Children and Young People Committee
Inquiry into Children’s Oral Health
Evidence
from Abertawe Bro Morgannwg University Health Board
The most common oral disease of childhood is dental caries, often called tooth decay. Tooth decay is found in deprived and affluent communities and is likely to affect more teeth per child in deprived communities throughout the ABMU area.
ABMU HB has a Designed to Smile (D2S) Steering Group, (see annex 1 membership). This Group sets out and oversees delivery of the annual costed D2S plan for Swansea, Neath and Port Talbot. Bridgend D2S is delivered by Cardiff and Vale Community Dental Service. The plan is signed off by the responsible Executive Director for dentistry.
In ABMU LHB the average decayed, missing and filled baby teeth (dmft) for those aged 5, surveyed in 2007-08 was 2.14 and the average dmft for those with experience of caries was 4.41. These averages were not significantly different from the Welsh averages (1.98 and 4.16 respectively). However, there are pockets of deprivation where the dmft is even higher.
One effect of this high prevalence of tooth decay is the large number of children who receive a general anaesthetic (GA) for tooth extraction from the ABMU area (in the order of 1700 annually). This is unacceptable for what is an almost totally preventable disease.
Responses to the Committee’s Questions
1. The take-up of :
a) the supervised tooth brushing scheme for 3-5 year olds
The initial target was 66 schools in this age range tooth brushing by 2011, this figure has been exceeded. Many schools requested extending the tooth brushing to older age groups; this has resulted in the following figures:
· 0 – 3 years = 30 settings tooth brushing
· 3 – 5 years = 58 settings tooth brushing
· 3 – 11 years = 109 settings tooth brushing
This equates to approximately 12,000 children in the Swansea, Neath and Port Talbot area tooth brushing.
To date 5 schools have declined the tooth brushing programme and 5 schools have temporarily withdrawn from the programme. Contact is maintained with these schools with a view to them agreeing to inclusion in the near future.
b) the promotional programme for 6-11 year olds
This part of the programme has been met with great enthusiasm and gratitude by the schools, evidence of this is provided with evaluations and feedback letters from the teaching staff, pupils and parents, examples are located in annex 2. These evaluations are discussed in team meetings and any necessary changes or improvements are implemented and best practice shared. D2S has supplied a teaching pack worth approximately £180 to 135 schools and other settings. The packs contain an assortment of oral health education (OHE) resources. Many schools using the packs have initiated follow up lessons provided by the class teacher a few weeks after the initial one provided by the D2S member of staff, feedback from these lessons by the teachers is positive with excellent knowledge retention by the children.
The Swansea, Neath and Port Talbot Designed to Smile team have provided age specific oral health education teaching sessions to all age groups since the beginning of it’s inclusion into the programme. The younger children have stories with puppets and mouth models, colouring in sheets and also a role play dressing up session with a dental surgery background and dental chair. The older children have PowerPoint lessons which include hands on experiments and worksheets. These lessons also incorporate healthy eating awareness and advice as well as OHE. By involving the children with a hands on and fun approach to OHE ensures that they retain and act on the information provided. Parents have also reported improved compliance with tooth brushing at home with fewer ‘tantrums’. Teaching sessions have been provided not only to those schools and nurseries taking part in the tooth brushing part of the scheme but many others who are not involved making a total of 140 settings. These lessons are diarised by the team and are repeated annually to maintain continuity; or on request of school staff if they are required before.
The content of the lessons provided to schools are in line with the National Curriculum and The Scientific Basis of Oral Health Education. The D2S team members are regularly assessed by the Designed to Smile Manager whilst they deliver these sessions; these assessments are discussed verbally and they are provided with a written lesson evaluation form. This method of internal monitoring ensures the consistency of high standards expected from the team.
2. Whether the investment has delivered improved health outcomes for the most disadvantaged children and young people;
The distribution of ‘home packs’ twice a year to the children, (these contain a toothbrush and toothpaste; this year they will receive three packs) has ensured that they are able to follow up the importance we place on cleaning their teeth effectively at home as well as in school as part of the D2S programme. An alarmingly large proportion of children that have received the packs have readily admitted to never having owned a toothbrush before. There is also potential for other health impacts particularly with regard to diet and obesity. A large section of the teaching sessions focus on healthy eating and drinking; children are encouraged to begin to make small, short term realistic changes in their diet; this will hopefully lead to more sustainable long term normal ‘healthy eating’ habits.
The D2S team have undertaken the Open College Network (OCN) level two training in ‘Community Food and Nutrition Skills for the Early Years’ and also ‘Brief Intervention in Smoking Cessation’. Both of these courses have proved invaluable in providing the D2S team with the knowledge and confidence to incorporate this information and expand on the OH training. This has been particularly beneficial as the team are having requests to attend senior citizen groups (as many grandparents are joint carers if not primary carers for their grandchildren).
3. Whether the programme is operating consistently across Wales in all areas of need;
The D2S team in the Swansea, Neath and Port Talbot area have worked tirelessly to make certain that all areas of need are receiving the highest quality of care and involvement from D2S. In line with the expansion and the aims and standardisation of the programme, this September sees the expansion of the Fissure Sealant programme and the introduction of fluoride varnish application in the New Year.
One issue that has become apparent since the programme began is the necessity for D2S input into the more affluent areas because there are pockets of deprivation in these.
4. How effective the expansion of the programme has been, particularly in relation to 0-3 year olds;
Combining schools, Flying Start and independent nurseries there are now 29 settings of this age group tooth brushing within the D2S programme.
By working in close collaboration with health visitors and providing them with packs to distribute at the child’s 7 month assessment has ensured that this has been a successful part of the expansion programme. Each child at 7 months old receives a suitable toothbrush, toothpaste (1000ppm), a doidy cup and explanatory leaflets. The D2S team has provided the health visitors with OHE which they are able to pass on to the parents. This service is distributed by the health visitors in addition to the already established referral pathway into dental services for those who have not yet accessed them.
Links have also been made with childcare providers who use their own homes as business premises. This group has also received OHE which includes a tooth brushing demonstration; they raised concerns that parents deliver the children at a very early hour and many are asleep when parents collect them, consequently if the childminder doesn’t clean the child’s teeth ‘they don’t get done at all’.
The D2S team also deliver oral health promotion advice to parents and carers through organised sessions in schools, mother and toddler groups, breastfeeding groups, fetes, coffee mornings and health awareness events.
5. Whether the programme addresses the needs of all groups of children and young people;
Networking, word of mouth, regular local advertising of the programme and recognition of the D2S logo has resulted in a constant stream of requests for D2S input into many groups and organisations these include:-
Action for Children
After school and youth clubs
Brownie Groups
Community First Play Schemes / Well being events
Drug and Alcohol User Groups
Engage Programme
Ethnic Minority Groups
Mobile Toy Library
OHE sessions in 5 Swansea Comprehensive schools
Pupil Referral Units
SNAC (Special Needs Activity Centres)
SPARK / Dove Workshop (family support groups)
Speech and Language Sessions
Sure Start
Swansea Young Single Homeless Project
Teaching sessions provided for final year teaching students at Swansea University
Teaching sessions provided for NVQ / CACHE Diploma childcare students at Neath and Port Talbot College
The Bridge Project / Tums to Mums (women and children affected by domestic abuse)
Travelling Community (children and adults)
Twins Groups
Ty Laura (residential care home for children with special requirements)
Young Teenage Mums Group
Contact has been made with the Looked After Children Team to discuss the process for effective delivery of the D2S programme for this group.
The contacts established with these various groups and the links between D2S and the wider CDS has also resulted in an enhanced awareness of the role of the CDS in the provision of dental care for vulnerable people and of the appropriate referral pathways for care within the CDS.
6. The extent to which the D2S programme has been integrated into wider local and national initiatives such as the Welsh Network of Healthy School Schemes and Flying Start;
Designed to Smile has integrated successfully with the local healthy school schemes, this has been achieved by:
D2S has taken advantage of the two way training opportunity with the ABMU HB dietetic department by providing evidence based oral health messages in training days for the Open College Network (OCN) on food and fitness.
D2S is also involved in the implementation of the Swansea Gold Standard Healthy snack Award for Pre-school Settings. Other partners in this group are; Dietetics Department ABMUHB, City and County Swansea Environment Department, Flying Start, Swansea Public Health Team – Healthy School Co-ordinator.
The D2S Manager has developed an excellent local D2S team that is clearly capable of networking and developing an oral health promotional initiative. This could have considerable potential benefits for not only the CDS but for other groups of vulnerable people in the future if the decision is made to develop other health promotion initiatives. Building such a team takes time and this success should deserve recognition.
7. The current and potential implications for paediatric dentistry, including reviewing the strengthened role of the CDS in children’s public health.
It is essential that health promotional messages from all the dental services are consistent. The involvement of D2S with the Welsh Government`s GDS Child Pilot has provided opportunities for the team to share resources and to work closely with the practice’s oral health educator to ensure that messages are consistent. The practice manager of the Swansea GDS Pilot also attends the Steering Group meetings.
ABM CDS provides dental care for vulnerable people of all ages who are unable to obtain treatment via the general dental services in line with guidance from the Welsh Assembly Government. The CDS Clinical Service Manager/Senior Dental Officer is also a member of the D2S Steering Group and works closely with the D2S Manager to ensure that both services operate in a complimentary, effective and efficient manner.
The CDS D2S team consistently promotes the services provided by the wider CDS, and provides information not only to schools but also to all the other groups it encounters of the best way CDS services can be accessed. This has resulted in the development of a wider range of contact groups referring patients to the CDS. Early evidence suggests that the numbers of children referred to the CDS has increased as a result.
This joint working between the D2S and wider CDS will facilitate the development of paediatric dental care within the CDS. This development is already underway with the introduction of a team within the CDS that is specifically responsible for the dental care of children. As many of the children seen by the CDS require some form of special care dentistry, the development of links with children’s carers and support groups by the D2S team is invaluable to the CDS.
The anticipated reduction in dental decay that the D2S programme will produce will result in children retaining more of their teeth. This will result in other challenges to the dental profession and the CDS that may include increased orthodontic, restorative and possibly conscious sedation service demands as fewer children will require multiple extractions and treatment under general anaesthesia.
The children’s team within ABM CDS is working to meet further demand on these services as part of an improved recruitment and retention staffing policy. Further development will include the recruitment of a specialist in paediatric dentistry within the CDS.
Into next year it is planned that the coordination of D2S input and other CDS provision e.g. school screening and mobile treatment services will be further developed. More children would come into the programme and many of these children will almost certainly require additional care via the CDS.
The expansion of D2S activities in the coming year will greatly facilitate the school screening carried out by the CDS and the coordination of CDS mobile dental unit activity for children’s dentistry.
The CDS also has a commitment to provide training for groups including Dental Foundation Trainees and other dental care professionals. The D2S team has kindly allowed CDS staff to attend and observe their activities and have provided these groups with an important instructional overview of an oral health promotional programme for children in action.
The Local Dental Committee (LDC) has received a joint presentation by the Chair of the Steering Group and the D2S Manager; the LDC also has representation on the Steering Group.
The work of the D2S team has helped to enhance the understanding of the local dental community of the importance of oral health promotion amongst children and of working with the CDS. The Clinical Service Manager/Senior dental Officer has also already had meetings with representatives of the Welsh Government`s local GDS Child Pilot initiative.
This is in line with the D2S/CDS role of developing joint working and liaison with other groups.
The D2S Manager has also established an efficient, motivated team within the CDS that could be aligned in the future to develop oral health promotional initiatives for other vulnerable groups. These groups could include dependent elderly people and the homeless. This activity could further complement and enhance the role of the CDS in the dental care of vulnerable people.
Conclusion
D2S, like its sister programme in Scotland, has the potential to deliver improved oral health of children.
We have made a start but there is long way to go. We urge that the Committee supports the sustainability of D2S, with appropriate levels of funding, so that the efforts of the past few years, in setting the foundations, are not wasted. We can then realize the improved health outcomes that our children deserve.
The Labour Party Manifesto states a commitment to “build” on the Designed to Smile Programme. The Health Board recommends that the programme is extended to children in secondary education to support and maintain oral health messages and behaviour in adolescence and into adulthood. Additional funding will be necessary to effectively deliver an extended Designed to Smile Programme within this setting.
In the absence of water fluoridation D2S can, given the necessary time and resources, make a significant contribution towards reducing the prevalence of children`s tooth decay in ABMU.
Annex 1
Swansea, Neath and Port Talbot Designed to Smile Steering Group Membership
Mandy Silva Designed to Smile Manager, CDS, ABMU HB
David Davies Clinical Service Manager, CDS, ABMU HB
Hugh Bennett Consultant in Dental Public Health, Public Health
Wales
Claire Thompson Health Promotion Specialist, Swansea Public
Health Team
Richard Williams Dental Contracts Manager, ABMU, Swansea Locality
Karen Adams Finance Manager, Surgery Directorate, ABMU HB
Beti Ede Healthy Schools Co-ordinator, Swansea Public Health Team
Catie Parry Healthy Schools Co-ordinator, Neath & Port Talbot Public Health Team
David Westcott Chair, Local Dental Committee
Paula Davies Operational Team Manager, Health Visiting, Swansea East
Vanessa Williams Practice Manager, Belgrave Dental Practice, Swansea
Annex 2
Examples of feedback received from
Foundation Phase Teacher – 24.3.11
“The programme is excellent with a wide range of hand on items for the children to use”.
Nursery Teacher – 22.11.10
“The demonstration was great fun and all the activities were pitched at the right level”.
Parent – 11.11.10
“Very informative and now my knowledge is at a standard I am happy about to keep my children’s mouth healthy”.
Teacher Year 3/4 – 26.10.10
“Your PowerPoint slides were age-appropriate and held the attention of all the pupils”.
Deputy Headteacher – 28.9.10
“Just a short note to say many thanks for your extremely informative visit today. You have worked with all classes throughout the school and I know the children gained a lot from your expertise and input. The professional manner in which you have approached the day has impressed all members of staff. I feel that your PowerPoint presentation and classroom delivery was both enlightening and productive and we hope the children will take on board the lessons from today and benefit from improved oral hygiene as a result.
The Headteacher felt that the Designed to Smile meeting with our parents was a real success and this was due to your friendly and sensitive approach. Needless to say, she was more than impressed with your input.
Moreover, I feel that you both ‘fitted in’ with our school day and you were very flexible in your approach. This again was appreciated by all staff.
We hope to see you both again in the very near future and that you will see positive results from today’s endeavours. In short, an excellent day was had by all. Many thanks again”.
Healthy Schools Subject leader- 22.6.11
“Many thanks to you regarding your recent visit. The nursery, reception and year 1 / 2 classes loved the puppets and visual aids and were obviously engrossed by your input by the excited talk about how we can keep our teeth healthy. Since your visit we have all done follow up work. Nursery are making their own ‘eat well plate’ and talking about healthy foods and treats. The nursery teacher has also sent home a sheet informing parents of your visit and some of the techniques needed for keeping mouths healthy.
In reception we have talked about healthy foods and treats also, and as a home-school activity, the children have brought in posters and food diaries. We felt this would also spread the message home. The year 1 / 2 class are also making an eatwell plate and vocabulary linked to the mouth.
The feedback is very positive from the staff, and the children (and adults actually) certainly learnt a lot from the visit.
We are all very much looking forward to the whole school visit in October and until then hope to keep our shiny smiles!
Many thanks”.