Heading and entries in checklistEvidence Source (Chapter in full guideline where discussed)Rationale for inclusion in checklist and explanatory notes
Social History
Caries in mothers and siblingsReview of caries risk assessment and prediction literature (Chapter Three Section 3.1.1)Applies to children only. The presence of caries in mothers and siblings is an indicator of increased caries risk for an individual child.
Tobacco useReview of risk factors for periodontal disease and oral cancer (Chapter Three Sections 3.2.3 and 3.3.3)Tobacco use is the most significant modifiable risk factor for periodontal disease. Smokers have been shown to have between a two-fold and seven-fold increase in risk for having periodontitis and/or periodontal tissue loss than non-smokers. Tobacco use (both smoking and smokeless tobacco[i.e. chewing tobacco, chewing tobacco with betel quid, snuff] also a risk factor for oral cancer.
Excessive alcohol useReview of risk factors for oral cancer (Chapter Three Section 3.3.3)Excessive alcohol consumption is a risk factor for the development of oral cancer. Current UK recommendations are that men should not drink more than 21-28 units of alcohol per week and women should not drink more than 14-21 units. Tobacco use and alcohol consumption are associated with oral cancer in a dose response fashion and have a synergistic effect when combined. Clinicians should maintain a high level of vigilance where these factors are associated with clinical evidence of potentially malignant lesions. Clinicians should also be aware that cases of oral cancer have been reported in young people who have little or no exposure to tobacco or alcohol, emphasising the importance of perpetual vigilance and of carrying out a thorough systematic examination of the oral mucosa for every patient as an integral part of their Oral Health Review, regardless of the presence or absence of risk factors
Family history of chronic or aggressive (early onset/juvenile) periodontitisReview of risk factors for periodontal disease (Chapter Three Section 3.2.3) and GDG expertise.Studies of genetic factors show that periodontitis, particularly aggressive periodontitis occurs in families. This is less clear for chronic periodontitis although there is a substantial genetic influence. Clinicians should consider the impact of a positive family history, especially if the stability of the periodontal status is not yet demonstrated.
Dietary Habits
High and/or frequent sugar intakeReview of caries risk assessment and prediction literature (Chapter Three, Section 3.1.1)High sugar intake increases caries risk. The frequency, amount and consistency of sugar containing foods and drinks consumed may impact on a patient's caries risk. Long-term regular low doses of medications containing glucose, fructose or sucrose may also increase caries risk (see also Medical History section above). The National Clinical Guidelines (1997) produced by the Faculty of Dental Surgery, suggest that greater than three sugary intakes daily is indicative of an increased caries risk.
High and/or frequent dietary acid intakeExpert opinion of GDGMany commonly available soft drinks have a low pH (acidic) and may contain considerable amounts of simple sugars. Hence they have both erosive and cariogenic potential (see entry below for ‘erosion and tooth surface loss’).
Exposure to Fluoride
Use of fluoride toothpasteReview of caries risk assessment and prediction literature (Chapter Three Section 3.1.1)Regular brushing with a fluoride containing toothpaste reduces caries risk.
Other sources of fluoride e.g. live in a fluoridated areaEvidence from McDonagh and coworkers (2000), Cochrane reviews by Marinho and coworkers (2003 and 2004) supplemented by GDG opinionThe dental team should be aware of the fluoride status of local water supplies and adjust their caries risk assessments accordingly. Teams in fluoridated areas must, however, be sensitive to the risk status of individuals who have not had life long residence in fluoridated areas and also be alert for those individuals for whom the overall cariogenic challenge is abnormally high.
Recent and Previous Caries Experience
New lesions since last check-up

Anterior caries or restorations

Premature extractions due to caries

Past root caries or large number of exposed roots

Heavily restored dentition
Review of caries risk assessment and prediction literature (Chapter Three, Section 3.1.1). Individual entries (new lesions etc.) are based on the expert opinion of GDG and ‘risk assessment tables’ in the following publications (Faculty of General Dental Practitioners 1998; Kidd 1998; Scottish Intercollegiate Guideline Network 2000)The most consistent predictor of caries risk is past caries experience (clinical evidence of previous disease). Patients with clinical evidence of new initial lesions (white or brown spots) or other new lesions, anterior caries or restorations, premature extractions due to caries, past root caries or large number of exposed roots or who have a heavily restored dentition, can be considered as being at increased risk of developing future disease.
Recent and previous periodontal disease experience
Previous history of periodontal disease

Evidence of gingivitis

Presence of periodontal pockets (Basic Periodontal Examination (BPE) code 3 or 4) and/or bleeding on probing

Presence of furcation involvements or advanced attachment loss (Basic Periodontal Examination (BPE) code *. BPE code * is used when attachment loss is ≥7mm and/or furcation involvements are present)
Review of periodontal disease literature (Chapter Three Section 3.2). Basic Periodontal Examination is devised by the British Society of Periodontology (Mosedale et al, 2001)A previous history of periodontitis clearly identifies an individual at increased susceptibility and risk of future disease.

Whilst only a minority of individuals with gingivitis will progress to periodontitis, gingivitis remains a risk factor for periodontitis. In addition, a continuous absence of gingival bleeding is a reliable predictor of periodontal health.

Sites with existing/advanced periodontitis are at greater risk of future breakdown than healthy sites
Mucosal LesionReview of oral cancer literature, including survival rates from oral cancer and stage at initial presentation (Chapter Three, Section 3.3.2) risk factors for oral cancer (Chapter Three, Section 3.3.3) and potentially malignant lesions and conditions (Chapter Three, Section 3.3.6)Oral cancer often apparently arises de novo from clinically normal mucosa. However, there are a number of clinically identifiable precursor lesions and conditions, principally leukoplakia, erythroplakia, oral lichen planus and oral submucous fibrosis. Erythroplakia has a high potential for malignant transformation. The reported rates of malignant transformation of leukoplakia in the international literature range from 0.3 to 17.5%. Estimates of the percentage of leukoplakias that regress to normal vary between 4.6% per year to 28.6%. Leukoplakia lesions on the floor of the mouth, lateral tongue and lower lip are most likely to show dysplastic or malignant change.

Clinicians should maintain a high index of suspicion for all intra-oral areas that appear unusual. Patients whose cancer is detected at an early stage generally have improved survival times than those presenting with late stage disease and in addition will usually require less radical treatment.
Plaque
Poor level of oral hygiene Plaque retaining factorsReview of caries risk assessment and prediction literature (Chapter Three, Section 3.1.1). Review of risk factors for periodontal disease (Section 3.2.3)Dental plaque is a key aetiological factor in the development of dental caries and periodontal diseases. Plaque retaining factors include appliances (orthodontic appliances, partial dentures), status of existing restorations, crowded teeth, deep fissures.
Saliva
Low saliva flow rateReview of caries risk assessment and prediction literature (Chapter Three Section 3.1.1).See Sections 3.1.1 and Section on Medical History above.
Erosion and tooth surface loss
Expert opinion of GDGSee section on ‘acid reflux’ in Medical History above. Tooth wear is usually due to a combination of processes, abrasion, attrition and erosion. The preventive management of tooth wear in an individual depends on the aetiology and which of these processes predominates. Management may include appropriate oral hygiene instruction, provision of occlusal protection, dietary assessment and counselling, determination of any reflux activity. Adequate follow up is required to determine whether the dentition is stable or deteriorating (Shaw 2003).

From: Appendix G, Implementing the Clinical Recommendations – selecting the appropriate recall interval for an individual patient

Cover of Dental Recall
Dental Recall: Recall Interval Between Routine Dental Examinations.
NICE Clinical Guidelines, No. 19.
National Collaborating Centre for Acute Care (UK).
Copyright © 2004, National Collaborating Centre for Acute Care.

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