Barriers to running supervised toothbrushing programs for young children must be overcome if the UK government is to successfully tackle childhood tooth decay, researchers say.

The team from the Universities of Sheffield and Leeds has completed a survey of supervised toothbrushing programs currently available to children in England.

They found that the number of programs has increased since their last survey in April 2022—but also identified several barriers preventing schools, nurseries, and other organizations from setting them up, including funding, time pressures and competing priorities.

The increase in numbers of programs can be attributed to an increased priority given by the NHS and local authorities to improving children’s oral health; recovery from the COVID-19 pandemic, and awareness of the Labor Party’s pledge to introduce targeted supervised toothbrushing for 3- to 5-year-olds.

However, the researchers say there are still many 3- to 5-year-olds living in the most deprived areas of England who would benefit from these programs, but do not yet have access to them—and call for the government to provide dedicated funding to ensure its campaign pledge is fulfilled.

The paper in the British Dental Journal is the latest to be published as part of the BRUSH project, which is researching how to implement supervised toothbrushing programs for children aged three to five across England. Under the same banner, the team previously developed a free online toolkit featuring all the resources needed to set up supervised toothbrushing programs in different settings.

Senior author Zoe Marshman, Professor in Dental Public Health from the University of Sheffield, said, “While it’s encouraging to see an increase in supervised toothbrushing programs, we must remember that every child deserves help to prevent tooth decay.

“Poor oral health can have far-reaching consequences, from self-esteem issues to difficulties in learning. By investing in these programs, we’re not just preventing tooth decay; we’re investing in our children’s future. Together, additional government funding and the BRUSH toolkit can help make more of these toothbrushing programs happen and so contribute to the government’s mission for this to be the healthiest generation of children ever.”

BRUSH is co-led by NIHR ARC South West Peninsula (PenARC) and NIHR ARC Yorkshire & Humber (YH ARC). BRUSH is one of four priority research projects investigating how evidence-based interventions can improve children’s and maternity services in England.

Peter Day, Professor of Children’s Oral Health, and Consultant in Pediatric Dentistry in the University of Leeds’ School of Dentistry, said, “Evidence shows that many young children are experiencing poor oral health, and we know that there are other issues associated with this, including children’s readiness for the earliest years of their education.

“Our new study shows there is clear progress in rolling out supervised toothbrushing programs among this group of children—but more needs to be done. Our toolkit can help those responsible for setting up new programs in schools and nurseries implement supervised toothbrushing by providing examples of good practice in this vital area of health.”

Dr. Shannu Bhatia, President of the British Society of Pediatric Dentistry (BSPD) said, “BSPD welcomes the fact that there are more children enrolled in a supervised toothbrushing scheme. It is also positive news to see the important role the BRUSH toolkit is playing. However, there is more work to be done.

“The report recognizes some of the implementation challenges and the need for dedicated funding. The new government needs to deliver on their manifesto pledge—because we know from experience that targeted supervised toothbrushing schemes work. They are easy to implement and take no longer than 10 minutes out of the school day.

“Teachers are not required to brush each child’s teeth, since it becomes a peer-led activity that the children quickly engage with and enjoy, as well as being effective in delivering on improving children’s oral health—and cost effective in the long-term.”

The researchers found that in April 2024 the number of supervised toothbrushing programs increased by 28% since the last survey in April 2022, while the number of children enrolled increased by 35%. There are now 2,978 clubs, and 143,200 individuals aged 0–19 years taking part in them.

The study shows that almost 60% of surveyed local authorities have rolled out programs, with collaborations with stakeholders; free resources such as the BRUSH toolkit; support from oral health professionals; awareness of the risks of poor oral health, and shared knowledge among schools all cited as examples of facilitators for setting them up.

However, respondents also highlighted barriers including a lack of funding to deliver programs and buy resources, such as toothbrushes; pressures at settings, such as high staff turnover or focus on Ofsted requirements; logistics, such as delays in delivery of supplies, and a lack of engagement, with some schools believing the process would be too time consuming or set a precedent for taking away parental responsibility.

The BRUSH research project is led by Professor Marshman, Professor Day and Dr. Kara Gray-Burrows (Lecturer in Behavioral Sciences and Complex Intervention Methodology, University of Leeds) with colleagues from Universities of Leeds, Sheffield and Bradford Improvement Academy.

Dental health inequalities

Around a quarter of 5-year-old children in England have tooth decay—rising to up to 50% in areas of deprivation. The burden of decay is significant, causing pain and suffering, affecting what children eat, their speech, quality of life, self-esteem, and social confidence.

In addition, decay has a wider societal impact on school readiness and attendance. In England, treatment of decay is the most common reason more than 33,000 young children every year are admitted to hospital, costing the NHS over £40 million annually.

A key behavior in preventing decay is toothbrushing with a fluoride toothpaste. Supervised toothbrushing programs in nurseries and schools do not replace toothbrushing at home but serve to complement home toothbrushing to help young children learn and practice good oral hygiene.

These programs are effective, especially for children at greatest risk, and are cost effective. However, uptake and maintenance of these programs is fragmented with funding coming from a variety of sources, and there is considerable variation in how they are implemented.

To combat this, the BRUSH evidence-based toolkit, which can be accessed for free, supports the implementation of supervised toothbrushing programs in England.

The toolkit includes all the resources necessary to establish supervised toothbrushing programs, including how to navigate the commissioning and procurement process; how to set up, run and evaluate the program; training and promotion, as well as focused information for early years settings and parents.

It was co-designed by academics and stakeholders at all levels of implementation following an extensive research program which started with a review of existing supervised toothbrushing programs in 2022, taking information from 141 local authorities across England.

The paper published today features the results of a survey of 152 local authorities carried out between December 2023 and April 2024. Of those, 59% had implemented a toothbrushing program.

Councilor David Fothergill, Chairman of the Local Government Association’s Community Wellbeing Board, said, “These findings emphasize both the progress made and the significant challenges we still face in addressing childhood tooth decay through supervised toothbrushing programs.

“Local government is committed to overcoming these barriers, but we need dedicated funding and support from central government to ensure every child—especially those in the most deprived areas—has access to these vital programs.

“Improving children’s oral health is not just a health issue, it’s about giving them the best start in life.”