Special Smiles is an innovative play-based dental health project which the charity, Action for Sick Children (Scotland), (ASC(S)), has been running for the last two years in special schools throughout Tayside. The purpose of the Special Smiles Dental Project (SSDP) is to improve the dental health and therefore overall quality of life of children and young people with a range of severe and complex additional support needs, by promoting learning through play using dental play resources.
Special Smiles is a development of the Dental Playbox Project, which ASC(S) launched in 2003 as their response to the Scottish Executive’s paper – Towards Better Oral Health in Children 1, a document which highlighted the poor record of children’s oral health in Scotland, namely:
- 55 per cent of all five-year-olds had dental disease
- by age 14, 68 per cent of children had dental disease in adult teeth
- more than a quarter of a million teeth were extracted from children each year
- tooth extraction was the largest single reason for children receiving general anaesthesia in hospital.
The need for a co-ordinated approach with key agencies and professionals working in partnership to tackle dental decay was also highlighted, giving rise to the idea of Dental Playboxes, based on the highly successful Hospital Playbox scheme run by ASC(S) for many years.
Play is a child’s language, but more than that, research shows that play reduces anxiety, facilitates communication and speeds recovery and rehabilitation2. ASC(S) believes in the importance of adequate preparation for any form of treatment and in the role of play in this regard and has long promoted the concept of hospital play as a way of helping children cope with the trauma of procedures, treatment and pain and to understand what is happening to them.
So, following discussions with staff at the Glasgow Dental Hospital and with funding from Boots Plc through their Community Investment Fund, ASC(S) developed 30 Dental Playboxes with the aims of encouraging children to attend the dentist, dispelling the anxieties associated with dental treatment, and promoting good oral health habits. The Playboxes contained books and toys about teeth and dentists, safe dental equipment, mini uniforms, worksheets, certificates and stickers.
These Dental Playboxes were available on loan to nurseries, primary schools, school nurses and hospitals throughout Scotland and 18,500 children had access to the Playboxes over the two-year period. The feedback received from schools, parents, children and dental professionals was overwhelmingly positive and an evaluation by an independent consultant indicated that the aims had been successfully realised. A need was identified for a resource specifically geared for children with physical disability, sensory or learning impairment.
At the same time, the Scottish Executive was setting out a commitment to improving children’s oral health in the Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland.3 A key principle of the Action Plan was that: “Services for children and young people should be focused on prevention and meet the oral health needs of those in the most disadvantaged circumstances.”
The Action Plan also set oral health targets that:
- 60 per cent of five-year-olds to show no signs of obvious dental disease by 2010
- 60 per cent of 11-12-year-olds to show no signs of obvious dental disease in their permanent teeth by 2010.
Research evidence suggests that children with additional and complex support needs have poorer oral health and receive less preventive care and restorative treatment than children in the general population. Reasons put forward to explain this include:
- children being unable to take care of their teeth
- children refusing to co-operate with carers with tasks such as tooth brushing
- children experiencing communication difficulties
- lack of experience among dentists in treating children with additional and complex support needs
- many children with additional and complex support needs experiencing dental anxiety which makes dental care difficult to carry out.
Children with additional and complex needs are therefore at a higher risk of needing specialist dental services than the general population and at the highest risk of having to undergo general anaesthesia for dental procedures. Despite the growing number of oral health initiatives for children in Scotland, it was found that none of them adequately addressed the needs of children with physical disability, sensory or learning impairment.
Thus, it was acknowledged that children and adolescents with additional and complex support needs required a specialised oral health intervention which would raise their awareness and improve oral health practices, and that using a therapeutic play strategy would prepare them for dental treatment. It is with these issues in mind that the SSDP was designed and received funding from Boots Plc for ASC(S) to refine the Dental Playboxes into a specialised resource for use with children with additional support needs. ASC(S) consulted and researched a wide range of individuals, organisations and publications during the course of this period and, in addition to the Dental Playboxes, developed a portable Dental Playpack for use at home by parents.
The basis of the SSDP was to test out these specially developed play resources, by piloting them in schools for children and young people with additional and complex support needs in one Scottish Health Board area over a two-year period (2007-2009).
Funding was secured from the Scottish Government and resources were placed in 29 schools throughout Tayside. These included specialist nursery, primary and secondary schools, a sensory service and also units in mainstream schools with specialist provision for pupils with additional and complex support needs which covered a range of conditions, such as Autistic Spectrum Disorders, as well as those with sensory and physical impairment. The project complemented the work of NHS Tayside as it implemented its Childsmile programme in mainstream schools.
Each school received a Special Smiles Dental Playbox and a portable Playpack for home use and training was provided for teaching staff and carers in the use of the various resources in school, nursery and home settings. The Special Smiles resources included books, DVDs, puppets, games and toys about teeth and dentists, safe dental equipment and mini-uniforms, worksheets and stickers, together with templates for social and multi-sensory stories which could be adapted to the individual needs of a child. Books, charts and worksheets with Makaton and Boardmaker symbols were also included. Additional resources such as inflatable dentist chairs were made available and replacement disposable materials were also supplied as required. Two-minute timers were supplied for every child. Throughout the project, back-up support was provided by the project staff in the form of workshops with children, meetings with parents, activity sessions and competitions and exchange of ideas through regular newsletters.
The aims of the project were to improve the oral hygiene understanding and practices of these children and young people and reduce the anxiety associated with dental treatment by promoting learning through play using the dental play resources. It was also hoped that the project would heighten the awareness of the dental health needs of these children and young people among parents, carers and relevant professionals, and assist them in providing for their oral healthcare needs.
Guidelines for use of the play resources were inserted in each box and pack and a training programme was offered to staff and parents. This included information on how to make best use of the resources, guidance on play, anxiety reduction, oral health and children with additional support needs and links to other organisations and websites.
The schools used the resources in different ways. There were opportunities for medical play, using a mixture of real and toy equipment to assess and encourage information sharing – what the child will experience and how procedures will occur; opportunities for projective play, using toys such as Play-Doh or teddy patients to help children play out their experiences; opportunities also for role-play, using the mini uniforms, masks, gloves and goggles, allowing them the chance to try on adult roles, giving them a sense of control which can help identify any hidden misunderstandings, fears or feelings.
Some schools ran sessions purely on oral health promotion, and used the resources to refer to healthy teeth and diet. Others set up a dental surgery with chair and held role-play sessions in class using all the resources, while other schools used the resources for short-term projects on related themes.
More than 700 hundred children in 29 schools had access to the resources over the period of the project. Because of the very complex needs of some of the children, it was difficult to measure any change in the children’s understanding using traditional methods, so there was a reliance on parents and carers to answer on their behalf using before and after questionnaires, and on other means such as photographs, drawings and observation. The greatest amount of feedback came from the teaching staff who were universally in favour of the project with very positive feedback.
The success of the Special Smiles Dental Project is in no doubt, having been received enthusiastically by children, parents, carers and professionals. The Evaluation Report4 can be accessed on the ASC(S) website. It concludes that the project met its main aims and that oral health understanding and practices improved among staff, parents and children, and child dental anxiety was reduced.
Research shows that dental anxiety can prevent children from accessing dental treatment5 and highlights children with additional and complex needs to be among the most vulnerable. Special Smiles staff received several reports of extremely anxious children who were initially totally non-compliant, but successfully completed a course of dental treatment after using the Dental Playpack.
It is hoped that by using the Special Smiles resources with the support of professionals, parents and carers, children will require less dental treatment and when they do, will have strategies in place reducing the need for general anaesthesia for treatment, a costly and risky procedure. ASC(S) believes that Special Smiles could greatly enhance the Scottish Government’s ability to achieve their oral health targets for children in Scotland.
Catherine Nelson is a Dental Playbox Co-ordinator. Further information about the project can be obtained from: Action for Sick Children (Scotland), 22 Laurie Street, Edinburgh EH6 7AB, tel 0131 553 6553,http://www.ascscotland.org.uk
FEEDBACK: Teachers and parents are all smiles
“The children loved dressing up and taking part in the role-play activities and at the end of the project all but one were able to indicate that they weren’t worried about going to the dentist.
“All parents reported that their children were more motivated to brush their teeth. One parent found the chart for brushing teeth particularly helpful in establishing a better routine and asked for copies so she could continue using at home.
“We are also now planning to brush teeth on a more regular basis and include more oral health care needs on their IEPs.”
Isla MacDonald, Grange Primary School, Monifieth
“The children had been brushing teeth individually before, but with Special Smiles, it became a group activity.
“I noted quite a big change in the children. Even the most sensory defensive child held a toothbrush. It is important to encourage independence in these children while young – to learn independent daily living skills. The project gave them the opportunity to watch and learn from each other.”
Heather Miller, Nursery Teacher, Fairview School, Perth
“This is a wonderful resource – very much appreciated and hopefully has improved the long term health of these pupils.
“I used the Playbox with two pupils, both in Primary Four, who ‘couldn’t work’ because they had sore teeth (on different occasions). Neither child wanted to go to the dentist. I showed them appropriate items from the box and we discussed teeth. Both subsequently had dental treatment.”
Anne Duncan, Hayshead Primary School, Arbroath
“My child treats teeth cleaning more as a game now, so it is much easier to help her.”
Parent, Fairview School
“Heather now brushes her teeth two to four times a day and visits the dentist every three months. She is still slightly apprehensive, but will now attend and have treatment.
“I really valued the resources. They helped support Heather prior to a visit to the dentist. The resources, combined with an understanding dentist, have made a big difference.”
Parent, Tulloch Primary School, Perth
“Previously J shook, vomited, had bowel movements and became very tired, withdrawn and upset when attending the dentist.
“We have now managed to encourage J to have his teeth brushed by the dentist, although he refuses to sit on the chair!
“Special Smiles is a great idea. It has been very beneficial to J, although he still has a long way to go as his fear is very deep rooted.
“But to be allowed access to information like this playbox has been very good and J has improved.”
Parent, Tulloch Primary School
1. Scottish Executive (2002)
Towards Better Oral Health in Children.
Edinburgh HMSO, 2002.
2. Russ, S. (2004)
Play in child development and psychotherapy: Towards empirically supported practiced.
Mahwah, NJ.: Lawrence Erlbaum Ass.
3. Scottish Executive (2005)
An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland.
Edinburgh HMSO, 2005.
4. Chambers, S., Turner, S. & Freeman, R. (2009)
Special Smiles Dental Project Evaluation Report
Dental Health Services Research Unit, University of Dundee, 2009
5. Howard, K.E. & Freeman, R. (2009)
An evaluation of the passivity to activity through live symbol after treatment modelling intervention to reduce dental anxiety in child dental patients.
International Journal of Paediatric Dentistry 2009.