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What is Supervised Toothbrushing?
Tooth decay can be prevented!
A key behaviour for preventing tooth decay is toothbrushing with fluoride toothpaste. Supervised toothbrushing programmes enable young children, typically those aged three to six years, to brush their teeth with fluoride toothpaste under the supervision of staff each day they attend nursery, school or a childminder. These programmes are designed to complement (rather than replace) toothbrushing at home. The ultimate goal is to establish good life-long oral health habits of toothbrushing with a fluoride toothpaste to prevent tooth decay and improve quality of life.
They are recommended in national guidance from the Office for Health Improvement and Disparities and NICE as they are effective in reducing tooth decay, especially for children with the greatest risk. They are cost-effective too!
In some areas, supervised toothbrushing programmes are run in conjunction with a fluoride varnish scheme, however, this toolkit focuses on supervised toothbrushing programmes alone.
Tooth decay is very common in children in England and children with tooth decay typically have 3 or 4 decayed teeth. The oral health survey of five-year-olds in 2024 found 1 in 4 five-year-olds in England have tooth decay and this proportion is nearly double in deprived areas. For three-year-olds, the oral health survey in 2020 found that 11% have visible tooth decay affecting their front teeth.
Here is a link to the National Dental Epidemiology Programme surveys from the Office for Health Improvement and Disparities (OHID)
If you want to find the statistics for your area, click the buttons below.
Tooth decay causes pain and suffering. It affects the daily lives of children (and their families) including what they eat, their speech, sleep, self-esteem and it stops them from doing things they enjoy. Parents of children with tooth decay often report feeling guilty and upset.
Tooth decay and its treatment can also cause children to worry and miss time from nursery or school. Many parents must take time off work to care for their child and attend appointments.
When young children have several decayed teeth, they often need treatment in hospital under general anaesthetic (being put to sleep). In England, dental treatment is the most common reason why children have a general anaesthetic. This care, in hospital, costs the NHS over £50 million every year.
Poor oral health in childhood has lifelong impacts. Children with decay in their primary teeth are four times more likely to then develop decay in their adult teeth.
For exact data on extractions, see here: Hospital-based tooth extractions in 0 to 19 year olds.
There are social inequalities not only in the prevalence and severity of tooth decay but also in terms of hospital admissions for dental extractions and the impact it has on children’s daily lives.
CORE20PLUS5 – Children and Young People, is a national NHS England initiative that aims to reduce health inequalities at a national and system level by targeting the most deprived 20% of the population.
Oral health is one of the 5 clinical areas requiring accelerated improvement.
Supervised toothbrushing directly addresses the concern of “the backlog for tooth extractions in hospital for under 10s”.
Government policy
On 7th March 2025, the government announced the investment of £11 million, for the 2025-26 period, to support daily supervised toothbrushing programmes for children aged 3-5 years old living in the most deprived areas of England. The funding aims to support 600,000 children to undertake supervised toothbrushing. The government announced the investment as a joint initiative between the Department of Health and Social Care and the Department for Education.
The funding is being given to local councils as part of their Public Health grant based on the number of children aged 3-5 years old living in the most deprived areas. Letters were sent to Directors of Public Health notifying them of their funding allocation on 14th March 2025.
The announcement was accompanied by an update to the national guidance on supervised toothbrushing:
The announcement recognised the existence of comprehensive programmes already running in some local authorities. Where such programmes are already in place and targeted towards children aged 3-5 years old living in the most deprived areas, the funding can be used flexibly for additional provision to:
older or younger children
children in less deprived areas
those with Special Educational Needs and/or Disabilities
those from “PLUS” groups, aligned with the CORE20PLUS5 framework and local oral health needs assessments.
Additionally, Colgate will provide 23 million toothbrushes and fluoride toothpaste over the next five years to support both the supervised toothbrushing programme and at-home brushing. Local councils have already been offered an allocation of toothbrushes and fluoride toothpaste from Colgate for 2025-26.
Useful links
Department for Education policy:
Help for Early years providers platform – Oral Health: https://help-for-early-years-providers.education.gov.uk/safeguarding-and-welfare/oral-health
Early years foundation stage (EYFS) statutory framework: https://www.gov.uk/government/publications/early-years-foundation-stage-framework--2
Development Matters (Non-statutory curriculum guidance for the early years foundation stage which specifically mentions supervised toothbrushing programmes): https://www.gov.uk/government/publications/development-matters--2
Health policy and guidance
Commissioning Better Oral Health for children and young people: https://www.gov.uk/government/publications/improving-oral-health-an-evidence-informed-toolkit-for-local-authorities
Oral health and local authorities guidance from NICE - PH55 NICE: https://www.nice.org.uk/guidance/ph55/resources/oral-health-local-authorities-and-partners-pdf-1996420085701
In 2022 and 2024 surveys of the distribution of supervised toothbrushing programmes in nurseries and schools across England were undertaken. Geographical maps of this data can be seen by clicking the button below.
Want more information?
The first national survey of supervised toothbrushing programmes in England 2022.
The second national survey of supervised toothbrushing programmes in England 2024.
Targeting of supervised toothbrushing programmes
The prevalence and severity of tooth decay are closely linked to the level of deprivation of an area and the socio-economic status of the families' attending educational settings. For that reason, toothbrushing programmes are particularly effective when run in deprived areas of the country. Within those areas, when choosing which educational settings to involve these are often ‘targeted’ based on area-based deprivation or socio-economic factors. The government’s investment in supervised toothbrushing is principally aimed at children aged 3 to 5 years old living in the 20% most deprived areas of England.
Other factors covered by the government’s investment:
age of children included
children with Special Educational Needs and/or Disabilities
children from “PLUS” groups, aligned with the CORE20PLUS5 framework
specific communities identified in local oral health needs assessments.
inclusion of mainstream schools, special schools and childminders
Factors to consider for targeting:
Deprivation: Based on the number of children living in the 20% most deprived Lower Super Output Areas according to the Indices of Multiple Deprivation. However, supervised toothbrushing is a classroom activity so is targeted at early-years settings in these areas rather than at individual children.
Educational indicators:
proportion of pupils eligible for free school meals
free early learning child spaces
pupil premium targets
school readiness
Level of dental decay: Some areas of the country have surveys with large sample sizes which allow nurseries/schools to be chosen based on the number of decayed, missing and filled teeth in those neighbourhoods.
While hospital episode statistic data are available for each local authority on the number of children admitted to hospital for dental reasons, the quality of that data in some areas may make it a less accurate way of targeting than using deprivation data.
Effectiveness
The most recent evidence for supervised toothbrushing programmes is based on the national Childsmile programme in Scotland.
Within Childsmile, supervised toothbrushing programmes is a universal offer to all preschool establishments (e.g., children aged 3-5 years old). It includes daily toothbrushing with fluoride toothpaste, and distribution of toothpaste and toothbrush packs for home use. Childsmile has been evaluated thoroughly for the clinical and cost-effectiveness of the programme overall.
In summary, when delivered as part of Childsmile, 89% (n=44,868) of children took part in the supervised toothbrushing component. Importantly, children living in the most deprived areas were more likely to participate (94%) compared to 83% of those living in the least deprived areas.
The impact of supervised toothbrushing programmes on the prevalence of tooth decay was seen within 12 months for those children living in the most deprived areas (reduced from 53% to 46%). For those children living in the second most deprived areas, significant benefits were seen with participation in supervised toothbrushing programmes at 12-24 months (prevalence reduced from 43% to 36%). Across all areas, a significant benefit was seen when participation was greater than 36 months.
There was a clear benefit of supervised toothbrushing programmes with a reduction in social inequalities, e.g., children with the greatest risk of tooth decay obtained the greatest benefit. These benefits were also seen for children with special educational needs and/or disabilities.
Cost and cost-effectiveness
As part of the evaluation of the Childsmile programme, the costs of running supervised toothbrushing programmes were an estimated £15-17 per child per annum in 2010. These costs were predominantly staff costs (50-90%), with other costs including resources (toothpaste, toothbrushes, toothbrushing racks, etc), transport and travel costs, administration and staff training. The supervised toothbrushing programme paid for itself within three years.
A Return on Investment model was undertaken by the University of York in 2016 using data from Childsmile. This model estimated that for every £1 spent, the health service benefit at five years was £3.06 and at ten years was £3.66. The largest savings were seen for children living in the most deprived areas. It should be noted that the model focused exclusively on oral health expenditure without consideration of the impact and benefits seen in education or other sectors.
Further reading
ChildSmile - Scotland's national oral health promotion programme including supervised toothbrushing
Designed to Smile - Wales' national oral health promotion programme including supervised toothbrushing
The NHS has set two ‘net zero’ targets:
By 2040, the NHS Carbon Footprint from greenhouse gas emissions that can be controlled directly will be reduced to net zero, with an 80% emissions reduction by 2032.
By 2045, the NHS Carbon Footprint Plus from emissions that can be influenced will be reduced to net zero, with an 80% emissions reduction by 2039.
Ways to make supervised toothbrushing programmes more environmentally friendly
Sustainable procurement
For example, when procuring toothbrushes, Childsmile has pledged to include sustainability as part of the product specification.
Sign up to a specialist recycling service.
As part of the Childsmile programme each local NHS health board is signed up to the recycling service provided by Terracycle. Terracycle offers free recycling schemes with the plastic products being made into plastic pellets which can be used to make new recycled products.
Transport
Consider sustainable transport choices when deciding on staff travel requirements and how to deliver supplies.
Toothbrushing method
Consider the toothbrushing method used - dry brushing has been recommended due to less water usage.