Guidance

Commissioning and delivering supervised toothbrushing schemes in early years and school settings

Updated 7 March 2025

Applies to England

Introduction

Tooth decay is the most common oral disease affecting children and young people in England, yet it is largely preventable. While children’s oral health has improved over the past 20 years, the recent Oral health survey of 5 year old schoolchildren 2024 and Oral health survey of 3 year old children 2020 reports have found that more than a fifth (22.4%) of 5 year olds and 10.7% of 3 year olds had tooth decay. This can affect their ability to sleep, eat, speak, play and socialise with other children.

The Health matters: child dental health guidance explains that the impacts of tooth decay can also affect school performance, with children missing school. In addition, it can affect parents or carers, who may need to take time off work to take children to the dentist or for a hospital visit.

While there have been improvements in the oral health of children in England, significant inequalities remain, including within local authorities at ward level.

In England, local authorities have the statutory duty for:

• assessing the oral health needs of their local population
• developing oral health strategies
• commissioning oral health improvement programmes to meet the needs of their local population

This is set out in The NHS Bodies and Local Authorities (Partnership Arrangements, Care Trusts, Public Health and Local Healthwatch) Regulations 2012. Since 2021 oral health promotion activities are required in early year settings. This is outlined in the Early years foundation stage (EYFS) statutory framework.

Purpose of this toolkit

The toolkit has been updated to support commissioners and providers of local supervised toothbrushing schemes to ensure activities are evidence-informed, safe and have clear accountability and reporting arrangements to demonstrate impact. It is underpinned by the evidence base in the following publications:

• Delivering better oral health - an evidence-based toolkit for prevention
• Improving oral health: an evidence-informed toolkit for local authorities

Toolkit users

This is intended for use by:

• public health teams and commissioners of local supervised toothbrushing schemes
• oral health teams involved in the provision of local supervised toothbrushing schemes
• other providers involved in the provision of local supervised toothbrushing schemes
• early years staff who implement supervised toothbrushing schemes for children in their care

Evidence for carrying out supervised toothbrushing 

There is strong evidence that the daily application of fluoride toothpaste to teeth reduces the incidence and severity of tooth decay in children. However, in the Children’s dental health survey 2013 (commissioned by the Health and Social Care Information Centre) it shows children in more deprived areas tend to have poorer oral health compared to their less socially disadvantaged peers, and are also less likely to brush their teeth twice daily.

The National Institute for Health and Care Excellence (NICE) public health guideline (PH55) Oral health: local authorities and partners recommends supervised toothbrushing schemes for nurseries and primary schools in areas where children are at high risk of poor oral health. Supervised toothbrushing schemes also support the NHS Core20PLUS5, an approach to reducing health inequalities for children and young people, of which oral health is one of the clinical priorities for children.

The infographic in the guidance Improving the oral health of children: cost effective commissioning describes supervised toothbrushing schemes having a return on investment (ROI) over 5 years of £3.06 for every £1 spent.

At a community level in school or early years level, evidence shows that brushing each day at school over a 3-year period is effective for preventing tooth decay in all children.^{[footnote 1]} Meanwhile children living in the most deprived 20% of areas can show significant reduction in tooth decay within one year. This is evidenced by the national complex oral health programme,^{[footnote 2]} which teaches children to brush their teeth from a young age and encourages good oral hygiene at home.

Commissioning and governance

To maximise their benefit, toothbrushing schemes need to align with the aims of local oral health strategies, co-ordinating with other initiatives and existing services targeting the same outcomes and population. Formal commissioning arrangements ensure that the schemes provided are safe, effective and integrated, thus avoiding duplication and providing the best outcome for the investment.

For commissioned schemes, the development of a service specification, focus on quality assurance and linked contract monitoring processes is highly recommended. For non‑commissioned schemes, it may still be possible to work with providers to establish equivalent governance arrangements. Advice is available to support this from local consultants in dental public health.

Quality assurance 

An example of quality assurance requirements for provision of supervised toothbrushing in an early years settings and schools is set out below. Performance should be monitored once every term. The requirements are as follows:

• there should be a designated lead person for the scheme who is responsible for it within their setting
• an agreement outlining the responsibilities of partners should be completed and signed by all partners
• commissioning and contract monitoring procedures should be in place
• there should be access to a named dental professional, such as the local oral health promoter or consultant in dental public health, for advice if needed
• there should be support and training available for staff to deliver the scheme, including infection prevention and control procedures. Training should be recorded and monitored
• permission or consent must be sought from parents or carers for their children to take part in the scheme and records are maintained
• all the equipment will be provided by the agreed supplier on request. Toothbrush and toothpaste packs will be provided at least once a year to support the scheme and encourage the continuation of toothbrushing at home
• quality assurance assessments must be carried out by staff each term and by the provider annually, using a quality assurance checklist. The monitoring meeting between the provider and the setting designated lead should involve:
  • observation of the toothbrushing session, discussion of the toolkit guidance and performance against the checklist
  • feedback being given to the overall scheme lead and arrangements being made for a follow-up visit

Ensuring effective preventive practice

The evidence base on delivery of supervised toothbrushing schemes shows that success is sensitive to changes in delivery. To be effective it is important that the scheme is delivered according to the existing evidence-based approaches. For example, in addition to the supervised toothbrushing at schools, toothpaste and toothbrush packs should be sent home with supporting information for school holiday periods.

Process measures should be defined during procurement and as part of contract monitoring to track delivery. If, however, the scheme adopts an approach not directly supported by the published evidence, then the scheme should also be evaluated in terms of outcomes (including clinical outcomes). Effective preventive practice includes ensuring that: 

• each child, whether in the setting full-time or part-time, brushes once a day as part of the supervised toothbrushing scheme. In addition, parents and carers are encouraged to brush with their child at home
• toothbrushing takes place at a time that is most suitable for each setting
• toothbrushing takes place in groups or individually, with children seated or standing
• the supervised toothbrushing scheme uses 1 of 2 models: dry or wet toothbrushing, which are described further below
• children are closely supervised by an adult when brushing their teeth
• fluoride toothpaste containing 1,350 to 1,500ppm (parts per million) is used
• specific non-foaming toothpastes can be used for children with swallowing and/or sensory difficulties
• the correct amount of toothpaste is used so that children under 3 years of age have a smear of paste applied to their brush, while children over 3 have a pea-sized amount of paste applied to their brush
• children are discouraged from swallowing toothpaste during or after brushing their teeth and toothpaste is not reapplied if swallowed
• after brushing, children spit out residual toothpaste and do not rinse
• a small-headed toothbrush with medium texture bristles is recommended. Toothbrushes are replaced termly or as soon as they appear damaged, the bristles are splayed, or if the toothbrush has fallen on the floor. For those who need assistance with toothbrushing, toothbrushes are available with adaptations
• all paper products are recyclable and biodegradable if possible
• if there are areas of concern, necessary remedial action is taken immediately. If these concerns cannot be addressed in the setting directly, the scheme should be suspended while appropriate advice is sought, action is agreed and carried out before recommencing

Roles and responsibilities

Clarity on roles and responsibilities help to support implementation. An agreement between the supervised toothbrushing setting and partners can be helpful. The example below is a model that has been used successfully.

Commissioners 

Commissioners are responsible for:

• using information from the oral health needs assessment to identify areas where children are at high risk of poor oral health and appropriate for targeted toothbrushing schemes
• co-ordinating schemes across the locality, preventing duplication and maximising use of resources
• ensuring appropriate governance and performance monitoring processes are in place

Oral health staff and providers

Oral health staff and providers are responsible for:

• providing training for all staff who supervise and deliver the toothbrushing scheme to ensure effectiveness and safe delivery. Training includes infection prevention control which should be provided by an appropriately trained and/or qualified person
• providing oral health improvement and/or scheme implementation advice, if needed
• providing the resources to support the scheme
• ensuring that the toothpaste used is free from animal derivatives and gluten
• ensuring that parents are fully informed about the scheme
• ensuring that parents receive an information and consent leaflet to enable informed choice
• providing each establishment with the guidelines for implementation and checking that this is taking place
• checking procedures at each establishment at least once in an academic year
• All of the above should be recorded by each team within the district.

See the example implementation plan on the BRUSH website for an example of how to work with settings and schools to support implementation.

Childcare staff

Childcare staff are responsible for:

• ensuring that staff who implement and supervise the scheme attend the training
• managing permission or consent forms. They must ensure they are kept by the nursery or school setting in the child’s personal file and that all staff are aware of the children who are not taking part in the toothbrushing scheme
• committing to the scheme, providing supervised toothbrushing on a daily basis and following the guidelines
• ensuring the scheme follows infection prevention control procedures
• checking equipment on a regular basis and ensuring the appropriate resources are used
• ensuring that the brush storage units are stored carefully and looked after for continued use
• contacting the oral health team when new staff need to be trained

Delivering a supervised toothbrushing scheme

When delivering a supervised toothbrushing scheme the general infection prevention and control guidance must be followed.

Approaches to supervised toothbrushing

There are 2 approaches to supervised toothbrushing, both of which follow the general infection prevention and control guidance. The appropriate approach will depend on which one best fits a setting.

Dry toothbrushing

One approach is toothbrushing in a dry area, brushing either without the use of water, or a sink. If the dry toothbrushing approach is being adopted, children may stand or sit while toothbrushing, however, the area surrounding them should be easy to clean. After brushing, children can spit excess toothpaste into a tissue or paper towel (encourage children to raise the tissue to their mouths to do so) and wipe their mouths.

Wet toothbrushing

Another approach is toothbrushing at a sink. If the wet toothbrushing approach is being adopted, toothbrushing takes place at the identified sink area. Children should be closely supervised and encouraged to spit excess toothpaste into the sink.

Avoiding cross-infection

Toothbrushes are a possible source of cross-infection. Good hygiene practice should be an essential part of childcare in nursery and school settings. Toothbrush storage systems comply with best practice in the prevention of cross-contamination.

Children returning to the setting after being unwell can participate in the supervised toothbrushing scheme without delay unless otherwise stated by specific locally implemented precautions and guidelines. If there is suspicion of or a confirmed case of a notifiable disease, seek and follow the advice of the local health protection team.

Toothbrush storage systems

Toothbrushes should be stored in appropriate storage racks, systems or individual ventilated holders that enable brushes to stand upright and not be in contact with each other, to avoid cross-contamination. The standards apply equally to individual holders as to the storage systems.

The storage system lids or covers are not interchangeable and should always be put back facing the same direction.

Storage systems display symbols corresponding with those on the toothbrushes to allow individual identification. Each toothbrush should always be replaced into the same hole in the storage system following toothbrushing.

Storage systems should allow airflow around the toothbrush heads to enable the toothbrushes to dry. Covers should only be used once brushes have dried, or if they allow sufficient ventilation to allow drying.

Storage systems should be stored within a designated toothbrush storage trolley or in a clean, dry cupboard and:

• have manufacturers’ covers that allow the free flow of air
• be stored at adult height or in a suitable toothbrush storage trolley

Dedicated household gloves should be worn when cleaning storage systems and sinks. After toothbrushing, sinks should be cleaned with neutral detergent or wipes.

Storage systems, trolleys and storage areas should be cleaned, rinsed and dried at least once a week (more if soiled) by staff using warm water and household detergent. Manufacturers’ guidelines should be followed when cleaning and maintaining storage systems, including dishwasher cleaning where appropriate. Disinfectant wipes are not recommended for cleaning storage systems.

The storage system should not be placed directly beside where toothbrushing takes place to avoid contamination via aerosol spread.

Storage systems should be replaced if cracks, scratches or rough surfaces develop.

Steps involved in supervised toothbrushing

The following steps include the general infection prevention and control criteria, and are appropriate for either approach that is implemented.

Step 1: wash or sanitise hands

Supervisors and children (under supervision) should wash their hands or use hand sanitiser before and after the toothbrushing session. Supervisors should cover any cuts, abrasions or breaks in their skin with a waterproof dressing before starting a toothbrushing session and before carrying out cleaning.

There is usually no need for the supervisor to wear personal protective equipment (PPE) such as aprons and gloves. The supervisor can, however, choose to wear PPE if they deem the likelihood of exposure to bodily fluids (for example saliva and blood) to be increased. If deemed necessary due to the likelihood of exposure, one pair of gloves should be used per child, and the supervisor needs to wash or disinfect hands between glove changes (after taking gloves off and before putting a new pair of gloves on). Aprons should be changed when they become heavily soiled or contaminated with bodily fluids such as saliva or blood.

Step 2: collect toothbrushes

The children under supervision collect their toothbrushes from the storage system, along with a tissue or paper towel so they can spit any excess toothpaste into this after brushing. Toothbrushes must be individually identifiable, enabling each child to be able to recognise their own brush. Discretion should be used if a child has additional support needs.

Step 3: dispense toothpaste

When a toothpaste tube is shared, the toothpaste must not be dispensed directly onto the toothbrushes. Supervisors should dispense the toothpaste onto a clean surface such as a plate or individual paper towel or tissue square to allow each child to apply the toothpaste to their brush. Toothpaste paper should be disposed of immediately in a waste bag.

There must be sufficient spacing between the quantities of dispensed toothpaste to allow transfer to each child’s brush without cross-contamination. When a reusable plate is used to dispense the toothpaste, it should be cleaned and washed afterwards at high temperatures. Paper or plastic plates should be disposed of immediately in a waste bag.

As shown in the images below, a smear of toothpaste is used for children under 3 (figure 1), and a pea-sized blob for children aged 3 to 6 years (figure 2).

Figure 1: a smear of toothpaste for infants and young children up to age 3

Figure 2: a pea-sized blob of toothpaste for children aged 3 to 6 years

Tissues or paper towels must be disposed of immediately after use in a refuse bag.

Step 4: supervise toothbrushing

Children to brush their teeth - the observing supervisor must ensure teeth are brushed effectively, following the training they have received.

Step 5: rinse toothbrushes

At the end of the toothbrushing session, observed by the supervisor, the toothbrushes must be rinsed.

The infection prevention and control steps for cleaning and handling toothbrushes should be followed. Toothbrushes should be rinsed straight away. The toothpaste should not be allowed to dry on the brush. Toothbrushes should not be washed together in the sink and should not touch the taps or sink when being rinsed.

There are 2 approaches for rinsing toothbrushes.

Supervisor rinses toothbrushes:

Toothbrushes can be returned to the storage system by each child and taken to the identified sink area by the supervisor. The supervisor is responsible for rinsing each toothbrush and its handle at a sink under cold running water. After rinsing the toothbrushes, the supervisor is responsible for shaking off excess water into the sink. Toothbrushes should not come into contact with the sink or tap at any point during the session. Discretion should be used if a child has additional support needs.

Routinely, if the supervisor rinses the toothbrushes, there is no need for them to wear PPE. If the toothbrushes are heavily contaminated (including the bristles and the handle), the supervisor should consider wearing gloves and apron. In that case, one pair of gloves should be used per toothbrush, and the supervisor needs to wash or disinfect hands between glove changes (after taking gloves off and before putting a new pair of gloves on). Aprons should be changed when they become heavily soiled or contaminated with bodily fluids (for example saliva or blood).

Child rinses their own toothbrush:

Toothbrushes can be rinsed at an identified sink area where each child is responsible for rinsing their own toothbrush. Each child should in turn rinse their own toothbrush and its handle at a sink under cold running water. After rinsing the toothbrushes, the child or the supervisor is responsible for shaking off excess water into the sink. Discretion should be used if a child has additional support needs.

Step 6: return the toothbrushes to the storage area

Each child under supervision of the supervisor should be responsible for returning their own toothbrush to the storage system to air dry. Toothbrushes should not touch other toothbrushes or storage system lids or covers at any point during or between sessions. Discretion should be used if a child has additional support needs. If the lids are used for the storage system, they should be replaced at this stage if there is sufficient air circulation to allow the toothbrushes to dry before the next use.

Toothbrushes must not be soaked in bleach or other cleaner or disinfectant. Paper towels should be used to mop up all visible drips on the storage system. Toothbrushes that are dropped on the floor should be discarded.

Step 7: clean the toothbrushing area

After toothbrushing, supervisors should clean the area where the toothbrushing has taken place with detergents and bleach. Supervisors are also responsible for cleaning sinks and surfaces following national guidance and using standard cleaning products such as detergents and bleach.

Opting out of a scheme

If, at any time, the decision is made to opt out of a supervised toothbrushing scheme, the setting lead should inform all partners immediately so that arrangements can be made to collect any surplus stock. If a school leaves a scheme after parents have given permission or consent, the head teacher is responsible for informing the parents of the decision to withdraw and for informing school governors.

There are very few medical reasons why children should not participate in supervised toothbrushing schemes. In specific cases where there is a medical diagnosis of infection or oral ulceration, children may be temporarily excluded from the scheme. Toothbrushing at home can continue as this will usually aid healing.

1. Anopa Y and others. ‘Improving child oral health: cost analysis of a national nursery toothbrushing programme’ PLoS ONE 2015 (viewed on 24 February 2025) ↩

2. Kidd JB and others. ‘Evaluation of a national complex oral health improvement programme: a population data linkage cohort study in Scotland’ BMJ Open 2020 (viewed on 24 February 2025) ↩