Children’s oral health in England is in crisis, with thousands of children across the country suffering from dental caries, the most prevalent and prominent form of dental disease. In response, the government has promised measures to tackle dental health inequalities. But how can policymakers best implement this plan to ensure it has the desired impact? Here, Dr George Kitsaras, Dr Michaela Goodwin, and Professor Tanya Walsh outline their research on behaviour change and oral health, and how health leaders can best design interventions.

• In some parts of England, up to 50% of 5-year-olds suffer from dental decay, with impacts on education and wellbeing.
• Tooth brushing and limiting sugar consumption can have a huge beneficial effect, with these measures forming the core of proposed policy interventions.
• Research from The University of Manchester shows evidence-based co-design and development of health programmes can lead to long-term change.

Dental caries – or tooth decay – is a preventable disease affecting millions of people in the UK, especially in areas of higher deprivation. In England, prevalence of dental caries is reducing. However, pockets of high disease in underserved areas remain, and for children in particular, dental decay can have adverse, lifelong implications. Up to 50% of 5-year-olds suffer from dental decay, missing days of school, facing sleepless nights, and in many cases undergoing dental extractions under general anaesthetic in hospital.

Oral hygiene behaviours, including brushing teeth twice a day with fluoride toothpaste and limiting sugar consumption, can have a hugely beneficial effect on caries prevention. Shaping positive oral hygiene habits from an early age is vital for healthy teeth. This has been recognised by health policymakers, with the government’s Health Mission including a Dentistry Rescue Plan that promises to introduce supervised tooth-brushing schemes for 3-5 year olds, prioritising areas of highest need.

However, to effectively tackle dental health inequalities, positive behaviour change – like increased tooth brushing – must be sustained. Educational settings, where children spend a significant time of their days, can play a crucial role in promoting and supporting good oral health behaviours. Research from The University of Manchester shows that making oral health a family priority, and working closely with parents of young children, can lead to changes in habits for the entire family supporting sustained benefits for children and parents alike.

Our work at Manchester – embedding healthy habits

At the Dental Health Unit of The University of Manchester we have undertaken a number of key projects focusing on community-based oral health behaviour change interventions. With funding from the Medical Research Council (MRC), and more recently in close partnership with Manchester’s Oral Health Improvement Team (OHIT), we have worked with communities in some of the most deprived areas of the city to develop and deliver these interventions for children.

These partnerships have led to three key pieces of work, the findings of which can inform national plans to improve children’s oral health. All three interventions follow the COM-B model of behaviour change, PRIME theory of motivation, and Delivering Better Oral Health guidance to: enhance capability (one’s knowledge of what to do, when to do it and how); create opportunity to engage with the behaviour on a daily basis; and build motivation for undertaking the first steps in engaging with the target behaviour and overcome inertia.

BRIC (Bedtimes Routines Intervention for Children), where – with parents of young children – we co-designed and co-developed a text message-based intervention to promote beneficial bedtime routine activities, including oral hygiene practices and reduced sugar intake. As a result, young children brushed their teeth more at night with a 16% increase in brushing behaviour; avoided sugary snacks and drinks around bedtime, with a 24% reduction in consumption of snacks/drinks before bedtime; and generally, parents’ mood and overall family functioning was improved with less mood disturbance around bedtime.

Leapfrog was a school-based oral health promotion programme with the incorporation of student activities, provision of brushes, and text message support for oral health behaviour change for families. This work targeted 6 primary schools in the areas of highest disease prevalence in Manchester. It led to improvements in their brushing behaviour following the intervention, with more children brushing their teeth twice a day at the end of the study.

Finally, the ongoing HeRo (Healthy Routines, Healthy Teeth) project is bringing together key learnings from our previous work in creating a holistic, co-designed and co-developed, school-based, community oral health intervention for positive oral health behaviour change in children. It is a community-based oral health intervention incorporating the provision of oral hygiene packs and behaviour change techniques (SMART goals) which aims to create good oral health habits for newborn children in areas of highest need. This work combines a universal approach, where all newborn children in Manchester will receive an oral health pack, and a targeted approach focusing on the most deprived areas of the city.

Our past and current work highlights a number of important, transferrable lessons for public health policy. Notably, the importance of co-design and co-development principles in designing interventions, and the positive effect of school-based and community activities on children’s oral health habits. It also demonstrates the key role of parents in supporting their children’s oral health, and how technology can aid behaviour change when developed with the populations that policymakers intend to reach. Finally, our research shows the importance of evidence-based approaches in ensuring long-lasting, beneficial oral health habits.

Key recommendations

Following from our work, there are several key principles that policymakers should follow – across local, regional, and national levels – when considering interventions to improve children’s oral health.

First and foremost, co-development and co-design principles with target populations should be followed from the start, not as an afterthought, to ensure meaningful benefits. Interventions should be tailored to target populations, with consideration of personal, local, and regional circumstances. A ‘one-size-fits-all’ approach will not deliver the change required. As such, sub-national bodies like Integrated Care Boards should have a role in coordinating and delivering bespoke interventions, based on core principles provided by the Department for Health and Social Care.

As well as co-design, these principles should include theory-informed, evidence-based approaches to sustained behaviour change. There must be recognition that positive changes and habit formation can take time, with funding and other resources provided accordingly.

There is an important role for technology – such as using smartphones to deliver timed messages and reminders – in supporting behaviour change, but it must be used with a clear rationale in place; what kind of technology will be used, for whom, how, where, and when. Technology can be used to help personalise information, which can improve the impact of interventions – but all technology-based interventions should be designed and developed in partnership with target populations to ensure they work for the intended audiences and purposes.

Finally, school-based oral health support needs to be easy and attractive for teachers to incorporate into their day-to-day work, and utilise social aspects such as class-based activities.

Children’s oral health is at a crisis point, with an immediate need for evidence-based, theory-informed solutions to help those most in need. Through our work at The University of Manchester, we have showcased how we can work with communities in improving their oral health outcomes for the long run. As policymakers recognise the scale of the issue and begin to address it, the lessons learned from our research provide a valuable foundation for the public health interventions required.