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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

This cost analysis showed that a Scotland-wide programme of supervised toothbrushing in nurseries is linked to large savings in dental treatment costs because of the reduced levels of tooth decay in five year-old children. In the eighth year, the programme saved more than two and a half times the programme’s cost of implementation. The greatest reductions in treatment costs were in deprived areas.

This study was conducted in Scotland, where the government and health service have prioritised improving children’s oral health and reducing health inequalities since 2001. This was initially through the toothbrushing programme and later through the broader Childsmile programme. Commissioners and local authorities in England face similar levels of tooth decay in many areas. In these high risk areas, the study’s findings may help justify the design of similar programmes.

Why was this study needed?

Tooth decay is almost entirely preventable, yet it currently affects almost a third of children in Scotland and England. It can cause pain, discomfort, absence from school and need for parental leave. Treatments such as fillings and extraction of teeth by general anaesthetic are expensive and extractions are the most common reason for planned admission to hospital for children in Scotland. Children living in the most deprived areas have the highest levels of tooth decay resulting in higher treatment costs for the NHS than those living in more affluent areas.

Previous research has shown that supervised toothbrushing works well for preventing tooth decay. The Scottish Government and NHS Scotland have prioritised improving children’s oral health and reducing inequalities since 2001 when tooth decay affected more than half of children. This study aimed to use modelling techniques to calculate the potential savings due to the national nursery toothbrushing programme in the 10 years since it started, 2001/2 to 2011/12.

What did this study do?

The study compared the cost of providing a national nursery supervised toothbrushing programme with actual and anticipated costs to the NHS in Scotland of treating five year old children’s decayed teeth. The total cost of treatment for each year was calculated using the National Dental Inspection Programme and earlier national inspection data of five year olds in each of Scotland’s 14 health districts. This provided an estimate of the number of decayed, missing and filled teeth per five year old child. These figures were then multiplied by the cost of providing likely treatments such as fillings or extraction. The starting point for data in the study was 1999/2000, before the nursery toothbrushing programme started, through 2001/2, when it began, to 2009/10. All costs were adjusted to the 2009/10 equivalent. As in most economic evaluations, the findings were based on assumptions about cost and the estimates of how many treatments for decayed teeth could be prevented. There was some scaling up of data from samples of children to the whole population. However, the study was rigorous and followed guidelines for economic evaluation of health interventions so we can be confident in the findings.

What did it find?

  • In 2009/10 terms, the national nursery toothbrushing programme cost nearly £1.8 million per year and was attended by 95% of three to four year olds.
  • The number of decayed teeth decreased by 47% from 107,925 in 1999/2000 to 57,167 in 2009/2010. Numbers of children with missing or filled teeth decreased by similar proportions in the same time period, with the greatest fall in the most deprived groups. As an index of all three measures, the number of decayed, missing or filled teeth per child decreased from 2.7 to 1.6. This trend is observed in other countries but the size and timing of the reduction suggests that it is associated with the toothbrushing programme.
  • Although there was a small increase (2.4%) in treatment costs in the first year of the programme, subsequent years showed large decreases, the greatest being a 54% reduction in 2009/10 compared with 2001/2 (from £8.8 million to £4.0 million).
  • Costs decreased most during this period for children living in the most deprived areas, a reduction of £137,348 per thousand children, compared with £30,174 per thousand children in the least deprived areas.

What does current guidance say on this issue?

A Scottish Intercollegiate Guidelines Network guideline from 2014 recommends tailoring preventative help to the child’s needs and circumstances. NICE guidelines from 2014 on oral health recommends toothbrushing schemes in nurseries in areas where children are at risk of poor oral health and focusses mainly on prevention in socioeconomically deprived areas rather than through universal services. Both guidelines recommend supervised toothbrushing for young children and give detailed instructions on toothpaste fluoride strength and amount of toothpaste to use. Detailed advice on how the programme is run is available from the Childsmile website.

What are the implications?

This study showed that a Scotland-wide programme of nursery supervised toothbrushing was cost saving, approximately halving subsequent dental treatment costs over 10 years. Improved oral health provided savings to the health service. It had most impact in the most deprived areas – potentially reducing health inequalities. Although Scottish and English guidelines make similar recommendations around prioritising need and supervising small children’s toothbrushing, only in Scotland is this implemented as universal support in public settings, in this case nurseries. Commissioners and local authorities in England, face similar levels of tooth decay in many areas. Local authorities and partners in England are required to carry out an oral health needs assessment. In high risk areas, these findings may help justify the design of similar programmes. Some variation in how the programme was implemented was noted. For example, in some cases the nurseries brought in dental technicians, or trained up nursery staff to deliver the intervention.



Anopa Y, McMahon AD, Conway DI, et al. Improving Child Oral Health: Cost Analysis of a National Nursery Toothbrushing Programme. PLoS One. 2015;10(8):e0136211.



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Turner S, Brewster L, Kidd J, Gnich W, Ball GE, Milburn K, et al. Childsmile: the national child oral health improvement programme in Scotland. Part 2: Monitoring and delivery. Br Dent J. 2010 Jul 24;209(2):79–83.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre


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The intervention was daily supervised toothbrushing in nurseries. The programme also provided and distributed fluoride toothpaste via the nurseries for home use.


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