Daily supervised brushing in early years and nursery school settings

LTP Priority: Better Care for Health Conditions: Dental

Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service

Type of Interventions: Daily supervised toothbrushing with a fluoride toothpaste in early years and nursery school settings

Major driver of health inequalities in your area of work

Tooth decay is the most common reason for hospital admission for children aged 6-10 years-old. Whilst it is largely preventable it still remains a serious public health problem. PHE data shows that in 2017, almost a quarter of 5-year-olds started school with tooth decay. Whilst oral health has improved in this age group significant inequalities persist with almost half (47%) of 5 year olds in Rochdale having tooth decay in comparison with 13% in Cambridgeshire. In the most deprived decile in England, over a third of children have dental decay (36.3%), compared to just 12.5% in the least deprived decile. Tooth decay impacts on children and families, children who have toothache or who need treatment may have; pain, infections and difficulties with eating, sleeping, speaking and socialising. They may have to be absent from school and parents may also have to take time off work to take their children to a dentist or to hospital. Children’s poor oral health links to other key policy areas such as getting the best start in life, inequalities, child obesity, school readiness and development of speech and language.

Target groups

  • Deprivation – People living in deprived areas
  • Inclusion health group
  • Migrants and Gypsy Roma Traveller groups (GRT)


Daily supervised toothbrushing with a fluoride toothpaste in early years and nursery school settings


What the intervention is

Children accessing early years and school settings are encouraged to participate in daily supervised tooth brushing with family fluoride toothpaste. Training in the implementation of supervised tooth brushing programmes can be delivered by local providers such as an existing community oral health team or an external supplier for the setting staff. Additional toothbrushes and toothpaste may be provided to those taking part, for use within the programme and at home to encourage home brushing. Providers of the programme will work in collaboration with the setting staff and parents/carers to encourage daily tooth brushing at home as well as to ensure support for the programme.

Outcomes expected

The programme would be based on the national nursery toothbrushing programme in Scotland. Evaluation of this programme confirmed the effectiveness of supervised tooth brushing programmes in reducing tooth decay but also that it would reduce oral health inequalities. The study found that the programme had an impact on absolute oral health inequalities with an average reduction in tooth decay (mean dmft ) of 1.71 in the most deprived children, in comparison with 0.43 in the least deprived children.

How this programme can be implemented at scale

A number of local authorities and NHSE commissioners in England already commission supervised brushing programmes in schools and nurseries. However, there is the potential to increase the number of programmes particularly in areas of deprivation.

Children are enrolled for a two-year period (as has been tested in studies of effectiveness). The children would be aged 3 to 5 years, including: the final year of nursery (aged 3-4 years) and reception class (aged 4-5 years). In order to target those children aged 3-5 with the poorest oral health the number of 4 and 5 year olds would be identified and numbers in the most deprived deciles established according to the NHS E footprint (using the Index of Multiple Deprivation).


Children in more deprived areas have higher levels of tooth decay and are less likely to brush their teeth at least twice daily (Child Dental Health Survey, 2013).

Strong evidence (from Cochrane systematic reviews) shows that the daily application of fluoride toothpaste to teeth reduces the incidence and severity of tooth decay in children. A greater effect is reported in those who have higher baseline levels of tooth decay, with an increased fluoride concentration in the toothpaste, increased frequency of use, and with supervised brushing (where there is a higher compliance with using the fluoride toothpaste as recommended). (Cochrane 2010)

Research has shown that at a population school or early years’ level, tooth brushing with fluoride toothpaste each day over a two year period is effective for preventing tooth decay (Macpherson et al., 2013; Marinho et al., 2003) and can establish life-long behaviour to promote oral health (NICE, 2014).

Macpherson L.M.D, Anopa Y, Conway D.I and McMahon A.D. (2013). National Supervised Toothbrushing Program and Dental Decay in Scotland. Journal of Dental Research 92(2):109-113, 2013

Marinho  VCC, Higgins  J, Logan  S, Sheiham (deceased)  A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002278. DOI: 10.1002/14651858.CD002278

The National Institute for Health and Care Excellence. (2014). Oral health: local authorities and partners (Public health guideline).

Whilst this may be seen as something that should be supervised by parents at home, for children in vulnerable families, often with chaotic lifestyles this is difficult to achieve without additional support. It is not intended to replace home brushing but to support and encourage the lifetime habit.

NICE guidance supports such programmes in; PH55 (2014) Oral health: local authorities and partners there are two relevant recommendations to improve the oral health of communities. Recommendation 15: consider supervised tooth brushing schemes for nurseries in areas where children are at high risk of poor oral health and Recommendation 19: consider supervised tooth brushing schemes for primary schools in areas where children are at high risk of poor oral health.

Guidance for commissioners

Improving oral health: supervised tooth brushing Programme toolkit – A toolkit to support commissioning of supervised tooth brushing programmes in early years settings and schools.