Fluoride Action Network

The Childsmile Program

By Ellen Connett | Fluoride Action Network | Updated November 2020

Childsmile has become the model program for the prevention of dental caries in young children in Scotland. Implemented in 2001 to target children from deprived areas, it has proven to be far more effective than the fluoridation of public drinking water in the U.S. and other fluoridating countries. Unlike fluoridation, it does not force children to swallow fluoride. However, Childsmile does target children at greatest risk of caries for fluoride sealants and they do encourage the use of toothpaste with fluoride. (There is a similarly successful program called the Nexø Program in Denmark that also focuses on teaching children and their parents to brush teeth from the youngest age.)

According to a BBC news report in 2013:

  • It’s a program to encourage nursery children to brush their teeth
  • It involves staff at all Scottish nurseries offering free supervised tooth-brushing every day.
  • It also helps parents establish a healthy diet from the earliest stage.
  • According to Public Health Minister Michael Matheson, “By this simple measure, NHS costs associated with the dental disease of five-year-old children have decreased dramatically.”
  • Glasgow researchers found that the scheme had reduced the cost of treating dental disease in five-year-olds by more than half between 2001 and 2010.
  • It costs about £1.8m a year [US$2,434,780 in Jan 2018].
  • It has saved more than £6m in dental costs, according to a new study [US$8,116,130 in Jan 2018].

The Scottish Government stated in a press release in September 2017: “The Childsmile programme, with its emphasis on prevention, rather than treatment has resulted in significant improvements in children’s oral health across Scotland. Our aim is that every child has access to Childsmile.”

We believe that the success of Childsmile is because from the government down, the Scottish people want health equality and they are willing to collaborate to achieve it. Secondly, the target of the program is prevention, not treatment.


In 2000, the British Dental Health Foundation called upon the Scottish Executive to implement fluoridation of the public drinking water “to combat tooth decay problems afflicting thousands of children.”

Four years later, in November 2004, the BBC reported that the Scottish Executive decided not to fluoridate its public drinking water and “was instead planning a range of other measures to improve the dental health of children.”

Preceding this decision opposition to fluoridation was “overwhelming.”

• In January 2002, the Scottish Consumer Council warned that pressing ahead with the proposals [to fluoridate] could expose the public to ‘adverse health effects’;

• In November 2002, the Shadow Health Minister Nicola Sturgeon “rejected any plans to add fluoride to water supplies.”

• According to The Scottish Herald in March 2003, “Thousands have raised objections to any move by the Scottish Executive to introduce what has been described as mass medication…”

• In September 2003, the Green Party MSP [Member of the Scottish Parliament] Robin Harper stated “We  [the Scottish Green Party] oppose water fluoridation on health and ethical grounds. Fluoridation breaches medical ethics and human rights by forcing people to take medication against their will, and has been linked to bone cancer and premature puberty.”

• A 2005 news article reported that “97% of responses from the public” opposed fluoridation.

On the Ethical Aspects of Childsmile

There is a 2009 published full-text paper on the web (which was also published in Bioethics) titled Tackling socially determined dental inequalities: ethical aspects of Childsmile, the national child oral health demonstration programme in Scotland. It’s a refreshing academic exploration of Childsmile, such as the “programme’s twin aims of improving oral health and reducing health inequalities; … the rationale for making particular elements universal or targeted; … an examination of the political values and evidence base in relation to the programme’s development; … the area of cost-effectiveness of Childsmile and whether prevention should be prioritised over treatment”; … and the consideration of “how Childsmile ‘scores’ in terms of utility and justice…”


Childsmile is the flagship national oral health improvement programme for Scotland. The overarching aims of Childsmile are to improve the oral health of children in Scotland and to reduce inequalities both in dental health and in access to dental services. There is also potential for other health impacts particularly with regard to diet and obesity. The Childsmile Programme is the main route to delivering the dental HEAT target.

“The Programme has three main arms:

1. Childsmile Core is a Scotland-wide initiative involving universal supervised nursery school toothbrushing provision extended to Primary 1 and 2 classes in most deprived areas [4-6 and 5-7 years of age respectively]; in addition to the free distribution of toothpaste and toothbrushes, oral health improvement packs are distributed to every child in Scotland on at least six occasions during their first five years.

2. Childsmile Practice targets children from birth and promotes oral health improvement and clinical caries prevention in dental practice, salaried primary care dental services and local community settings. This element has focused on reorientating dental practice to an anticipatory care and team approach to children’s dentistry, and integrating dental services with wider health services and community initiatives. There has been significant workforce development in creating Dental Health Support Worker roles within public health nursing teams, developing referral pathways, and training Dental Nurses ( DN) in clinical prevention including toothbrush demonstration, dietary advice and support, and as the child gets older the application of fluoride varnish.

3. Childsmile Nursery and School targets the most deprived 20% of nurseries and schools by identifying the 20% of establishments with the highest proportion of children living in the most deprived local quintile, as defined using SIMD. These nurseries and schools receive additional preventive initiatives in the form of twice yearly fluoride varnish applications to children’s teeth by Childsmile teams. These teams comprise DNs and DHSWs. The Childsmile teams also deliver oral health promotion advice to parents and carers. In addition, the Childsmile Nursery and School programme contributes to the creation of a health-promoting environment within nurseries and primary schools and provides additional pathways of referral into dental services for those who have not yet accessed dental care…” Read more of this longer article here.

In 2020, Key findings from a UK report on the State of Children

In the past decade, oral health among children has improved at a faster rate in Scotland and Wales than in England – coinciding with the establishment of their national oral health strategies. In terms of the prevalence of visually obvious tooth decay among 5 year old children:

  • England: Between 2008 and 2017, prevalence fell from 30.9% to 23.3% (7.6 percentage point reduction).10
  • Scotland: Between 2008 and 2018, prevalence fell from 42.3% to 28.9% (13.4 percentage point reduction).11
  • Wales: Between 2008 and 2016, prevalence fell from 47.6% to 35.4% (12.2 percentage point reduction).12

To access the news articles on Childsmile at FAN’s NewsTracker, click here.