Guidance

Chapter 2: Summary guidance tables for dental teams

Updated 9 November 2021

This guidance is issued jointly by the Department of Health and Social Care, the Welsh Government, the Department of Health Northern Ireland, Public Health England, NHS England and NHS Improvement, and with the support of the British Association for the Study of Community Dentistry.

Delivering Better Oral Health has been developed with the support of the 4 UK Chief Dental Officers.

Whilst this guidance seeks to ensure a consistent UK wide approach to prevention of oral diseases, some differences in operational delivery and organisational responsibilities may apply in Wales, Northern Ireland and England. In Scotland the guidance will be used to inform oral health improvement policy.

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How to use these tables

These summary tables list the advice and actions that should be provided for all patients to maintain good oral health. They also outline the additional support that should be offered to people identified as being at higher risk of dental disease. Recent thinking suggests that all patients should be given the benefit of advice, care and support to improve their general and oral health, not just those thought to be at risk.

Patients giving concern are those at higher risk of dental disease, or for whom dental disease, or its management (such as requiring admission to hospital), would provide a significant challenge. They may include:

• children or adults presenting with current or past dental disease
• children with siblings who have dental caries experience
• children who have required dental treatment, including treatment under general anaesthetic or sedation, or whose siblings have done so
• children and adults with physical and learning disabilities
• children or adults who are medically compromised, for example those with diabetes
• mentally and physically frail older people including those with cognitive decline
• people undergoing treatments or therapies that place them at additional risk, for example some cancer treatments or drug therapy that results in dry mouth
• people who are homeless
• people who have contextual or environmental factors that may place them at additional risk for example social disadvantage
• people with specific conditions that may place them at additional risk of disease in specific teeth for example hypoplasia or retained impacted third molars
• people with vulnerabilities that would place them at additional risk from treatment for example chemotherapy

Further details on assessing risk are outlined in Chapter 1. Each patient’s risk needs to be assessed at every dental recall visit and monitored across the life course, as disease risk will change over time.

The grading of the quality (or certainty) of evidence and strength of recommendations in the following summary tables is based on GRADE (Grading of Recommendations, Assessment, Development and Evaluations). It reflects the extent to which the relevant disease-based Guideline Development Group (GDG)^{[footnote 1]} is confident that desirable effects of an intervention outweigh undesirable effects across the range of patients for whom the recommendation is intended.

Strong recommendations – the GDG is highly confident that desirable consequences outweigh undesirable or undesirable consequences outweigh desirable, typically based on high or moderate certainty evidence.

Conditional recommendations – the GDG is less confident of the effectiveness of an intervention (low or very low certainty evidence) or the balance between benefits and harms is unclear.

Good practice – clinical opinion suggests this advice is well established or supported. No robust underpinning research evidence exists. Good practice points are primarily based on extrapolation from research on related topics and/or clinical consensus, expert opinion and precedent, and not on research appropriate for rating the certainty or quality of the evidence^{[footnote 2][footnote 3][footnote 4]}.

It is important to recognise that where a recommendation is conditional rather than strong, this does not mean that the intervention does not work but simply that the current evidence supporting it is not of the highest certainty.

The following tables provide evidence in relation to the prevention of dental caries, periodontal disease, oral cancer and tooth wear. Where appropriate, the tables provide advice according to age and/or specific risk factors.

Table 1: Prevention of dental caries

Prevention of dental caries in children 0 to 6 years of age

All children aged up to 3 years

Recommendation	Strength of recommendation
Advice
Breastfed babies experience less tooth decay and breastfeeding provides the best nutrition for a baby’s overall health. Support mothers to: • breastfeed exclusively for around the first 6 months of a baby’s life • continue breastfeeding while introducing solids from around the age of 6 months	Strong
For parents or carers feeding babies by bottle: • only breastmilk, infant formula or cooled boiled water should be given in a bottle • babies should be introduced to drinking from a free-flow cup from the age of 6 months • feeding from a bottle should be discouraged from the age of 1 year	Good practice
Gradually introduce a wide variety of solid foods (of different textures and flavours) from around the age of 6 months. Sugar should not be added to food or drinks given to babies and toddlers	Good practice
Parents or carers should brush their children’s teeth: • as soon as they erupt • twice a day • last thing at night (or before bedtime) and on one other occasion • with a toothpaste containing at least 1000 ppm fluoride • using only a smear of toothpaste	Strong
Minimise consumption of sugar-containing foods and drinks	Strong
Use sugar-free versions of medicines if possible	Good practice
Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost	Good practice
Professional intervention
Assign a recall interval ranging from 3 to 12 months based on oral health needs and disease risk	Conditional

All children aged 3 to 6 years

Recommendation	Strength of recommendation
Advice
Teeth should be brushed by a parent or carer. As the child gets older, a parent or carer should assist them to brush their own teeth: • on all tooth surfaces • at least twice a day • last thing at night (or before bedtime) and on at least one other occasion • with toothpaste containing at least 1,000 ppm fluoride • using a pea-sized amount of the toothpaste • spitting out after brushing rather than rinsing, to avoid diluting the fluoride concentration	Strong
Minimise amount and frequency of consumption of sugar-containing food and drinks	Strong
Use sugar-free versions of medicines if possible	Good practice
Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost	Conditional
Professional intervention
Apply fluoride varnish (2.26% NaF) to teeth 2 times a year	Strong
Assign a recall interval ranging from 3 to 12 months based on oral health needs and disease risk	Conditional

Children aged 0 to 6 years giving concern because of dental caries risk

Recommendation	Strength of recommendation
All the above, plus:
Advice
Use toothpaste containing 1,350 to 1,500 ppm fluoride	Strong
For children taking medication frequently or long term, choose or request sugar-free medicines if possible	Good practice
Professional intervention
Apply fluoride varnish (2.26% NaF) to teeth 2 or more times a year	Strong
Where the child is prescribed medication frequently or long term, liaise with medical practitioner to request that it is sugar free	Good practice
Investigate diet and assist adoption of good dietary practice in line with the Eatwell Guide	Good practice
Assign a shortened recall interval based on dental caries risk	Conditional

Prevention of dental caries in children aged from 7 years and young people (up to 18 years)

All children from 7 years and young people up to 18 years

Recommendation	Strength of recommendation
Advice
Brush teeth at least twice daily (with assistance from parent or carer if required): • last thing at night (or before bedtime) and on at least one other occasion • with toothpaste containing 1,350 to 1,500 ppm fluoride • spitting out after brushing rather than rinsing with water, to avoid diluting the fluoride concentration	Strong
Minimise amount and frequency of consumption of sugar-containing food and drinks	Strong
Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost	Conditional
Professional intervention
Apply fluoride varnish to teeth 2 times a year (2.26% NaF)	Strong
Assign a recall interval within the range of 3 to 12 months based on oral health needs and disease risk	Conditional

Children from 7 years and young people up to 18 years giving concern because of dental caries risk

Recommendation	Strength of recommendation
All the above, plus:
Advice
Parent or carer to assist and supervise toothbrushing if required	Good practice
Use a fluoride mouth rinse daily (0.05% NaF; 230 ppmF) at a different time to brushing	Conditional
Professional intervention
Apply resin sealant to permanent teeth on eruption	Strong
Apply fluoride varnish to teeth 2 or more times a year (2.26% NaF)	Strong
For those 8 years and above with active dental caries, consider recommending or prescribing daily fluoride mouth rinse (0.05% NaF; 230ppm F), to be used at a different time from brushing, until dental caries risk is reduced	Conditional
For those 10 years and above with active dental caries, consider prescribing 2,800ppm fluoride toothpaste until dental caries risk is reduced	Conditional
For those 16 years and above with active dental caries, consider prescribing either 2,800ppm or 5,000ppm fluoride toothpaste until dental caries risk is reduced	Conditional
Where a child or young person is prescribed medication frequently or long term, liaise with medical practitioner to request that it is sugar free	Good practice
Investigate diet and assist adoption of good dietary practice in line with the Eatwell Guide	Good practice
Assign a shortened recall interval based on dental caries risk	Conditional

Prevention of dental caries in adults

All adults

Recommendation	Strength of recommendation
Brush teeth at least twice daily: • last thing at night (or before bedtime) and on at least one other occasion • with toothpaste containing 1,350 to 1,500ppm fluoride • spitting out after brushing rather than rinsing with water, to avoid diluting the fluoride concentration	Strong
Minimise the amount and frequency of consumption of sugar-containing food and drinks	Strong
Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost	Conditional
Professional intervention
Assign a recall interval ranging from 3 to 24 months, based on oral health needs and disease risk	Conditional

Adults giving concern because of dental caries risk

Recommendation	Strength of recommendation
All the above, plus:
Advice
Support toothbrushing where required (for example carer assistance, specialised brush, non-foaming toothpaste)	Good practice
Use a fluoride mouth rinse daily (0.05% NaF; 230 ppmF) at a different time to toothbrushing	Conditional
Professional intervention
Apply fluoride varnish to teeth 2 times a year (2.26% NaF)	Strong
For those with active coronal or root caries, consider recommending or prescribing daily fluoride rinse (0.05% NaF; 230 ppmF, to be used at a different time from toothbrushing) until dental caries risk is reduced	Conditional
For those with obvious active coronal or root caries, consider prescribing 2,800 or 5,000ppm fluoride toothpaste until dental caries is stabilised and risk is reduced	Conditional
Where a patient is prescribed medication frequently or long term, liaise with medical practitioner to request that it is sugar free	Good practice
Investigate diet and assist adoption of good dietary practice in line with the Eatwell Guide	Good practice
Assign a shortened recall interval based on dental caries risk	Conditional

Table 2: Prevention of periodontal diseases

Prevention of periodontal diseases – to be used in addition to dental caries prevention

All patients

Recommendation	Strength of recommendation
Advice
Self-care plaque removal:
• daily, effective plaque removal is critical to periodontal health	Conditional
• remove plaque effectively using methods shown by the dental team. This will prevent gingivitis (gum bleeding or redness) and reduces the risk of periodontal disease	Good practice
Toothbrushing and toothpaste: • brush gum line and each tooth at least twice daily (last thing at night or before bedtime and on at least one other occasion)	Conditional
Toothbrush type
• use a manual or powered toothbrush	Strong
• use a small toothbrush head, medium texture	Conditional
Around orthodontic appliances and bridges, plaque control should be undertaken using the aids suggested by the orthodontic or dental team	Good practice
Professional intervention
Advise best methods of plaque removal to prevent gingivitis and achieve lowest risk of periodontitis and tooth loss	Conditional
Use behaviour change methods with oral hygiene instruction	Conditional
Correct factors that impede effective plaque control including supra and subgingival calculus, open margins and restoration overhangs and contours, which prevent effective plaque removal	Good practice
For people with extensive inflammation, start with toothbrushing advice, followed by interdental plaque control	Good practice
Assess patient, parent or carer’s preferences for plaque control: • decide on manual or powered toothbrush • demonstrate methods and types of brushes • assess plaque removal abilities and confidence with brushing • patient sets SMART goals (see chapter 3) for toothbrushing for next visit	Good practice

All adults (and young people aged 12 to 17 years with evidence of periodontal disease)

Recommendation	Strength of recommendation
Advice
Interdental plaque control: • clean daily between the teeth to below the gum line before toothbrushing • where there is space for an interdental or single-tufted brush, this should be used • for small spaces between teeth, use dental floss or tape	Conditional
Professional intervention
Assess patient’s preferences for interdental plaque control: • decide on appropriate interdental aids • demonstrate methods and types of aids • assess plaque removal abilities and confidence with aids • patient sets SMART goals (see chapter 3) for interdental plaque control	Good practice

Prevention of peri-implantitis

All adults with dental implants

Recommendation	Strength of recommendation
Advice
Dental implants require the same level of oral hygiene and maintenance as natural teeth	Good practice
Clean around and between implants carefully with interdental aids and toothbrushes	Conditional
Attend for regular checks of the health of gum and bone around implants	Conditional
Professional intervention
Advise best methods for self-care plaque control, both toothbrushing and interdental cleaning	Good practice

Control of specific risks for periodontitis

Tobacco

Recommendation	Strength of recommendation
Professional intervention
Ask, Advise, Act: at every opportunity, ask patients if they smoke and record smoking status, advise on the most effective way of quitting and act on patient response, such as refer to local stop smoking support (see Table 3 tobacco section of oral cancer below for more detail)	Strong

Diabetes

Recommendation	Strength of recommendation
Advice
Patients with diabetes should try to maintain good diabetes control as they are: • at greater risk of developing serious periodontitis and • less likely to benefit from periodontal treatment if the diabetes is not well controlled	Conditional
Professional intervention
For patients with diabetes: • explain risk related to diabetic control; ask about HbA1c (glycated haemoglobin) levels • assess and discuss clinical management (see Chapter 5)	Good practice

Medications

Recommendation	Strength of recommendation
Advice
Some medications can affect gingival health
Professional intervention
For patients who use medications that cause dry mouth or gingival enlargement: • explain oral health findings and risk related to medication • assess and discuss clinical management (see Chapter 5)	Good practice

Table 3: Prevention of oral cancer

Use of tobacco, both smoked (for example cigarettes, pipes, waterpipes or shisha) and smokeless (for example paan, chewing tobacco, gutkha), seriously affects general and oral health. The most significant risk is for oral cancer and pre-cancers. The combined use of tobacco and alcohol further increases the risk of oral cancer. Encourage children and young people not to start smoking or using tobacco.

Tobacco

All adults and young people

Recommendation	Strength of recommendation
Professional intervention – Very Brief Advice (VBA)
Ask, advise, act	Strong
Ask At every opportunity, ask patients if they smoke and record smoking status (smoker, ex-smoker, never smoker)	Strong

For those who smoke

Recommendation	Strength of recommendation
Advise Explain that a combination of behavioural support and the medication varenicline, or short-acting with long-acting Nicotine Replacement Therapy, are likely to be most effective.	Strong
Act Act on patient response: • refer people who want to stop smoking to local stop smoking support, preferably where behavioural support and prescribed stop smoking medicines are available.	Strong
Acknowledge that e-cigarettes may be helpful for some smokers for quitting or reducing smoking.	Conditional

Smokeless tobacco

(Predominantly used by those of South Asian origin)

Adults and young people

Recommendation	Strength of recommendation
Ask Ask patients if they use smokeless tobacco, using the names that the various products are known by locally. It may be helpful to show a picture of what the products look like (Chapter 11).	Strong
Advise If someone uses smokeless tobacco, ensure they are aware of the health risks and provide very brief advice.	Strong
Act Refer patients who want to quit to specialist support services.	Strong

Alcohol

Regularly drinking more than 14 units of alcohol per week can adversely affect general and oral health, with the most significant oral health impact being the increased risk of oral cancer. The combined use of tobacco and alcohol further increases the risk of oral cancer.

Alcohol Identification and Brief Advice (IBA) uses the AUDIT-C tool (or similar) to ask and assess risk and provide advice.

All adults and young people

Recommendation	Strength of recommendation
Professional intervention - Identification and Brief Advice (IBA)
Ask, advise, act	Strong
Ask Use the AUDIT-C tool (or similar) to assess a patient’s level of risk of alcohol harm by completing 3 consumption questions:	Strong

Questions			Scoring system			Your score
	0	1	2	3	4
How often do you have a drink containing alcohol?	Never	Monthly or less	2 to 4 times per month	2 to 3 times per week	4 or more times per week
How many units of alcohol do you drink on a typical day when you are drinking?	0 to 2	3 to 4	5 to 6	7 to 9	10 or more
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily

Advise and Act If AUDIT C score is 4 or below, give positive feedback and encourage your patient to keep their drinking at lower risk levels. If score is 5 to 10, give brief advice to encourage a reduction in alcohol consumption and reduce the risk of alcohol harm. Feedback to the patient that their level of drinking is putting them at risk of developing a range of health problems (including cancers of the mouth, throat and breast) and this increases the more you drink and the more frequently you drink. Highlight ‘low risk’ guidelines for alcohol consumption from UK Chief Medical Officers: • to keep health risks from alcohol to a low level, it is safest not to drink more than 14 units a week on a regular basis • if you regularly drink as much as 14 units per week, it’s best to spread your drinking evenly over 3 or more days • if you wish to cut down the amount you drink, a good way to help achieve this is to have several drink-free days a week Give a leaflet	Strong
For those who are pregnant or think they could become pregnant, the safest approach is not to drink alcohol at all, to remove the risk of alcohol-related harm to the baby.	Good practice
AUDIT-C score of 11 or above, refer to GP or community specialist alcohol service.	Good practice

Diet

Increasing fruit and vegetable intake reduces the risk of cancers in general and contributes to overall health.

All patients

Recommendation	Strength of recommendation
Promote increased consumption of non-starchy vegetables and fruit	Good practice

Early detection

Oral cancer survival rates are strongly associated with the stage at diagnosis. Early detection is key to improving oral cancer survival rates and quality of life.

All patients (with and without teeth)

Recommendation	Strength of recommendation
Professional intervention
Obtain an updated medical, social and dental history and perform an intraoral and extraoral visual and tactile examination for all patients at each oral health assessment visit.	Good practice

Those giving concern

Recommendation	Strength of recommendation
In line with national referral recommendations, patients should be referred on an urgent or suspected cancer pathway if they have any of the following: • an unexplained ulceration in the oral cavity lasting for more than 3 weeks • a persistent and unexplained lump in the neck • a lump on the lip (inner or outer) or in the oral cavity consistent with oral cancer • a red patch in the oral cavity consistent with erythroplakia • a red and white patch in the oral cavity consistent with erythroleukoplakia • persistent unexplained hoarseness • persistent pain in the throat or pain on swallowing lasting for more than 3 weeks	Good practice
It’s not recommended to use vital staining, oral cytology or light‐based detection and/or oral spectroscopy for evaluating lesions for malignancy.	Strong

Table 4: Prevention of tooth wear

All patients

Recommendation	Strength of recommendation
Maintain standard oral hygiene practices. Brush teeth at least twice daily: • last thing at night (or before bedtime) and at least on one other occasion • with toothpaste containing fluoride (appropriate to age – see dental caries table) • spitting out after brushing, rather than rinsing with water, to avoid diluting the fluoride concentration	Good practice for preventing tooth wear Strong recommendation for preventing dental caries
Maintain good dietary practice in line with the Eatwell Guide including avoiding or minimising sugar sweetened drinks (especially carbonated) and fruit juice and/or smoothies (limited to 150ml per day).	Good practice
Professional intervention
Assess tooth wear using a validated tool (for example Basic Erosive Wear Examination (BEWE)) at the start of any new course of treatment.	Good practice

Patients at higher risk (those with accelerated tooth wear)

Identify possible sources of risk: intrinsic, extrinsic and mechanical (see Chapter 7).	Good practice
Support patient in risk reduction and management.	Good practice

Resources

E-learning for healthcare: Delivering Better Oral Health. Key oral health improvement messages for families includes the evidence base that underpins these for use in practice by the clinical dental team and for non-clinical staff.

E-learning for healthcare: Children’s oral health advice for all. This session aims to improve the knowledge of the general public and early years healthcare workers regarding children’s oral health.

Dental teams can utilise Change4Life Top Tips for Teeth dental toolkit and resources.

Prevention: Key oral health messages and evidence (0 to 6 years) training guide for dental teams.

References

1. Public Health England. Improving oral health: guideline development manual. London: PHE; 8 January 2020. ↩

2. Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, and others. GRADE guidelines: 4. Rating the quality of evidence–study limitations (risk of bias). Journal of Clinical Epidemiology. 2011;64(4):407-15. ↩

3. Guyatt GH, Schünemann HJ, Djulbegovic B, Akl EA. Guideline panels should not GRADE good practice statements. Journal of Clinical Epidemiology. 2015; 68(5),597-600. ↩

4. Tugwell P, Knottnerus JA. When does a good practice statement not justify an evidence based guideline? Journal of Clinical Epidemiology. 2015; 68(5),477-479. ↩