Consultant in Public HealthTelephone No: 01642 526828Email address: sarah.bowman2@stockton.gov.ukAppendix 1: Dental disease and fluoridation of water supplies (Source: Jones and Worthington, Nature 2005)

Levels of dental disease (as measured by dmft) are lower where water supplies are fluoridated, than where they are unfluoridated, and fluoridation has a particularly positive impact where deprivation is higher. I.e. water fluoridation reduces dental disease and also reduces inequalities in dental disease. The impact of artificial water fluoridation is less than in areas where water is naturally fluoridated, as levels of fluoride are lower where water is artificially fluoridated.

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Appendix 2: Results of the toothbrushing pilot in Tees schools

0 1 2 3 4 5 6 70

1

2

3

4

5

6

7

8

f(x) = 0.4563582305452 x + 0.309661581517899R² = 0.208464388347395

f(x) = 0.650293315826005 x − 0.0850133296287701R² = 0.379246068386049

Decayed, missing and filled teeth (dmft) in 5-year-olds, Tees schools, 2006 and 2012

Other schoolsLinear (Other schools)OHP schoolsLinear (OHP schools)

mean dmft 2006

mea

n dm

ft 20

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The mean dmft was lower in primary schools which had received the intervention, than in schools which had not. Analysis showed this difference to be statistically significant.

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