All children and adolescents in Scotland are able to obtain all their dental care from the NHS free of charge until their 19th birthday.  For many years the prevalence of dental caries in Scottish children has been higher than in England.  In the early years of the current century, the Childsmile initiative was launched to address this problem.

Childsmile is a national programme designed to improve the oral health of children in Scotland and reduce inequalities both in dental health and access to dental services. It is funded by the Scottish Government (Macpherson et al 2010). It commenced as pilots in 2006, and since 2011 has been delivered as an integrated programme in all Health Board areas throughout Scotland. Childsmile is a complex public health intervention and aims to adopt a common risk factor approach, recognising the importance of multidisciplinary and multi-settings approaches – integrating oral health with other groups and agencies.  It combines targeted and universal elements, adopting a proportionate universalism approach, aiming to provide a comprehensive pathway of care, with the intensity of support related to needs at the individual and community level. Childsmile attempts to address the social determinants of health using a combination of upstream, midstream and downstream interventions (Macpherson et al. 2018).

The programme also follows the principles of the national approach in Scotland for supporting the wellbeing of children and young people and improving outcomes by offering the “right help at the right time from the right people.” This is known as Getting it Right for Every Child (GIRFEC) and supports young people and their families to work in partnership with the services that can help them (Scottish Government 2017).

An important part of the work is that of  Dental Health Support Workers and the links to primary care via Health Visitors, to community agencies and to the third sector.

What does Childsmile deliver?

It is envisaged that every child in Scotland will, from birth, have access to Childsmile.

  • At a population level, every child will have access to:
  • A tailored programme of preventive care within Primary Care Dental Services
  • Free daily supervised tooth-brushing in the nursery (kindergarten) setting (aged 3-4 years)
  • Free Dental Packs (toothbrush / 1450ppm fluoride toothpaste) to support tooth-brushing at home.

Directed support targeting children and families in greatest need through:

  • Community interventions involving home visits and links to public health nurses and community agencies and third sector organisations via dental health support workers;
  • Clinical preventive programmes, involving fluoride varnish application, in priority* nursery and primary schools by extended duties dental nurses (age 3-8 years);
  • Daily supervised tooth-brushing in primary 1 and 2 classes (age 5-6 years) in priority* primary schools.

* priority nursery / school settings defined by children being from the most socioeconomically deprived communities.

What has Childsmile Achieved ?

  • A large improvement in the percentage of P7 children (11-12 year-olds) with no obvious dental caries (decay at the D3 level)  from 53% in 2005 to 77% in 2017 (range from 65.6 % in the most deprived areas to 86.5% in the least deprived areas).
  • A national mean D3MFT in this age group of 0.49 in 2017.
  • A reduction In the Significant Caries Index (SIC) in this age group from 2.55 in 2009 to 1.50 in 2017 (National Dental Inspection Programme 2017).

Is Childsmile Cost Effective?

Childsmile is a publicly-funded health improvement programme and is subject to a full evaluation to assess whether or not it works and which parts are most successful.

A recent study compared the cost of providing the Scotland-wide nursery tooth-brushing programme with associated National Health Service (NHS) cost savings from improvements in the dental health of 5-year-old children: through avoided dental extractions, fillings and potential treatments for decay (Anopa et al 2015).

The study showed that the estimated cost of the nursery tooth-brushing programme in Scotland was around £1.8 million per year. The estimated cost of dental treatments in the baseline year 2001/02 was just under £8.8 million, while in 2009/10 it was around £4 million. In 2002/03 the costs of dental treatments increased by 2.4%. However, in the following years the costs decreased dramatically with the estimated annual savings ranging from £1.2 million in 2003/04 (14% of costs in 2001/02) to £4.7 million in 2009/10 (54%).


The Childsmile programme has had significant achievements and been associated with major improvements in child dental health over time. However, socioeconomic inequalities persist, with children from the most deprived backgrounds bearing the greatest disease burden. A new national Oral Health Improvement Plan has recently been published (Scottish Government 2018) and sets the future direction for the programme to expand.

The future direction of the Childsmile programme includes: i) optimising the delivery of the existing programme through lessons learned from the evaluation, this will include a focus on vulnerable groups (e.g. children looked after by the state; McMahon et al 2017); ii) further community development work, this will include further work with the third (NGO) sector, social prescribing / linking with ongoing community-based initiatives; iii) influencing policy and programmes (“upstream”), including common risk work as part of the Non-communicable Disease (NCD) agenda (e.g. obesity / sugar strategy).


  • Anopa Y, McMahon AD, Conway DI, Ball GE, McIntosh E, Macpherson LM (2015). Improving child oral health: cost analysis of a national nursery toothbrushing programme. PloS one, 10(8), p.e0136211.
  • Childsmile (2011). Incorporating Childsmile into the SDR. NHS Health Scotland (Accessed Feb 2018).
  • Childsmile (2015). National Standards for Nursery and School Toothbrushing Programmes. NHS Health Scotland (Accessed Feb 2018).
  • Macpherson LM, Ball GE, Brewster L, Duane B, Hodges CL, Wright W, Gnich W, Rodgers J, McCall DR, Turner S, Conway DI (2010). Childsmile: the national child oral health improvement programme in Scotland. Part 1: Establishment and development. Br Dent J 209(2):73-8.
  • Macpherson LMD, Anopa Y, Conway DI, and McMahon AD (2013). National supervised toothbrushing program and dental decay in Scotland.  Journal of Dental Research 92(2):109-113.
  • McMahon AD, Elliott L, Macpherson LM, Sharpe KH, Connelly G, Milligan I, Wilson P, Clark D, King A, Wood R, Conway DI (2018). Inequalities in the dental health needs and access to dental services among looked after children in Scotland: a population data linkage study. Arch Dis Child 103(1):39-43.
  • National Dental Inspection Programme (2017). National Dental Inspection Programme NDIP. NHS Scotland (Accessed Feb 2018).
  • Scottish Government (2015) Universal Health Visiting Pathway in Scotland – Pre Birth to Pre School (Accessed Feb 2018).
  • Scottish Government (2016). Scottish Index of Multiple Deprivation. 2016 Scottish Government. Feb 2018).
  • Scottish Government (2017) Getting it right for every child (GIRFEC) (Accessed Feb 2018).
  • Scottish Government (2018) Oral Health Improvement Plan (Accessed Feb 2018)
  • Wright W, Turner S, Anopa Y, McIntosh E, Wu O, Conway DI, Macpherson LM, McMahon AD (2015). Comparison of the caries-protective effect of fluoride varnish with treatment as usual in nursery school attendees receiving preventive oral health support through the Childsmile oral health improvement programme – the Protecting Teeth@3 Study: a randomised controlled trial. BMC Oral Health 15:160.

Much of the material presented in this description comes directly from the Childsmile website and from Macpherson L, Anopa Y, Rodgers J, Conway D. Childsmile – the national child oral health programme for Scotland. Transformative Education for Health Professionals. WHO Guidelines. Case Studies. March 2018  The Oral Health Working Group of the World Federation of Public Health Associations thank the Childsmile team for permission to reproduce the images and some commentary in this brief description.

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