CG19 Dental Recall - Full Guideline M

i
Dental Recall
Recall interval between routine
dental examinations
EVIDENCE, METHODS & GUIDANCE

ii D E N TA L R E C A L L
CONTENTS iii
Contents
Acknowledgements v 2.2.5 Other caries outcome measures used in our

Stakeholder Organisations vii updated review 13
Abbreviations used in Guideline ix 2.2.6 Periodontal Disease Outcomes 14
2.2.7 Oral Cancer 15
1 Introduction 1 2.2.8 Quality of Life 15
1.1 Background 1 2.3 Cost-effectiveness 15
1.2 What is a guideline? 2 2.3.1 The HTA Report model 16
1.3 Remit of the Guideline 3 2.3.2 Other studies 16
1.4 What the guideline covers 3 2.4 Conclusions 17
1.5 What the guideline does not cover 3
1.6 Who developed the guideline? 3 3 The Context of Dental Recall 20
1.7 Guideline Methodology 4 3.1 Dental Caries 21
1.7.1 Outline of methods used 4 3.1.1 Caries Risk Assessment 22
1.7.2 Questions addressed in developing the guideline 4 3.1.2 Rate of Progression of Dental Caries 23
1.7.3 Systematic Review Methods for Key Clinical 3.1.3 Threshold for intervention 24
Questions 5 3.1.4 Occlusal surface caries 24
1.7.4 Hierarchy of evidence 6 3.1.5 Caries on contacting approximal surfaces 25
1.7.5 Health economics methods 6 3.1.6 Restorative threshold of free smooth surface
1.7.6 Forming and grading the recommendations 7 lesions 25
3.2 Periodontal Diseases 25
2 Clinical effectiveness and cost- 3.2.1 Summary of the Literature Reviewed 25
effectiveness of routine dental 3.2.2 Gingivitis 26
checks (HTA update) 9 3.2.3 Risk factors 26
2.1 Characteristics of the Included Studies 9 3.2.4 Rates of Progression 27
2.1.1 Characteristics of the study settings and 3.3 Oral Cancer 28
study design 9 3.3.1 Summary of the Literature Reviewed 28
2.1.2 Characteristics of the Participants 10 3.3.2 Epidemiology 28
2.1.3 Characteristics of the Intervention and 3.3.3 Risk factors for oral cancer 30
Comparisons 10 3.3.4 The accuracy of clinical oral examinations in
2.1.4 Outcomes 11 detecting oral cancer and potentially malignant
2.1.5 Quality Assessment 11 conditions 31
2.1.6 Data synthesis and analysis 11 3.3.5 Toluidine blue dye 31
2.2 Results 11 3.3.6 Potentially malignant lesions and conditions 31
2.2.1 Outcome Measure: Number of teeth present 12 3.4 Effectiveness of Dental Health Education
2.2.2 Outcome Measure: DMFT/DMFS 12 and Oral Health Promotion 33
2.2.3 Outcome Measure: Decayed Teeth (DT)/Decayed 3.4.1 Summary of the Literature Reviewed 33
Surfaces (DS) 13 3.4.2 General Oral Health Promotion 33
2.2.4 Outcome Measure: Filled Teeth (FT) 13 3.4.3 Smoking Cessation 34
iv D E N TA L R E C A L L
3.4.4 Dietary Advice 34 References 46

3.5 Factors Affecting Dental Attendance and
Satisfaction with the Current Service 35 Glossary of Terms 54
3.5.1 Summary of the Literature Reviewed 35
3.5.2 Motivation for visiting the dentist 35 Appendix A – NHS Clinical Care Pathways: Oral Health
3.5.3 Factors influencing the frequency with which Assessment and Oral Health Review 59
NHS patients see their dentist 35 Appendix B – Questions addressed by the guideline 60
3.5.4 Satisfaction with NHS dental services in Appendix C – HTA Update Literature Searches 62
England and Wales 36 Appendix D – HTA Update Key Study Characteristics 65
Appendix E – Economic Modelling 83
4 Economic Modelling 38 Appendix F – Restorations, Diagnostic Accuracy and
4.1 Methods 38 Caries Epidemiology 92
4.2 Conclusions 38 Appendix G – Implementing the Clinical
Recommendations – selecting the
5 Recommendations 40 appropriate recall interval for an
5.1 Part I: Clinical Recommendations 40 individual patient. 100
6 Implementation and Audit 42

6.1 Background 42
6.2 Implementation 42
6.3 Audit 43
6.4 Research Recommendations 44
ACKNOWLEDGEMENTS v
Acknowledgements
Guideline Development Group

Professor Nigel Pitts Chair, Dental Health Services Research Unit, University of Dundee
Dr Paul Batchelor British Association for the Study of Community Dentistry
Dr Jan Clarkson Cochrane Oral Health Group
Dr Clare Davenport West Midlands Health Technology Assessment Collaboration
Mr Ralph Davies British Dental Association
Miss Karen Elley Sandwell Primary Care Trusts
Mr Stephen Fayle Faculty of Dental Surgery, Royal College of Surgeons of England
Mrs Eleanor Grey Patient Representative, Lay Advisory Group, Faculty of General Dental Practitioners (UK)
Miss Kathryn Harley Faculty of Dental Surgery, Royal College of Surgeons of England
Miss Sara Hawksworth Patient Representative, Age Concern England
Professor Mike Lewis University of Wales College of Medicine
Mr Peter Lowndes Faculty of General Dental Practitioners
Mr Mike Mulcahy Faculty of General Dental Practitioners
Mr Derek Richards Centre for Evidence Based Dentistry
Mr Richard Seppings British Dental Association
Dr Graham Smart Faculty of Dental Surgery
Mrs Elaine Tilling British Dental Hygienists Association
Mr Peter Wilkins Faculty of General Dental Practitioners
Professor Helen Worthington Cochrane Oral Health Group
Staff who worked on the guideline

Dr Paul Beirne Research Fellow, Oral Health Services Research Centre, University College Cork
Dr Jacqueline Dutchak Director, NCC-AC
Dr Ian Needleman International Centre for Evidence-Based Periodontal Health, Department of Periodontology,
Eastman Dental Institute, University College London
Ms Guldem Okem Health economist, NCC-AC
Mr Carlos Sharpin Information scientist and reviewer, NCC-AC
Ms Louise Thomas Research Associate, NCC-AC
Mr David Wonderling Health economist, NCC-AC
Conflict of interests
The Guideline Development Group were asked to declare any possible conflict of interest
and none that could interfere with their work on the guideline were declared.
All documentation is held by the National Collaborating Centre for Acute Care.
vi D E N TA L R E C A L L
Acknowledgements
The development of this guideline was greatly assisted by the following people: Jennifer
Wood (Office Administrator, NCC-AC), Gerry Cooney (medical writer), the Cochrane Oral
Health Group, the Oral Health Services Research Centre (University Dental School and
Hospital, Cork), Jane Cowl (Patient Involvement Unit).
The Guideline Review Panel is an independent panel that oversees the development of the
guideline and takes responsibility for monitoring its quality. The Panel includes experts on
guideline methodology, health professionals and people with experience of the issues
affecting patients and carers. The members of the Guideline Review Panel were as follows:
Peter Robb (Chair) Consultant ENT Surgeon, Epsom and St Helier and Royal Surrey NHS Trusts
Joyce Struthers Patient Representative, Bedford
Peter Duncan (Deputy Chair) Consultant in Anaesthetics
Anne Williams Assistant Director of Clinical Governance, Kettering General Hospital NHS Trust,
Northamptonshire
S TA K E H O L D E R O RG A N I S AT I O N S vii
Stakeholder Organisations
Addenbrooke’s NHS Trust Faculty of General Dental Practitioners
Alan Martin & Associates Faculty of Public Health
Anglesey Local Health Board GC United Kingdom Limited
Association of Consultants and Specialists General Dental Practitioners’ Association

in Restorative Dentistry (ACSRD)
Gorlin Syndrome Group
Bedfordshire & Hertfordshire NHS Strategic Health
Health Development Agency
Authority
Healthcare Commission
Bradford South & West Primary Care Trust
Herefordshire Primary Care Trust
British Association for the Study of Community
Dentistry (BASCD) L’Arche UK
British Association of Head and Neck Oncologists Medicines and Healthcare Products Regulatory
Agency (MHRA)
British Dental Association
Mouthpeace Dental Practices
British Dental Health Foundation
National Audit Office
British National Formulary (BNF)
National Council for Disabled People, Black, Minority
British Orthodontic Society
and Ethnic Community (Equalities)
British Psychological Society, The
National Patient Safety Agency
British Society for Oral and Maxillofacial Pathology
National Public Health Service, Wales
British Society of Oral Medicine
National Screening Committee
British Society of Periodontology
NHS Information Authority (PHSMI Programme)
Centre for Evidence-based Dentistry
NHS Modernisation Agency, The
Changing Faces
NHS Quality Improvement Scotland
Cochrane Oral Health Group
North Warwickshire Primary Care Trust
Defence Dental Agency
Oral Rehabilitation
Department of Health
PracticeWorks Ltd
Eastman Dental Institute
Relatives and Residents Association
Faculty of Dental Surgery
Richmond & Twickenham PCT
viii D E N TA L R E C A L L
Rotherham Primary Care Trust
Royal College of General Practitioners
Royal College of General Practitioners Wales
Royal Pharmaceutical Society of Great Britain
Scottish Intercollegiate Guidelines Network (SIGN)
Sheffield Teaching Hospitals NHS Trust
Software of Excellence International Ltd
South & Central Huddersfield PCTs
South Birmingham Primary Care Trust
South Devon Health Care Trust
Southampton City PCT
The British Dental Trade Association
The Royal Society of Medicine
The Royal West Sussex Trust
Tregenna Hill Dental Surgery
University College Londons Hospital NHS Trust
Welsh Assembly Government (formerly National

Assembly for Wales)
West Norfolk PCT
Westmeria Healthcare Ltd

A B B R E V I AT I O N S U S E D I N G U I D E L I N E ix
Abbreviations used in Guideline
AIDS Acquired Immune Deficiency Syndrome
BPE Basic Periodontal Examination
CDS Community Dental Service
CEA Cost Effectiveness Analysis
COHG Cochrane Oral Health Group
DMF Decayed Missing Filled
DMFS Decayed Missing Filled Surfaces
DFS Decayed Filled Surfaces
DMFT Decayed Missing Filled Teeth
DPB Dental Practice Board
DT Decayed Teeth
DS Decayed Surfaces
EBV Epstein Barr Virus
FGDP General Dental Practitioners
FT Filled Teeth
GDG Guideline Development Group
GDS General Dental Service
GP General Practitioner
GPP Good Practice Point
HIV Human Immunodeficiency Virus
HPV Human Papilloma Virus
HSV Herpes Simplex Virus
HTA Health Technology Assessment
ICD International Classification of Diseases
NCC-AC National Collaborating Centre for Acute Care

x D E N TA L R E C A L L
HEED Health Economic Evaluations Database
NHS National Health Service
HMIC Health Management Information Consortium
NICE National Institute for Clinical Excellence
NeLH National electronic Library for Health
NHANES III The Third National Health and Nutrition Examination Survey
NHS National Health Service
NHS HEED NHS Economic Evaluations Database
NZGG New Zealand Guidelines Development Group
OFT Office of Fair Trading
OHA Oral Health Assessment
OHR Oral Health Review
OR Odds Ratio
OSMF Oral Submucous fibrosis
PDS Personal Dental Service
PCT Primary Care Trusts
RCT Randomised Control Trial
SHA Strategic Health Authorities
SIGN Scottish Intercollegiate Guideline Network
SIGLE System for Information on Grey Literature in Europe
SOHSI Subjective Oral Health Status Indicators
UK United Kingdom
VT Vocational Trainee
INTRODUCTION 1
1. Introduction
1.1 Background The ‘recall interval debate’ has also coincided with an
Analysis of dental attendance patterns using the important period of change in the NHS dental
Dental Practice Board’s longitudinal data has services in England and Wales, designed to encourage
demonstrated that attendance behaviour in NHS these services to move towards a more preventive-
primary dental care is variable and that many patients oriented and clinically effective way of meeting
attend less frequently than six monthly. However, six patient needs. The strategy document “NHS Dentistry:
monthly dental check-ups have been customary in the Options for Change” (Department of Health 2002)
General Dental Service (GDS) in the United Kingdom and subsequent legislation are bringing about
since the inception of the National Health Service changes in the organisation of dental services, the
(NHS). Although a recall interval of six months is not remuneration of dentists and the way in which oral
explicitly recommended by the NHS, current health is assessed. The new proposed ‘gateway to
regulations implicitly recognise this practice by NHS dentistry’ is through a comprehensive Oral
remunerating dental practitioners for providing six- Health Assessment (OHA). Under the new
monthly check-ups. In addition, registration with an arrangements a comprehensive Oral Health
NHS dentist lapses if the interval between check-ups Assessment will be conducted when a patient first
is greater than 15 months (Davenport et al. 2003). visits a practice and will involve taking full patient
[Note: there are proposals to change the current histories, carrying out thorough dental and head and
registration system from 1st October 2005]. neck examinations and providing initial preventive
advice. The dentist and patient will discuss the
In recent years there has been significant debate over findings and then agree a personalised care plan
the timing of recall intervals for dental check-ups. and a ‘destination’ for this particular journey of care.
In the strategy document ‘Modernising NHS Dentistry The dental team and the patient will then work
– Implementing the NHS Plan’ (Department of through this first personal care plan (see diagram
Health 2000) it was argued that a blanket six- in Appendix A).
monthly recall policy was too rigid and that patients
should be recalled at intervals matching their After an agreed interval the patient will return for an
individual needs more closely. Furthermore, the Oral Health Review (OHR), during which the histories
government explicitly stated its intention to examine and examination will be updated and any changes in
the evidence for changing working practices risk factors noted. The dental team will also assess the
‘including more flexible recall intervals for routine effectiveness of the treatment and preventive advice
examinations, to ensure the most appropriate provided previously, and will give more advice as
treatment and care for patients’ (Department of necessary. The patient and dentist will discuss the
Health 2000). This view has been reiterated in a findings of the review and agree the next, refined,
more recent assessment of primary care dental personalised care plan and a specific ‘destination’ for
services by the Audit Commission, which suggested this new journey of care (see diagram in Appendix A).
that evidence-based criteria should be introduced to
determine the best check-up attendance interval for Taking into account these new arrangements and the
each individual patient (Audit Commission 2002). remit and agreed Scope of this guideline, the term
2 D E N TA L R E C A L L
Oral Health Review (OHR) is used throughout this the individual clinical judgement and expertise of
guideline to refer to the continuing re-examination dental personnel and takes into consideration the
of an individual’s oral health and risk status. values and expectations of patients.
This guideline focuses on providing guidance for
clinicians on assigning recall intervals between The recommendations contained in this guideline are
Oral Health Reviews. intended to assist clinicians in selecting recall
intervals between Oral Health Reviews (OHRs) that
Unfortunately, there is a paucity of reliable scientific are appropriate to the needs of individual patients.
evidence in relation to this area of dental practice. Patients should be informed that a single ‘set’ recall
A report published by the West Midlands Health interval for their entire lives may not be deemed
Technology Assessment Collaboration (hereafter appropriate and that the recall interval may vary over
referred to as the HTA Report) systematically reviewed time to take into account any changes in their level
the effectiveness of routine dental checks of different of risk of or from oral disease.
recall frequencies in adults and children (Davenport et
al. 2003). The authors found limited evidence of poor 1.2 What is a guideline?
overall quality and concluded that there was no high Guidelines are recommendations for the care
quality evidence to either support or refute the of individuals in specific clinical conditions or
current practice of encouraging six-monthly dental circumstances – from prevention and self-care
checks in children and adults. An ‘update’ of this though primary and secondary care to more
review (presented in Chapter Two of this guideline) specialised services. Clinical guidelines are based
also highlights the lack of high quality research to on the best available evidence, and are produced
inform clinical practice on assigning recall intervals. to help health care professionals and patients make
informed choices about appropriate health care.
Further primary research is warranted in order to Guidelines do not replace the knowledge and skills
assess the relative effectiveness of different recall of healthcare professionals – they complement
intervals for dental check-ups. However, in the clinical judgement with the primary objective
absence of such evidence, it has been suggested that of enhancing quality of care.
the period between check-ups should be based on a
professional assessment of an individual patient’s risk Clinical guidelines are based on the best available
of or from oral disease (Health Development Agency evidence and their development is facilitated by the
2001). availability of high quality research. However, it is
often in areas where the evidence is weak or
For many years, it has been argued in the scientific conflicting that guidance for clinicians is most
literature that a risk-based assessment of an needed. When the scientific evidence needed to
individual patient’s dental history and oral health answer key clinical questions is either of poor quality,
status is an important prerequisite for treatment inconsistent or non-existent, recognized methods for
planning and the delivery of appropriate preventive developing consensus can be used by guideline
care and advice. This risk assessment is an important developers to assist in the formulation of
part of contemporary dental practice and is a process recommendations.
that dental professionals typically engage in every
day of their working lives when examining patients, Clinical guidelines for the NHS in England and Wales
albeit in a somewhat informal and intuitive fashion. are produced as a response to a request from the
This guideline capitalises on clinicians’ efforts to Department of Health and the Welsh Assembly
tailor care to meet the needs of patients by Government. They select topics for guideline
advocating the adoption of a formal risk-based development and consult with the relevant patient
procedure for determining recall intervals for bodies, professional organisations and companies
individual patients at a specific point in time. In the before deciding whether to refer a particular topic to
traditions of evidence-based practice, this process the National Institute for Clinical Excellence (NICE) –
incorporates the best available scientific evidence, an organisation independent of government and
INTRODUCTION 3
the Department of Health. Once a topic is referred, loss; and avoiding pain and anxiety have been
NICE then commissions one of seven National considered.
Collaborating Centres to produce a guideline.
The Collaborating Centres are independent of 1.5 What the guideline does not cover
government and comprise partnerships between a This guideline does not consider recall intervals for
variety of academic institutions, health profession routine scale and polish treatments. Although the
bodies and patient groups. The Collaborating Centres provision of a scale and polish following a recall
establish a multidisciplinary Guideline Development examination is common practice in primary dental
Group (GDG) comprising health professionals, lay care settings, the frequency of dental check-ups does
representatives and technical experts. The GDG not have to be directly linked to the frequency of
assesses the evidence available on the guideline scaling and polishing. A systematic review of this
topic and makes recommendations. Consensus area is currently being conducted by the Cochrane
methods may be used by the GDG where the Oral Health Group (COHG).
available evidence is of limited quantity and quality.
The guideline does not cover the prescription and
1.3 Remit of the Guideline timing of dental radiographs. Guidance on selection
The following remit was received from the criteria for dental radiographs has been developed in
Department of Health and the Welsh Assembly the UK by the Faculty of General Dental Practitioners
Government in May 2002 as part of the Institute’s (Faculty of General Dental Practitioners 2004).
7th wave programme of work:
The guideline does not cover intervals between
“To prepare guidance for the NHS in England and
dental examinations that are not routine dental
Wales on the clinical and cost-effectiveness of a
recalls; that is, intervals between examinations
dental recall examination for all patients at an
related to ongoing courses of treatment, or part
interval based on the risk from oral disease”
of current dental interventions.
The recommendations in this guideline were arrived
at following careful consideration of the available The guideline does not cover emergency dental
evidence. Where the scientific evidence needed to interventions, or intervals between episodes of
answer key clinical questions was either of poor specialist care.
quality, inconsistent or non-existent, recognised
methods for developing consensus were used. Finally, although this guidance is focussed at the
level of the individual patient, it is important that
1.4 What the guideline covers efforts should continue to promote broader
The guideline includes recommendations for patients population-based strategies for preventing dental
of all ages (both dentate and edentulous patients) disease and improving oral health, an area outside
and covers primary care received from NHS dental the scope for this guideline.
staff (dentists, independent contractors contracting
within the NHS, dental hygienists and therapists) 1.6 Who developed the guideline?
practising in England and Wales. The guideline takes A multidisciplinary Guideline Development Group
into account the potential of the patient and the (GDG) comprising professional group members
dental team to improve or maintain the quality of (including several practising dentists) and consumer
life and to reduce morbidity associated with oral representatives of the main stakeholders developed
and dental disease. this guideline (see Acknowledgements). The National
Institute for Clinical Excellence funds the National
In arriving at recommendations, the impact of dental Collaborating Centre for Acute Care and thus
checks on patients’ well-being, general health and supported the development of this guideline. The
preventive habits; caries incidence and avoiding GDG was convened by the National Collaborating
restorations; periodontal health and avoiding tooth Centre for Acute Care (NCC-AC) and Chaired by
Professor Nigel Pitts. In accordance with the NICE
guideline development process (National Institute for 1.7.2 Questions addressed in developing the
Clinical Excellence 2001), all guideline development guideline
group members have made and updated any The GDG established that, for the purposes of
declarations of interest. The Group met on a monthly developing the guideline, two groups of questions
basis during development of the guideline. would need to be examined: key clinical questions
specifying the populations, interventions,
Staff from the NCC-AC, the COHG (Manchester), and comparisons and outcomes of interest; and
the Oral Health Services Research Centre (University background and epidemiology questions including:
College Cork, Ireland) provided methodological rate of progression of oral diseases, advice and
support and guidance for the development process, preventive measures against oral diseases and
undertook systematic searches, retrieval and patient views and expectations of their dentist and
appraisal of the evidence and drafted the guideline. dental treatment. Please see Appendix B for a full
Staff were also assisted by the Director of the list of these questions.
International Centre for Evidence-Based Periodontal
Health at the Eastman Dental Institute, University KEY CLINICAL QUESTIONS
College London.
In relation to the key clinical questions, an update
of the HTA Report was undertaken. The aim of this
The Glossary to the guideline contains definitions
update was to review any additional evidence
of terms used by staff and the GDG.
published between February 2001 (the date of
completion of the HTA search) and July 2003 (the
1.7 Guideline Methodology
date of completion of NCC-AC search) judged to
be of relevance in addressing the original questions
1.7.1 Outline of methods used
posed in the HTA review, namely:
There were several steps involved in the development
of these guidelines: (a) How effective are routine dental checks of
different recall frequencies in improving quality
> Systematic review of the literature – to ‘update’
of life and reducing the morbidity associated
the previous Health Technology Assessment
with dental caries and periodontal disease in
review on the clinical effectiveness and cost-
children?
effectiveness of routine dental checks
(Davenport et al. 2003) (b) How effective are routine dental checks of
different recall frequencies in improving quality
> Review of background literature relating to oral
of life, reducing the morbidity associated with
diseases, patient views and the effectiveness of
dental caries, periodontal disease and oral
oral health promotion. Modelling of cost-
cancer, and reducing the mortality associated
effectiveness of different recall intervals
with oral cancer in adults?
> Use of formal and informal consensus methods
The updated review sought to replicate the methods
for a variety of tasks, including clarifying
adopted in the original HTA review. In this context,
questions addressed by the guideline and
similar study populations, interventions, comparators
making guideline recommendations
and outcomes of interest were specified.
> The Guideline Development Group found that
the scientific evidence in relation to many
aspects of dental recall intervals was weak and
conflicting. However, there was evidence relating
to risk factors for oral disease and evidence on
the effectiveness of dental health education and
oral health promotion that was used to inform
the guideline recommendations.
INTRODUCTION 5
1.7.3 Systematic Review Methods for Key Clinical TYPES OF STUDIES
Questions There was no restriction on study design and all

observational epidemiological study designs were
TYPES OF STUDY POPULATION
included.
The populations considered (in both the HTA Report
and our updated review) were children and adults. LITERATURE SEARCH
These populations were further sub-divided according The literature review for our guideline was designed
to dentition type: deciduous dentition, mixed to find references published since the completion
dentition, permanent dentition and edentulous. of searching for the HTA Report in February 2001.
The updated review explicitly recognised edentulous The search terms used in the HTA Report and some
patients as a population category. additional key words were used to form the basis
of the search strategy. Search filters for systematic
TYPES OF INTERVENTIONS
reviews, randomised controlled trials and other
The intervention considered was a ‘routine dental observational studies were combined with this to
check’ as defined in the NHS General Dental Service retrieve quality studies. No language restrictions were
Statement of Remuneration: “Clinical examination, applied to the search. The search strategies of the
advice charting (including monitoring of periodontal following databases are included in Appendix C.
status) and report.” In practice it proved impossible
> Medline (Ovid) 2001 – 17 July 2003
to apply the intervention inclusion criteria (in both
the HTA Report and our updated reviews) as no > Embase (Ovid) 2001 – week 29 2003
identified publications provided sufficient detail
> The Cochrane Library 2001 up to Issue 3, 2003
about the intervention under study. Studies were
therefore included if the intervention was termed a We searched the System for Information on Grey
‘dental check,’ a ‘dental examination,’ a ‘dental visit’ Literature in Europe (SIGLE) and Health Management
or a ‘dental attendance.’ In describing the results of Information Consortium (HMIC) for reports, and we
this updated review the term ‘dental check’ has been searched for guidelines and consensus documents on
used throughout to embrace these different terms. the guideline web sites listed below. Bibliographies
of identified reports and guidelines were also
TYPES OF COMPARATORS
checked to identify relevant literature.
The comparator was ‘no routine dental check’ (as
> Canadian Medical Association Infobase
defined above) or routine dental check of different (http://mdm.ca/cpgsnew/cpgs/)
frequency.
> National Institute of Clinical Excellence (NICE)
TYPES OF OUTCOMES (http://www.nice.org.uk)
The outcomes of interest were divided into: > National electronic Library for Health (NeLH)
(http://www.nelh.nhs.uk/)
> Primary Outcomes: Caries, periodontal disease,
oral cancer and quality of life > National Institutes of Health Consensus
Development Program
> Secondary Outcomes: Mucosal lesions, behaviour (http://www.consensus.nih.gov)
change, need for orthodontic treatment.
> New Zealand Guidelines Development Group
In the updated review, erosion and tooth surface loss (NZGG) (http://www.nzgg.org.nz/)
were included as secondary outcomes of interest.
> Scottish Intercollegiate Guideline Network
However, we found no relevant studies that reported (SIGN) (http://www.sign.ac.uk)
these particular outcome measures.
> US National Guideline Clearing House
(http://www.guidelines.gov)
SELECTING STUDIES Collaborating Centres to use the system for evidence

shown in Table 1.
Two reviewers independently scanned the titles and
abstracts of the observational studies in order to
identify potentially relevant studies. They excluded
TABLE 1: Levels of evidence for intervention
papers that were considered definitely irrelevant. studies*
We obtained full publications for any studies
LEVEL OF
identified by one or both reviewers as being of
EVIDENCE TYPE OF EVIDENCE
potential relevance to the review or where there was
insufficient information from the title and abstract
1++ High-quality meta-analyses, systematic
to make a decision. Two reviewers applied the
reviews of RCTs, or RCTs with a very low
inclusion criteria to all potentially relevant studies
risk of bias
and any disagreements were resolved by discussion.
No formal analysis of agreement between the 1+ Well-conducted meta-analyses, systematic
reviewers was performed. reviews of RCTs, or RCTs with a low risk
of bias
DATA EXTRACTION
1- Meta-analyses, systematic reviews of RCTs,
One reviewer carried out the data extraction process. or RCTs with a high risk of bias
Data extracted from each study regarding the patient
2++ High-quality systematic reviews of case-
population, intervention, comparators and outcomes
control or cohort studies
were used to construct two summary tables: a ‘Key
Study Characteristics’ table and an ‘Effectiveness High-quality case-control or cohort studies
table’ (Appendix D). with a very low risk of confounding, bias
or chance and a high probability that the
QUALITY ASSESSMENT relationship is causal
Two reviewers carried out the quality assessment of 2+ Well-conducted case-control or cohort
eligible studies using similar appraisal checklists to studies with a low risk of confounding,
those used in the HTA Report (Davenport et al. bias or chance and a moderate probability
2003). The checklists were specific to study design that the relationship is causal
with a view to capturing design-specific biases.
2- Case-control or cohort studies with a high
Attempts to control for selection biases through
risk of confounding bias or chance and a
adjustment for potential confounders were assessed.
significant risk that the relationship is not
causal
As this guideline is intended to inform practice in the
NHS in England and Wales, the external validity of 3 Non-analytic studies (for example, case
the results of studies carried out in settings other reports, case series)
than the UK was also considered as part of the
4 Expert opinion, formal consensus
assessment.
*Reproduced with kind permission of the Scottish Intercollegiate
1.7.4 Hierarchy of evidence Guidelines Network
There are many different methods of ranking the

evidence and there has been considerable debate
1.7.5 Health economics methods
about what system is best. A number of initiatives
It is important to investigate whether dental health
are currently under way to find an international
services are clinically effective and also cost-effective
consensus on the subject, but until a decision is
(that is, provide value for money). If, hypothetically,
reached on the most appropriate system, for the
frequent Oral Health Reviews (OHRs) were found to
NICE guidelines the Institute advises the National
yield little health gain, relative to the resources used,
then we would be better off by having less frequent
INTRODUCTION 7
OHRs and re-deploying resources to other activities > the outcome used for health gain in dental
that yield greater health gain. caries prevention (in the model for adults it was
number of DMFT-free teeth at age 80) was not
LITERATURE REVIEW ideal.
We obtained published economic evidence on

On the basis of this guideline’s systematic review
different recall intervals for OHR from a systematic
a modified model was constructed that would
search of the following databases:
improve on limitations one and three. However,
> Medline (Ovid) (2001-2003) the incorporation of other aspects of oral health
(limitation two) was not possible because of the lack
> Embase (2001-2003)
of suitable data and also the absence of an overall
> Health Economic Evaluations Database (HEED) measure of health outcome.
> NHS Economic Evaluations Database (NHS EED)
1.7.6 Forming and grading the recommendations

We also identified and reviewed relevant references
NICE guideline recommendations are graded
in the bibliographies of reviewed papers including
according to the strength of the supporting evidence,
those from the HTA Report. We did not conduct
which is assessed from the design of each study
original searches of Medline and Embase prior to
(see Table 1). The grading system currently used is
2001 as this would duplicate the systematic searches
presented in Table 2.
of the HTA Report.
The Guideline Development Group was presented

The strategy was designed to find any applied
with the summaries (text and evidence tables) of
economic study related to different dental recall
the best available research evidence to answer their
intervals. The health economist reviewed abstracts
questions. Recommendations were based on, and
and database reviews of papers, and discarded those
explicitly linked to, the evidence that supported
that appeared not to contain any original data on
them.
cost or cost-effectiveness and where the analysis was
not incremental (and was not described adequately
The Group worked, where possible, on an informal
to allow incremental analysis).
consensus basis. Formal consensus methods
(modified Delphi techniques or nominal group
COST-EFFECTIVENESS MODELLING
technique) were employed if required (for example,
The cost-effectiveness analysis contained in the HTA agreeing recommendations and audit criteria). The
Report was the most relevant to this guideline recommendations were then graded according to
because it estimated both incremental cost and the level of evidence upon which they were based.
incremental health gain for a number of different
recall intervals from a UK NHS perspective. The
model represented a promising start to research in
this area, but it did have three major limitations:
> the report does not state what assumptions/

data were used in the model that would lead
to oral health being greater with narrower recall
intervals
> it considered only dental caries prevention and

no other aspects of oral health
TABLE 2: Grading of recommendations**

GRADE EVIDENCE
A > At least one meta-analysis, systematic

review, or RCT rated as 1++, and
directly applicable to the target
population, or
> A systematic review of RCTs or a body

of evidence consisting principally of
studies rated as 1+, directly applicable
to the target population, and
demonstrating overall consistency of
results
B > A body of evidence including studies

rated as 2++, directly applicable to the
target population, and demonstrating
overall consistency of results, or
> Extrapolated evidence from studies

rated as 1++ or 1+
C > A body of evidence including studies

rated as 2+, directly applicable to the
target population and demonstrating
overall consistency of results, or

rated as 2++
D > Evidence level 3 or 4, or

rated as 2+, or
> Formal consensus
(GPP) A good practice point (GPP) is a

recommendation for best practice based
on the clinical experience of the Guideline
Development Group
**Adapted with kind permission of the Scottish Intercollegiate
Guidelines Network
C L I N I C A L E F F E C T I V E N E S S A N D C O S T- E F F E C T I V E N E S S O F RO U T I N E D E N TA L C H E C K S ( H TA U P DAT E ) 9
2. Clinical effectiveness and

cost-effectiveness of routine
dental checks (HTA update)
In order to inform the guideline development 2.1 Characteristics of the Included Studies
process, the GDG decided that it was essential to
identify and assess systematically the evidence for 2.1.1 Characteristics of the study settings and
the clinical effectiveness of routine dental checks of study design
different recall frequencies. As a systematic review See Appendix D for further details.
addressing this issue had recently been carried out
and published as a Health Technology Assessment Thirteen studies were included in our updated review.
(HTA) Report (Davenport et al. 2003), it was decided Of these, there were three cohort/longitudinal
that an ‘update’ of this Report should be undertaken. studies (Chavers et al. 2002; Locker 2001; Thomson
The aim of this exercise was to review any additional 2001), two case-control studies (Bullock et al. 2001;
evidence published since the date of completion of Lissowska et al. 2003), seven cross-sectional studies
the HTA search judged to be of relevance in (Boehmer et al. 2001; Campus et al. 2001; Carvalho
addressing the original clinical effectiveness et al. 2001; Freire et al. 2002; Petersen et al. 2001;
questions posed in the HTA Report, namely: Ugur et al. 2002; Ullah et al. 2002) and one study
that was described by the authors as a ‘case study,’
How effective are routine dental checks of different based on consecutive patients’ responses to a dental
recall frequencies in improving quality of life and health questionnaire administered over a six month
reducing the morbidity associated with dental caries period (Richards et al. 2002).
and periodontal disease in children?
The included studies were conducted in a variety of
How effective are routine dental checks of different different populations and settings. Only two studies
recall frequencies in improving quality of life, (Bullock et al. 2001; Richards et al. 2002) were
reducing the morbidity associated with dental caries, conducted in general dental practice settings in
periodontal disease and oral cancer, and reducing England and Wales. One of these studies (Bullock
the mortality associated with oral cancer in adults? et al. 2001) was conducted in a mixed private/NHS
practice in Stoke-on-Trent, North Staffordshire. The
The updated review sought to replicate the methods other study (Richards et al. 2002) was conducted in
adopted in the HTA Report. In this context, similar a general dental practice in an urban area of
study populations, interventions, comparators and Swansea, South Wales.
outcomes of interest were specified. The methods
used are described in chapter one. Of the remaining studies, four were conducted in
European countries (Campus et al. 2001; Carvalho
et al. 2001; Lissowska et al. 2003; Ugur et al. 2002),
two in the United States (Boehmer et al. 2001;
Chavers et al. 2002), one in Brazil (Freire et al.
2002), one in Canada (Locker 2001), one in
Southern Thailand (Petersen et al. 2001), one in
New Zealand (Thomson 2001) and one in participants varied in age from 13 (Ugur et al. 2002)
Bangladesh (Ullah et al. 2002). to 80 (Lissowska et al. 2003) years. All the studies
found looked at people with permanent dentition.
Ten studies used a ‘subjective’ measure of dental
check frequency and relied on reported attendance Access to dental care for the population under
by participants, obtained either from self- investigation was not stated in eight studies
administered questionnaires, questionnaires (Boehmer et al. 2001; Chavers et al. 2002; Freire
completed by parents/guardians or structured et al. 2002; Lissowska et al. 2003; Locker 2001;
interviews (Boehmer et al. 2001, Campus et al. 2001, Petersen et al. 2001; Ugur et al. 2002; Ullah et al.
Carvalho et al. 2001, Chavers et al. 2002, Freire et al. 2002). In only two studies (Bullock et al. 2001;
2002, Lissowska et al. 2003, Petersen et al. 2001, Richards et al. 2002) could the participants and
Thomson 2001, Ugur et al. 2002, Ullah et al. 2001). settings be assumed to be representative of the
Only three studies used an ‘objective’ measure of population groups and health care settings covered
dental check frequency and directly consulted clinical by this guideline. In both studies, participants were
records to provide evidence of frequency of dental recruited opportunistically as they presented
checks or gleaned information on patients’ themselves at general dental practices. In the
attendance patterns from their dentists (Bullock et al. remaining studies where access was described
2001; Locker 2001; Richards et al. 2002). (Campus et al. 2001; Carvalho et al. 2001; Thomson
2001), the dental health-care system was not
2.1.2 Characteristics of the Participants comparable with that in England and Wales.
See Appendix D for further details.
2.1.3 Characteristics of the Intervention and
The effects of dental check frequency were examined Comparisons
in a diverse range of age groups. The most common There was little information included in the studies
age group considered was 12-year olds, who formed on what a ‘dental check’ actually entailed (or could
the study population in four studies (Campus et al. be presumed to entail). In most studies it was not
2001; Carvalho et al. 2001; Petersen et al. 2001; clear whether the relationship between frequency of
Ullah et al. 2002). In the remaining studies the dental checks or frequency of dental treatment
TABLE 3: Comparisons between ‘regular’ and ‘irregular’ attenders made in selected studies from the
‘updated’ HTA review
STUDY ID “REGULAR ATTENDERS” “IRREGULAR ATTENDERS”
Bullock and co- Attended for at least two dental examinations No dental attendance in past two years and
workers, 2001 in past two years (‘regular attender’) who had attended in response to a dental
problem (‘casual attender’)
Chavers and co- Respondent described approach to dental care Respondent described approach to dental care
workers, 2002 as “I go to a dentist occasionally, whether or as “I never go to a dentist” or “I go to a dentist
not I have a problem” or “I go to a dentist when I have a problem or I know I need to get
regularly” something fixed”
Richards and Last attendance within the last two years Last attendance more than two years ago
Ameen, 2002
Ugur and Respondents reported regular visits every year Respondents reported only going to the dentist
Gaengler, 2002 to have their teeth examined if there was a ‘tooth problem’
Ullah and co- Respondent reported visiting the dentist more Respondent reported visiting the dentist less
workers, 2002 than once a year than once a year
and/or dental checks and oral health outcomes was in measures. A minority of studies reported changes
being investigated. Where ‘dental visiting’ or ‘dental in the proportion or number of individuals exhibiting
attendance’ patterns were being studied it proved a certain outcome.
impossible to distinguish between prevention
oriented/motivated visits (for asymptomatic check- 2.1.5 Quality Assessment
up) and treatment oriented/motivated visits for a We assessed the 13 included studies for internal and
specific problem, infection etc. external validity. There was a preponderance of cross-
sectional studies included in the updated review that
There was a diverse range of comparisons made in are particularly susceptible to selection biases and
the included studies. The most common comparison confounding. The quality assessment of all studies
made in studies was between the oral health status focused on various potential sources of bias,
of ‘regular’ and ‘irregular’ attenders. However, specifically selection bias, performance bias, attrition
different studies used different definitions of what bias and measurement bias. All of the included
was deemed to be ‘regular’ or ‘irregular’ attendance. studies were judged as having some threat to validity.
The diversity of some of these definitions are
illustrated in Table 3 opposite. 2.1.6 Data synthesis and analysis
We deemed quantitative pooling as inappropriate
The ‘irregular’ category was thus used to encapsulate due to the considerable methodological and clinical
‘casual’ or ‘problem-oriented attenders.’ The differing heterogeneity of the 13 studies included in this
definitions of regular and irregular attendance used updated review. The problems with defining the
in the studies constituted another source of intervention, the range of dental check frequencies
heterogeneity making comparisons between studies studied, the diverse comparisons made and the range
difficult. of outcome measures used, precluded the provision
of anything other than a narrative summary of the
See Appendix D for details of the comparisons made findings. No sensitivity analysis was undertaken in
in the remaining included studies. this updated review.
2.1.4 Outcomes 2.2 Results

The 13 studies reported a diversity of clinical status In order to interpret the results of this updated
outcomes for dental caries, periodontal disease and review, the included studies must be considered in
oral cancer, including: mean number of teeth present, the context of the 28 studies included in the HTA
mean DMFS (Decayed Missing Filled Surfaces), mean Report (Davenport et al. 2003). In the sections that
DFS (Decayed Filled Surfaces) increment, mean DMFT follow, the results of the HTA Report are first
(Decayed Missing Filled Teeth), decayed coronal summarised narratively, the results of the updated
surfaces, root caries, caries severity, dentinal caries on review are then presented and a brief commentary
bitewing radiography, visual caries causing is added as to whether the latter results have any
cavitation, periodontal treatment need, presence or impact on the conclusions of the former. The
absence of mobile teeth, oral hygiene, mean number updated review only found studies concerning
of periodontally involved teeth, plaque scores, permanent teeth, consequently, the results are
mucosa scores, oral cavity and pharynx cancer. compared with the HTA Report results for permanent
Three studies used oral health related quality of life teeth only. Due to the considerable study
outcome measures (Chavers et al. 2002; Locker heterogeneity, emphasis has been placed on the
2001; Richards et al. 2002). consistency of the direction of outcome of study
results. There are obvious limitations associated with
Although a number of studies used the same presenting the results of studies in this manner.
outcome measures, because of poor reporting, it In particular, it fails to reflect important differences
could not be assumed that the diagnostic criteria between studies such as the different frequencies
used in the studies were the same. The majority of being compared for each single outcome and does
studies reported outcomes in terms of mean changes not take into account salient aspects of study design.
Nevertheless, such an approach can be used to with a decrease in dental check frequency
summarise results of a group of observational studies (Davenport et al. 2003).
and gives some indication (albeit a crude indication)
of the consistency or lack of consistency of results. 2.2.2 Outcome Measure: DMFT/DMFS
Where the term ‘significant’ has been used in the RESULTS OF THE ORIGINAL HTA REPORT
following passages, it pertains only to the question

Eleven studies investigating the relationship
of statistical significance and does not allude to the
between dental check frequency and DMFT
clinical significance or otherwise of the findings.
reported inconsistent findings. Two studies reported
a significant increase in DMFT or DMFS with a
2.2.1 Outcome Measure: Number of teeth present
decrease in dental check frequency. Four reported a
decrease in DMFT with a decrease in dental check
RESULTS OF THE ORIGINAL HTA REPORT
frequency (two of which were significant differences)
Sixteen studies investigated the relationship between and two were of uncertain significance. Five studies
dental check frequency and number of teeth present. reported no significant difference between DMFT
No study reported an increase in the number of teeth and frequency of dental attendance.
with a decrease in dental check frequency. Twelve
studies reported a decrease in the number of teeth RESULTS OF UPDATED REVIEW
with a decrease in dental check frequency (eight of

One study (Campus et al. 2001) reported no
which were significant differences), one study
significant difference in DMFS scores according to
reported an increase in the number of individuals
dental check frequency (see list above for
who became edentulous over a 10 year follow up
comparisons made), while another (Carvalho et al.
period but the result was of uncertain statistical
2001) reported a significant increase in mean DMFS
significance and three studies reported no significant
score in symptomatic (appointment on pain) versus
difference between the number of teeth/surfaces
asymptomatic attenders. The latter study reported no
and frequency of dental checks. (The term ‘uncertain
significant differences between those who reported a
statistical significance’ was used in the HTA Report
control visit once a year versus those who did not
where tests of statistical significance were not
report a control visit once a year.
performed in individual studies and could not be
calculated from available data.)
Petersen and co-workers reported a significant
increase in mean DMFT in those who reported an
RESULTS OF UPDATED REVIEW
annual dental visit versus those who reported no
The three studies reporting the mean number of annual dental visit (Petersen et al. 2001), while
teeth present demonstrated no consistency in the Thomson reported that problem-oriented attenders
direction of outcomes. One study (Boehmer et al. had significantly higher mean DMFS and DFS
2001) reported a significant decrease in the number increment scores compared with those who attended
of teeth with a decrease in dental check frequency. for a check-up (Thomson 2001).
One study (Bullock et al. 2001) reported no
difference in the number of teeth present according Finally, one study reported no significant difference in
to dental check frequency. One study (Richards et al. mean DMFT comparing regular (more than once a
2002) reported a significant increase in the number year) versus irregular (less than once a year) attenders
of teeth with a decrease in dental check frequency. (Ullah et al. 2002). However, those who attended a
dentist either regularly or irregularly, had significantly
These studies, when considered in the context of the higher mean DMFT scores compared with those who
results of the HTA review, do not impact on the reported never having attended a dentist.
overall consistency of findings, namely that there was
generally a decrease in the number of teeth present
2.2.3 Outcome Measure: Decayed Teeth (DT)/ 2.2.4 Outcome Measure: Filled Teeth (FT)
Decayed Surfaces (DS)

The studies investigating the relationship between
Fifteen studies investigated the relationship between dental check frequency and filled teeth reported
dental check frequency and decay. Twelve reported inconsistent findings. Six studies reported a decrease
an increase in decay with a decrease in dental check in filled teeth/surfaces with a decrease in dental
frequency (eight of which were significant differences check frequency of which five out of six were
and four of which were of uncertain significance). significant differences. Three studies reported no
Two studies reported no significant difference significant difference between filled teeth/surfaces
between decay and frequency of dental checks. and frequency of dental checks.
One study reported a significant association between
dental check frequency and decay but the direction RESULTS OF UPDATED REVIEW
of the relationship was not given.

One study reported no significant difference in the
mean number of filled surfaces in the four dental
RESULTS OF UPDATED REVIEW: DENTAL CARIES
check frequency groups compared (Campus et al.
There was no consistency in the direction of outcomes 2001) (see Appendix D for details of comparisons
in the four studies using these outcome measures. made), while another reported that irregular attenders
had significantly fewer filled teeth when compared
One study reported no significant difference in the with regular attenders (Ugur et al. 2002) (see Table 3
mean number of decayed coronal surfaces for definitions of ‘regular’ and ‘irregular’).
(comparing those who attended during last year with
those who attended between one and two years ago) 2.2.5 Other caries outcome measures used in our
(Boehmer et al. 2001). However, both of the latter updated review
groups had significantly fewer decayed coronal
surfaces compared with those who reported a last ROOT CARIES
visit as two or more years ago.

One study reported significantly fewer untreated root
caries lesions in those who reported attending the
One study reported no significant difference in the
dentist during the last year compared with those who
mean number of decayed surfaces according to
attended between one and two years ago and two or
dental check frequency across the four dental check
more years ago (Boehmer et al. 2001).
frequency groups compared (Campus et al. 2001)
(Appendix D for details of comparisons made) whilst
There were no significant differences in the mean
another study reported a significant increase in the
number of untreated plus filled root caries lesions
number of decayed teeth with a decrease in the
according to dental check frequency.
dental check frequency (Ugur et al. 2002).
MISSING TEETH
One study reported no significant differences in the
mean number of decayed teeth between regular and One study found a significantly higher proportion
irregular attenders (Ullah et al. 2002). However, of ‘problem-oriented attenders’ had more than one
those who reported attending either regularly or missing tooth due to caries by age 26 compared with
irregularly had significantly more decayed teeth ‘routine attenders’ (Thomson 2001) (see ‘Appendix D
compared to whose who never attended a dentist for details of comparisons made). Similarly, Ugur and
(see Table 3 above for definitions of ‘regular’ and Gaengler reported significantly fewer missing teeth
‘irregular’ used in this study). in regular attenders compared with irregular
attenders (Ugur et al. 2002).
VISUAL CARIES CAUSING CAVITATION Three studies investigated the relationship between
plaque or calculus and dental check frequency and
One case-control study, comparing regular attenders
reported no consistency in the direction of outcomes.
with casual attenders, reported a significant increase
Two studies investigated the relationship between
in the proportion of subjects with visual caries
bone score and dental check frequency and reported
causing cavitation with a decrease in dental check
no consistency in the direction of outcomes. Three
frequency (Bullock et al. 2001). The same study
studies investigated the relationship between the
reported a significant increase in the proportion of
presence of gingivitis and frequency of dental checks
subjects with dentinal caries on bite-wing
and reported no consistency in the direction of
radiographs with a decrease in dental check
outcomes. Three studies investigated the relationship
frequency. These differences persisted after adjusting
between dental check frequency and periodontal
for age, gender, social class and smoking.
health (the absence of gingivitis, periodontitis and
calculus) and reported no consistency in the direction
CARIES SEVERITY
of outcomes.
One study reported an increased risk of having a high
caries severity among those who attended the dentist RESULTS OF OUR UPDATED REVIEW
mainly when in trouble compared with those
One study reported a significantly increased mean
attending mainly for check-ups (Freire et al. 2002).
periodontal treatment need for those who reported
Adolescents who reported never being to the dentist
time since last dental visit as between one to two
had a lower risk of high caries severity compared with
years ago, when compared with those who reported
those attending mainly for check-ups, although the
a visit during the last year (Boehmer et al. 2001).
numbers reporting no dental visits was very small.
No significant difference in periodontal treatment
need was found in this study when comparing those
Considering all dental caries outcomes included in
who reported their last dental visit between one and
the updated review in the context of the original
two years ago and those who reported that their last
HTA Report findings, there is no consistency in the
visit was two or more years ago.
direction of outcomes and no meaningful inferences
can be drawn from the available data.
Bullock and co-workers reported that a significantly
greater proportion of casual attenders had >30%
2.2.6 Periodontal Disease Outcomes
tooth bone loss and mobile teeth compared with
regular attenders (see Table 3.1 above for definitions
of ‘regular’ and ‘casual’) (Bullock et al. 2001) while
Nine observational studies investigated the Thomson reported a significant increase in mean
relationship between dental check frequency and plaque score in problem attenders versus those who
periodontal disease in the permanent dentition. reported that their usual reason for attending the
The main findings are as follows: dentist was for a check-up (Thomson 2001). One
study reported that irregular attenders had
Three studies investigating the relationship between significantly more periodontally involved teeth
dental check frequency and bleeding reported no compared with regular attenders (Ugur et al. 2002).
consistency in the direction of outcomes. One study
investigated the relationship between attachment Two studies, using different measures of periodontal
level and dental check frequency and reported a disease, found no difference in outcomes with
significant decrease in the proportion of individuals varying dental check frequency (Campus et al. 2001;
with an attachment level of >3mm with an overall Ullah et al. 2002).
decrease in dental check frequency. Six studies
investigated the relationship between probing In the updated review a number of studies used
depth/pockets and dental check frequency and different outcomes to those included in the original
reported no consistency in the direction of outcomes. HTA review. There was no consistency in the direction
of outcomes.
Considering these results in the context of the original increased frequency of dental checks and a perception
results of the HTA review does not alter the principal that oral health positively or negatively affects quality
finding of the latter, namely that the results of studies of life. However, there were no studies identified
investigating the relationship between dental check linking empirical measures of quality of life associated
frequency and measures of periodontal disease in with oral health and dental check frequency.
permanent dentition provide conflicting results.
RESULTS OF THE UPDATED REVIEW
2.2.7 Oral Cancer

In our update, we identified three studies all using
different measures of quality of life as it pertains to
oral health (‘oral disadvantage,’ ‘oral health self-rating’
One study demonstrated a significant relationship and ‘subjective oral health status indicators’. In one
between time since last dental check and tumour size study it was reported that those making one or more
at diagnosis, but it remained unclear whether there dental visits over the three year period of the study
was a consistent (or linear) trend in outcome with were more likely to report that their oral health had
decreasing dental check frequency. One study found improved when compared with those making no visits
no significant relationship between the presence or (‘oral health self-rating’) (Locker 2001). In another
absence of a cancerous or potentially malignant study, Richards and Ameen reported that ‘regular
lesion at examination and time since last dental attenders’ had significantly improved oral health
check (< or = 12 months to >12 months). related quality of life (measure of oral health derived
from the Subjective Oral Health Status Indicators
RESULTS OF THE UPDATED REVIEW (SOHSI) compared with ‘irregular attenders’ (Richards
et al. 2002). In the final study regular attenders
One case control study found a significant association
reported significantly lower rates of oral disadvantage
of risk with frequency of dental check-ups (Lissowska
due to disease/tissue damage and function compared
et al. 2003). Subjects who never had dental check-ups
with irregular attenders (Chavers et al. 2002). There
had an oral cancer risk almost 12 times elevated
was no significant difference in oral disadvantage due
(Odds Ratio (OR) 11.89) compared with subjects
to pain between regular and irregular attenders.
visiting a dentist at least every year for a check-up.
There was a wide confidence interval reported around
2.3 Cost-effectiveness
this estimate (3.33 – 42.51). The reported Odds Ratios
A health economist identified and reviewed a total
and confidence intervals for a) subjects who attended
of 351 abstracts. Sixty papers were ordered and five
for a dental check every two-five years and b) subjects
economic studies on different recall intervals for OHR
who attended for a dental check less than once every
were selected (Davenport et al. 2003; Dawson et al.
5 years were 1.94 (0.7 – 5.34) and 4.67 (1.56 – 14.01)
1992; Lunder 1994; Wang et al. 1992; Wang et al.
respectively. The odds of oral cancer thus increased as
1995). Four of these studies were reviewed in the
the frequency of dental check-ups decreased.
HTA Report and the other was an economic model
developed for the HTA Report itself.
2.2.8 Quality of Life
The model reported in the HTA Report (Davenport et al.

2003) was unique in each of the following respects:
One study investigated the relationship between
> It explicitly evaluated a range of different recall
dental check frequency and quality of life. No
intervals
significant relationship was demonstrated between
frequency of dental checks and a perception that oral > It was an incremental cost-effectiveness analysis
health negatively affects quality of life. A significant (it estimated both health gain and resource cost
relationship was demonstrated between increased for each recall interval)
frequency of dental checks and a perception that oral
> It had a UK NHS setting and considered a broad
health positively affects quality of life, and between
range of patients.
The other studies analysed resource implications of conjecture. The results were not sensitive to changes
various intervals for dental check-ups. Table 4 and in hazard rate and restoration survival rate. However,
Table 5 show the methodological summaries and not all model parameters were tested in the
results of these studies. sensitivity analysis – the biggest omission being the
clinical effectiveness of dental check-ups, an
2.3.1 The HTA Report model assumption that was not made explicit in the report.
The HTA Report model aimed to assess the cost-
effectiveness of 3, 6, 12, 18, 24 and 36 monthly The model had the following limitations:
routine dental checks. Cohort simulations (Markov
> The report incorporated only dental caries and
models) were constructed to estimate for each recall
not periodontal diseases and mucosal
interval:
abnormalities. (Patients with mixed-dentition
> The total cost of OHRs and the cost associated and edentate patients were also omitted.
with the treatment of decay (filling deciduous Different risk factors other than social class and
and permanent dentition) per patient water fluoridation were not taken into account).
> and number of teeth free from decay, extraction > The assumptions about the effectiveness of
or fillings for deciduous teeth (dmft) and dental check-ups were not explicit, (that is, no
permanent teeth (DMFT). mention was made of sensitivity and specificity
of dentists’ identifying enamel caries nor of the
Separate models were constructed for a cohort effectiveness of prevention).
between the ages of one and six and for another
> The outcome measure DMFT at the end of the
cohort between the ages of 12 and 80. Separate
model simulation does not fully incorporate the
analyses were undertaken for different risk subgroups
health gain associated with caries prevention
according to socio-economic background (manual
and treatment.
versus non-manual) and water fluoridation. For each
risk group, the outcome of the model was cost per > The calculation of the cost of treatment was
tooth free from decay, fillings or extraction at the restricted to the cost of OHR and fillings. The
end of the model simulation. cost of radiography, scaling and polishing,
extractions, crowns, bridges, etc. were not
They defined the risk factor group included.
manual/nonfluoridated as the base case. For the
> Although, the model suggests that reduced
base case analysis, the rate of progression of decay
dental recall intervals are not good value for
experience (from DMF-free to DMF) is 0.3 teeth per
money, the outcome measure chosen does not
year in deciduous dentition and 0.37 teeth per year
allow comparison with a standard threshold or
in permanent dentition. Caries progression was
with other studies. Hence, it can’t be concluded
assumed to be 14.6% lower in fluoridated areas and
which interval is optimal in terms of cost-
20.7% lower for non-manual socio-economic groups.
effectiveness.
They found that, as the recall interval decreases,

2.3.2 Other studies
overall costs are increased but there are more DMF-
One cost analysis (Dawson et al. 1992) and three
free teeth. The increased effectiveness was highest in
resource impact analyses (Lunder 1994; Wang et al.
non-fluoridated and manual socio-economic classes.
1992; Wang et al. 1995) were selected for tabulation
As recall intervals moved step by step from 36
(Table 4 andTable 5). All four had been reported in
months to three months the incremental cost per
the HTA Report.
additional dmf-free tooth gained became greater and
greater. Moving from six months to three months
According to the results of Dawson and Smales
intervals was considered to be not cost-effective,
(Dawson et al. 1992), extending recall intervals
however given that the threshold of cost per DMF-
reduced the number of restorations received and
free tooth is not known, such a conclusion is largely
restoration survival but these results were not Due to the study designs employed it is impossible
statistically significant. The other three studies to determine whether observed differences between
suggested that extending recall intervals could save comparison groups are due to differences in the
some resources through reduction in dentist’s time frequency of provision of the intervention (dental
but may have an adverse effect on the level of dental check) or whether these differences can be attributed
health (measured in terms of DMFS) (Lunder 1994; to the presence of other known or unknown potential
Wang et al. 1992; Wang et al. 1995). confounding factors not controlled for in the analysis.
These studies may not be generalisable because: Overall, there was no consistency observed across
studies in the direction of effect of different dental
> The main focus of these studies was on children
check frequencies on measures of caries and
or military personnel.
periodontal disease. There appears to be some weak
> The studies were set in locations with different evidence from three studies that regular attendance
oral health systems and different levels of oral is associated with improved quality of life as it
hygiene and oral health. We would expect the pertains to oral health. Due to the heterogeneity of
impact of dental recall intervals on the number populations, interventions, comparisons and outcome
of restorations to be influenced by the oral measures used in these studies, this finding should
health system. For example, in systems where be interpreted cautiously.
dentists receive a fee per restoration and where
these fees are set at a relatively high level, the There were no economic comparisons of dental recall
incentives are such that we could see the intervals published since the HTA report. Those
number of restorations increasing with narrower studies that were included in the HTA report were
recall intervals – a phenomenon known as based on specific populations and were not based
‘supplier induced demand’. on rigorously controlled trials. The model that was
developed for the HTA report itself was the only
> The studies had relatively short periods of
study to compare costs and health outcomes for a
observation (from 2 years to 10 years) and
number of different recall intervals in a UK context
variable sample size (from 46 to 2750).
but it too had major limitations (referred to
> The measure of the impact of change in recall previously in this chapter).
intervals on dental health is restricted to DMFS/
DMFT or decline in number of new decayed Considered in the context of the HTA Report, the
teeth. This would not capture all of the health results of this updated review fail to alter the
gain attributable to the OHR. conclusions of the original review:
> There is little evidence to either support or refute

2.4 Conclusions
the practice of encouraging 6 monthly dental
The studies included in this updated review are
checks in adults or children
methodologically and clinically heterogenous,
restricting comparisons between studies and limiting > There is little evidence to suggest an optimal
generalisability to the UK context. All studies were dental check frequency for any of the outcomes
judged to have some threat to validity and a major considered
limitation of a number of studies was the method
> There remains uncertainty in how patients value
used to measure the frequency of the intervention.
their oral health
The majority of studies used a subjective measure
of dental check frequency, which compromised the > Further primary research is needed in order to
validity of the data collected. It is reasonable to assess the relative clinical effectiveness and cost-
assume that attendance frequency is ‘over-estimated’ effectiveness of different frequencies of dental
in questionnaire/interview type surveys and there is check in terms of impact on caries, periodontal
some empirical evidence to support this assumption. disease, oral cancer and quality of life.
18
TABLE 4: Oral Health Review Economics Papers – Characteristics of Studies

Type of Effectiveness
Study Comparison Target group the study measure Cost/resource Method
Davenport et al., 3 , 6, 12, 18, 24, 1-6 years of age with only deciduous dentition, Cost Effectiveness Number of teeth free Average cost of OHR Markov Decision
2003, UK 36 months 12-80 years of age with only permanent Analysis (CEA) from decay, extraction and cost associated Analysis
dentition according to: or fillings for with the treatment of
– manual/non-fluoridated deciduous (dmft) and decay (filling
D E N TA L R E C A L L
– manual-fluoridated permanent (DMFT) deciduous and

– non-manual/non-fluoridated permanent dentition)
– non-manual/fluoridated
Dawson and 6 vs. 12 months Aircrew (n=24) and Groundcrew (n=76) from Cost Impact Analysis Average number of Average cost of 10 year Retrospective
Smales, 1992, Australian defence force restorations and treatment +
Australia Restoration survival examination
Wang et al., 12 vs. 24 months 185 children, Resource Use Increment in decayed, Mean total time 2 year RCT
1992, Norway 3-5 year old 16-18 year old 18-20 year old missing, filled and (minutes) for
12 months 12 months 12 months sound tooth surfaces examination and
(n=27) (n=43) (n=23) (DMFS) treatment
24 months 24 months 24 months
(n=31) (n=35) (n=26)
Wang and Holst, 12.5 (mean) children aged 3-18 years of age Resource Use Decline in number of Mean Clinical time 2 year cohort
1995, Norway months vs. 13.7 (approx.2750) new decayed teeth (min) (examination+
(mean) months treatment) spent per
patient-excluding
orthodontic treatment
Lunder, 1994, 12 vs. 18 months 46 high school children Resource use Increment in DMFS Overall mean 7 year
Norway time/patient Current study
Examination mean (ecological)
time/patient
TABLE 5: Oral Health Review Economics Papers
Study Comparison Effectiveness Cost or resource used Incremental cost-effectiveness
Davenport et al., 2003, Decay-free teeth Incremental cost (£) Incremental cost per extra decay free tooth at (£)
UK (DMFT/dmft) (manual, non-flouridated)
age 80 age 6 age 80 age 6 age 80 age 6
3 vs. 6 0.2 0.1 200 64 907 533
6 vs. 12 0.1 0.2 75 31 538 154
12 vs. 18 0.6 0.2 15 9 27 52
18 vs. 24 1.3 0.2 21 4 17 23
24 vs. 36 3.1 0.4 2 3 1 8
Dawson and Smales, 6 vs. 12 months Decrease in number of Incremental cost of treatment and examination – Average cost of treatment was significantly
1992, Australia restorations -$AUS36 related to the frequency of examination.
0.1* – Restoration longevity/the number of restorations
Decrease in restoration received were not significantly influenced by
75% survival recall frequency.
1.23* – More frequent attenders received more expensive
treatments rather than more treatment.
Wang et al., 1992, 12 vs. 24 months DMFS Increment* Difference in Difference in Difference in – The longer interval was associated with greater
Norway Age Group Examination Treatment Total time DMFS but this was not statistically significant.
3–5 years 0.9 time (min) time* (min) (min) – There was no significant relationship between the
16–18 years 1.2 -16 -5 -10 length of interval and the treatment time.
18–20 year 0.5 -21 -1 -18 – Examination time and total time were
-27 -2 -30 significantly shorter for patients examined every
24 months than for patients examined every
12 months.
– 30% reduction in clinical time was obtained due
to less time being spent on examinations.
Wang and Holst, 1995, 12.5 vs. 13.7 months Decline in number Difference in Clinical time (min) – Dental health in children did not change after
Norway of decayed teeth (examination+treatment ) extending recall intervals.
0.06 -8 – 10% increase in interval length corresponds to a
14% reduction in dentists equivalent time.
C L I N I C A L E F F E C T I V E N E S S A N D C O S T- E F F E C T I V E N E S S O F RO U T I N E D E N TA L C H E C K S ( H TA U P DAT E )
Lunder, 1994, Norway 12 vs. 18 months DMFS increment Overall mean Examination mean –
0.8 time/patient time/patient
-45 minutes -31 minutes
*Not statistically significant
19
3. The Context of Dental Recall
As noted in the previous Chapter, based on of a risk based recall interval between Oral Health
a systematic review of the evidence on the Reviews (OHRs) is that patients deemed to be at
effectiveness of routine dental checks of different increased risk may benefit from more frequent OHRs
recall frequencies, there is a lack of good quality, and patients deemed to be at low risk may need to
directly applicable research with which to inform be recalled less frequently. The rationale for reducing
clinical practice on assigning appropriate recall the interval between Oral Health Reviews for
intervals. This absence of evidence complicated the patients deemed to be at increased risk is that the
task of fulfilling the original remit given by the OHR affords an opportunity for primary prevention
Department of Health and the Welsh Assembly (the prevention of oral disease before it occurs) and
Government, namely: “To prepare guidance for the secondary prevention (limiting the progression and
NHS in England and Wales, on the clinical and cost- effect of oral diseases at as early a stage as possible
effectiveness of a dental recall examination for all after onset). Based on these premises and
patients at an interval based on the risk from oral assumptions the GDG decided to examine the
disease” (our emphasis). The GDG decided that, in literature surrounding clinical, behavioural and
order to fulfil this remit, further literature (other than etiological factors that could be used by clinicians
that directly relevant to addressing the Key Clinical to determine a patient’s risk of acquiring new disease
Questions detailed in the previous Chapter) would or the risk of existing disease progressing. The GDG
have to be explored. Specifically, the GDG felt that further considered that aspects of the natural history
the concept of risk as applied to provision of dental of oral diseases should also be examined, in
care and the possibility of developing a ‘risk-based particular the rate of progression of oral diseases.
recall interval’ should be explored. The GDG also wished to ensure that the guideline
would be grounded in the principles of modern
Risk is the probability of an event occurring in a preventive management of oral diseases and
specific time (Reich et al. 1999). Applied to a health would reflect the evolution of NHS dentistry from
event, risk is the probability of an individual a restorative-centred approach towards a more
developing a given disease or experiencing a health preventive-oriented and clinically effective way
status change over a specified period. Extending the of meeting patient needs. In addition, it was also
definition of risk to the term ‘risk factor’ implies that considered important to examine the literature
there are certain factors associated with an increased surrounding patients’ satisfaction with the current
probability of an individual developing a disease or NHS dental services and factors influencing dental
experiencing a health status (Beck 1990). The attendance.
premise underpinning the application of these
concepts to the selection of an appropriate recall In order to explore these issues, the GDG formulated
interval for an individual patient is that the appropriate contextual questions relating to risk
frequency and type of oral health supervision needed factors for dental caries, periodontal disease and oral
by an individual patient can be based on a patient’s cancer, the rate of progression of oral diseases and
risk of developing future disease or of existing the early detection and preventive management of
disease progressing. Thus, the operating premise oral diseases. In developing and prioritising the
T H E C O N T E X T O F D E N TA L R E C A L L 21
contextual questions to be addressed, two issues 3.1.1 Caries Risk Assessment

were considered:
SUMMARY OF THE LITERATURE REVIEWED
a) the relevance and usefulness of these questions
in developing the guideline > The most consistent predictor of caries risk is
past caries experience (clinical evidence of
b) the work reasonably achievable in the limited
previous disease)
time available
> Caries risk assessment for individual patients
Many of the contextual questions posed by the GDG,
can be carried out by the clinician using
in and of themselves, could have provided the focus
information readily obtained at an oral health
for a separate systematic review. However, it was
review
agreed by the GDG that, for the purposes of
developing this guideline, a systematic review of the > The clinical judgement of the dentist and his or
evidence in relation to each of these questions was her ability to combine risk factors, based on
neither appropriate nor feasible. In relation to each their knowledge of the patient and clinical and
question, it was agreed that a search would be made socio-demographic information is as good as, or
for existing systematic reviews or other high quality better than, any other method of predicting
and reliable evidence. Members of the GDG with caries risk
expertise in that particular topic area were also
> The following should be considered when
consulted for references to pertinent literature for
assessing caries risk for an individual patient:
each question.
Medical History; Social History; Dietary Habits;
Use of Fluoride; Clinical Evidence; Oral Hygiene;
The literature reviewed in order to address the
Salivary flow rate
contextual questions posed by the GDG is presented
in the subsequent sections in this Chapter. The GDG > Assessment of caries risk should be repeated
also considered the issues of longevity of dental every time a patient attends for an oral health
restorations, the accuracy of basic diagnostic methods review
used by clinicians for detecting carious lesions in
primary and permanent teeth, and the epidemiology Over the past four decades, changes have been
of dental caries of children (Appendix F). observed in the prevalence of dental caries and in
the distribution and pattern of the disease in the UK.
3.1 Dental Caries Although overall caries levels have declined
For some of the background dental caries questions, significantly, this improvement has not been
the review team were able to draw upon a series of uniformly experienced throughout the population.
systematic reviews presented at the National Epidemiological studies have demonstrated that the
Institute of Health Consensus Development distribution of dental caries is skewed, with most of
Conference on the diagnosis and management of the disease being concentrated in a minority of the
dental caries throughout life (March 26 – 28, 2001). population. There is also considerable geographic
Some of the questions addressed at this Conference variation in caries experience across England and
using systematic review methods were particularly Wales on a regional and county basis. Generally
relevant to this guideline (for example, “what are the lower levels of mean caries prevalence (DMFT <1 (12
best indicators for an increased risk of dental year olds) have been reported in the south, the west
caries?”). and the midlands compared with the rest of England,
Wales and the Isle of Man (mean DMFT levels
between 1.01 and 1.50).
Contemporary changes in the pattern and In identifying the best indicators of increased caries
distribution of dental caries have led to increasing risk we drew upon the findings of a number of
research interest in caries risk assessment and in systematic reviews that were used in developing a
identifying ‘high risk’ susceptible individuals who can National Institutes of Health Consensus Statement
be targeted for preventive intervention. The aim of on the Diagnosis and Management of Dental Caries
caries risk assessment is to predict future disease and Throughout Life (National Institutes of Health 2001).
disease progression. However, the precise estimation The conclusions of these reviews can be summarised
of future caries risk is difficult as dental caries is an as follows:
etiologically complex and multi-factorial disease
> There is evidence of matrilinear transmission of
process and there are many factors that can impinge
mutans streptococci in early childhood. Hence,
on an individual patient’s caries risk. Nevertheless,
the presence of caries in mothers and siblings is
caries risk assessment can be regarded as an
an indicator of increased caries risk for an
important part of planning for prevention and
individual child.
provides a basis for the provision of dental care as
well as planning recall appointments (Adelaide > Low socio-economic status is associated with
University et al. 1999). elevated caries levels. Low socio-economic status
may be associated with reduced access to care,
In reviewing the caries risk assessment literature, the reduced oral health aspirations and health
Guideline Development Group decided to examine 1) behaviours that may enhance caries risk.
the predictive validities of currently available
> Regular brushing with a fluoride containing
multivariate caries risk assessment strategies and 2)
toothpaste reduces caries risk.
to ascertain the best indicators for an increased risk
of dental caries. > Conditions that may compromise the long-term
maintenance of good oral hygiene are positively
We found one recent systematic review (Zero et al. associated with caries risk. These include the
2001) evaluating the degree to which various presence of multiple restorations and oral
combinations of risk indicators could predict dental appliances and physical and mental disabilities
caries (that is, the predictive validity of the test) in which may result in a decreased ability to
primary and permanent teeth. The authors of this perform effective oral hygiene.
review emphasised the paucity of randomised
> Fermentable carbohydrate consumption is
longitudinal studies available to inform clinical
associated with caries, particularly in the
practice. Of all the models reviewed, none of those
absence of fluoride. The frequency, amount and
graded as being of good quality reached the
consistency of sugar containing foods and drinks
desirable combined level of sensitivity and specificity
consumed may impact on a patient’s caries risk.
(160%). On the basis of the available evidence it was
Long-term regular doses of medications
concluded that, in general, the best indicators of
containing glucose, fructose or sucrose may also
caries risk could easily be obtained from dental
increase caries risk. The relationship between
charts and did not require additional testing (for
sugar consumption and caries is much weaker in
example, microbiological examinations). Previous
the modern age of fluoride exposure than it used
caries experience was also found to be an important
to be.
predictor in most models tested for primary,
permanent and root surface caries. Two of the > Certain medical conditions (for example,
longitudinal studies reviewed (graded as being of Sjögrens syndrome), pharmacological agents
‘good quality’) found that predicted caries by the with xerostomic side-effects (for example, anti-
clinician, using routinely available clinical and socio- cholinergics, tricyclic antidepressants) and head
demographic information, was an important predictor and neck radiation therapy, can lower salivary
and as good as, or better than, other methods for flow rates to levels that will dramatically elevate
predicting caries risk (Evidence Grade 2++). a patient’s risk of caries
All of the above factors, together with clinical (Mejàre et al. 2003; Kay et al. 1995; Pitts 1983).
evidence of previous disease, should be considered Comparisons of data from these studies are rendered
in assessing a patient’s caries risk. As an individual’s problematic by variations in diagnostic criteria,
caries risk status may change over time, risk examiner inconsistencies and external factors
assessment must be an ongoing process and should influencing the natural history of lesion dynamics
be carried out every time a patient attends for an (for example, varying exposures of the populations
oral health review. under investigation to fluoride). The limited quantity
and variable quality of the available evidence, and
A patient’s caries risk should be reviewed in the light the considerable study heterogeneity, renders it
of each new clinical examination and any relevant difficult to draw anything other than the following
change in their dental, medical and social history very broad and general conclusions from this body
and any alteration in their diet and oral hygiene of literature:
practices.
> On an individual patient basis, progression rates
are very variable and differ between individuals
3.1.2 Rate of Progression of Dental Caries
as well as between lesions within an individual
SUMMARY OF THE LITERATURE REVIEWED > For the majority of individuals, the progression
of approximal carious lesions in permanent teeth
> Literature examining the rate of progression
is a slow process and large numbers of lesions
of dental caries has to be interpreted cautiously
can remain apparently unchanged for long
due to the limited quantity and variable quality
periods (Pitts 1983)
of the available evidence and considerable study
heterogeneity > The time for which caries remains confined to
the enamel radiographically varies considerably.
> On an individual patient basis, progression rates
A mean time of 3 to 4 years has been reported
are very variable
(Pitts 1983)
> There is evidence that the rate of progression
> Caution should be exercised in the interpretation
of caries can be more rapid in children and
of ‘mean time’ figures as the rate of progression
adolescents than in many older persons
is more rapid in ‘high risk’ or ‘caries active’
> There is a paucity of evidence on: lesion individuals (Shwartz et al. 1984)
progression in older adults, the rate of
> The rate of progression through the enamel in
progression of occlusal caries, dentine lesions,
permanent teeth appears to be relatively faster
free smooth surface lesions and root surface
in young children (< 12 years) when compared
lesions
with adolescents and adults (Mejare et al. 2000;
Shwartz et al. 1984)
Most of the available information on caries
progression emanates from radiographic studies of > The rate of progression through enamel is slower
approximal lesion progression in the permanent teeth in populations and individuals with adequate
of children and young adults. There is sparse fluoride exposure (Lawrence et al. 1997)
information on lesion progression in older adults and
> The limited data available on lesion progression
on the rate of progression of occlusal caries, dentine
in primary teeth suggest that the rate of
lesions, free smooth surface lesions and root surface
progression is faster than in permanent teeth
lesions. There is also a paucity of data available on
caries progression in primary teeth and many of > The limited data available on the rate of
these studies are confounded by the presence of progression in dentine, suggest that progression
preventive regimes (Tinanoff et al. 2001). Reviews rates are faster than in enamel (Mejare et al.
of the caries progression literature illustrate the 1999; Pine et al. 1996)
different populations, settings, treatment variables
and measurement variables used in different studies
> From the limited data available, lesion restorations are provided when a certain threshold
progression in adults does not appear to be of lesion severity has been exceeded (Murray et al.
related to age and there are no major 1997). This change in practice has been influenced
differences in the rate of progression between by number of factors including an improved
younger and older adults (Berkey et al. 1988; understanding of the caries process, contemporary
Foster 1998) changes in the epidemiology of dental caries and an
alteration in the rate of progression of the disease.
> The exact range of rates of progression of free
In particular, a slowing in the rate of progression of
smooth surface lesions is not known
early caries lesions through the enamel and the fact
> The natural history of root caries is largely that early lesions can be arrested or even reversed
unknown as is the rate of progression through justifies consideration of the use of remineralising
root surface cementum (Banting 2001; Leake procedures (preventive intervention) for such lesions
2001). as opposed to automatic restorative intervention.
3.1.3 Threshold for intervention In terms of the clinical management of caries and
for successful treatment decisions to be made, it is
SUMMARY OF THE LITERATURE REVIEWED important to know at what stage a carious lesion
is likely to progress, irrespective of efforts to arrest
> Early caries lesions can be arrested or even
it by common preventive means and, hence, when
reversed thus justifying consideration of the
restorative intervention is warranted. There is a
use of remineralising procedures (preventive
continuing debate in Europe on precisely where this
intervention) for such lesions as opposed to
restorative threshold should lie. Increasing emphasis
automatic restorative intervention.
has been placed on cavitation (a break in the
> Contemporary emphasis is placed on cavitation continuity of the enamel surface) as a threshold for
(a break in the continuity of the enamel surface) restorative intervention, rather than dentine
as a threshold for restorative intervention rather involvement (depth of the lesion), per se (Pitts 2001).
than dentine involvement (depth of the lesion) The threshold for intervention may also vary
depending on the tooth surface affected by caries.
> Operative intervention of cavitated lesions is
generally indicated to restore the integrity of the
3.1.4 Occlusal surface caries
tooth surface and allow for plaque removal by
In general the limit for arresting occlusal caries is
the patient
considered to be clinical cavitation. A number of
> Progressive hidden dentinal lesions can sometimes studies have found that when an occlusal lesion
be found in sites that appear clinically sound is cavitated the dentine is always involved in the
(‘hidden’ or ‘occult’ caries). These lesions should process, the lesion contains many micro-organisms
be scheduled for operative care and can generally be considered as an ‘active’ lesion
(Ekstrand et al. 1995; Ekstrand et al. 1997; Ekstrand
> Radiographic findings must be considered with
et al. 1998b; Espelid et al. 1994; van Amerongen
all other available clinical information on a
et al. 1992). The opinion that cavitated lesions
patient when planning care.
inevitably progress provides the basis for considering
operative treatment of such lesions a necessity
Over the past four decades the approach to the
(Lunder et al. 1996). This inevitable progression is
provision of dental care in many developed countries
attributed to the impossibility of a thorough plaque
is considered to have undergone a progressive shift
removal once cavitation has occurred and operative
from a ‘restorative phase,’ where the detection of
intervention is generally indicated in order to restore
caries lesions was promptly followed by lesion
the integrity of the tooth surface and allow for
excision and restoration placement, to a less
appropriate cleaning. However, it is also important
interventive ‘preventive phase,’ where the emphasis
to appreciate that operative intervention for occlusal
is on primary and secondary prevention and where
surface lesions may be required before cavitation
has taken place. The decision when to intervene and jointly with all other available clinical information
restore an occlusal surface lesion is complicated by on a patient when planning care.
an apparent change in the presentation of caries in
recent decades, particularly with the widespread 3.1.6 Restorative threshold of free smooth surface
availability of fluoride, in which cavitation appears lesions
to occur at a later stage. It is now recognised that The accessibility of free smooth surface lesions
progressive, hidden dentinal lesions can sometimes means that they may be amenable to preventive
be found in sites that appear clinically sound regimes, even when cavitated. In this context,
(‘hidden’ or ‘occult’ caries). Cavitated occlusal lesions adequate plaque removal, exposure to fluoride and
into dentine should be scheduled for operative care. appropriate dietary modification may provide an
Occlusal surfaces with a suspicion of hidden dentine environment conducive to the arrest of cavitated
caries should be investigated carefully. carious lesions on free smooth surfaces. Similar
arguments apply to active lesions on root surfaces
3.1.5 Caries on contacting approximal surfaces which can be rendered inactive by daily plaque
The restorative threshold for contacting approximal removal and adequate exposure to fluoride (Nyvad
surfaces is probably reached when frank clinical et al. 1986; Nyvad et al. 1997). The ability to remove
cavitation occurs. As these surfaces are generally plaque is critical in order to arrest active carious
inaccessible to visual examination, the clinician lesions. If a patient is unable to access such lesions
usually has to rely on the use of radiographs as an and remove plaque adequately, operative
aid to diagnosis. However, although radiographs can intervention is necessary.
provide an estimate of the depth of lesion
penetration towards the pulp, they are unable to For all of the above lesions, the threshold for
provide direct and unambiguous evidence about intervention will also be influenced by the values
cavitation at approximal sites. Traditionally, dental and preferences of the patient for treatment and
practice has adopted the criterion that restorations outcomes, which may be different from those of the
should be placed when an approximal radiolucency clinician.
has reached the junction of the enamel and the
dentine (Tyas et al. 2001). However, a problem with 3.2 Periodontal Diseases
adopting this criterion is that it cannot be assumed
that all radiolucencies that have reached this point 3.2.1 Summary of the Literature Reviewed
represent cavitation. > The main risk factors for the development
of periodontal disease include the presence
Several clinical studies have related radiographic of plaque, smoking and diabetes
appearance with cavitation in permanent teeth.
> There is a paucity of data investigating the
Where a radiolucency has reached the inner half of
impact of gingivitis on oral health and well
dentine, the probability of cavitation is high (Mejàre
being
et al. 2003) and restorative intervention is
warranted. However, when radiolucency is confined > Untreated periodontal disease is likely to
to the outer half of dentine, cavitation may or may progress faster than treated periodontal disease
not be present and clinical judgement should be
used to determine when restorative intervention, Epidemiological studies of periodontal diseases are
rather than preventive maintenance and monitoring, complicated by the diversity of measures used to
is warranted. This clinical decision is facilitated by describe and quantify them and the lack of
research which suggests that cavitation is more likely consensus as to a uniform definition and
in ‘high risk’ patients and where the adjacent classification (Kingman et al. 2002). This is reflected
gingival papilla is inflamed (Ekstrand et al. 1998a; in the estimates given by the World Health
Lunder et al. 1996; Ratledge et al. 2001). Organisation Global Data Bank (World Health
Radiographic findings must thus be considered Organisation 2004) which state the prevalence of
moderate severity disease occurs in 2 to 67% of
individuals and that advanced disease occurs in on oral diseases, and the impact of gingivitis on
1 to 79% of the population. restorations, for example restoration longevity or the
integrity of the restoration margin. No studies were
Tooth loss might be the true clinical outcome for found that directly investigated gingivitis and the
periodontal disease but can occur for other reasons, quality of life on an individual. However, some
even in those with established destructive studies looked at the impact of periodontal health in
periodontitis (Nunn 2003). Consequently, general (Jones et al. 2001; Needleman et al. 2004;
alternatives such as probing depth and attachment Peek et al. 2002). The data suggest that there is an
level are often used as surrogate outcomes, effect although it is not possible to discriminate the
particularly to determine treatment need or response. impact of gingivitis alone from all periodontal
Hujoel provides some evidence for the validity of diseases. While gingivitis has shown to be a risk
these measures (Hujoel et al. 1999). The effect of factor for periodontitis (Schatzle et al. 2003) and
these uncertainties may over- or underestimate may be a risk indicator for caries (Ekstrand et al.
treatment need. For the patient, the impact of 1998a), there are no data for gingivitis as a risk
disease on their quality of life and well-being is also factor for other aspects of oral health. No studies
important but few studies have yet investigated the were found researching the impact of gingivitis on
effect of periodontal status on these measures. restorations.
3.2.2 Gingivitis 3.2.3 Risk factors

Gingivitis is an inflammation of the superficial gum The accumulation of dental plaque at the gingival
tissues. It is caused by the accumulation of bacterial margin is considered to be the primary aetiological
plaque at the gum line (Loe et al. 1965; Thielade factor for the development of periodontal diseases
1986). Gingivitis can be recognised by the signs of (Socransky et al. 2003). Risk factors are considered
bleeding from the gums (for instance following tooth to be those exposures, genetic influences or
brushing), a change from pink to red colouration and behaviours which modify the effect of plaque on the
mild tenderness from the edges of the gum. These gingival tissues.
signs are often missed or thought to be normal
changes. Thorough and regular removal of plaque by Although poor oral hygiene and plaque accumulation
methods such as tooth brushing and flossing will have been shown to correlate positively with
allow health to be re-established without irreversible gingivitis and the prevalence and severity of
effects to the gums. periodontal disease on a population level, oral
hygiene is a much weaker predictor of periodontal
Gingivitis is highly prevalent in most populations and tissue loss at the individual level (Albandar 2002a).
at most ages (Albandar 2002b; Corbet et al. 2002; Such a paradox might be explained by the
Sheiham et al. 1986) with global values ranging from contribution of risk factors which will vary
50-90% of populations. The fact that gingivitis can substantially between individuals.
be a precursor to more severe periodontal disease
(periodontitis) has traditionally been regarded as its One readily assessable marker of risk is gingival bleeding.
greatest significance. However, there has been Lang and co-workers have shown that continuous
surprisingly little research looking at the effect of this absence of bleeding is a reliable predictor for the
condition on future oral health and wellbeing. Since maintenance of periodontal health (Lang et al. 1990)
the condition affects the majority of people such that is, health gingival tissues predict further periodontal
information is critical to the development of policy health. It is not clear whether this relationship holds true
on managing gingivitis. for both smokers and non-smokers.
We decided to examine the impact of gingivitis on A review by Nunn concludes smoking is “probably
the well being and oral health of an individual. the most significant modifiable risk factor for
Three areas of interest were considered: the impact periodontal disease (Nunn 2003). In the United
of gingivitis on quality of life, the impact of gingivits States The Third National Health and Nutrition
Examination Survey (NHANES III) estimates that 3.2.4 Rates of Progression

more than half the cases of periodontitis affecting The Guideline Development Group was interested in
adults may be due to smoking with 41.9% (6.4 a comparison of the rates of progression of treated
million) cases of periodontitis due to current smoking and untreated chronic periodontitis. However, few
and 10.9% (1.7 million) cases of periodontitis due to studies investigated the rates of progression of
former smoking (Tomar et al. 2000). Albandar periodontal disease for both treated and untreated
reports on several cross-sectional studies that show subjects in the same study. As a surrogate for this,
a strong association between the various types and we looked at the data for treated periodontitis where
intensity of smoking on gingival tissue, periodontal the subjects are randomised to receive adequate
tissue loss and the severity of periodontitis. Smokers maintenance care compared to inadequate care
are shown to have between a two and seven fold (Axelsson et al. 1981). The treatment group
increase in risk for having periodontitis and/or represents a treated and best case sample and the
periodontal tissue loss than non-smokers. Heavy control group represent individuals where
cigarette smoking is associated with more severe periodontitis is allowed to re-establish (a proxy for
periodontal disease than light smoking and the untreated and if anything, a modest estimate as the
number of smoking years significantly associated subjects have received some care). The results
with tooth loss and periodontal disease, irrespective indicate that the percent of sites with at least 2mm
of other social and behavioural factors (Albandar loss of attachment over six years was 1% for subjects
2002a). There is no evidence to suggest a safe level receiving adequate maintenance care and between
of smoking on periodontal health. 52% to 65% depending on the type of tooth
(incisors, canines and molars) for those with
Nunn reports strong evidence for a direct relationship inadequate maintenance care.
between diabetes and periodontitis (Nunn 2003).
Both type I (insulin dependent) and type II (non- Cobb reviewed several studies to determine mean
insulin dependent) diabetics appear to be at a higher annualised rates of progression of untreated
risk than non-diabetics. However, certain sub-groups periodontal diseases determined by clinical probing
appear to be at particularly high risk. These include depth and clinical attachment loss, or radiographic
diabetics with poor oral hygiene and/or poor measurement of alveolar bone loss (Cobb 1996).
diabetic control and diabetic complications (Kinane Adjusting for one study that appeared to have some
2001). Evidence has begun to emerge suggesting individuals with much greater progression than most
a bidirectional relationship between both types of populations (0.8mm per year) the range is 0 to
diabetes and periodontal disease (Taylor 2001). 0.3mm per year.
Albandar reports that studies show aggressive However, annualised rates are highly problematic
periodontitis to occur in families and suggests that and tend to underestimate true disease progression.
genetic factors are partly responsible for the They are generally calculated across all sites in the
increased susceptibility to this disease (Albandar mouth (whether per patient or across all sites of
2002a). Several other factors have only limited the study group rather than grouped per patient).
evidence of or a variable association with periodontal The result is the inclusion of large numbers of non-
diseases. These are osteoporosis, rheumatoid arthritis, progressing and healthy sites. Since progressing sites
hormonal changes in the body associated with are less common than non-progressing sites the
puberty and pregnancy, smokeless tobacco, low effect could be to underestimate disease progression
vitamin C or calcium intake, high alcohol intake, of the sites that are progressing, often called ‘loser’
socioeconomic status, psychosocial factors such as sites. Loser sites could be more common on teeth
stress, age, gender, race, and tooth or local factors lost during follow-up. If the effect of the loss of sites
such as occlusal discrepencies or tooth position on extracted teeth is not assessed, diseased or
(Albandar 2002a; Nunn 2003) progressing sites will be preferentially lost from the
data set, introducing a bias. Studies that report on
rates of progression of ‘loser’sites only indicate that
much greater rates can occur (Cobb 1996; Haffajee > Cases of oral cancer have been reported in
et al. 1991; Lindhe et al. 1989). young persons (below the age of 45 years) with
little or no exposure to tobacco or alcohol
Converting this information into the Basic
> The use of toluidine blue dye as a screening tool
Periodontal Examination (BPE) suggests a mean
in primary care should be discouraged
annualised rate of progression of between 0.0 and
0.3mm per year for patients with no history of > Oral cancer often apparently arises de novo from
periodontitis and a BPE code of 0 (no residual clinically normal mucosa. The percentage of oral
pockets and no gingivitis and no calculus or cancers arising from precursor lesions is not
overhangs), 1 or 2 (gingivitis or calculus/overhangs accurately known
but no pockets) and for patients with a history of
> Potentially malignant lesions include leukoplakia
periodontitis and a BPE code of 0. For patients with
and erythroplakia of varying clinical
a history of periodontitis and a BPE code of greater
presentations. The incidence and prevalence of
than 0 the data suggests a maximum annualised
oral leukoplakia and erythroplakia in the UK are
rate for progression of 3mm per year.
not known.
3.3 Oral Cancer > The reported rates of malignant transformation

of oral leukoplakia in the international literature
3.3.1 Summary of the Literature Reviewed range from 0.3 to 17.5%
> On average about four people a day die from
> Lesions of leukoplakia on the floor of the mouth,
oral cancer in the UK
lateral tongue and lower lip are most likely to
> The poor survival rate from oral cancer (50%) is show dysplastic or malignant changes
generally attributed to the late diagnosis of oral
> Erythroplakia has a high potential for malignant
cancer at an advanced stage when nodal
transformation
involvement and neck metastases have occurred
> Clinicians should maintain a high index of
> The incidence of oral cancer increases with age
suspicion for mucosal lesions that appear
in both males and females, typically peaking in
unusual. This vigilance is especially important
the seventh to eight decades of life. An
for isolated lesions occurring in locations at
increasing incidence in younger age groups (35-
higher risk for the development of squamous cell
64 years) has been recently reported
carcinoma, such as the lateral and ventral
> It has been consistently reported that there is a surfaces of the tongue and the floor of the
prognostic advantage associated with early mouth.
detection of oral cancer. Early diagnosis allows
for treatment with less aggressive therapies that 3.3.2 Epidemiology
are associated with less morbidity Quoted incidence rates for oral cancer in the UK vary
from 3.4 to 4.5 per 100,000 per annum (National
> The incidence of oral cancer in males is around
Screening Committee: unpublished data 2001). In
twice that in females in virtually all age groups.
1998, there were 4,081 cases of oral cancer
An exception to this has been reported in those
diagnosed in the UK and in the year 2000, there
under the age of 40 years where the usual male
were 1,649 deaths from the disease. On average
dominance does not appear to hold (See Section
about four people a day die from oral cancer in the
3.3.2)
UK. Oral cancer is also associated with significant
> Tobacco use (both smoking and smokeless morbidity arising as a consequence of the disease
tobacco) and excessive consumption of alcohol process itself and the therapy provided to oral cancer
are the principal risk factors for oral cancer patients. Oral cancer associated morbidities include:
psychosocial disability in terms of appearance, self-
esteem and withdrawal from familial and other social
interactions, functional disabilities (difficulty in There is limited evidence available relating to ethnic
maintaining oral hygiene, swallowing and variations in the incidence of oral cancer in England
maintenance of nutritional status, difficulties in and Wales. Incidence rates appear to be higher in
speaking), therapy-specific morbidities (related to Asian immigrants (that is, immigrants from India,
neck dissection and radiotherapy) including thyroid Pakistan, Bangladesh, Nepal and Sri Lanka). These
and parathyroid dysfunction, xerostomia (dry mouth), ethnic differences have been attributed to tobacco
osteo-necrosis of facial bones and the side-effects of use and tobacco chewing habits (specifically betel
chemotherapy (Rosati 1994). quid chewing) and to possible dietary factors,
genetic predisposition, socio-economic differences
As with all neoplasms, it is believed that oral cancer and lack of awareness about the risk factors.
results from cumulative damage to epithelial cells Research into the incidence of oral cancer in specific
over a period of time (Quinn et al. 2004). Hence, the ethnic groups in the UK is hampered by the fact that
incidence of the disease increases with age in both entry of ethnic group for an incident case only
males and females, typically peaking in the seventh became part of the contract minimum data set in
to eighth decades of life. Oral cancer is extremely rare 1993 (Warnakulasuriya et al. 1999).
below the age of about 40 years with approximately
4 – 6 % of oral cancers occurring below this age The overall five-year survival rate for oral cancer in
(Llewellyn et al. 2001). The incidence of oral cancer England and Wales generally remains poor at an
in males is around twice that in females in virtually average of 50%. There has been little reported
all age groups. An exception to this has been improvement in survival rates from oral cancer since
reported in those under the age of 40 years, where the 1960s despite improvements in surgery and
the usual male dominance of the condition does radiotherapy. This poor survival is generally attributed
not appear to hold (Llewellyn et al. 2001). to the late diagnosis of most oral cancers at an
advanced stage when nodal involvement and neck
The overall age-standardised incidence of oral cancer metastases have occurred (British Dental Association
has risen gradually since the 1990s and an 2000; Epstein et al. 2002; Silverman 2001).
increasing incidence in younger age groups (35 – 64
years) has been reported. In the 35 – 64 year age It has been consistently reported that there is a
group, the incidence of tongue, mouth and prognostic advantage associated with early detection
oropharyngeal cancer rose from 3.61 per 100,000 of oral cancer. There is some evidence from studies
per annum (1962 – ‘66) to 5.52 (1982 – ‘86) in of therapy for early stage oral cancer, that five-year
males and from 1.85 to 2.19 in females (Hindle et al. survival is better for Stage I (where tumour diameter
1996). More recently, Quinn and co-workers have is 2cm or less and there is no nodal involvement and
reported a 40% increase in the incidence rate of lip, no metastases) than Stage II (where tumour diameter
mouth and pharyngeal cancer in males aged 55 – 64 is >2cm but <4cm in diameter and there is no nodal
years in England and Wales between 1971 and 1997 involvement and no metastases). Hawkins and co-
and a 25% increase in the incidence rates in females workers reviewed nine studies (published between
of the same age group (Quinn et al. 2004). 1980 and 1997) reporting data from retrospective
reviews of patient charts (Hawkins et al. 1999). The
In England and Wales the incidence of oral cancer only measure provided in all studies was the five-year
exhibits marked regional variation with above survival rate: for Stage I five-year survival ranged
average rates in the North of England and in Wales from 57% to 90% and for Stage II, from 41% to
(Greenwood et al. 2003). The regional pattern in 72%. However, all of these studies were case-series
mortality is similar to that for incidence. It has been studies where a group of patients received an
suggested that this difference may be related, at intervention and outcomes were assessed (there was
least in part, to material deprivation (O’Hanlon et al. no comparison group). The influence of lead-time
1997). bias was not considered in the statistical analysis of
these data. This evidence is insufficient to establish
with confidence whether earlier detection improves
the prognosis in patients with oral cancer. in younger people with oral cancer. However, many
Nevertheless, early diagnosis is considered to be of authors also reported a complete lack of the usual
importance in improving the outcome of therapy – aetiological factors associated with older patients that
diagnosis at earlier stages allows for treatment with is, cases of oral cancer have been reported in young
less aggressive therapies that are associated with less people who have had little or no exposure to tobacco
morbidity (Epstein et al. 1997). or alcohol (Llewellyn et al. 2003).
It should also be noted that small tumours may not A strong association between betel quid chewing
necessarily be ‘early’ in the chronological sense – and oral cancer and various potentially malignant
some small tumours may be very aggressive and at lesions and conditions (primarily leukoplakia and oral
an advanced stage at presentation even though they submucous fibrosis) has been established. The
are 2cm or less in their greatest dimension. addition of tobacco to the quid significantly
increases the risk of oral cancer (Moss S, Melia J,
3.3.3 Risk factors for oral cancer Rodrigues V, Tuomainen H: unpublished data 1997;
Tobacco use (both smoking and smokeless tobacco Thomas et al. 1993).
[that is, chewing tobacco, chewing tobacco with betel
quid, snuff]) and excessive consumption of alcohol are The habit of betel quid chewing is extremely common
recognised risk factors in the development of oral in India and South East Asia, Eastern Melanasia and
cancer (British Dental Association 2000; Conway et al. the East African Coast. There is evidence that this
2002; Horowitz et al. 2001; Rosati 1994). Both factors habit remains prevalent in UK immigrants from these
are associated with oral cancer in a dose response areas (Farrand et al. 2001). In the UK it has been
fashion and have a synergistic effect when combined reported that 19% of Bangladeshi men and 26%
(Moss S, Melia J, Rodrigues V, Tuomainen H: of women use some form of ‘chewed tobacco’
unpublished data 1997). There is some controversy over (Department of Health 2001). Other authors have
the precise role of alcohol as an independent risk factor reported that this may be as high as 39% and 82%
for oral cancer. Nevertheless, the epidemiological respectively, in some areas (Bedi et al. 1995). Between
evidence suggests that all forms of alcoholic drink are 2% and 6% of UK Indian and Pakistani community
dangerous if heavily consumed. In this context there is members use some form of chewed tobacco.
evidence for the role of beer, wine and spirits as risk
factors for oral cancer. In many studies only high levels Certain dietary deficiencies have been shown to play
of alcohol consumption (for example, >20oz/week or a role in oral carcinogenesis. Case control studies
>55 drinks/week) have indicated significant increases have consistently shown that oral cancer patients
in risk. Due to the tendency in self-reporting to have histories of diets low in fruit and vegetables
underestimate alcohol intake, particularly high levels of (that is, a diet low in Vitamin A and C has been
intake, the effect of alcohol may be stronger than the associated with an increased risk of oral cancer)
studies suggest (Shah et al. 2003). Current UK (Moss S, Melia J, Rodrigues V, Tuomainen H:
recommendations are that men should not drink more unpublished data 1997). Iron deficiency anemia in
than 21-28 units per week and women should not combination with dysphagia and esophageal webs
drink more than 14-21 units. One in four men and one (Plummer-Vinson syndrome) is associated with an
in ten women in the UK are believed to be drinking elevated risk for development of carcinoma.
over the recommended limits, with the number of
habitual heavy drinkers estimated at 4 million (British It is well established that outdoor workers (for
Dental Association 2000). example, those involved in farming, fishing and
postal delivery) are at greater risk from lip cancer
In young persons (below the age of 45 years) who because of long-term exposure to ultra-violet light.
develop oral cancer, there is mixed evidence of the role The risk of developing cancer of the lip increases
of alcohol and tobacco as risk factors. Several studies with both the duration and frequency of exposure
have reported that the risk factors of smoking and to ultraviolet radiation and is cumulative over time
alcohol consumption were present to varying degrees (Casiglia et al. 2001).
OTHER RISK FACTORS FOR ORAL CANCER oral cancer and precancer screening studies concluded
that systematic visual examination of the oral mucosa
Other factors have been associated with an increased
has a high discriminatory ability (Moles et al. 2002).
risk for oral cancer but evidence is not conclusive on
In the latter study a weighted pooled average for
whether the relationship is causal. These factors
sensitivity was calculated as 0.796. The corresponding
include:
value for specificity was 0.977
> Previous carcinoma
3.3.5 Toluidine blue dye
> Bacterial and viral infections
The use of toluidine blue dye has been suggested as
> Genetics an adjunct to visual examination in the identification
and management of oral cancer since the 1960s and
> Occupational risk
Toluidine blue dye oral cancer screening kits have
> Poor oral hygiene been marketed to General Dental Practitioners in the
UK. However, a recent systematic review of the
> Mouthwashes with a high alcohol content
evidence found wide variation in the sensitivity and
> Immune Deficiency specificity of the test (Gray et al. 2000). The authors
of this review concluded that although toluidine blue
3.3.4 The accuracy of clinical oral examinations in might pick up additional cancers in high risk patients
detecting oral cancer and potentially in secondary care, there was no evidence to support
malignant conditions the use of toluidine blue as an adjunct to screening
The sensitivity and specificity of screening for oral in primary care. The policy implications of this
cancer by clinical examination depend on such systematic review are that the use of toluidine blue
factors as the training of the individual performing dye as a screening tool in primary care should be
the examination, and on the criteria used to discouraged.
determine which lesions are counted as ‘positive’
and warrant referral for further investigation. The 3.3.6 Potentially malignant lesions and conditions
yield and positive predictive value depend on the Although oral cancer often apparently arises de novo
population screened (Rodrigues et al. 1998). from clinically normal mucosa, there are also a
number of clinically identifiable precursor lesions,
There have been a number of population-based which constitute a detectable pre-clinical phase
studies of screening by clinical oral examination for (Downer 1997). The percentage of oral cancers which
oral cancer. These studies have generally found a arise from precursor lesions is not accurately known,
relatively high specificity between 81 to 99%. but has been estimated as more than 75% in India
However, the sensitivity has varied widely from 59 to (a high incidence region for oral cancer). Although
85%. The positive predictive values have varied from there are suggestions that the percentage of oral
31 to 87 % depending on the prevalence of oral cancer cases arising de novo from clinically normal
cancer. Consequently, due to the low prevalence of mucosa is greater in the Western world as compared
oral cancer in developed countries, two significant to India, it has been argued that there are
issues for screening programmes are a low yield in insufficient data to provide firm evidence particularly
the general population and a high proportion of in countries such as the UK (Moss S, Melia J,
false positive referrals (Hawkins et al. 1999). Rodrigues V, Tuomainen H: unpublished data 1997).
In the UK, screening by clinical examination of the Clinically identifiable precursor lesions are a
oral cavity has been reported to have a sensitivity heterogenous group of (usually) asymptomatic oral
ranging from 71 to 81% and a specificity of 99% or pathological entities with malignant potential. This
more when screening was carried out by general broad group is generally classified under ‘lesions’ and
dental practitioners, with dental specialists’ diagnosis ‘conditions’ – the latter are more generalised and
as the gold standard (Rodrigues et al. 1998). A recent widespread with significant systemic involvement.
meta-analysis of measures of performance reported in There is a paucity of data on the prevalence and
incidence of potentially malignant lesions and The most common oral sites for leukoplakia are the
conditions in the UK. Potentially malignant lesions buccal mucosa, alveolar mucosa, and lower lip. The
include leukoplakia and erythroplakia of varying location of leukoplakia has a significant correlation
clinical presentations (such as homogenous, with the frequency of finding dysplastic or malignant
verrucous, nodular or speckled) and mixed lesions. changes at biopsy. Lesions on the floor of the mouth,
lateral tongue, and lower lip are most likely to show
LEUKOPLAKIA dysplastic or malignant changes (Neville et al. 2002).
Some leukoplakias occur in combination with
Leukoplakia is usually defined as an adherent white
adjacent red patches or erythroplakia. If the red and
patch that cannot be diagnosed as any other disease
white areas are intermixed, the lesion is called a
process. Leukoplakia is thus a clinical diagnosis of
speckled leukoplakia or speckled erythroplakia.
exclusion – if an oral white patch can be diagnosed
Speckled leukoplakia or mixed
as some other condition (for example, candidiasis,
leukoplakia/erythroplakia are at greatest risk for
lichen planus) then the lesion should not be
showing dysplasia or carcinoma.
considered to be an example of leukoplakia. As there
have been somewhat unsatisfactory definitions and
The risk of malignant transformation is also reported
changes in the definitions of leukoplakia over time,
to vary with gender (higher among women), type of
there has been a wide range of figures for prevalence
leukoplakia (higher among those that are idiopathic,
and incidence reported in the international literature.
non-homogenous, of a long duration), presence of
Leukoplakia is the most common potentially
Candida albicans, and presence of epithelial
malignant condition. The incidence and prevalence of
dysplasia. Leukoplakias in non-smokers are also more
oral leukoplakia in the UK are not known. However,
likely to undergo malignant transformation than
outside the UK the prevalence has been estimated to
leukoplakias in patients who do smoke. This should
range from 0.2 to 11.7%. The variation in prevalence
not be interpreted to detract from the well-
between studies is likely to be due to varying
established role of tobacco in oral carcinogenesis
methodology and clinical criteria used in the
but may indicate that non-smokers who develop
identification of leukoplakia as well as population
leukoplakia do so as a result of more potent
differences in risk factor prevalence.
carcinogenic factors (van der Waal et al. 1997).
Data on malignant transformation of leukoplakia are

ERYTHROPLAKIA
limited and difficult to interpret because of variable
follow up, disease definitions, diagnostic criteria and Erythroplakia is a term used analogously to
treatment interventions. Several clinical studies have leukoplakia to designate oral mucosal lesions that
been conducted in Europe and the US to assess the present as red areas and cannot be diagnosed as
potential for malignant transformation of oral any other definable lesion (Shah et al. 2003). The
leukoplakia. The reported rates of malignant prevalence of erythroplakia is not known but it is less
transformation in the international literature range common than leukoplakia. Studies in India and
from 0.3 to 17.5% (Rodrigues et al. 1998). Most of Burma have found a prevalence of 0.02 and 0.1%
the earlier studies have reported a risk of malignant respectively (Shah et al. 2003). Oral erythroplakia
transformation in the range of 3.6 to 6 per cent. occurs most frequently in older men (sixth and
However, several more recent studies have reported seventh decades) and appears as a red macule or
malignant transformation rates ranging from 8.9 to plaque with a soft, velvety texture which may be
17.5 percent. Although the reason for these results is slightly depressed below the level of the oral mucosa.
unclear, it may be due to a more restrictive definition The floor of the mouth, lateral tongue, retromolar
of what is considered clinical leukoplakia and further pad and soft palate are most common sites of
underscores the seriousness of ‘true leukoplakia’ involvement. There are no studies reporting follow-up
(Neville et al. 2002). Estimates of the percentage of of series of cases of erythroplakia, perhaps due to its
leukoplakias that regress to normal vary between relatively low prevalence or due to its more active
4.6% per year in India to 28.6% in the USA. management. The rate of malignant transformation is
high: most studies of biopsied cases of erythroplakia chewing. Sporadic cases have been reported among
have found that the majority show areas of epithelial non-Asians (Europeans) (Moss S, Melia J, Rodrigues
dysplasia, carcinoma in situ or invasive cancer, V, Tuomainen H: unpublished data 1997).
leading most authors to conclude that erythroplakia
has a high potential for malignant transformation. 3.4 Effectiveness of Dental Health Education
However, the role of erythroplakia as a precursor and Oral Health Promotion
lesion, as opposed to an early sign of carcinoma in
situ or invasive cancer, is not clear (Rodrigues et al. 3.4.1 Summary of the Literature Reviewed
1998). > Dental health education advice should be
provided to individual patients at the chairside
ORAL LICHEN PLANUS as this intervention has been shown to be
beneficial (in the short term).
Lichen planus is a relatively common mucocutaneous
disorder estimated to affect 0.5% to 2% of the > The effectiveness of other means of delivering
general population. Lichen planus affects primarily dental health education and oral health
middle-aged adults and the prevalence is greater promotion is unclear since, despite its
among women. The classic skin lesions of the importance, some issues have been poorly
cutaneous form of lichen planus can be described researched and there are design challenges
as purplish, polygonal, planar, pruritic papules and around the use of randomised controlled trials.
plaques. These skin lesions commonly involve the
> Although evidence may be insufficient on
flexor surfaces of the legs and arms, especially the
whether it changes behaviour, dentists arguably
wrists. Given that 30 – 50% of patients with oral
have an ethical obligation to deliver good oral
lesions also have cutaneous lesions, the presence of
hygiene, dietary and smoking cessation advice
these characteristic cutaneous lesions can aid in the
to patients.
diagnosis of oral lichen planus.
3.4.2 General Oral Health Promotion

The malignant potential of oral lichen planus has
We found two recent general systematic reviews on
been the subject of controversy for some time (Shah
the effectiveness of health promotion and dental
et al. 2003). Some studies indicate an increased risk
education on improving oral health. A report
of squamous cell carcinoma in patients with oral
commissioned by Health Promotion Wales concluded
lichen planus lesions. This increased risk appears
that there is clear evidence that oral health
most common with the erosive and atrophic forms
education can change people’s knowledge and
and in cases of lesions of the lateral border of the
improve their oral health (Sprod et al. 1996).
tongue. Other studies suggest that in some cases of
However, it also concluded that while one-to-one
purported malignant transformation, the malignancy
oral health education is capable of reducing plaque
may not have developed from true lesions of oral
levels, evidence strongly suggests that the changes
lichen planus but may instead have arisen from areas
achieved are short-term and unsustainable.
of dysplastic leukoplakia with a secondary lichenoid
inflammatory infiltrate. The role of oral lichen planus
The authors of the second review were able to reach
as a true precursor lesion remains unclear (Rodrigues
few definitive conclusions given the paucity of
et al. 1998).
rigorous, well-designed studies in this area (Kay et al.
1998). From the studies that were rigorous and well-
ORAL SUBMUCOUS FIBROSIS
designed, Kay and Locker (Kay et al. 1998) were able
Oral Submucous fibrosis (OSMF) is a chronic disease to conclude that:
of the oral mucosa which manifests as a unique
> Health promotion that leads to use of fluoride
generalised fibrosis of the oral soft tissues. The
containing agents results in caries reduction
condition is most frequently seen in South-East Asia,
particularly in the Indian subcontinent and is > Simple instruction in oral hygiene could alter
strongly associated with the habit of betel quid people’s behaviour in the short term
> School based health education aimed at Smokers may be more receptive to advice if it is
improving oral hygiene has not been shown to linked with an existing medical condition. The
be effective. One-to-one interventions are smoker must be ready to quit and once an attempt
effective but are likely to be expensive due to to quit has been made, then follow-up should occur.
professional costs (few studies looked at cost- There is no suggestion of when first follow-up should
benefit ratios or sustainability of programmes) be made and how often additional follow-ups should
occur. Additionally, these guidelines assume that
> There is no evidence that mass media
people will be visiting their GP once a year, which
programmes significantly alter any oral health
may not be the case.
related outcomes
However, as noted earlier, these conclusions are

It should be noted that only studies published in
based on studies looking at health professionals
English were included in this study thus the results
outside of dentistry. While Watt and Daly suggest
may be subject to publication bias. Although Kay
the recommendations may be applied to health
and Locker reviewed each paper separately, they also
professionals in dentistry (Watt et al. 2003a), authors
aggregated the results. The papers included in the
of a recent study (Rikard-Bell et al. 2003) suggest
review differed on intervention, design, population
that more research is needed to determine whether
and outcomes and thus it could be argued that it
smoking cessation advice delivered by dentists is
was inappropriate for Kay and Locker to pool the
indeed effective. They cite only one well-designed
results as they did.
study that demonstrated significant results in
smoking cessation following advice from a dentist,
3.4.3 Smoking Cessation
and three well-designed studies that failed to
Recent UK-based guidelines from the Health
demonstrate successful results.
Education Authority conclude that health
professionals can play a significant role in helping
Rikard-Bell et al’s own study in this area focused on
smokers to give up the habit (West et al. 2000).
patient views of dentist-delivered smoking cessation
More specifically, a recent Cochrane review
advice in Australia. They found that while 77% of
concluded that smoking cessation counselling
patients agreed that dentists should provide smoking
delivered on an individual basis can assist smokers to
cessation advice, less than one-third of all smokers
quit (Lancaster et al. 2002). Although few studies
would try to quit upon advice from their dentist.
have examined the role of dental professionals in this
Furthermore, over one-third of patients had little
role, Watt and Daly suggest their success rates could
confidence in their dentist’s knowledge of helping
be comparable with those in other primary care
smokers quit.
settings (Watt et al. 2003a). The key conclusions on
efficacy from the recent UK guidelines (West et al.
3.4.4 Dietary Advice
2000) on offering smoking cessation advice to
Kay and Locker (Kay et al. 1998) reviewed a number
patients are:
of studies that looked at modifying the consumption
> Brief advice (less than 5 minutes) can result in of food and drink that contained sucrose. However,
1 to 3% of smokers quitting smoking each year all studies used behavioural intentions or reported
behaviour as outcome measures rather than those of
> The cessation rate increases to 6% if advice is
oral health. Watt and McGlone (Watt et al. 2003b)
up to 10 minutes and nicotine replacement
found little evidence on dietary interventions
therapy is utilized.
delivered in primary dental care settings, and thus
could not conclude whether giving dietary advice is
With regard to implementation, the recent UK
effective.
guidelines recommend ascertaining a patient’s
smoking status at least once a year and the provision
of GP advice to current smokers, during routine
consultations, to stop smoking at least once a year.
3.5 Factors Affecting Dental Attendance and been deregistered. It is important to note that first,
Satisfaction with the Current Service there may be a group of patients included in these
studies who may not know their registration status
3.5.1 Summary of the Literature Reviewed and second, that all of the studies obtained findings
> People will attend the dentist either for an Oral from the self-reported attendance of patients and not
Health Review (‘check-up’) or for relief of their attendance from dental records.
symptoms. However, it is not clear from the
literature reviewed here what the distribution of Broadly speaking, there are two reasons a person will
the population between these categories is, nor present to the dentist: either for an oral health
how stable it is. review (‘check-up’) or for symptomatic relief. Their
attendance pattern, however, can vary substantially
> One study reported that regular attendees cited
and many studies have sought to classify different
keeping their teeth as their main reason for their
patterns. The most widely known terms in the UK for
more frequent attendance. A larger body of
describing attendance are ‘regular attendees’,
literature on irregular attendees reported that
‘occasional attendees’ and people who only attend
people overwhelmingly cited a lack of perceived
when experiencing oral problems. These terms
need to explain their symptomatic attendance
originated in the National Dental Health Survey
pattern. Additional reasons commonly cited by
1968 but have different inclusion criteria from study-
patients for non-attendance were fear, cost and
to-study (Newsome et al. 1999). Several authors
time. The attendance pattern of dependant
however, have described the inadequacy of these
groups (children and dependant adults) is
terms. Newsome and coworkers for example, report
determined by the motivations and priorities
that the terms ‘regular’ and ‘occasional check-up’
of their parents, guardians or carers.
refers to both the frequency and reason for the visit,
> People are generally satisfied with their NHS while the latter term refers only to the reason. As an
dental service and consider interpersonal skills alternative, the categories ‘symptomatic attendee’
to be the most important quality of their dentist. and ‘asymptomatic attendee’ have recently been
used to describe dental attendance. Asymptomatic
This chapter summarises the most recent and attendees are defined as those people who have
comprehensive literature on public views of NHS attended for a check-up at least twice in three years,
dentistry, specifically motivations for visiting the although this definition can vary.
dentist, factors that affect attendance patterns and
satisfaction with the current service. Our literature While information about self-reported attendance is
search found no evidence regarding the public’s collected through surveys such as the Office of Fair
views on specific recall intervals or whether people Trading (OFT), the ratio between symptomatic
follow their dentist’s recommendations about when attendees and asymptomatic attendees will be more
to return for a check-up. Due to substantial variation accurately reported using results from the dental
internationally in the provision of, and payment for, records, as there will inevitably be some discrepancy
dental care, we limited the scope to studies between perceived self-reported attendance patterns
conducted in England and Wales. versus real attendance. Within both of these sources
however, there is an important issue with the
3.5.2 Motivation for visiting the dentist stability of these categories; some people for
As the patterns of dental attendance vary example, will maintain a pattern of asymptomatic
substantially in England and Wales, it was important attendance before lapsing into larger periods of
to query a broad spectrum of the population on their symptomatic attendance (Bullock et al. 2001).
motivation for visiting the dentist. Therefore, we
included NHS registered patients, in addition to users 3.5.3 Factors influencing the frequency with which
of NHS dentistry who are not currently registered. NHS patients see their dentist
This latter group may be regular attendees but There was good evidence concerning factors
having not attended for over 15 months, will have influencing symptomatic attendance. However,
obtaining factors that prompted asymptomatic In another study of expectant mothers (Rogers et al.
people to attend the dentist was more difficult. In 1991), the main factor for non-attendance was the
terms of factors that affect the dental attendance of same although fear was reported more frequently
the general population, Bullock and coworkers than the other reports, which again, could have been
reports results from a case control study set in a exacerbated as the research was conducted in a
General Dental Practice in Stoke-on-Trent (Bullock et clinical setting (Rogers et al. 1991).
al. 2001). Two hundred patients, were divided into
regular attendees (patients 18 yrs or over who had Studies that focus on dependent groups (children,
attended for two dental examinations in the last 2 adults with disabilities and frail older people)
years) and causal attendees (patients 18 or over who demonstrate the way in which their dental
had not attended for a dental examination for the attendance depends on other individuals. Hendricks
past 2 years and who attended at time of and co-workers for example, reported that
questionnaire in response to a dental problem) each asymptomatic dental attendance among children is
completing a self-administered questionnaire. The based on the tension in the relationship between the
most frequent reason cited by regular attendees for mother’s positive attitude towards preventative care
their asymptomatic attendance was ‘to keep my versus the fear and dislike of pain or discomfort
teeth’ (96%), followed by a concern with the early caused to their children (Hendricks et al. 1990).
diagnosis of problems and the cosmetic appearance Mothers’ past experience of dentistry also influenced
of teeth, the avoidance of pain and to encourage attendance patterns, in addition to a lack of
their children to attend the dentist regularly. Fifty six confidence or issues of trust. Newsome and co-
per cent of irregular attendees reported a fear or a workers also outlined however, the way in which
dislike of dental treatment, followed by concerns childhood dental anxiety can also negatively impact
about cost (41%) and time (32%). The OFT survey on attendance (Newsome et al. 1999). In a study on
however, reported the primary reason for not being reported barriers to dental care for dependent older
registered with a dentist was overwhelmingly lack of adults by Lester and co-workers, responses by both
perceived need (43%), in a similar cohort of patients. carers and patients themselves were recorded and
Fear or dislike of dentists was much less frequently compared (Lester et al. 1998). While patients most
reported (2%). This discrepancy over the primary frequently reported lack of perceived need and cost
reason for non-attendance could possibly be as the most influential factors affecting their
explained by exploring the circumstances in which attendance, the carers of this same group of patients
the research took place; questionnaires in the Bullock cited transport, health, cost and lack of escort as the
and coworkers study were completed in the dentists most significant reasons.
waiting room, which may have exacerbated any fears
of the dentist/dental treatment (Bullock et al. 2001). 3.5.4 Satisfaction with NHS dental services in
England and Wales
The results of several studies that focus on The scope of this search was limited to people who
attendance of specific demographic groups report believed they were currently registered with an NHS
similar results in many instances. A sub-group dentist (although there may be a sub-set of these
analysis of older people within the Bullock and who were unknowingly deregistered) and to their
co-workers study, revealed that the prime reason for satisfaction with the NHS dental service. It did not
non-attendance was lack of perceived need (Bullock cover access to NHS dental services; however, this is
et al. 2001). A study on non-attending dentate older currently being reviewed by the National Audit
adults conducted within three areas of Britain by Office. In addition, it was important that the views of
Steele and co-workers also reported a perception that a nationally representative sample of the population
there was no need to attend as the most common were sought as findings from regional studies may be
factor for non-attendance. A significant proportion misleading as service provision varies within England
of respondents also had concerns over the high and Wales.
financial cost (22-37.5%) and a fear or dislike of
the treatment (23.6-38.2%) (Steele et al. 1996).
The most recent and comprehensive survey that While the general trends reported by the OFT study
considered the satisfaction of the public with NHS are reliable, the design of such surveys are limited by
dentistry was conducted by the Office of Fair Trading their lack of flexibility in possible responses, the
(OFT) in 2003. The Consumer’s Experience of Dental potential for poor interpretation of the questions/
Services (Office of Fair Trading 2003) comprises answers and their intention, which may create
nearly 4,000 interviews with adults over 18 years of suspicion by respondents. The review by Newsome
age, nearly 2,000 of whom said they were registered and co-workers for example, recognised that studies
with an NHS dentist. The OFT survey was carried out seeking to explore patient satisfaction with NHS
by a company called Capibus who ensure their dentistry often explore patient’s perceptions of
samples are nationally and regionally representative, various service quality attributes (Newsome et al.
from urban and rural areas of Great Britain. 1999). For instance, although some patients may
Newsome and co-workers also provides a review of acknowledge instances in which they have received
studies from 1980 to 1997 that look at patient poor treatment, it is unlikely that they will be able to
satisfaction, although it is not apparent if these assess all levels of clinical competence in dentistry,
studies were restricted to the NHS service (Newsome yet the OFT survey cited ‘bad treatment’ as being the
et al. 1999). Two additional reports published strongest determinant of dental satisfaction. This
recently, Calnan and co-workers (Calnan et al. 1999) illustrates how impressions of the service are usually
and Hancock and co-workers (Hancock et al. 1999), formed from a number of other features. The
were conducted on a much smaller scale and there is Newsome and co-workers review suggests that
substantial overlap in conclusions. interpersonal factors (including provision of
information, a caring attitude and discussion with
The OFT study concluded that NHS patients are the patient over treatment options) are consistently
generally positive about quality of service they reported by patients to be the most important
receive, information provided, advice and value for factors in a dentist. Furthermore, the cost of
money (Office of Fair Trading 2003) although with treatment per se, is not a source of contention with
the exception of value of money, private patients patients who are within the NHS system, but the
rated their dentists significantly higher. Calnan at al’s communication about fee (for example, ignorance of
work on NHS dental patients reported that there was charge until after the treatment or anger about the
some evidence to suggest that older people value the way in which the final bill was presented).
service slightly higher compared with the younger
population, although the effect is small (Calnan et al. In conclusion, patients are generally satisfied with
2003). Related to this, there is also an overall their NHS dental service and they view interpersonal
confidence in dentists, which seems to increase with factors with the dentist as the most important aspect
age. Both private and NHS patients aged 15-24 are of this satisfaction.
significantly less confident than any age group, while
those aged 65 and over have the highest mean score
for confidence (in their dentists). In terms of areas of
patients dissatisfaction, only 6% of both private and
NHS patients in the OFT survey said that they had
cause to complain. The most common grievance was
bad treatment, followed by incompetence and pain
and infection. Although only 3% of all patients
actually did complain, it should be noted that 70% of
NHS patients who had not complained, were not
aware of the procedure to do so. There was also a low
satisfaction among NHS patients regarding how the
complaint was handled (Office of Fair Trading 2003).
4. Economic Modelling
4.1 Methods The new model took the following characteristics

Currently, the most relevant published study of the from the HTA Report model:
cost-effectiveness of dental recall intervals is the
> The objective was to estimate the relative cost-
model contained in the HTA Report. However, this
effectiveness of different recall intervals
study had a number of limitations, including the
between 3 months and 36 months (based on
following:
caries risk)
> The HTA Report does not state what
> The target population was a cohort of general
assumptions/data were used in the model that
population of England and Wales aged 12 at
would lead to oral health being greater with
baseline.1
shorter recall intervals
> A cohort simulation (Markov model) estimated
> It considered only dental caries prevention and
oral health and the number of both Oral Health
not other aspects of oral health
Reviews (OHR) and caries treatment episodes
> The outcome used for health gain in dental over the lifetime of the patients to age 80.
caries prevention (in the model for adults it was
number of DMFT at age 80) was not ideal. 4.2 Conclusions
With the evidence base as it stands, we are currently
Using evidence from this Guideline’s systematic a long way from determining the optimal dental
review we decided to construct a modified model recall intervals on the basis of cost-effectiveness.
that would improve on limitations one and three. If we are to assess this in the future then research
However, the incorporation of other aspects of oral is needed that will:
health (limitation two) was not possible because of
the lack of suitable data and also the absence of an Give a more precise definition of the components
overall measure of health outcome. of and duration of an oral health review.
Despite these modifications, the model presented in Further the development of outcome measures (such as
this guideline (see Appendix E) is highly constrained the quality-adjusted tooth-year) that capture the most
by data availability and therefore cannot be used to important aspects of oral health by weighting different
decide optimal recall intervals. Its primary purpose is health states according to people’s preferences.
to explore the possible patterns of cost-effectiveness,
identify the main parameters driving cost- Estimate the rate of transmission over time between
effectiveness and highlight gaps in the evidence-base these different health states (e.g. between decayed
such that cost-effectiveness of recall intervals can be and filled or between decayed and missing). Ideally
more adequately addressed in the future. this should be estimated separately for different risk
subgroups
1
The HTA Report also conducted a model for children with deciduous dentition, however because of the lack of precision in the model parameters,
we have restricted our analysis to the 12-80 age range.
ECONOMIC MODELLING 39
Evaluate how different recall intervals affect the

transmission rates, preferably in the context of a
well-conducted clinical trial. (Ideally this should be
stratified by risk subgroups)
For the chosen health outcome measure, determine

a cost-effectiveness threshold, beyond which the
clinical improvement would be considered too small
to justify the cost.
The model presented in Appendix E represents a

starting point from which more sophisticated models
based on good quality data should be developed.
5. Recommendations
The recommendations in this guideline are designed The diagram illustrates and summarises for clinicians
to assist dentists in using their clinical judgement to the process of selecting, agreeing and reviewing
assign recall intervals that are appropriate to the appropriate recall intervals.
needs of individual patients. These recommendations
are made by the Guideline Development Group The clinical scenarios have been devised by the GDG
(GDG) following a review of the scientific literature to illustrate how recall interval selection will work in
that was considered in the context of the Group’s practice when the guidance is followed.
collective clinical expertise and views on patient
preferences. 5.1 Part I: Clinical Recommendations
1. The recommended interval between oral health
This guidance is evidence-based and the grading reviews should be determined specifically for each
scheme (A, B, C, D, GPP) used for recommendations patient and tailored to meet his or her needs, on
is that described in Chapter One. A recommendation’s the basis of an assessment of disease levels and
grade may not necessarily reflect the importance risk of or from dental disease. [D]
attached to the recommendation. For example, the
2. This assessment should integrate the evidence
Guideline Development Group agreed that the
presented in this guideline with the clinical
principles underlying the individualisation of recall
judgement and expertise of the dental team, and
intervals advocated in this guideline are particularly
should be discussed with the patient. [GPP]
important. However, most of the related
recommendations receive a D or good practice 3. During an oral health review, the dental team
point (GPP) grading. (led by the dentist) should ensure that
comprehensive histories are taken, examinations
In order to provide assistance and support for are conducted and initial preventive advice is
clinicians in implementing these recommendations, given. This will allow the dental team and the
an Appendix is provided (Appendix G) which consists patient (and/or his or her parent, guardian or
of a ‘checklist,’ a diagram and a series of clinical carer) to discuss, where appropriate:
scenarios.
> the effects of oral hygiene, diet, fluoride use,
tobacco and alcohol on oral health [B]
The ‘checklist’ can be used when assessing a patient’s
risk of or from oral disease. Dentists may use this > the risk factors (see the checklist in Appendix G)
‘checklist’ as it is or may modify it to develop their that may influence the patient’s oral health, and
own electronic records or patient questionnaire. The their implications for deciding the appropriate
manner in which this ‘checklist’ can be used as part recall interval [D]
of a risk assessment process is explained in
> the outcome of previous care episodes and the
Appendix G.
suitability of previously recommended intervals
[GPP]
R E C O M M E N DAT I O N S 41
> the patient’s ability or desire to visit the dentist Recall intervals for patients who have
at the recommended interval [GPP] repeatedly demonstrated that they can
maintain oral health and who are not
> the financial costs to the patient of having the
considered to be at risk of or from oral disease
oral health review and any subsequent
may be extended over time up to an interval of
treatments. [GPP]
24 months. Intervals of longer than 24 months
4. The interval before the next oral health review are undesirable because they could diminish the
should be chosen, either at the end of an oral professional relationship between dentist and
health review if no further treatment is indicated, patient, and people’s lifestyles may change.
or on completion of a specific treatment journey.
6. For practical reasons, the patient should be
[GPP]
assigned a recall interval of 3, 6, 9 or 12 months
5. The recommended shortest and longest intervals if he or she is younger than 18 years, or 3, 6, 9,
between oral health reviews are as follows. 12, 15, 18, 21 or 24 months if he or she is aged
18 years or older. [GPP]
> The shortest interval between oral health reviews
for all patients should be 3 months. [GPP] 7. The dentist should discuss the recommended
recall interval with the patient and record this
A recall interval of less than 3 months is not
interval, and the patient’s agreement or
normally needed for a routine dental recall.
disagreement with it, in the current record-
A patient may need to be seen more frequently
keeping system. [GPP]
for specific reasons such as disease
management, ongoing courses of treatment, 8. The recall interval should be reviewed again at
emergency dental interventions, or episodes the next oral health review, to learn from the
of specialist care, which are outside the scope patient’s responses to the oral care provided and
of an oral health review. the health outcomes achieved. This feedback and
the findings of the oral health review should be
> The longest interval between oral health reviews
used to adjust the next recall interval chosen.
for patients younger than 18 years should be
Patients should be informed that their
12 months. [GPP]
recommended recall interval may vary over time.
There is evidence that the rate of progression [GPP]
of dental caries can be more rapid in children
and adolescents than in older people, and it
seems to be faster in primary teeth than in
permanent teeth (see Chapter Three, Section
3.1.2)). Periodic developmental assessment of
the dentition is also required in children.
Recall intervals of no longer than 12 months

give the opportunity for delivering and
reinforcing preventive advice and for raising
awareness of the importance of good oral
health. This is particularly important in young
children, to lay the foundations for life-long
dental health.
> The longest interval between oral health reviews

for patients aged 18 years and older should be
24 months. [GPP]
6. Implementation and Audit
6.1 Background Since August 2002, new legislation has been

The bulk of the Primary Dental Care Services in the introduced and a fundamental change in the
NHS in England have been provided (since 1948) by methods of delivery and remuneration of primary
independent contractors working under so-called care dentistry is being introduced. The Scope agreed
“item of service” arrangements in the General Dental for this Guideline specifically asked the Guideline
Services (GDS). A smaller, salaried Community Dental Development Group to “take account of the current
Service (CDS) has provided dental primary care for system of delivering dental care and also the policy
children and special needs groups. Changes from the direction in which the clinical and payment systems
late 1990s introduced a number of locally tailored are being modernised” and referred to the Options
methods of delivering dental primary care under the document as the blueprint for this modernisation.
Personal Dental Services (PDS) arrangements and, in
turn, some of these have become linked to “dental From April 2005 all contracts with General Dentists
access centres” in recent years. will be held with local primary care trusts (PCTs) and
a new “Base Contract” will operate remunerating
In August 2002 the Department of Health Published practices on the basis of a rolling average of previous
a document called “Options for Change” (Department earnings and expenditures. The direct link to item of
of Health 2002) which set out the results of an service care will be broken. It is anticipated that this
extended process of considering how NHS Dentistry Base Contract will gradually evolve over coming years
could best be modernised to reflect the sentiments of in a variety of ways with a focus on access and
the wider NHS Plan and at the same time address patient-centred preventive care services with an
some of the concerns that had been raised for some emphasis on quality rather than quantity of care.
years by both the profession and patient groups. This
document mapped out a future shape for NHS Dental Thus as the final form of this guidance will be
Primary Care. Options for Change listed eight key published on 29th September 2004, the earliest the
areas for significant change: initial recalls according to this strategy could be
planned would be at the end of 2004/early 2005.
> Local commissioning and funding. It would be expected that the majority would fall
after April 1st 2005 and come under the new
> Methods of remuneration for GDPs.
arrangements. It will be necessary to ensure that
> Prevention and Oral Health Assessments. reasonable arrangements are put in place to make
the position clear to both patients and the profession
> The patient experience.
as new arrangements develop and evolve.
> Information and communication technology.
6.2 Implementation
> Practice structure.
This guidance contains a number of tools and
> Development of the Dental Team. suggestions to facilitate effective implementation
and review. The provision in Appendix G of i) a
> Clinical Pathways.
comprehensive risk checklist with explanatory notes
I M P L E M E N TAT I O N A N D AU D I T 43
ii) a diagram to illustrate the steps involved in recall Postgraduate and Continuing Education – It is
interval selection and iii) a series of clinical scenarios hoped that the key messages of the guidance and
which provide a range of worked clinical examples, the clinical, preventive philosophy behind it can be
all designed to help NHS dental practices and their incorporated in planned educational activities.
patients get used to what will be for many a new
way of planning and receiving routine NHS dental NeLH, the virtual Centre for Improving Oral Health
care. (vC-IOH) and the developing National Oral Health
Knowledge Service – A number of developments
NHS Clinical Care Pathways – A clinical care in supporting and coordinating evidence-based
pathway is an outline of anticipated care, placed in dentistry are currently under development. Steps will
an appropriate timeframe, to help a patient with a be taken to ensure that the guidance appears on the
specific condition move progressively through a National electronic Library for Health (NeLH)
clinical experience to positive outcomes. NHS clinical [www.nelh.nhs.uk] and that its rationale and
care pathways are being developed to further the recommendations are promoted by the virtual
aims outlined in the Department of Health’s strategy Centre for Improving Oral Health (vC-IOH)
document NHS Dentistry: Options for Change [www.dundee.ac.uk/dhsru/iks/mona/hotel1.htm]
(2002). The first clinical care pathway for NHS and are linked to new dental IT developments.
dentistry is being developed by the Dental Health
Services Research Unit at the University of Dundee 6.3 Audit
and deals with the initial oral health assessment and Patient records should reflect that appropriate recall
the subsequent oral health review (see diagram in intervals have been identified on the basis of the
Appendix A). It is being tested by NHS Options for assessment of risk in discussion with the patient.
Change field sites, which include dental practices, The following four criteria can be used to audit
primary care trusts and strategic health authorities adherence to the guideline recommendations:
who volunteered to test the modernisation proposals
> At the end of each oral health review there is
outlined in Options for Change. The pathway
a record for each patient of an assessment of
accommodates the NICE recommendations on recall
disease and disease risk.
intervals and this should help a seamless move into
modernised, preventive NHS dental care. > At the end of each oral health review, or at
completion of treatment, there is a record for
Support for Practices and Dental Teams – each patient of the recall interval recommended
The NICE guideline, Quick Reference Guide, public by the dentist for the next oral health review.
information leaflets and posters and the patient
> The interval agreed each time, for each patient is:
version of the guidance should all ensure that easy-
– 3, 6, 9, or 12 months for patients younger
to-access information about the recall
than 18 years, or
recommendations are widely available to dental
– 3, 6, 9, 12, 15, 18, 21, or 24 months for
practices and clinics delivering NHS care in England
patients aged 18 years or older.
and Wales.
> Where there is disagreement between dentist
Support for Patients – This guideline is different and patient over the recall interval, the reason
from the majority of guidelines in that the whole for this is recorded.
population is affected. The guideline document,
including an information leaflet and poster for the
public, should ensure that easy access to information
about the recall recommendations are widely
available to all people in England and Wales.
Given that the guideline recommendations will Audit at the local (PCT) level – this will become
represent a significant departure from current more important as PCTs develop the local
practice for many dentists, the Guideline arrangements and seek to understand the quality
Development Group also recommends that: dimensions and patient acceptability of the new
styles of dental care. The Strategic Health Authorities
> The acceptability and performance of the
(SHAs) and Welsh Health Boards may also call for
guidance should be assessed routinely in order
the (anonymised) results of such local audits.
to refine and improve the guidance informing
the recommended interval and the effectiveness
Audit at National level – with the radical changes
of the Oral Health Assessment/Oral Health
in commissioning NHS dental care, there will be a
Review.
need to understand how the new arrangements are
working and to evaluate the overall performance to
This means that as the new arrangements for
the new systems and the quality of care being
delivering dental care come in and settle down,
delivered. Once again, this will demand more of the
an impact assessment of the introduction of this
new IT arrangements which hold the key to ready
guidance should be introduced. It is hoped that
and efficient access to understanding change and
arrangements can be made to establish what
quality.
changes in recall behaviour are brought about by
the publication of this guidance, although the
New Dental and NHS-wide IT developments should,
simultaneous introduction of a number of changes
over time, allow much of this routine information to
may complicate this.
be collected without additional administrative
> A new minimum dataset should be established, burdens. It is essential that these needs are reflected
consistent with the new, more preventive, in the design, specification and development of new
philosophy inherent in the evolving IT systems and that these requirements are met while
arrangements for NHS Dentistry. Data should be satisfying contemporary data protection and privacy
recorded routinely in such a way to facilitate its requirements.
use for service improvement at the patient,
practice, primary care trusts, Shadow Health If not addressed early on, there is a danger that the
Authority and national levels. automated collection and processing of audit data
about dental recalls, which will be needed, may be
Minimum Data requirements – it will be important compromised. This is due to the scale and pace of
for the profession, the PCTs and the Shadow Special the remuneration changes which will be introduced
Health Authority (Dental Practice Board) to agree a in 2005. Confidentiality is a further consideration as
coherent and workable dataset to allow efficient appropriate information and agreement must be
collection of data and the comparison of what obtained from the patient, where necessary, to
happens in different localities over time. Continuity ensure that the legitimate use of patient information
of existing longitudinal data sets is necessary. for improving the quality of patient care can
continue.
Audit at the Practice level – Recall intervals will
make a ready and important audit topic at the 6.4 Research Recommendations
practice level. Some coordinated production of audit While developing this guideline, the research
tools may facilitate this process. The incorporation of evidence in a number of areas was found either to be
the minimum data set into Dental IT software would inconclusive or not to exist. The absence of reliable
help automate the data collection and reduce the research was partly a consequence of a lack of
administrative burden. It is important that any funding in certain areas and poor or inappropriate
patient who may suffer from disease progression and study design in others. Research in the following
is allocated a more extended recall should be areas would help in updating this guideline and
monitored. implementing it in general dental practice.
I M P L E M E N TAT I O N A N D AU D I T 45
> Dental attendance patterns should be examined

for changes after the publication of the
guideline. To allow this, the future use of routine
data for this purpose must be communicated
appropriately to patients in order to satisfy
confidentiality considerations.
> After publication of the guideline, information

will be needed on whether patients visit the
dentist at the agreed interval, and their reasons
for this.
> Research is needed on the long-term clinical and

cost effectiveness of one-to-one oral health
advice and whether this may depend upon:
– The frequency with which it is delivered
– The physical/oral health of the patient
– Other characteristics of the patient (for
example, age, sex, social class, occupation)
– The medium used to deliver the advice
– Who delivers the advice
> Research is needed to examine the effects of

varying dental recall intervals on oral health,
and on which aspects of the oral health review
influence oral health.
> Research is needed to examine the impact of

oral health (relating to gingivitis, caries,
periodontal disease and mucosal disease) on
quality of life.
> Research is needed to examine the effects on

periodontal health of routine scale and polish
treatment (in conjunction with oral hygiene
instruction) in different populations. Specifically,
research is needed to examine the clinical
effectiveness and cost effectiveness of providing
this intervention at different time intervals
Research designs will need to accommodate the

mix of arrangements (NHS, private and mixed
configurations) under which dental primary care
is provided.
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Glossary of Terms
Active carious lesion Caries lesions may be classified according to their activity. The clinical distinction between active and
arrested lesions is sometimes difficult to make. There will often be a continuum of transient changes
from active to arrested and vice versa. A lesion considered to be progressive can be described as an
active caries lesion. In contrast, a lesion that may have formed years previously and then stopped
further progression can be referred to as an arrested or inactive caries lesion. Once cavitation has
occurred, exposed dentine is a good indicator of activity status. Active or progressing caries in
dentine is usually light brown in colour and very soft. In long standing caries, the dentine is usually
much firmer to touch and dark in colour. Root caries also usually shows these characteristics
(Adelaide University et al. 1998).
AIDS Acquired Immune Deficiency Syndrome. AIDS is the result of damage to the immune system.
A damaged immune system is unable to protect the body against certain specific ‘opportunistic’
infections and tumours.
Bulimia nervosa A syndrome characterised by recurrent episodes of binge eating and by compensatory behaviour
(vomiting, purging, fasting or exercising) in order to prevent weight gain. Binge eating is
accompanied by a subjective feeling of loss of control over eating. This is a normal weight syndrome
in which the body mass index (BMI) is maintained above 17.5 kg/m2.
Caries experience the sum of filled and unfilled cavities, together with any missing teeth resulting from decay.
Caries risk assessment A process that attempts to identify people who are at greater risk for a high level of caries and who
may need more oral health supervision and preventive intervention.
Cavitated lesions Carious lesions where there is a visible macroscopic breakdown in the tooth surface (that is, a visible
‘hole’) and the area may have softened walls or floor.
Dental caries (dental An initially subsurface, preventable disease of the mineralised tissues of the teeth with a
decay, tooth decay or multi-factorial aetiology related to the interactions over time between tooth substance and
‘cavities’) certain micro-organisms and dietary carbohydrates producing plaque acids.
Dental hygienist The primary role of a dental hygienist is to educate patients to take care of their teeth and gums,
including demonstrating cleaning techniques and providing advice about the effects of diet.
Dental therapist A dental therapist carries out certain clinical work, and acts as an educator, teaching patients the
necessary skills to enable them to maintain their oral hygiene effectively. A dental therapist works
under direction and to the dentist’s written prescription
Dentate A term applied to a person who has one or more natural teeth present.
GLOSSARY OF TERMS 55
Dentist A person qualified to practice dentistry. Dentists provide regular check ups on your teeth and gums.
Part of their work involves teaching people to look after their teeth and gums in order to prevent
problems. It also includes restoration of teeth damaged or lost by decay, trauma or other reasons,
using a wide variety of techniques and materials.
Edentulous/edentate A term applied to a person who has no natural teeth remaining.
Early childhood caries Dental decay of the primary teeth (‘baby’ or ‘first’ teeth) of infants and young children (aged 1 to 5
years) often characterised by rapid destruction of tooth tissue.
Early, initial or incipient Refer to the stage of lesion development. Used to describe the first sign of a caries lesion on enamel
lesion that can be detected with the naked eye. An initial lesion appears as a white, opaque change (a
white-spot) but not all white-spot lesions are incipient.
Fissure sealants Plastic coatings applied to the surfaces of teeth with developmental pits and grooves (primarily the
(or ‘sealants’) chewing surfaces of teeth) to protect the tooth surfaces from collecting food debris and bacteria that
promote the development of dental decay.
Fluoride A compound of the element fluorine. Fluoride is used in a variety of ways to reduce dental decay.
Gingivitis A reversible inflammatory condition of the gum tissue, where the gum can appear reddened and
swollen and frequently bleeds easily. It is usually caused by inadequate personal oral hygiene.
Gingivitis is a precursor to periodontitis in some people.
‘Hidden’ or ‘occult’ caries Non-cavitated lesions in dentine that may be overlooked on a visual clinical examination but which
are large and demineralised enough to be detected radiographically.
HIV Human Immunodeficiency Virus. A virus, belonging to a group of retroviruses, that can lead to AIDS.
HTA Report Refers to the report “The clinical effectiveness and cost-effectiveness of routine dental checks: a
systematic review and economic evaluation” written by Davenport et al. and published by the Health
Technology Assessment NHS R& D HTA Programme(Davenport et al. 2003)
Inflammation A localised protective response elicited by injury or destruction of tissue, which serves to destroy,
dilute, or wall off both the injurious agent and the injured tissue. A cellular and vascular reaction
of tissues to injury (American Academy of Periodontology 1996).
International Classification Most international databases for recording statistics on oral cancer use the International
of Disease (ICD) Classification of Diseases (ICD) coding system of the World Health Organisation (WHO). Most of the
data currently available are expressed according to the ninth revision of this system (ICD-9).
Lesion arrest and lesion The progression of enamel lesions with macroscopically intact surfaces is often slow and such lesions
reversal do not inevitably progress to cavitation; they can stop (or be stopped via appropriate preventive
intervention for example, application of topical fluoride) – lesion arrest, or even reverse (or be
reversed by appropriate preventive intervention for example, application of topical fluoride) –
lesion reversal/regression.
Meta-analysis Results from a collection of independent studies (investigating the same treatment) are pooled,
using statistical techniques to synthesise their findings into a single estimate of a treatment effect.
Where studies are not compatible for example, because of differences in the study populations or in
the outcomes measured, it may be inappropriate or even misleading to statistically pool results in
this way.
Non-cavitated lesions Lesions where there is no macroscopically visible disruption of the continuity of the enamel surface.
Non-cavitated smooth These lesions typically manifest on the smooth surfaces of teeth as chalky white or light brown
surface lesions in enamel demineralisation of the enamel where the discoloured area has no signs of cavitation after a careful
visual inspection. Such lesions are usually located in areas where dental plaque may accumulate
(close to the gingival margin). The surface of the area is matted (not glossy) when a tooth is dried.
Non-cavitated pit and These lesions typically manifest as light or dark brown discoloration at the base of the pit or fissure
fissure lesions in enamel with or without white demineralisation at the sides of the pit or fissure that can be detected visually
after cleaning and drying the teeth.
Non-cavitated lesions These lesions have visible signs of undermined enamel that show as opacity or discolouration
in dentine beneath an apparently intact enamel surface.
Odds ratio Odds are a way of representing probability, especially familiar for betting. In recent years odds ratios
have become widely used in reports of clinical studies. They provide an estimate (usually with a
confidence interval) for the effect of a treatment. Odds are used to convey the idea of ‘risk’ and an
odds ratio of 1 between two treatment groups would imply that the risks of an adverse outcome
were the same in each group.
Oral cancer The term ‘oral cancer’ is used in this guideline to refer to cancer of the lip (ICD-9 code 140), tongue
(code 141), gum (code 143), floor of mouth (code 144), other unspecified parts of the mouth (code
145), oropharynx (code 146), hypopharynx (code 148) and other ill-defined sites within the lip, oral
cavity and pharynx (code 149). This definition excludes cancers of the salivary glands (code 142)
and the nasopharynx (code 147).
Oral cavity The mouth
Oral health Oral health is a standard of health of the oral and related tissues which enables an individual to eat,
speak, and socialise without active disease, discomfort or embarrassment and which contributes to
general well-being (Oral Health Strategy Group 1994).
Oral Health Assessment A comprehensive assessment of a patient’s oral health status carried out when a patient first visits a
practice. It involves taking full patient histories, carrying out thorough dental and head and neck
examination and providing initial preventive advice. The findings are discussed between dentist and
patient who then agree a provisional personalised care plan and a ‘destination’ for this particular
journey of care (see Appendix A).
Oral Health Review The continuing re-examination of a patient’s oral health and risk status (see Appendix A).
Oral health risk assessment A (prognostic) tool that helps dental professionals individualise oral health supervision. It is based
on the concept that the frequency and type of oral health supervision needed by a person depends
on the likelihood that specific diseases or conditions may develop. Risk assessment involves
examining risk factors that may negatively impact an individuals oral health, and protective factors
that promote oral health. Using risk assessment, the dental professional is better positioned to make
specific preventive and treatment recommendations to reduce an individual patient’s risk and
improve their oral health (Bright Futures 1996).
Oral mucosa The tissue lining the oral cavity.
Oral mucosal abnormalities A disorder of the soft tissue that lines the mouth.
Periodontal disease A cluster of diseases caused by microbial plaque and resulting in inflammatory responses and
chronic destruction of the soft tissues and bone that support the teeth. Periodontal disease is a
broad term encompassing several diseases of the gums and tissues supporting the teeth.
GLOSSARY OF TERMS 57
Periodontitis Inflammation of the gums leading to the development of gum pockets with destruction of the soft
tissue attachment of teeth and their supporting bone. Periodontitis is a major cause of tooth loss.
Pharynx the muscular cavity behind the nose and throat
Plaque Bacteria and their products which cling to the tooth surface when oral hygiene is neglected.
Preventive treatment A dental care philosophy which encourages prevention and monitoring rather than early intervention
approach (Davenport et al. 2003).
Primary caries Caries lesions on unrestored tooth surfaces.
Primary prevention Primary prevention protects people against disease, often by placing barriers between the
aetiological agent and the host. It is aimed at keeping a population healthy to minimise the risk
of disease or injury.
Probing attachment level The distance from the cemento-enamel junction (CEJ) to the location of the tip of a periodontal
probe inserted in the pocket with moderate probing force (Papapanou et al. 2003).
Probing depth The distance from the gingival margin to the location of the tip of a periodontal probe inserted in
the pocket with moderate probing force (Papapanou et al. 2003).
Rampant caries Multiple active carious lesions occurring in the same patient. This frequently involves surfaces of
teeth that do not usually experience dental caries (for example, the free smooth surfaces of anterior
teeth). Patients with rampant caries can be classified according to the assumed causality for
example, bottle or nursing caries, baby caries, early childhood caries, radiation caries or drug-induced
caries.
Randomised controlled trial A study to test a specific drug or other treatment in which people are randomly assigned to two (or
more) groups: one (the experimental group) receiving the treatment that is being tested, and the
other (the comparison or control group) receiving an alternative treatment, a placebo (dummy
treatment) or no treatment. The two groups are followed up to compare differences in outcomes to
see how effective the experimental treatment was. (Through randomisation, the groups should be
similar in all aspects apart from the treatment they receive during the study.)
Recall interval The time period, usually expressed in months or years, between an Oral Health Assessment and the
first Oral Health Review, or between two Oral Health Reviews).
Recurrent or Caries lesions that develop adjacent to a filling or other dental restoration.
secondary caries
Restorative treatment A dental care philosophy which encourages early intervention and repair of dental caries at an early
approach stage (Davenport et al. 2003).
Risk The probability of an event occurring in a specific time. In the context of preventive medicine and
preventive dentistry risk, it is the probability of an individual developing a given disease or
experiencing a particular health status over a specified period. Caries risk, for example, is the
probability of an individual developing a carious lesion. By definition, risk is aimed at assessing
developments in the future. However, it can only be assessed on the basis of symptoms present at,
or having manifested themselves by, the time of assessment (Reich et al. 1999).
Risk factor An exposure that is statistically related in some way to an outcome, for example, smoking is a risk
factor for periodontitis. If present, a risk factor directly increases the probability of a disease
occurring and if absent or removed, reduces the probability.
Root caries Dental decay that occurs on the root portion of a tooth. Early lesions on root surfaces are often
difficult to observe visually and require tactile examination with a blunt instrument for example,
periodontal probe. Use of a periodontal probe will allow detection of the leathery consistency of
demineralised cementum/dentine. Colour change (darkening) is usually (but not always) present.
Secondary prevention Secondary prevention aims to limit the progression and effect of a disease at as early a stage as
possible after onset. It includes further primary prevention.
Sensitivity In diagnostic testing, it refers to the chance of having a positive test result given that you have the
disease. 100% sensitivity means that all those with the disease will test positive, but this is not the
same the other way around. A patient could have a positive test result but not have the disease –
this is called a ‘false positive’. The sensitivity of a test is also related to its ‘negative predictive value’
(true negatives) – a test with a sensitivity of 100% means that all those who get a negative test
result do not have the disease. To fully judge the accuracy of a test, its specificity must also be
considered.
Sjögren’s syndrome A condition which features abnormal dryness of the eyes, mouth and vagina. It is associated with
diseases that arise from an immune system that is not working well. The basic cause is unknown.
The dryness results from the reduced secretion of various kinds of glands, following invasion and
damage by white cells (lymphocytes) that are part of the immune system.
Soft tissue lesion An abnormality of the soft tissues of the oral cavity or pharynx.
Specificity In diagnostic testing, it refers to the chance of having a negative test result given that you do not
have the disease. 100% specificity means that all those without the disease will test negative, but
this is not the same the other way around. A patient could have a negative test result yet still have
the disease – this is called a ‘false negative’. The specificity of a test is also related to its ‘positive
predictive value’ (true positives) – a test with a specificity of 100% means that all those who get a
positive test result definitely have the disease. To fully judge the accuracy of a test, its sensitivity
must also be considered.
Tertiary prevention Tertiary prevention is concerned with limiting the extent of disability once a disease has caused
some functional limitation. At this stage, the disease process will have extended to the point where
the patient’s health status has changed and will not return to the pre-diseased state.
Vocational Trainee Vocational training in general dental practice is primarily aimed at the new dental graduate to
provide the initial stage of general professional training and education. The Vocational Trainee
(also known as Vocational Dental Practitioner) is encouraged to develop and expand the clinical
and personal skills learned as an undergraduate during their vocational training year. New graduates
have the opportunity during this year to consider their future – whether a career in general dental
practice, the community dental service, or specialisation within dental practice or the hospital
service.
White-spot lesion Describes the first sign of a caries lesion on enamel that can be detected with the naked eye.
However, whitespot lesions are not necessarily ‘early’ caries lesions – white-spot lesions may have
been present for many years in an arrested state and it is thus misleading to describe such a lesion
as ‘early.’
Xerostomia A condition in which the mouth is dry because of a lack of saliva

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What is the purpose of the guideline?

What is the purpose of the guideline?

What methodology was used to develop the guideline?

What methodology was used to develop the guideline?

i

EVIDENCE, METHODS & GUIDANCE

Acknowledgements v 2.2.5 Other caries outcome measures used in our

3.4.4 Dietary Advice 34 References 46

6 Implementation and Audit 42

Guideline Development Group

Staff who worked on the guideline

Addenbrooke’s NHS Trust Faculty of General Dental Practitioners

Alan Martin & Associates Faculty of Public Health

Anglesey Local Health Board GC United Kingdom Limited

Association of Consultants and Specialists General Dental Practitioners’ Association

Rotherham Primary Care Trust

Royal College of General Practitioners

Royal College of General Practitioners Wales

Royal Pharmaceutical Society of Great Britain

Scottish Intercollegiate Guidelines Network (SIGN)

Sheffield Teaching Hospitals NHS Trust

Software of Excellence International Ltd

South & Central Huddersfield PCTs

South Birmingham Primary Care Trust

South Devon Health Care Trust

Southampton City PCT

The British Dental Trade Association

The Royal Society of Medicine

The Royal West Sussex Trust

Tregenna Hill Dental Surgery

University College Londons Hospital NHS Trust

Welsh Assembly Government (formerly National

West Norfolk PCT

Westmeria Healthcare Ltd

Abbreviations used in Guideline

AIDS Acquired Immune Deficiency Syndrome

BPE Basic Periodontal Examination

CDS Community Dental Service

CEA Cost Effectiveness Analysis

COHG Cochrane Oral Health Group

DMF Decayed Missing Filled

DMFS Decayed Missing Filled Surfaces

DFS Decayed Filled Surfaces

DMFT Decayed Missing Filled Teeth

DPB Dental Practice Board

EBV Epstein Barr Virus

FGDP General Dental Practitioners

GDG Guideline Development Group

GDS General Dental Service

GPP Good Practice Point

HIV Human Immunodeficiency Virus

HPV Human Papilloma Virus

HSV Herpes Simplex Virus

HTA Health Technology Assessment

ICD International Classification of Diseases

NCC-AC National Collaborating Centre for Acute Care

HEED Health Economic Evaluations Database

NHS National Health Service