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There is a staggering 3.5 billion people on this planet with oral diseases, and this now affects more people than all those with major non-communicable diseases combined.1 Of this number, over half a billion children have untreated dental caries (tooth decay),2 which significantly impacts their development and quality of life.3 Children's performance in school can be also affected.1 In the United States, it is calculated that around 34.4 million school hours are lost annually because of acute dental problems and unplanned dental visits.4 Dental caries in children remains a persistent problem. The frustration is borne from the fact that it is a preventable condition. However, even in high-income countries like England, dental caries remains the number one reason for childhood hospital admissions.5 Health promotion and prevention is the key to securing the oral health of our next generation. Reduced sugar consumption and oral hygiene habits can play a preventative role; children should practice healthy diets and oral hygiene at home as well as in schools.6 To secure and advance the oral health of school-age children, pre-school to secondary schools, we propose that oral health should now be integrated not only into existing health systems, but also beyond health systems. We argue that oral health should no longer be viewed as the sole domain of dental professionals, but now actively shared and integrated across everyone who cares for and interacts with school-aged children. Education settings are ideal for children to learn attitudes, behaviors and skills that promote health.7 The World Health Organization and the United Nations Educational, Scientific and Cultural organization's recent Global Health Promoting Schools Initiative champions schools as strategic platforms for health prevention services, owing to their effective reach over large populations.8 Schools have historically been the setting for prevention and clinical care carried out by dental teams, including dental screening, fluoride varnish, fissure sealants and other restorative treatment. One such model is New Zealand's school-based oral health services which has spanned around a century of activity.9 However, owing to a myriad of reasons including financing, workforce and parental consent, these programs cannot be readily available in every school, and so addressing health inequity remains an issue. Therefore, oral health promotion must also extend beyond dental staff toward education staff who can better assure that every child is included. Schools are also in a prime position to share evidence-based oral health knowledge to students and engage positively with parents and families on all health issues. Schools should include oral health in their health education curriculums and other activities, and also ensure that the information given to children is consistent, engaging and evidence-based. School-based programs like establishing daily supervised toothbrushing in schools have already improved child oral health around the world. Childsmile, the national initiative in Scotland has increased the percentage of 5-year-olds with no obvious dental caries from 45% in 2003 to 71% in 2018.10 Such integrated school programs help to set a routine for children who may not receive this teaching at home—and these healthy habits can persist for life. The provision of oral hygiene kits by schools can also assist low-income families who struggle to provide consistent access to toothbrushes, toothpaste, and other oral hygiene supplies for their children, further helping to reduce health disparities. Sugar-free school environments are also a key to achieving oral health in school-aged children. Sugar not only causes dental caries in children, but it is also responsible for a host of other chronic conditions, such as diabetes, cardiovascular disease, obesity, and cancer. We need to inspire wider health professionals and school leaders to develop and enact policies for healthier, child-friendly environments. To do so, we need to create and enable an environment for oral health promotion and equip and empower educators to bring oral health messages and preventive measures to classrooms, cafeterias, and other parts of school facilities and activities. Other school-based policies which can transform lives include establishing "water only schools," whereby only water or unsweetened milk are available for students. The consumption of sugary drinks and flavoured fruit juices is one of the primary causes of dental caries; up to 66% of children and 77% of adolescents in the United States consume sugar sweetened beverages daily.11 Therefore, it is crucial for educational settings to set a norm that water is the first choice of beverage to quench thirst. Fluoridated community water, where safe and accessible, is to be encouraged for drinking as it has been shown to reduce dental caries by up to 25% in children and adults.12 Non-flavored milk can be an alternative source depending on the contexts, but flavored or sweetened beverages should not be within easy access for school-aged children. Such healthy drinking school initiatives or policies can also help to prevent obesity as well as environmental waste reduction. Teachers and school staff should be placed in the center when driving this momentum, identifying insertion points where oral health can be integrated into existing school health curricula, such as nutrition, hygiene, life science, and health promotion. Food labeling literacy and healthy recipes can serve as such integration points and are also invaluable lessons for life. Over the years, we have clearly witnessed the consequences of treatment-focused care, which has failed to secure and promote oral health, along with the continued problems with access to oral health services and the persistence of oral diseases. We must now join with change-agents in the educational sector to co-design what works best to advance oral health in a school-based context. The authors do not have any conflicts of interest for this commentary.
Wordley et al. (Tue,) studied this question.