Dental checks: intervals between oral health reviews

This guideline covers assigning recall intervals between oral health reviews that are appropriate to the needs of individual patients. The guideline takes account of the effect of dental checks on: peoples wellbeing, general health and preventive habits; caries incidence and avoiding restorations; periodontal health and avoiding tooth loss; and avoiding pain and anxiety. It aims to improve or maintain patients quality of life and reduce morbidity associated with oral and dental disease.

# Introduction
Six-monthly dental check-ups have been customary in the General Dental Service in the UK since the inception of the NHS. In recent years there has been significant debate over the timing of recall intervals for dental check-ups, and this has coincided with a move towards making NHS dental services in England and Wales more oriented to prevention and more clinically effective in meeting patients' needs.
The Department of Health's strategy document NHS Dentistry: Options for Change (2002) and subsequent legislation are bringing about changes in the organisation of dental services and the way in which oral health is assessed. Under the new arrangements, a comprehensive oral health assessment will be conducted when a patient first visits a dental practice and will involve taking full histories, carrying out thorough dental and head and neck examinations and providing initial preventive advice. The dentist and patient will discuss the findings and agree a personalised care plan and a 'destination' for this journey of care. The dental team and patient will then work through this first personal care plan.
After an agreed interval, the patient will return for an oral health review, during which the histories and examination will be updated and any changes in risk factors noted. The dental team will also assess the effectiveness of the treatment and preventive advice provided previously, and will give more advice as necessary. The patient and dentist will discuss the findings of the review and agree the next, refined, personalised care plan and a specific 'destination' for this new journey of care.
The purpose of this guideline is to help clinicians assign recall intervals between oral health reviews that are appropriate to the needs of individual patients. The recommendations apply to patients of all ages (both dentate and edentulous) receiving primary care from NHS dental staff in England and Wales. The guideline takes into account the potential of the patient and the dental team to improve or maintain the patient's quality of life and to reduce morbidity associated with oral and dental disease.
The recommendations take account of the impact of dental checks on: patients' wellbeing, general health and preventive habits; caries incidence and avoiding restorations; periodontal health and avoiding tooth loss; and avoiding pain and anxiety.
This guideline does not cover:
recall intervals for scale and polish treatments
the prescription and timing of dental radiographs
intervals between examinations that are not routine dental recalls; that is, intervals between examinations relating to ongoing courses of treatment
emergency dental interventions or intervals between episodes of specialist care.
The following guidance is based on the best available evidence. There is evidence relating to risk factors for oral disease and on the effectiveness of dental health education and oral health promotion, and this was used to inform the guideline recommendations. However, the research evidence on many aspects of dental recall intervals was limited, and recommendations were based on the clinical experience of the guideline development group and advice received during the consultation process.# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
The recommended interval between oral health reviews should be determined specifically for each patient and tailored to meet his or her needs, on the basis of an assessment of disease levels and risk of or from dental disease.
This assessment should integrate the evidence presented in this guideline with the clinical judgement and expertise of the dental team, and should be discussed with the patient.
During an oral health review, the dental team (led by the dentist) should ensure that comprehensive histories are taken, examinations are conducted and initial preventive advice is given (see NICE's guideline on oral health promotion: general dental practice). This will allow the dental team and the patient (and/or his or her parent, guardian or carer) to discuss, where appropriate:
the effects of oral hygiene, diet, fluoride use, tobacco and alcohol on oral health
the risk factors (see the checklist in appendix G of the full guideline) that may influence the patient's oral health, and their implications for deciding the appropriate recall interval
the outcome of previous care episodes and the suitability of previously recommended intervals
the patient's ability or desire to visit the dentist at the recommended interval
the financial costs to the patient of having the oral health review and any subsequent treatments.
The interval before the next oral health review should be chosen, either at the end of an oral health review if no further treatment is indicated, or on completion of a specific treatment journey.
The recommended shortest and longest intervals between oral health reviews are as follows:
The shortest interval between oral health reviews for all patients should be 3 months.A recall interval of less than 3 months is not normally needed for a routine dental recall. A patient may need to be seen more frequently for specific reasons such as disease management, ongoing courses of treatment, emergency dental interventions, or episodes of specialist care, which are outside the scope of an oral health review.
The longest interval between oral health reviews for patients younger than 18 years should be 12 months. There is evidence that the rate of progression 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 the full guideline). 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. Recall intervals for patients who have repeatedly demonstrated that they can maintain oral health and who are not considered to be at risk of or from oral disease may be extended over time up to an interval of 24 months. Intervals of longer than 24 months are undesirable because they could diminish the professional relationship between dentist and patient, and people's lifestyles may change.
For practical reasons, the patient should be assigned a recall interval of 3, 6, 9 or 12 months if he or she is younger than 18 years old, or 3, 6, 9, 12, 15, 18, 21 or 24 months if he or she is aged 18 years or older.
The dentist should discuss the recommended recall interval with the patient and record this interval, and the patient's agreement or disagreement with it, in the current record-keeping system.
The recall interval should be reviewed again at the next oral health review, to learn from the patient's responses to the oral care provided and the health outcomes achieved. This feedback and the findings of the oral health review should be used to adjust the next recall interval chosen. Patients should be informed that their recommended recall interval may vary over time. The interval may be maintained at the same level if it is achieving its aims. For someone with low disease activity, it may be possible to gradually extend the interval towards the 24month maximum period  once the patient and the dental team are confident that this is satisfactory. Patients whose disease activity continues unabated may need a shorter interval and may need more intensive preventive care and closer supervision.Patients should be encouraged to seek advice from a dentist before their next scheduled review if there are any significant changes in their risk factors. They also need to understand that (as is the case with the current 6month recall regimen) there is no guarantee that new disease will not develop between recall visits.# Recommendations for research
While developing this guideline, the research evidence in a number of areas was found either to be inconclusive or not to exist. Research in the following areas would help in updating this guideline and implementing it in general dental practice:
Dental attendance patterns should be examined for changes after the publication of the guideline.
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 on:
the frequency with which it is delivered
the physical or oral health of the patient
-ther 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.