EXCERPTS Strengths and limitations of the study This is the first population-wide data linkage cohort study to evaluate the reach and impact of a complex public health intervention. There is evidence of effectiveness of oral health improvement interventions for children including fluoride toothpaste and professionally applied fluoride varnish; however, the evidence of combining these into a complex oral health improvement programme delivered via a proportio

Abstract

Objectives Child dental caries is a global public health challenge with high prevalence and wide inequalities. A complex public health programme (Childsmile) was established. We aimed to evaluate the reach of the programme and its impact on child oral health.

Setting Education, health and community settings, Scotland-wide.

Interventions Childsmile (national oral health improvement programme) interventions: nursery-based fluoride varnish applications (FVAs) and supervised daily toothbrushing, community-based Dental Health Support Worker (DHSW) contacts and primary care dental practice visits—delivered to the population via a proportionate universal approach.

Participants 50 379 children (mean age=5.5 years, SD=0.3) attending local authority schools (2014/2015).

Design Population-based individual child-level data on four Childsmile interventions linked to dental inspection survey data to form a longitudinal cohort. Logistic regression assessed intervention reach and the independent impact of each intervention on caries experience, adjusting for age, sex and area-based Scottish Index of Multiple Deprivation (SIMD).

Outcome measures Reach of the programme is defined as the percentage of children receiving each intervention at least once by SIMD fifth. Obvious dental caries experience (presence/absence) is defined as the presence of decay (into dentine), missing (extracted) due to decay or filled deciduous teeth.

Results 15 032 (29.8%) children had caries experience. The universal interventions had high population reach: nursery toothbrushing (89.1%), dental practice visits (70.5%). The targeted interventions strongly favoured children from the most deprived areas: DHSW contacts (SIMD 1: 29.5% vs SIMD 5: 7.7%), nursery FVAs (SIMD 1: 75.2% vs SIMD 5: 23.2%). Odds of caries experience were markedly lower among children participating in nursery toothbrushing (>3 years, adjusted OR (aOR)=0.60; 95% CI 0.55 to 0.66) and attending dental practice (>6 visits, aOR=0.55; 95% CI 0.50 to 0.61). The findings were less clear for DHSW contacts. Nursery FVAs were not independently associated with caries experience.

Conclusions The universal interventions, nursery toothbrushing and regular dental practice visits were independently and most strongly associated with reduced odds of caries experience in the cohort, with nursery toothbrushing having the greatest impact among children in areas of high deprivation.


*Original study in full text online at https://bmjopen.bmj.com/content/10/11/e038116

EXCERPTS

Strengths and limitations of the study

  • This is the first population-wide data linkage cohort study to evaluate the reach and impact of a complex public health intervention.

  • There is evidence of effectiveness of oral health improvement interventions for children including fluoride toothpaste and professionally applied fluoride varnish; however, the evidence of combining these into a complex oral health improvement programme delivered via a proportionate universal approach has not previously been evaluated.

  • The study uses routine administrative data, which have some limitations in the variables available, including a lack of information on intermediate individual behaviours.

  • The outcome data available, the presence or absence of obvious dental caries experience, collected by trained and standardised dental inspection teams and available at the population level show a high level of agreement with detailed decay, missing, and filled teeth (dmft) index scores collected by calibrated dental inspection teams on a much smaller sample of children.

  • The study strengths are in the robust data linkage approach, where there were no concerns about the quality and completeness of the data linkage, resulting in a cohort with population-wide coverage of outcome and intervention data.

Introduction

Oral health is a global public health challenge with oral diseases estimated to be the most prevalent condition in the world.1 Untreated dental caries (tooth decay) of the deciduous teeth affects 8% of the global child population, with greatest prevalence in those under 5 years of age.2 In Scotland, at the beginning of the 21st century, dental caries in 5 year olds was among the worst in Europe, with 60% affected, wide inequalities identified and no improvement observed in the previous decade.3

A 2002 Scottish Government consultation resulted in fluoridation of the public water supply being ruled out,4 5 but with a realisation that a traditional health education approach for oral health improvement was both ineffective and could potentially widen inequalities.6 The resultant national oral health strategy established demonstration pilot projects which developed into the national child oral health improvement programme—Childsmile.7 The Childsmile programme is described in detail elsewhere8—briefly, it is a multicomponent preventive programme operating at upstream (policy), midstream (community) and downstream (clinical) levels. It follows a proportionate universal approach—delivering both universal interventions to all children and additional targeted interventions focused on children predicted to be at higher risk of dental caries from the most socioeconomically deprived backgrounds, with the twin aims of improving child oral health and reducing associated inequalities in the population.9 10 Childsmile’s main focus has been on preschool children (aged up to 5 years). The four main interventions of the programme for this age group are (1) dental health support worker (DHSW) home and community contacts (targeted from birth to children and their parents/carers in greatest need as identified by health visitors, for prevention advice, to help facilitate attendance in primary care dental practice, and to link families with community assets); (2) nursery (kindergarten) fluoride varnish applications (FVAs) (targeted to children from the of age 3 years from the more deprived communities, applied twice per year by extended duty dental nurses); (3) primary care dental practice visits (available from birth for all children attending where toothbrushing instruction, diet advice and FVAs are offered); and (4) nursery-supervised toothbrushing (universal to all preschool establishments in Scotland, including daily toothbrushing with fluoride toothpaste and distribution of toothbrush/toothpaste packs for home use). Following piloting, these interventions were collectively rolled out nationally from 2010/2011.

A monitoring and evaluation strategy for the Childsmile programme was developed based on recommended approaches for the evaluation of complex interventions.11 A theory-based approach to evaluation, incorporating a logic model, guided the development of studies to gather process and outcome measures. The evaluation plan included an ecological evaluation of nursery-supervised toothbrushing,12 13 an embedded randomised controlled trial of nursery fluoride varnish14 and an individual child-level data linkage study using the emerging NHS Scotland infrastructure (this present study).15

Several Cochrane reviews show effectiveness of the fluoride-based interventions16 17; however, the evidence in relation to the proportionate universal delivery of combinations of these interventions at the population level is untested. Here, we developed a cohort using data linkage methods of routine administrative data to assess the reach of the Childsmile programme (with its universal and targeted interventions) by area-based socioeconomic deprivation and to undertake an analysis of the impact of the Childsmile interventions on dental caries outcomes among Primary 1 children (age range 4–6 years old) in 2014/2015 in Scotland (the first cohort of children to be born into the nationally rolled-out programme) by the overall population and then by area-based socioeconomic deprivation…

References

  1. Peres MA, Macpherson LMD, Weyant RJ, et al. Oral diseases: a global public health challenge. Lancet 2019;394:249–60.doi:10.1016/S0140-6736(19)31146-8pmid: http://www.ncbi.nlm.nih.gov/pubmed/31327369
  2. Kassebaum NJ, Smith AGC, Bernabé E, et al. Global, regional, and national prevalence, incidence, and Disability-Adjusted life years for oral conditions for 195 countries, 1990-2015: a systematic analysis for the global burden of diseases, injuries, and risk factors. J Dent Res 2017;96:3807.doi:10.1177/0022034517693566pmid: http://www.ncbi.nlm.nih.gov/pubmed/28792274
  3. Scottish Dental Epidemiological Co-ordinating Committee. Scotland’s National Dental Inspections Programme, 2003. Available: https://ndip.scottishdental.org/wp-content/uploads/2014/08/ndip_scotland2003.pdf [Accessed 01 Nov 2020].
  4. Scottish Executive. Towards Better Oral Health in Children – A Consultation Document on Children’s Oral Health in Scotland, 2002. Available: https://www.webarchive.org.uk/wayback/archive/20180517060905/http://www.gov.scot/Publications/2002/09/15477/11087 [Accessed 01 Nov 2020].
  5. Scottish Executive Health Department. Towards Better Oral Health in Children – Analysis of Consultation Responses, 2005
  6. Schou L, Wight C. Does dental health education affect inequalities in dental health? Community Dent Health 1994;11:97–100.pmid: http://www.ncbi.nlm.nih.gov/pubmed/8044719
  7. Scottish Executive. An action plan improving oral health and modernising NHS dental services in Scoltand, 2005. Available: https://www.gov.scot/publications/action-plan-improving-oral-health-modernising-nhs-dental-services-scotland/ [Accessed 01 Nov 2020].
  8. Macpherson LMD, Ball GE, King P, et al. CHILDSMILE: the CHlLD oral health improvement programme in Scotland. Prim Dent J 2015;4:33–7. doi:10.1308/205016815816682236pmid: http://www.ncbi.nlm.nih.gov/pubmed/26966770
  9. Marmot M. Fair Society, healthy lives: the Marmot review, 2010. Available: http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf [Accessed 01 Nov 2020].
  10. Shaw D, Macpherson L, Conway D. Tackling socially determined dental inequalities: ethical aspects of Childsmile, the National child oral health demonstration programme in Scotland. Bioethics 2009;23:131–9.doi:10.1111/j.1467-8519.2008.00715.xpmid: http://www.ncbi.nlm.nih.gov/pubmed/19531166
  11. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new medical Research Council guidance. Int J Nurs Stud 2013;50:587–92.doi:10.1016/j.ijnurstu.2012.09.010pmid: http://www.ncbi.nlm.nih.gov/pubmed/23159157
  12. Macpherson LMD, Anopa Y, Conway DI, et al. National supervised toothbrushing program and dental decay in Scotland. J Dent Res 2013;92:109–13.doi:10.1177/0022034512470690pmid: http://www.ncbi.nlm.nih.gov/pubmed/23264611
  13. Anopa Y, McMahon AD, Conway DI, et al. Improving child oral health: cost analysis of a national nursery toothbrushing programme. PLoS One 2015;10:e0136211. doi:10.1371/journal.pone.0136211pmid: http://www.ncbi.nlm.nih.gov/pubmed/26305577
  14. Wright W, Turner S, Anopa Y, et al. 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 2015;15:160. doi:10.1186/s12903-015-0146-zpmid: http://www.ncbi.nlm.nih.gov/pubmed/26681191
  15. Pavis S, Morris AD. Unleashing the power of administrative health data: the Scottish model. Public Health Res Pract 2015;25:e2541541. doi:10.17061/phrp2541541pmid: http://www.ncbi.nlm.nih.gov/pubmed/26536503
  16. Marinho VCC, Worthington HV, Walsh T, et al. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2013;7:CD002279. doi:10.1002/14651858.CD002279.pub2pmid: http://www.ncbi.nlm.nih.gov/pubmed/23846772
  17. Wong MCM, Clarkson J, Glenny A-M, et al. Cochrane reviews on the benefits/risks of fluoride toothpastes. J Dent Res 2011;90:573–9. doi:10.1177/0022034510393346pmid: http://www.ncbi.nlm.nih.gov/pubmed/21248357
  18. ISD Scotland Childsmile. NHS National Services Scotland.. Available: https://www.isdscotland.org/Health-Topics/Dental-Care/Childsmile/ [Accessed 01 Nov 2020].
  19. ISD Scotland. General Dental Service – Registrations and Participation Analysis:. Available: https://www.isdscotland.org/Health-Topics/Dental-Care/General-Dental-Service/registration-and-participation.asp [Accessed 01 Nov 2020].
  20. ISD Scotland. National Dental Inspection Programme (NDIP) 2019 – Report of the 2019 Detailed Inspection Programme of Primary 7 Children and the Basic Inspection of Primary 1 and Primary 7 children NHS National Services Scotland; 2019. https://ndip.scottishdental.org/wp-content/uploads/2019/10/2019-10-22-NDIP-Report.pdf [Accessed 01 Nov 2020].
  21. Scottish Government. Overall SIMD 2009 and individual domains. Available: https://www2.gov.scot/Topics/Statistics/SIMD/Background-Data-2009 [Accessed 01 Nov 2020].
  22. Kidd JBR. Developing a population data linkage cohort to investigate the impact on child oral health outcomes following the roll-out of the Childsmile programme in Scotland, 2019. Available: http://theses.gla.ac.uk/76718/1/2019KiddPhD.pdf [Accessed 01 Nov 2020].
  23. Kendrick SW, Douglas MM, Gardner D, et al. Best-link matching of Scottish health data sets. Methods Inf Med 1998;37:64–72.pmid :http://www.ncbi.nlm.nih.gov/pubmed/9550849
  24. Central Evaluation & Research Team. Childsmile national Headline data, 2015. Available: http://www.child-smile.org.uk/uploads/documents/5225-Childsmile%20National%20Headline%20Data%202015%2011.pdf [Accessed 01 Nov 2020].
  25. ISD Scotland. National dental inspection programme (NDIP) 2015 report of the 2015 detailed national dental inspection programme of primary 7 children and the basic inspection of primary 1 and primary 7 children. Available: https://ndip.scottishdental.org/wp-content/uploads/2015/10/ndip_scotland2015-P7.pdf [Accessed 01 Nov 2020].
  26. Pine CM, Pitts NB, Nugent ZJ. British association for the study of community dentistry (BASCD) guidance on the statistical aspects of training and calibration of examiners for surveys of child dental health. A BASCD coordinated dental epidemiology programme quality standard. Community Dent Health 1997;14 Suppl 1:18–29. pmid: http://www.ncbi.nlm.nih.gov/pubmed/9114555
  27. ISD Scotland, eDRIS. Public Health Scotland [formerly NHS National Services Scotland]. Available: https://www.isdscotland.org/Products-and-Services/eDRIS/ [Accessed 01 Nov 2020].
  28. Benchimol EI, Smeeth L, Guttmann A, et al. The reporting of studies conducted using observational Routinely-collected health data (record) statement. PLoS Med 2015;12:e1001885. doi:10.1371/journal.pmed.1001885pmid: http://www.ncbi.nlm.nih.gov/pubmed/26440803
  29. Gilbert R, Lafferty R, Hagger-Johnson G, et al. Guild: guidance for information about linking data sets. J Public Health 2018;40:191–8. doi:10.1093/pubmed/fdx037pmid: http://www.ncbi.nlm.nih.gov/pubmed/28369581
  30. Macpherson LMD, Ball GE, Brewster L, et al. Childsmile: the National child oral health improvement programme in Scotland. Part 1: establishment and development. Br Dent J 2010;209:73– . doi:10.1038/sj.bdj.2010.628pmid :http://www.ncbi.nlm.nih.gov/pubmed/20651768
  31. Turner S, Brewster L, Kidd J, et al. Childsmile: the National child oral health improvement programme in Scotland. Part 2: monitoring and delivery. Br Dent J 2010;209:79–83.doi:10.1038/sj.bdj.2010.629pmid :http://www.ncbi.nlm.nih.gov/pubmed/20651769
  32. Hodgins F, Sherriff A, Gnich W, et al. The effectiveness of dental health support workers at linking families with primary care dental practices: a population-wide data linkage cohort study. BMC Oral Health 2018;18:191. doi:10.1186/s12903-018-0650-z pmid :http://www.ncbi.nlm.nih.gov/pubmed/30463549
  33. Duijster D, Verrips GHW, van Loveren C. The role of family functioning in childhood dental caries. Community Dent Oral Epidemiol 2014;42:193–205. doi:10.1111/cdoe.12079pmid: http://www.ncbi.nlm.nih.gov/pubmed/24117838
  34. Marshman Z, Ahern SM, McEachan RRC, et al. Parents’ experiences of toothbrushing with children: a qualitative study. JDR Clin Trans Res 2016;1:122–30. doi:10.1177/2380084416647727pmid: http://www.ncbi.nlm.nih.gov/pubmed/28879241
  35. Lambert MJ, Vanobbergen JSN, Martens LC, et al. Socioeconomic inequalities in caries experience, care level and dental attendance in primary school children in Belgium: a cross-sectional survey. BMJ Open 2017;7:e015042. doi:10.1136/bmjopen-2016-015042pmid: http://www.ncbi.nlm.nih.gov/pubmed/28729310
  36. Nuttall NM, Gilbert A, Morris J. Children’s dental anxiety in the United Kingdom in 2003. J Dent 2008;36:857–60. doi:10.1016/j.jdent.2008.05.014pmid :http://www.ncbi.nlm.nih.gov/pubmed/18755532
  37. Harris R, Gamboa A, Dailey Y, et al. One-To-One dietary interventions undertaken in a dental setting to change dietary behaviour. Cochrane Database Syst Rev 2012:CD006540. doi:10.1002/14651858.CD006540.pub2pmid: http://www.ncbi.nlm.nih.gov/pubmed/22419315
  38. Tickle M, O’Neill C, Donaldson M, et al. A randomized controlled trial of caries prevention in dental practice. J Dent Res 2017;96:741–6. doi:10.1177/0022034517702330pmid: http://www.ncbi.nlm.nih.gov/pubmed/28375708
  39. de Sousa FSdeO, Dos Santos APP, Nadanovsky P, et al. Fluoride Varnish and dental caries in preschoolers: a systematic review and meta-analysis. Caries Res 2019;53:502–13.doi:10.1159/000499639pmid: http://www.ncbi.nlm.nih.gov/pubmed/31220835
  40. Fleming M, Fitton CA, Steiner MFC, et al. Educational and health outcomes of children treated for type 1 diabetes: Scotland-Wide record linkage study of 766,047 children. Diabetes Care 2019;42:1700–7. doi:10.2337/dc18-2423pmid : http://www.ncbi.nlm.nih.gov/pubmed/31308017
  41. Public Health Research Data Forum. Enabling data linkage to maximise the value of public health research data: full report. Available: https://wellcome.ac.uk/sites/default/files/enabling-data-linkage-to-maximise-value-of-public-health-research-data-phrdf-mar15.pdf [Accessed 01 Nov 2020].
  42. Julihn A, Soares FC, Hjern A, et al. Socioeconomic determinants, maternal health, and caries in young children. JDR Clin Trans Res 2018;3:395–404. doi:10.1177/2380084418788066pmid: http://www.ncbi.nlm.nih.gov/pubmed/30263967
  43. Bohensky MA, Jolley D, Sundararajan V, et al. Data linkage: a powerful research tool with potential problems. BMC Health Serv Res 2010;10:346. doi:10.1186/1472-6963-10-346pmid: http://www.ncbi.nlm.nih.gov/pubmed/21176171

 

 

View Abstract

Supplementary materials