Oral health is one of the most significant yet overlooked areas of preventable ill health in England. The scale of the problem is substantial, the inequalities are stark, and the costs to the NHS are rising.
The case for action
In the financial year ending 2025, there were 56,143 hospital tooth extractions for children and young people aged 0 to 19 in England — a 14% increase on the previous year. Of these, 33,976 were due to tooth decay, around three in five of all extractions in this age group. The estimated cost to the NHS was £87.7 million for all extractions, of which £51.2 million was for decay-related extractions.¹ Tooth decay remains the most common reason for hospital admission in children aged 5 to 9.¹ These are not inevitable outcomes — they're the result of largely preventable disease.
The inequalities are particularly striking. The decay-related extraction rate for children in the most deprived communities is just over three times that of children in the most affluent.¹ This gradient persists across every measure of oral health: poor oral health concentrates where other disadvantages concentrate.
For adults in care settings, the picture is equally concerning. The CQC's Smiling Matters review found that most residents' care plans only partly covered oral health or didn't cover it at all, most care homes had no oral health policy, and nearly half provided no staff training to support daily mouth care.² Poor mouth care contributes to pain, malnutrition, social isolation, and preventable infections including aspiration pneumonia.
These aren't problems dental services can solve alone — the people most affected are often those least likely to access routine dental care. Effective improvement requires action across the whole system: commissioning for prevention, not just treatment. NHS England's Core20PLUS5 framework recognises this, naming oral health as one of five clinical priority areas for children and young people, with a specific focus on reducing decay-related extractions among children in the most deprived communities.³ It sits alongside asthma, diabetes, epilepsy and mental health as a marker of health equity — not a peripheral concern.
The evidence base
Oral health improvement works. The evidence for effective interventions is strong, the policy alignment is clear, and the return on investment is demonstrable.
Supervised toothbrushing is among the most cost-effective public health interventions available: children brush with fluoride toothpaste in nursery or school, supervised by trained staff, supplementing brushing at home. Evidence from Scotland's Childsmile programme and from programmes across England shows consistent reductions in tooth decay, with the largest benefits for children in the most deprived areas.⁴ The economic case is compelling — a University of York model for Public Health England, using Childsmile data, estimated a return of £3.06 for every £1 spent over five years, rising to £3.66 over ten years, with programmes paying for themselves within three years.⁴ In 2025 the government committed £11 million to support supervised toothbrushing for children aged 3 to 5 in the most deprived areas of England.⁵
Fluoride varnish provides additional protection for children at higher risk; NICE recommends considering community-based programmes for nurseries and primary schools in high-risk areas.⁶ And workforce development extends reach beyond dental settings — when care home staff, health visitors, school nurses and community workers are trained in basic oral health, they can support daily mouth care, spot problems early and signpost to dental services.
Policy alignment. Commissioning oral health improvement isn't additional work — it's delivery of existing commitments:
- The 10 Year Health Plan for England (2025) sets out a shift from treatment to prevention and from hospital to community, with specific attention to children's oral health including expanding supervised toothbrushing and fluoride varnish.⁷
- Core20PLUS5 names oral health as a clinical priority, focused on reducing decay-related extractions in the most deprived communities.³
- NICE PH55 provides guidance for local authorities and partners on needs assessment, strategic planning and evidence-based interventions.⁶
- NICE NG48 sets standards for oral health in care homes.⁸
- Health and Wellbeing Boards carry oral health responsibilities as part of the Joint Strategic Needs Assessment and local health improvement planning.
Commissioning oral health improvement
Effective commissioning translates evidence into local action.
Needs assessment. The Joint Strategic Needs Assessment (JSNA) should include oral health, drawing on hospital tooth extraction data from OHID (broken down by local authority and deprivation),¹ National Dental Epidemiology Programme surveys, adult oral health survey data, CQC care home inspection findings, and local dental access data. Together these identify where to focus resources for greatest impact.
Service specification. Specifications should include clear outcomes linked to population health (not just activity), evidence-based interventions aligned with NICE guidance and Delivering Better Oral Health, workforce development components that build sustainable capacity, quality standards aligned with NICE (QS151 for care homes) and CQC, and partnership requirements ensuring providers work with dental services, local authorities, schools and care settings.¹⁰
Key performance indicators. Effective KPIs focus on outcomes, not just outputs:
- Population outcomes — reduction in hospital extractions (0–19), reduction in decay prevalence in epidemiological surveys, improved oral-health-related quality of life.
- Service quality — percentage of care homes meeting NICE NG48, percentage of residents with an oral health care plan, percentage of target settings running supervised toothbrushing.
- Workforce development — number of non-dental staff trained, percentage of care homes with a Mouth Care Champion, training completion and competency rates.
- Access — percentage of care home residents with access to dental services, community dental waiting times, uptake of fluoride varnish and fissure sealants.
Workforce development as a commissioning lever. One of the most cost-effective approaches is investing in workforce development. Training care home staff, health visitors and community workers in basic oral health creates extended reach (non-dental staff see populations dentists rarely reach), daily impact (support happens every day, not only at appointments), sustainable capacity (a trained workforce continues beyond individual programme funding), and system resilience (improvement doesn't depend solely on dental workforce capacity). Health Education England's Mouth Care Matters programme provides free training that supports this;⁹ what's often needed is commissioning that incentivises settings to release staff for training and implement what they learn.
What good looks like
When oral health is commissioned effectively, the results are visible across the system:
- Fewer children in hospital for preventable extractions. Areas with established supervised toothbrushing show significant reductions in decay, particularly among children in the most deprived areas.⁴
- Better quality care in care homes. Between 2019 and 2022, care homes with an oral health policy rose from 25% to 53%, staff receiving specific oral health training doubled from 30% to 60%, and managers unaware of national guidance fell from 39% to 9%.² Not just compliance — better care.
- Reduced health inequalities. When prevention reaches the children and communities who need it most, the gradient in outcomes begins to narrow — achievable, but it requires deliberate targeting.
- Integration across services — dental services, public health, social care and community providers working together, so oral health becomes part of how the whole system works.
Commissioning checklist
- Needs assessment — oral health in the JSNA; extraction data analysed by deprivation; local epidemiology reviewed; care home practice assessed; dental access and capacity mapped.
- Strategic planning — oral health in the Health and Wellbeing Strategy; Core20PLUS5 focus adopted; prevention prioritised alongside treatment; workforce development included.
- Service specification — outcomes-focused; evidence-based interventions; workforce training components; partnership requirements; quality standards aligned with NICE and CQC.
- Quality monitoring — outcome-focused KPIs; regular extraction data; care home compliance monitoring; training uptake tracked; resident and patient experience captured.
Support is available: OHID publishes oral health profiles and data tools and can advise on evaluation; local dental public health consultants can help interpret data and develop strategy; NICE guidance provides detailed recommendations; the national supervised toothbrushing toolkit includes commissioning guidance and the ROI evidence; and Health Education England and Skills for Care support workforce development.
