Designed to Smile

Description / The programme is first and foremost a fluoride supplementation programme based on population level preventative interventions and was a £3.5m WG investment to address their commitment to the Eradicating child poverty in Wales strategy. The core programme incorporates three elements: supervised toothbrush training for 3-5 year olds / oral health promotion for 6-11 year olds / promoting oral health from birth (0-3).
Priority area / Nutrition (Oral Health)
Life course stage / Early Years and Children
Intervention / Designed to Smile is a multi-component programme that includes oral health education by health visitors; supervised tooth brushing and supply of toothpaste and toothbrushes for children aged 3 – 5 years, fluoride varnish and oral health education for children in year 6.
Level of intervention: Targeted population
‘total’ spend 2012/13 / £3.75M (WG funded)
Evidence of effect AIII / A III The Designed to Smile programme draws on evidence of the effectiveness of fluoride toothpaste and evidence of increased efficacy of supervised programmes in the school setting. The evidence base for fluoride varnish is also established although less strong. There is potential for this targeted programme to be effective.
Cost effectiveness
GII / Green II – Small number of good quality economic evaluations showing cost-effectiveness/cost-savings/ cost-benefits as appraised by Drummond et al’s 2005 Checklist for a sound economic evaluation
Three evaluations conducted in the U.S. (Zabos et al. 1996), U.K. (Davies et al. 2003) and Finland (Hietasalo et al. 2009) showed dental interventions consisting of the provision of toothbrushes, dental sealants and individual advice from a dental hygienist were all cost-effective. The two modelling exercises found showed sealants and the application of fluoride varnish to be cost-effective.
Reach / The programme is designed to improve oral health in children, focussing on areas of need. As at September 2012, 1211 settings are taking part with 78,350 children brushing, 9.044 being assessed for fissure sealants and 6,656 having fluoride varnish. These figures are not mutually exclusive.
Inequalities / The programme focus is on disadvantaged areas where tooth decay is most prevalent. It aims to improve the dental health of the most deprived fifth of 5–12 year old children to that presently found in the middle fifth by 2020. Monitoring data show that 80% of settings taking part came from the three most deprived quintiles.
Mechanisms of delivery / Delivery: Training and information.
Setting: Community and primary schools.
The core programme incorporates three elements:
  • Supervised toothbrush training for 3-5 year olds.
  • Oral health promotion for 6-11 year olds.
  • Promoting oral health from birth (0-3).

Wider views / Engagement events
Designed to Smile was rated positively by 2 teams who identified it as an evidence based programmes rolled out nationally with good monitoring data available locally. D2S was identified as a valued service in the South Wales external stakeholder events.
Online form findings:
Nine out of the 51 responders said they were aware of Designed to Smile, and four said they thought it worked well.
Primary Care:
The view was expressed that D2S is now an integral part of a field trial facilitating high profile research on preventive dental technologies in SE Wales.
Provider Response:
The feasibility of implementing water fluoridation in Wales has been thoroughly explored and is estimated to involve substantial cost, be technically difficult in some areas in addition to generating widespread public opposition and legal challenge. The D2S programme is considered to be the most practical and effective alternative.
Alternative delivery as proposed by stakeholders / Has the potential forreplication in other settings. A pilot in prisons was well received. Whilst committed to this programme for this period of Welsh Government (Programme for Government), there should be a review of the scheme as there are potentially more sustainable and cost-effective methods of delivering fluoride to children. One such alternative model could be delivering the above to schoolchildren through the WNHSS or fluoridation of drinking water.
Policy link(s) / This initiatives is explicitly referenced in the current Welsh Government ‘Programme for Government’
Together For Health -A National Oral Health Plan for Wales (Draft) 2012.
Identified Actions:
“Provide each dental practice with Delivering Better Oral Health Together linked to Designed to Smile.”
“Expand Designed to Smile to include vulnerable adults residing in care homes.”
“Prevent poor oral health and reduce inequalities through the continued implementation of Designed to Smile to improve the oral health of children;”
“It is intended to examine whether Designed to Smile can influence decay levels in 12 year olds by 2020. In 2012 those children are aged 4 years.”
Child Poverty Strategy for Wales: Delivery Plan (2010)
Identified Action:
“Roll out the Designed to Smiledental health initiative across the whole of Wales, and take forward developments that will see younger and older children included in the programme.”

Appended information from Welsh Government:

  • Designed to Smile (D2S) meets two major oral health priorities: the need to reduce oral health inequalities in children and, develop the capacity and capability of Community Dental Service (CDS) provision across Wales. The CDS are in a unique position to facilitate the continuing integration of D2S with other school and community based health promotion programmes and to deliver care to those high-risk children and young people who would otherwise not access dental services
  • The programme delivery process is based on unequivocal international evidence and is subject to both independent performance monitoring and qualitative evaluation. The Children’s and Young People Committee (NAW) recently supported the continuation of this programme following its review. It is important to note highly successful outcomes have been achieved by a similar programme in Scotland.
  • The cost and cost effectiveness of the programme (approximately 13 pence per child per day) should be set against both the impact of 9000 annual general anaesthetics for extraction (costing circa £4.5 million), and £20 million p.a. spent in general dental services on curative dental treatments for children in Wales.
  • D2S is the main plank for fluoride strategy in Wales and is also contributing to the development of a preventive based dental service through links to the Welsh Dental Pilot Programme. In addition it is a integral part of a field trial facilitating high profile research on preventive dental technologies in SE Wales.

PBMA Report – Design to Smile22/11/2012 Version 1