Scottish Oral Health Improvement Homelessness Programme: Smile4life

Developing, implementing and evaluating an oral health preventive programme for homeless populations across Scotland


In March 2005 the then Scottish Executive produced a set of Health and Homelessness Standards, aimed at ensuring that NHS Boards within Scotland gave special consideration to improving the understanding, planning and treatment of people experiencing homelessness within their Board areas.  Improving the oral health of homeless people in Scotland was identified as a priority in An Action Plan for Improving Oral Health and Modernising NHS Dental Services (2005), which stated that it would be desirable for NHS Boards to develop and implement oral health care promotion for priority groups of ‘adults most in need’.  Homeless people were highlighted as one of these priority groups.

In 2007, when monies became available to develop oral health improvement programmes for priority group patients, including homeless people, a successful proposal was put to Scotland’s  Chief Dental Officer. The proposal was called ‘Smile4life’, and was submitted by a consortium of seven NHS Boards.

The Scottish Government’s commitment to improving the oral health of homeless people in Scotland was further strengthened in June 2012 by the publication of the National Oral Health Improvement Strategy for Priority Groups. The Strategy made various recommendations for homeless people, including those relating to dental referrals and the provision of oral health education. It was also recommended that staff in the homelessness sector should play a key role in assisting homeless people to improve their oral health.

Aim and Objectives

The aim of the Smile4life proposal was to facilitate the development, implementation and evaluation of evidence-based oral health preventive programmes for homeless (roofless and houseless) people throughout Scotland.

The specific objectives were to:

  1. Conduct a needs assessment to inform the current oral health and preventive oral health needs from the homeless (roofless and houseless) clients’ perspective (Smile4life oral health survey and qualitative exploration)
  2. Conduct a needs assessment as viewed from health professionals’ perspective
  3. Scope current models of preventive service and practice for homeless populations in Scotland
  4. Develop and evaluate an evidence-based oral health care preventive package tailored to the specific needs of homeless (roofless and houseless) populations in Scotland

Research Team


Smile4Life Reflexive mapping exercise

The RME provides a practical framework to tackle homelessness by providing an understanding of the current availability of services under eight areas of support, in the context of the design and implementation of health and social care integration.








The Smile4life Report

A needs assessment survey of 853 people experiencing homelessness in Scotland identified exceptional oral health needs among this population. Oral health was poor: 98% of those surveyed had experienced dental decay.  Over 50% of the sample had had at least one tooth extracted.  Sixty-eight percent of the sample stated that they only accessed dental care when experiencing pain or in an emergency.  Over 20% of this population experienced severe dental anxiety.









Smile4life Guide for Trainers and Smile4life Intervention

The Smile4life Guide for Trainers and associated Smile4life Intervention is an evidence-based resource for all health and social care professionals to deliver training to staff working directly with people experiencing homelessness.  The overall purpose of Smile4life is to enable health and social care staff and support workers to provide evidence-based tailored oral health messages to meet the specific and exceptional needs of homeless (roofless and houseless) people in Scotland.  Smile4life is currently being implemented in the majority of NHS Boards in Scotland.









Beaton, L. & Freeman, R. (2015) Oral health promotion and homelessness: A theory-based approach to understanding processes of implementation and adoption. Health Education Journal.

 Freeman, R., Coles. E., Watt, C., Edwards, M., & Jones, C. (2012) Smile4life Guide for Trainers: Better Oral Care for Homeless People. Edinburgh: NHS Health Scotland. [PDF attached, also external link to NHS Health Scotland website, see below]

Coles, E., Themessl-Huber, M. & Freeman, R. (2012) Investigating community-based health and health promotion for homeless people: A mixed methods review. Health Education Research, 27(4), 624-644.

Coles, E., Freeman, R., Watt, C. (2012) Something to Smile About: an evaluation of a capacity-building oral health intervention for staff working with homeless people. Health Education Journal, 72(2), 146-155.

Yeung, A., Coles, E., Moore, A., Watt, C., & Freeman, R. (2012) Bringing home the message - An in-depth survey of homeless people has flagged up where improvements can be made in dental care programmes. Scottish Dental Magazine, 3: 46-51.

Coles, E., Edwards, M., Elliot, G.M., Freeman, R., Heffernan, A., & Moore, A. (2011) The Oral Health of Homeless People across Scotland: Report of the Homeless Oral Health Survey in Scotland, 2008-2009. Dundee: University of Dundee, Dental Health Services Research Unit. [PDF attached]

Coles, E., Chan, K., Collins, J., Humphris, G.M., Richards, D., & Williams, B., Freeman, R. (2011) Decayed and missing teeth and oral health-related factors: predicting depression in homeless people. Journal of Psychosomatic Research, 71: 108-112.

Collins, J., & Freeman, R. (2007) Homeless in North and West Belfast: an oral health needs assessment. British Dental Journal doi/10.1038/ bdj.2007.47.