Oral health is one of the most significant yet often overlooked areas of preventable illness in England. Even worse, the populations that suffer the most from oral disease are those already facing considerable socioeconomic disadvantage.
In 2023-24, there were 49,112 hospital tooth extractions for children and young people aged 0-19¹, most of which were preventable. These extractions not only cause individual pain and family stress but also lead to unnecessary NHS bed utilisation.
The issue is made worse by significant health inequalities. Children in the most deprived areas experience tooth decay at rates 3.5 times higher than those in less deprived areas. In some regions, over half of five-year-olds suffer from tooth decay, while in others, the prevalence is below 15%.
For adults in residential care, the situation is equally concerning. The Care Quality Commission's Smiling Matters report identified that two-thirds of care homes were not meeting residents' oral health needs.² Residents were not receiving daily oral hygiene care. Dentures were not being cleaned appropriately. Oral pain was being overlooked. This extends beyond dental concerns and it affects dignity, nutritional status, infection risk, and quality of life.
These challenges cannot be addressed by dental services alone. The populations most affected frequently have limited access to dental care: preschool children whose families face multiple competing pressures, older adults in care homes who cannot access dental care independently, and families who lack awareness that prevention should begin before tooth eruption.
NHS England's Core20PLUS5 framework for children and young people acknowledges this reality. Oral health is designated as one of five clinical priority areas due to the severity of inequalities and the feasibility of effective interventions.³
The Evidence Base
Interventions aimed at improving oral health have proven effective. The evidence supporting these effective interventions is strong, policy alignment is evident, and the return on investment is significant.
What Works
Supervised toothbrushing programs are among the most cost-effective public health interventions available. When fluoride toothpaste is applied to children's teeth daily in familiar settings, such as nurseries, schools, and special educational needs schools, the rates of dental caries decrease significantly. The evidence supporting this approach is strong. The Department of Health’s commissioning guide shows that these programs lead to measurable improvements in target populations.⁴
The economic rationale is also compelling. Analysis of supervised toothbrushing programs indicates a return of approximately £3.06 for every £1 invested, taking into account reduced treatment costs and avoided hospital admissions. This calculation does not even factor in the educational benefits from decreased absenteeism or the positive impact on families from reduced pain and distress.
Fluoride varnish programmes offer extra protection against cavities for children at higher risk. The National Institute for Health and Care Excellence (NICE) recommends this treatment for children aged two and older in areas with higher rates of tooth decay.⁵ Additionally, when these programs are provided in community settings instead of requiring dental appointments, participation rates significantly increase.
Workforce training expands the impact of oral health improvement beyond conventional dental environments. When staff in care homes are trained in daily oral hygiene practices, residents benefit from lower infection rates, improved nutritional health, and a better quality of life. This same principle applies to early childhood educators, school staff, and community health workers. By training the professionals who engage with vulnerable populations daily, we can create sustainable, systemic change.
Policy Alignment
Oral health improvement aligns with multiple policy priorities:
NHS Long Term Plan commits to expanding supervised toothbrushing, increasing preventive interventions, and shifting care delivery from hospital to community settings.⁶
Core20PLUS5 (Children and Young People) identifies oral health as a clinical priority area, with a specific focus on reducing decay-related hospital admissions in the most deprived 20% of areas.³
NICE PH55 provides comprehensive guidance for local authorities and partners on oral health improvement, with detailed commissioning recommendations.⁵
NICE NG48 establishes standards for oral health in care homes, with explicit expectations for assessment, care planning, and daily oral hygiene care.⁷
Health and Wellbeing Board responsibilities include oral health as part of the Joint Strategic Needs Assessment (JSNA) and Health and Wellbeing Strategy.
Commissioning oral health improvement is not additional work. It represents delivery of existing policy commitments with robust evidence and clear return on investment.
The Whole-System Approach
Improving oral health requires more than just dental services. Populations with the poorest oral health often face significant barriers to accessing dental care. Therefore, effective commissioning should integrate four key elements:
- Population-level interventions: Initiatives aimed at reaching children before oral health problems develop.
- Workforce development: Training non-dental staff to support daily oral hygiene practices.
- Community engagement: Building health literacy and promoting healthy behaviours within the community.
- Dental service access: Ensuring that treatment is available when clinically necessary.
Commissioners are in a unique position to integrate these elements into a coherent, effective system to improve oral health.
Commissioning Oral Health Improvement
Effective commissioning translates evidence into local action. The following framework provides a structured approach.
Needs Assessment
The Joint Strategic Needs Assessment (JSNA) should include comprehensive oral health data. Key data sources include:
- Hospital tooth extraction data from OHID, disaggregated by local authority and deprivation quintile. This identifies where preventable problems lead to hospital admissions and enables targeted resource allocation.
- National Dental Epidemiology Programme surveys provide local data on children's dental health, including caries prevalence and severity. This enables identification of geographic and demographic patterns.
- Adult oral health survey data demonstrate patterns in adult populations, including the impact of socioeconomic deprivation and access barriers.
- Care home inspection findings from CQC indicate where oral health standards in residential care settings require attention.
- Local dental access data demonstrates capacity, utilisation, and unmet need within the area.
Conducting a comprehensive needs assessment gives local authorities and commissioners confidence in resource allocation, ensuring maximum impact for the population.
Service Specification
When commissioning oral health improvement services, specifications should include:
- Clear outcomes linked to population health improvement, not solely activity metrics. Measure reductions in caries prevalence, hospital admissions, and health inequalities, not only the number of brushing sessions delivered.
- Evidence-based interventions aligned with NICE guidance and Delivering Better Oral Health. Avoid commissioning unproven approaches when effective interventions with robust evidence are available.
- Workforce development components that build sustainable capacity. Training non-dental staff creates a long-term infrastructure that continues beyond individual programme funding cycles.
- Quality standards aligned with NICE quality standards (QS151 for care homes) and CQC regulatory expectations.
- Partnership requirements ensure providers collaborate with dental services, local authorities, educational settings, and care providers to deliver integrated approaches.
Key Performance Indicators
Effective KPIs focus on outcomes rather than outputs. Consider:
Population outcomes:
- Reduction in hospital tooth extractions (0-19 years)
- Reduction in caries prevalence in epidemiological surveys
- Improvement in oral health-related quality of life measures
Service quality:
- Percentage of care homes meeting NICE NG48 standards
- Percentage of care home residents with oral health care plans
- Percentage of target settings implementing supervised toothbrushing
Workforce development:
- Number of non-dental staff trained in oral health
- 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
- Waiting times for community dental services
- Uptake of preventive interventions (fluoride varnish, fissure sealants)
Workforce Development as a Commissioning Lever
Investing in workforce development is a cost-effective approach to commissioning. Training non-dental staff to support oral health provides numerous benefits.
- Extended reach. Non-dental staff interact with populations that dental professionals rarely access (care home residents, nursery children, housebound adults).
- Daily impact. Trained staff support oral hygiene care daily, not solely during dental appointments.
- Sustainable capacity. A trained workforce continues to function beyond individual programme funding cycles.
- System resilience. Oral health improvement does not depend exclusively on dental workforce capacity.
The Mouth Care Matters program offers an established training infrastructure at no cost. What is often needed is commissioned support to allow staff to dedicate time to training, implementation assistance, and formal acknowledgement of the oral health champion role.
What Good Looks Like
When oral health is commissioned effectively, results are observable across the system.
Fewer children are requiring hospital admission for preventable extractions. The Core20PLUS5 target of reducing decay-related admissions is achievable when supervised toothbrushing reaches the populations with the greatest need.
Improved quality of care in residential settings. The CQC's 2023 progress report demonstrated outcomes when oral health is prioritised. Increased proportion of residents with care plans. Increased staff training completion. Increased delivery of daily oral hygiene care. Improved nutritional status, reduced infection rates, enhanced quality of life.
Reduced health inequalities. When preventive interventions reach the children and communities with the greatest need, health equity gaps begin to close. This requires sustained effort, but it demonstrates effectiveness.
Integration across services. Effective commissioning integrates dental services, public health, children's services, adult social care, and community providers. This creates a system where all stakeholders understand their role in supporting oral health.
How MDBuddy Can Support
We provide practical resources and digital tools that support oral health improvement at scale.
Supervised Toothbrushing School Dashboard
Our School Dashboard is a comprehensive management platform for local authorities commissioning supervised toothbrushing programmes. It is designed to facilitate implementation for settings and monitoring for commissioners.
The dashboard provides:
For settings and classrooms:
- Toothbrushing instructional videos for classroom sessions, with step-by-step tutorials supporting effective brushing technique
- Brushing session logs for Ofsted documentation and evidence
- Class and setting management tools
For local authority programme managers:
- Real-time monitoring of setting participation and engagement
- Identification of settings requiring support, including flagging where brushing sessions exceed expected duration
- Resource delivery management and supply requests
- Recall period scheduling to ensure consistent follow-up with settings
- Priority contact lists indicating which settings have been engaged, which are active, and which require attention
For reporting and assurance:
- Automated quarterly reports with key programme metrics
- Data on settings engaged, active settings, and children brushing
- Breakdown by Index of Multiple Deprivation (IMD) and setting type, including maintained and private settings
- Audit support and management system
- Feedback recording, including incident reporting
Workforce Training Resources
- Staff training modules for care settings, schools, and community workers
- Resource centre with downloadable guides aligned to NICE and CQC standards
- Visual identification tools enabling non-dental staff to identify oral health problems
- Implementation guides for programme delivery
We collaborate with commissioners, providers, and local authorities to build sustainable oral health improvement programmes that deliver measurable results.
Quick Reference: Commissioning Checklist
Needs Assessment
- [ ] Oral health included in JSNA
- [ ] Hospital extraction data analysed by deprivation
- [ ] Local dental epidemiology data reviewed
- [ ] Care home oral health practice assessed
- [ ] Dental access and capacity mapped
Strategic Planning
- [ ] Oral health included in Health and Wellbeing Strategy
- [ ] Core20PLUS5 oral health targets adopted
- [ ] Prevention prioritised over treatment
- [ ] Workforce development included in planning
Service Specification
- [ ] Outcomes-focused (not solely activity)
- [ ] Evidence-based interventions specified
- [ ] Workforce training components included
- [ ] Partnership requirements defined
- [ ] Quality standards aligned with NICE/CQC
Quality Monitoring
- [ ] KPIs focused on outcomes
- [ ] Regular data on hospital extractions
- [ ] Care home compliance monitoring
- [ ] Workforce training uptake tracked
- [ ] Patient/resident experience captured
When to Get Help
Commissioning oral health improvement may represent unfamiliar territory for some teams. Support is available.
For needs assessment support: OHID publishes oral health profiles and data tools. Local dental public health teams can provide data interpretation and priority identification.
For service specification: NICE guidance provides detailed recommendations. The Supervised Toothbrushing Toolkit offers practical advice for commissioning.
For workforce development: Health Education England's Mouth Care Matters programme provides an established training infrastructure at no cost.⁸ Skills for Care offers oral health resources for social care workforce development.
For implementation: MDBuddy provides practical resources and can discuss workforce training approaches and digital tools to support programme delivery.
For evaluation: OHID can advise on impact measurement and alignment with national data collections.
