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Dental Recall: Recall Interval Between Routine Dental Examinations. London: National Collaborating Centre for Acute Care (UK); 2004 Oct. (NICE Clinical Guidelines, No. 19.)

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Dental Recall: Recall Interval Between Routine Dental Examinations.

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3The Context of Dental Recall

As noted in the previous Chapter, based on a systematic review of the evidence on the effectiveness of routine dental checks of different recall frequencies, there is a lack of good quality, directly applicable research with which to inform clinical practice on assigning appropriate recall intervals. This absence of evidence complicated the task of fulfilling the original remit given by the Department of Health and the Welsh Assembly Government, namely: “To prepare guidance for the NHS in England and Wales, on the clinical and cost-effectiveness of a dental recall examination for all patients at an interval based on the risk from oral disease” (our emphasis). The GDG decided that, in order to fulfil this remit, further literature (other than that directly relevant to addressing the Key Clinical Questions detailed in the previous Chapter) would have to be explored. Specifically, the GDG felt that the concept of risk as applied to provision of dental care and the possibility of developing a ‘risk-based recall interval’ should be explored.

Risk is the probability of an event occurring in a specific time (Reich et al. 1999). Applied to a health event, risk is the probability of an individual developing a given disease or experiencing a health status change over a specified period. Extending the definition of risk to the term ‘risk factor’ implies that there are certain factors associated with an increased probability of an individual developing a disease or experiencing a health status (Beck 1990). The premise underpinning the application of these concepts to the selection of an appropriate recall interval for an individual patient is that the frequency and type of oral health supervision needed by an individual patient can be based on a patient's risk of developing future disease or of existing disease progressing. Thus, the operating premise of a risk based recall interval between Oral Health Reviews (OHRs) is that patients deemed to be at increased risk may benefit from more frequent OHRs and patients deemed to be at low risk may need to be recalled less frequently. The rationale for reducing the interval between Oral Health Reviews for patients deemed to be at increased risk is that the OHR affords an opportunity for primary prevention (the prevention of oral disease before it occurs) and secondary prevention (limiting the progression and effect of oral diseases at as early a stage as possible after onset). Based on these premises and assumptions the GDG decided to examine the literature surrounding clinical, behavioural and etiological factors that could be used by clinicians to determine a patient's risk of acquiring new disease or the risk of existing disease progressing. The GDG further considered that aspects of the natural history of oral diseases should also be examined, in particular the rate of progression of oral diseases. The GDG also wished to ensure that the guideline would be grounded in the principles of modern preventive management of oral diseases and would reflect the evolution of NHS dentistry from a restorative-centred approach towards a more preventive-oriented and clinically effective way of meeting patient needs. In addition, it was also considered important to examine the literature surrounding patients' satisfaction with the current NHS dental services and factors influencing dental attendance.

In order to explore these issues, the GDG formulated appropriate contextual questions relating to risk factors for dental caries, periodontal disease and oral cancer, the rate of progression of oral diseases and the early detection and preventive management of oral diseases. In developing and prioritising the contextual questions to be addressed, two issues were considered:

  1. the relevance and usefulness of these questions in developing the guideline
  2. the work reasonably achievable in the limited time available

Many of the contextual questions posed by the GDG, in and of themselves, could have provided the focus for a separate systematic review. However, it was agreed by the GDG that, for the purposes of developing this guideline, a systematic review of the evidence in relation to each of these questions was neither appropriate nor feasible. In relation to each question, it was agreed that a search would be made for existing systematic reviews or other high quality and reliable evidence. Members of the GDG with expertise in that particular topic area were also consulted for references to pertinent literature for each question.

The literature reviewed in order to address the contextual questions posed by the GDG is presented in the subsequent sections in this Chapter. The GDG also considered the issues of longevity of dental restorations, the accuracy of basic diagnostic methods used by clinicians for detecting carious lesions in primary and permanent teeth, and the epidemiology of dental caries of children (Appendix F).

3.1. Dental Caries

For some of the background dental caries questions, the review team were able to draw upon a series of systematic reviews presented at the National Institute of Health Consensus Development Conference on the diagnosis and management of dental caries throughout life (March 26 - 28, 2001). Some of the questions addressed at this Conference using systematic review methods were particularly relevant to this guideline (for example, “what are the best indicators for an increased risk of dental caries?”).

3.1.1. Caries Risk Assessment


  • The most consistent predictor of caries risk is past caries experience (clinical evidence of previous disease)
  • Caries risk assessment for individual patients can be carried out by the clinician using information readily obtained at an oral health review
  • The clinical judgement of the dentist and his or her ability to combine risk factors, based on their knowledge of the patient and clinical and socio-demographic information is as good as, or better than, any other method of predicting caries risk
  • The following should be considered when assessing caries risk for an individual patient: Medical History; Social History; Dietary Habits; Use of Fluoride; Clinical Evidence; Oral Hygiene; Salivary flow rate
  • Assessment of caries risk should be repeated every time a patient attends for an oral health review

Over the past four decades, changes have been observed in the prevalence of dental caries and in the distribution and pattern of the disease in the UK. Although overall caries levels have declined significantly, this improvement has not been uniformly experienced throughout the population. Epidemiological studies have demonstrated that the distribution of dental caries is skewed, with most of the disease being concentrated in a minority of the population. There is also considerable geographic variation in caries experience across England and Wales on a regional and county basis. Generally lower levels of mean caries prevalence (DMFT <1 (12 year olds) have been reported in the south, the west 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 distribution of dental caries have led to increasing research interest in caries risk assessment and in identifying ‘high risk’ susceptible individuals who can be targeted for preventive intervention. The aim of caries risk assessment is to predict future disease and disease progression. However, the precise estimation of future caries risk is difficult as dental caries is an etiologically complex and multi-factorial disease process and there are many factors that can impinge on an individual patient's caries risk. Nevertheless, caries risk assessment can be regarded as an important part of planning for prevention and provides a basis for the provision of dental care as well as planning recall appointments (Adelaide University et al. 1999).

In reviewing the caries risk assessment literature, the Guideline Development Group decided to examine 1) the predictive validities of currently available multivariate caries risk assessment strategies and 2) to ascertain the best indicators for an increased risk of dental caries.

We found one recent systematic review (Zero et al. 2001) evaluating the degree to which various combinations of risk indicators could predict dental caries (that is, the predictive validity of the test) in primary and permanent teeth. The authors of this review emphasised the paucity of randomised longitudinal studies available to inform clinical practice. Of all the models reviewed, none of those graded as being of good quality reached the desirable combined level of sensitivity and specificity (160%). On the basis of the available evidence it was concluded that, in general, the best indicators of caries risk could easily be obtained from dental charts and did not require additional testing (for example, microbiological examinations). Previous caries experience was also found to be an important predictor in most models tested for primary, permanent and root surface caries. Two of the longitudinal studies reviewed (graded as being of ‘good quality’) found that predicted caries by the clinician, using routinely available clinical and socio-demographic information, was an important predictor and as good as, or better than, other methods for predicting caries risk (Evidence Grade 2++).

In identifying the best indicators of increased caries risk we drew upon the findings of a number of systematic reviews that were used in developing a National Institutes of Health Consensus Statement on the Diagnosis and Management of Dental Caries Throughout Life (National Institutes of Health 2001). The conclusions of these reviews can be summarised as follows:

  • There is evidence of matrilinear transmission of mutans streptococci in early childhood. Hence, the presence of caries in mothers and siblings is an indicator of increased caries risk for an individual child.
  • Low socio-economic status is associated with elevated caries levels. Low socio-economic status may be associated with reduced access to care, reduced oral health aspirations and health behaviours that may enhance caries risk.
  • Regular brushing with a fluoride containing toothpaste reduces caries risk.
  • Conditions that may compromise the long-term maintenance of good oral hygiene are positively associated with caries risk. These include the presence of multiple restorations and oral appliances and physical and mental disabilities which may result in a decreased ability to perform effective oral hygiene.
  • Fermentable carbohydrate consumption is associated with caries, particularly in the absence of fluoride. The frequency, amount and consistency of sugar containing foods and drinks consumed may impact on a patient's caries risk. Long-term regular doses of medications containing glucose, fructose or sucrose may also increase caries risk. The relationship between sugar consumption and caries is much weaker in the modern age of fluoride exposure than it used to be.
  • Certain medical conditions (for example, Sjögrens syndrome), pharmacological agents with xerostomic side-effects (for example, anti-cholinergics, tricyclic antidepressants) and head and neck radiation therapy, can lower salivary flow rates to levels that will dramatically elevate a patient's risk of caries

All of the above factors, together with clinical evidence of previous disease, should be considered in assessing a patient's caries risk. As an individual's caries risk status may change over time, risk assessment must be an ongoing process and should be carried out every time a patient attends for an oral health review.

A patient's caries risk should be reviewed in the light of each new clinical examination and any relevant change in their dental, medical and social history and any alteration in their diet and oral hygiene practices.

3.1.2. Rate of Progression of Dental Caries


  • Literature examining the rate of progression of dental caries has to be interpreted cautiously due to the limited quantity and variable quality of the available evidence and considerable study heterogeneity
  • On an individual patient basis, progression rates are very variable
  • There is evidence that the rate of progression of caries can be more rapid in children and adolescents than in many older persons
  • There is a paucity of evidence on: lesion progression in older adults, the rate of progression of occlusal caries, dentine lesions, free smooth surface lesions and root surface lesions

Most of the available information on caries progression emanates from radiographic studies of approximal lesion progression in the permanent teeth of children and young adults. There is sparse information on lesion progression in older adults and on the rate of progression of occlusal caries, dentine lesions, free smooth surface lesions and root surface lesions. There is also a paucity of data available on caries progression in primary teeth and many of these studies are confounded by the presence of preventive regimes (Tinanoff et al. 2001). Reviews of the caries progression literature illustrate the different populations, settings, treatment variables and measurement variables used in different studies (Mejàre et al. 2003; Kay et al. 1995; Pitts 1983). Comparisons of data from these studies are rendered problematic by variations in diagnostic criteria, examiner inconsistencies and external factors influencing the natural history of lesion dynamics (for example, varying exposures of the populations under investigation to fluoride). The limited quantity and variable quality of the available evidence, and the considerable study heterogeneity, renders it difficult to draw anything other than the following very broad and general conclusions from this body of literature:

  • On an individual patient basis, progression rates are very variable and differ between individuals as well as between lesions within an individual
  • For the majority of individuals, the progression of approximal carious lesions in permanent teeth is a slow process and large numbers of lesions can remain apparently unchanged for long periods (Pitts 1983)
  • The time for which caries remains confined to the enamel radiographically varies considerably. A mean time of 3 to 4 years has been reported (Pitts 1983)
  • Caution should be exercised in the interpretation of ‘mean time’ figures as the rate of progression is more rapid in ‘high risk’ or ‘caries active’ individuals (Shwartz et al. 1984)
  • The rate of progression through the enamel in permanent teeth appears to be relatively faster in young children (< 12 years) when compared with adolescents and adults (Mejare et al. 2000; Shwartz et al. 1984)
  • The rate of progression through enamel is slower in populations and individuals with adequate fluoride exposure (Lawrence et al. 1997)
  • The limited data available on lesion progression in primary teeth suggest that the rate of progression is faster than in permanent teeth
  • The limited data available on the rate of progression in dentine, suggest that progression rates are faster than in enamel (Mejare et al. 1999; Pine et al. 1996)
  • From the limited data available, lesion progression in adults does not appear to be related to age and there are no major differences in the rate of progression between younger and older adults (Berkey et al. 1988; Foster 1998)
  • The exact range of rates of progression of free smooth surface lesions is not known
  • The natural history of root caries is largely unknown as is the rate of progression through root surface cementum (Banting 2001; Leake 2001).

3.1.3. Threshold for intervention


  • Early caries lesions can be arrested or even reversed thus justifying consideration of the use of remineralising procedures (preventive intervention) for such lesions as opposed to automatic restorative intervention.
  • Contemporary emphasis is placed on cavitation (a break in the continuity of the enamel surface) as a threshold for restorative intervention rather than dentine involvement (depth of the lesion)
  • Operative intervention of cavitated lesions is generally indicated to restore the integrity of the tooth surface and allow for plaque removal by the patient
  • Progressive hidden dentinal lesions can sometimes be found in sites that appear clinically sound (‘hidden’ or ‘occult’ caries). These lesions should be scheduled for operative care
  • Radiographic findings must be considered with all other available clinical information on a patient when planning care.

Over the past four decades the approach to the provision of dental care in many developed countries is considered to have undergone a progressive shift from a ‘restorative phase,’ where the detection of caries lesions was promptly followed by lesion excision and restoration placement, to a less interventive ‘preventive phase,’ where the emphasis is on primary and secondary prevention and where restorations are provided when a certain threshold of lesion severity has been exceeded (Murray et al. 1997). This change in practice has been influenced by number of factors including an improved understanding of the caries process, contemporary changes in the epidemiology of dental caries and an alteration in the rate of progression of the disease. In particular, a slowing in the rate of progression of early caries lesions through the enamel and the fact that early lesions can be arrested or even reversed justifies consideration of the use of remineralising procedures (preventive intervention) for such lesions as opposed to automatic restorative intervention.

In terms of the clinical management of caries and for successful treatment decisions to be made, it is important to know at what stage a carious lesion is likely to progress, irrespective of efforts to arrest it by common preventive means and, hence, when restorative intervention is warranted. There is a continuing debate in Europe on precisely where this restorative threshold should lie. Increasing emphasis has been placed on cavitation (a break in the continuity of the enamel surface) as a threshold for restorative intervention, rather than dentine involvement (depth of the lesion), per se (Pitts 2001). The threshold for intervention may also vary depending on the tooth surface affected by caries.

3.1.4. Occlusal surface caries

In general the limit for arresting occlusal caries is considered to be clinical cavitation. A number of studies have found that when an occlusal lesion is cavitated the dentine is always involved in the process, the lesion contains many micro-organisms and can generally be considered as an ‘active’ lesion (Ekstrand et al. 1995; Ekstrand et al. 1997; Ekstrand et al. 1998b; Espelid et al. 1994; van Amerongen et al. 1992). The opinion that cavitated lesions inevitably progress provides the basis for considering operative treatment of such lesions a necessity (Lunder et al. 1996). This inevitable progression is attributed to the impossibility of a thorough plaque removal once cavitation has occurred and operative intervention is generally indicated in order to restore the integrity of the tooth surface and allow for appropriate cleaning. However, it is also important to appreciate that operative intervention for occlusal surface lesions may be required before cavitation has taken place. The decision when to intervene and restore an occlusal surface lesion is complicated by an apparent change in the presentation of caries in recent decades, particularly with the widespread availability of fluoride, in which cavitation appears to occur at a later stage. It is now recognised that progressive, hidden dentinal lesions can sometimes be found in sites that appear clinically sound (‘hidden’ or ‘occult’ caries). Cavitated occlusal lesions into dentine should be scheduled for operative care. Occlusal surfaces with a suspicion of hidden dentine caries should be investigated carefully.

3.1.5. Caries on contacting approximal surfaces

The restorative threshold for contacting approximal surfaces is probably reached when frank clinical cavitation occurs. As these surfaces are generally inaccessible to visual examination, the clinician usually has to rely on the use of radiographs as an aid to diagnosis. However, although radiographs can provide an estimate of the depth of lesion penetration towards the pulp, they are unable to provide direct and unambiguous evidence about cavitation at approximal sites. Traditionally, dental practice has adopted the criterion that restorations should be placed when an approximal radiolucency has reached the junction of the enamel and the dentine (Tyas et al. 2001). However, a problem with adopting this criterion is that it cannot be assumed that all radiolucencies that have reached this point represent cavitation.

Several clinical studies have related radiographic appearance with cavitation in permanent teeth. Where a radiolucency has reached the inner half of dentine, the probability of cavitation is high (Mejàre et al. 2003) and restorative intervention is warranted. However, when radiolucency is confined to the outer half of dentine, cavitation may or may not be present and clinical judgement should be used to determine when restorative intervention, rather than preventive maintenance and monitoring, is warranted. This clinical decision is facilitated by research which suggests that cavitation is more likely in ‘high risk’ patients and where the adjacent gingival papilla is inflamed (Ekstrand et al. 1998a; Lunder et al. 1996; Ratledge et al. 2001). Radiographic findings must thus be considered jointly with all other available clinical information on a patient when planning care.

3.1.6. Restorative threshold of free smooth surface lesions

The accessibility of free smooth surface lesions means that they may be amenable to preventive regimes, even when cavitated. In this context, adequate plaque removal, exposure to fluoride and appropriate dietary modification may provide an environment conducive to the arrest of cavitated carious lesions on free smooth surfaces. Similar arguments apply to active lesions on root surfaces which can be rendered inactive by daily plaque removal and adequate exposure to fluoride (Nyvad et al. 1986; Nyvad et al. 1997). The ability to remove plaque is critical in order to arrest active carious lesions. If a patient is unable to access such lesions and remove plaque adequately, operative intervention is necessary.

For all of the above lesions, the threshold for intervention will also be influenced by the values and preferences of the patient for treatment and outcomes, which may be different from those of the clinician.

3.2. Periodontal Diseases

3.2.1. Summary of the Literature Reviewed

Epidemiological studies of periodontal diseases are complicated by the diversity of measures used to describe and quantify them and the lack of consensus as to a uniform definition and classification (Kingman et al. 2002). This is reflected in the estimates given by the World Health Organisation Global Data Bank (World Health Organisation 2004) which state the prevalence of moderate severity disease occurs in 2 to 67% of individuals and that advanced disease occurs in 1 to 79% of the population.

Tooth loss might be the true clinical outcome for periodontal disease but can occur for other reasons, even in those with established destructive periodontitis (Nunn 2003). Consequently, alternatives such as probing depth and attachment level are often used as surrogate outcomes, particularly to determine treatment need or response. Hujoel provides some evidence for the validity of these measures (Hujoel et al. 1999). The effect of these uncertainties may over- or underestimate treatment need. For the patient, the impact of disease on their quality of life and well-being is also important but few studies have yet investigated the effect of periodontal status on these measures.

3.2.2. Gingivitis

Gingivitis is an inflammation of the superficial gum tissues. It is caused by the accumulation of bacterial plaque at the gum line (Loe et al. 1965; Thielade 1986). Gingivitis can be recognised by the signs of bleeding from the gums (for instance following tooth brushing), a change from pink to red colouration and mild tenderness from the edges of the gum. These signs are often missed or thought to be normal changes. Thorough and regular removal of plaque by methods such as tooth brushing and flossing will allow health to be re-established without irreversible effects to the gums.

Gingivitis is highly prevalent in most populations and at most ages (Albandar 2002b; Corbet et al. 2002; Sheiham et al. 1986) with global values ranging from 50-90% of populations. The fact that gingivitis can be a precursor to more severe periodontal disease (periodontitis) has traditionally been regarded as its greatest significance. However, there has been surprisingly little research looking at the effect of this condition on future oral health and wellbeing. Since the condition affects the majority of people such information is critical to the development of policy on managing gingivitis.

We decided to examine the impact of gingivitis on the well being and oral health of an individual. Three areas of interest were considered: the impact of gingivitis on quality of life, the impact of gingivitis on oral diseases, and the impact of gingivitis on restorations, for example restoration longevity or the integrity of the restoration margin. No studies were found that directly investigated gingivitis and the quality of life on an individual. However, some studies looked at the impact of periodontal health in general (Jones et al. 2001; Needleman et al. 2004; Peek et al. 2002). The data suggest that there is an effect although it is not possible to discriminate the impact of gingivitis alone from all periodontal diseases. While gingivitis has shown to be a risk factor for periodontitis (Schatzle et al. 2003) and may be a risk indicator for caries (Ekstrand et al. 1998a), there are no data for gingivitis as a risk factor for other aspects of oral health. No studies were found researching the impact of gingivitis on restorations.

3.2.3. Risk factors

The accumulation of dental plaque at the gingival margin is considered to be the primary aetiological factor for the development of periodontal diseases (Socransky et al. 2003). Risk factors are considered to be those exposures, genetic influences or behaviours which modify the effect of plaque on the gingival tissues.

Although poor oral hygiene and plaque accumulation have been shown to correlate positively with gingivitis and the prevalence and severity of periodontal disease on a population level, oral hygiene is a much weaker predictor of periodontal tissue loss at the individual level (Albandar 2002a). Such a paradox might be explained by the contribution of risk factors which will vary substantially between individuals.

One readily assessable marker of risk is gingival bleeding. Lang and co-workers have shown that continuous absence of bleeding is a reliable predictor for the maintenance of periodontal health (Lang et al. 1990) that is, health gingival tissues predict further periodontal health. It is not clear whether this relationship holds true for both smokers and non-smokers.

A review by Nunn concludes smoking is “probably the most significant modifiable risk factor for periodontal disease (Nunn 2003). In the United States The Third National Health and Nutrition Examination Survey (NHANES III) estimates that more than half the cases of periodontitis affecting adults may be due to smoking with 41.9% (6.4 million) cases of periodontitis due to current smoking and 10.9% (1.7 million) cases of periodontitis due to former smoking (Tomar et al. 2000). Albandar reports on several cross-sectional studies that show a strong association between the various types and intensity of smoking on gingival tissue, periodontal tissue loss and the severity of periodontitis. Smokers are shown to have between a two and seven fold increase in risk for having periodontitis and/or periodontal tissue loss than non-smokers. Heavy cigarette smoking is associated with more severe periodontal disease than light smoking and the number of smoking years significantly associated with tooth loss and periodontal disease, irrespective of other social and behavioural factors (Albandar 2002a). There is no evidence to suggest a safe level of smoking on periodontal health.

Nunn reports strong evidence for a direct relationship between diabetes and periodontitis (Nunn 2003). Both type I (insulin dependent) and type II (non-insulin dependent) diabetics appear to be at a higher risk than non-diabetics. However, certain sub-groups appear to be at particularly high risk. These include diabetics with poor oral hygiene and/or poor diabetic control and diabetic complications (Kinane 2001). Evidence has begun to emerge suggesting a bidirectional relationship between both types of diabetes and periodontal disease (Taylor 2001).

Albandar reports that studies show aggressive periodontitis to occur in families and suggests that genetic factors are partly responsible for the increased susceptibility to this disease (Albandar 2002a). Several other factors have only limited evidence of or a variable association with periodontal diseases. These are osteoporosis, rheumatoid arthritis, hormonal changes in the body associated with puberty and pregnancy, smokeless tobacco, low vitamin C or calcium intake, high alcohol intake, socioeconomic status, psychosocial factors such as stress, age, gender, race, and tooth or local factors such as occlusal discrepencies or tooth position (Albandar 2002a; Nunn 2003)

3.2.4. Rates of Progression

The Guideline Development Group was interested in a comparison of the rates of progression of treated and untreated chronic periodontitis. However, few studies investigated the rates of progression of periodontal disease for both treated and untreated subjects in the same study. As a surrogate for this, we looked at the data for treated periodontitis where the subjects are randomised to receive adequate maintenance care compared to inadequate care (Axelsson et al. 1981). The treatment group represents a treated and best case sample and the control group represent individuals where periodontitis is allowed to re-establish (a proxy for untreated and if anything, a modest estimate as the subjects have received some care). The results indicate that the percent of sites with at least 2mm loss of attachment over six years was 1% for subjects receiving adequate maintenance care and between 52% to 65% depending on the type of tooth (incisors, canines and molars) for those with inadequate maintenance care.

Cobb reviewed several studies to determine mean annualised rates of progression of untreated periodontal diseases determined by clinical probing depth and clinical attachment loss, or radiographic measurement of alveolar bone loss (Cobb 1996). Adjusting for one study that appeared to have some individuals with much greater progression than most populations (0.8mm per year) the range is 0 to 0.3mm per year.

However, annualised rates are highly problematic and tend to underestimate true disease progression. They are generally calculated across all sites in the mouth (whether per patient or across all sites of the study group rather than grouped per patient). The result is the inclusion of large numbers of non-progressing and healthy sites. Since progressing sites are less common than non-progressing sites the effect could be to underestimate disease progression of the sites that are progressing, often called ‘loser’ sites. Loser sites could be more common on teeth lost during follow-up. If the effect of the loss of sites on extracted teeth is not assessed, diseased or 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 et al. 1991; Lindhe et al. 1989).

Converting this information into the Basic Periodontal Examination (BPE) suggests a mean annualised rate of progression of between 0.0 and 0.3mm per year for patients with no history of periodontitis and a BPE code of 0 (no residual pockets and no gingivitis and no calculus or overhangs), 1 or 2 (gingivitis or calculus/overhangs but no pockets) and for patients with a history of periodontitis and a BPE code of 0. For patients with a history of periodontitis and a BPE code of greater than 0 the data suggests a maximum annualised rate for progression of 3mm per year.

3.3. Oral Cancer

3.3.1. Summary of the Literature Reviewed

  • On average about four people a day die from oral cancer in the UK
  • The poor survival rate from oral cancer (50%) is generally attributed to the late diagnosis of oral cancer at an advanced stage when nodal involvement and neck metastases have occurred
  • The incidence of oral cancer increases with age in both males and females, typically peaking in the seventh to eight decades of life. An increasing incidence in younger age groups (35-64 years) has been recently reported
  • It has been consistently reported that there is a prognostic advantage associated with early detection of oral cancer. Early diagnosis allows for treatment with less aggressive therapies that are associated with less morbidity
  • The incidence of oral cancer in males is around twice that in females in virtually all age groups. An exception to this has been reported in those under the age of 40 years where the usual male dominance does not appear to hold (See Section 3.3.2)
  • Tobacco use (both smoking and smokeless tobacco) and excessive consumption of alcohol are the principal risk factors for oral cancer
  • Cases of oral cancer have been reported in young persons (below the age of 45 years) with little or no exposure to tobacco or alcohol
  • The use of toluidine blue dye as a screening tool in primary care should be discouraged
  • Oral cancer often apparently arises de novo from clinically normal mucosa. The percentage of oral cancers arising from precursor lesions is not accurately known
  • Potentially malignant lesions include leukoplakia and erythroplakia of varying clinical presentations. The incidence and prevalence of oral leukoplakia and erythroplakia in the UK are not known.
  • The reported rates of malignant transformation of oral leukoplakia in the international literature range from 0.3 to 17.5%
  • Lesions of leukoplakia on the floor of the mouth, lateral tongue and lower lip are most likely to show dysplastic or malignant changes
  • Erythroplakia has a high potential for malignant transformation
  • Clinicians should maintain a high index of suspicion for mucosal lesions that appear unusual. This vigilance is especially important for isolated lesions occurring in locations at higher risk for the development of squamous cell carcinoma, such as the lateral and ventral surfaces of the tongue and the floor of the mouth.

3.3.2. Epidemiology

Quoted incidence rates for oral cancer in the UK vary from 3.4 to 4.5 per 100,000 per annum (National Screening Committee: unpublished data 2001). In 1998, there were 4,081 cases of oral cancer diagnosed in the UK and in the year 2000, there were 1,649 deaths from the disease. On average about four people a day die from oral cancer in the UK. Oral cancer is also associated with significant morbidity arising as a consequence of the disease process itself and the therapy provided to 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 maintaining oral hygiene, swallowing and maintenance of nutritional status, difficulties in speaking), therapy-specific morbidities (related to neck dissection and radiotherapy) including thyroid and parathyroid dysfunction, xerostomia (dry mouth), osteo-necrosis of facial bones and the side-effects of chemotherapy (Rosati 1994).

As with all neoplasms, it is believed that oral cancer results from cumulative damage to epithelial cells over a period of time (Quinn et al. 2004). Hence, the incidence of the disease increases with age in both males and females, typically peaking in the seventh to eighth decades of life. Oral cancer is extremely rare below the age of about 40 years with approximately 4 – 6 % of oral cancers occurring below this age (Llewellyn et al. 2001). The incidence of oral cancer in males is around twice that in females in virtually all age groups. An exception to this has been reported in those under the age of 40 years, where the usual male dominance of the condition does not appear to hold (Llewellyn et al. 2001).

The overall age-standardised incidence of oral cancer has risen gradually since the 1990s and an increasing incidence in younger age groups (35 – 64 years) has been reported. In the 35 – 64 year age group, the incidence of tongue, mouth and oropharyngeal cancer rose from 3.61 per 100,000 per annum (1962 – ‘66) to 5.52 (1982 – ‘86) in males and from 1.85 to 2.19 in females (Hindle et al. 1996). More recently, Quinn and co-workers have reported a 40% increase in the incidence rate of lip, mouth and pharyngeal cancer in males aged 55 – 64 years in England and Wales between 1971 and 1997 and a 25% increase in the incidence rates in females of the same age group (Quinn et al. 2004).

In England and Wales the incidence of oral cancer exhibits marked regional variation with above average rates in the North of England and in Wales (Greenwood et al. 2003). The regional pattern in mortality is similar to that for incidence. It has been suggested that this difference may be related, at least in part, to material deprivation (O'Hanlon et al. 1997).

There is limited evidence available relating to ethnic variations in the incidence of oral cancer in England and Wales. Incidence rates appear to be higher in Asian immigrants (that is, immigrants from India, Pakistan, Bangladesh, Nepal and Sri Lanka). These ethnic differences have been attributed to tobacco use and tobacco chewing habits (specifically betel quid chewing) and to possible dietary factors, genetic predisposition, socio-economic differences and lack of awareness about the risk factors. Research into the incidence of oral cancer in specific ethnic groups in the UK is hampered by the fact that entry of ethnic group for an incident case only became part of the contract minimum data set in 1993 (Warnakulasuriya et al. 1999).

The overall five-year survival rate for oral cancer in England and Wales generally remains poor at an average of 50%. There has been little reported improvement in survival rates from oral cancer since the 1960s despite improvements in surgery and radiotherapy. This poor survival is generally attributed to the late diagnosis of most oral cancers at an advanced stage when nodal involvement and neck metastases have occurred (British Dental Association 2000; Epstein et al. 2002; Silverman 2001).

It has been consistently reported that there is a prognostic advantage associated with early detection of oral cancer. There is some evidence from studies of therapy for early stage oral cancer, that five-year survival is better for Stage I (where tumour diameter is 2cm or less and there is no nodal involvement and no metastases) than Stage II (where tumour diameter is >2cm but <4cm in diameter and there is no nodal involvement and no metastases). Hawkins and co-workers reviewed nine studies (published between 1980 and 1997) reporting data from retrospective reviews of patient charts (Hawkins et al. 1999). The only measure provided in all studies was the five-year survival rate: for Stage I five-year survival ranged from 57% to 90% and for Stage II, from 41% to 72%. However, all of these studies were case-series studies where a group of patients received an intervention and outcomes were assessed (there was no comparison group). The influence of lead-time 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. Nevertheless, early diagnosis is considered to be of importance in improving the outcome of therapy – diagnosis at earlier stages allows for treatment with less aggressive therapies that are associated with less morbidity (Epstein et al. 1997).

It should also be noted that small tumours may not necessarily be ‘early’ in the chronological sense – some small tumours may be very aggressive and at an advanced stage at presentation even though they are 2cm or less in their greatest dimension.

3.3.3. Risk factors for oral cancer

Tobacco use (both smoking and smokeless tobacco [that is, chewing tobacco, chewing tobacco with betel quid, snuff]) and excessive consumption of alcohol are recognised risk factors in the development of oral cancer (British Dental Association 2000; Conway et al. 2002; Horowitz et al. 2001; Rosati 1994). Both factors are associated with oral cancer in a dose response fashion and have a synergistic effect when combined (Moss S, Melia J, Rodrigues V, Tuomainen H: unpublished data 1997). There is some controversy over the precise role of alcohol as an independent risk factor for oral cancer. Nevertheless, the epidemiological evidence suggests that all forms of alcoholic drink are dangerous if heavily consumed. In this context there is evidence for the role of beer, wine and spirits as risk factors for oral cancer. In many studies only high levels of alcohol consumption (for example, >20oz/week or >55 drinks/week) have indicated significant increases in risk. Due to the tendency in self-reporting to underestimate alcohol intake, particularly high levels of intake, the effect of alcohol may be stronger than the studies suggest (Shah et al. 2003). Current UK recommendations are that men should not drink more than 21-28 units per week and women should not drink more than 14-21 units. One in four men and one in ten women in the UK are believed to be drinking over the recommended limits, with the number of habitual heavy drinkers estimated at 4 million (British Dental Association 2000).

In young persons (below the age of 45 years) who develop oral cancer, there is mixed evidence of the role of alcohol and tobacco as risk factors. Several studies have reported that the risk factors of smoking and alcohol consumption were present to varying degrees in younger people with oral cancer. However, many authors also reported a complete lack of the usual aetiological factors associated with older patients that is, cases of oral cancer have been reported in young people who have had little or no exposure to tobacco or alcohol (Llewellyn et al. 2003).

A strong association between betel quid chewing and oral cancer and various potentially malignant lesions and conditions (primarily leukoplakia and oral submucous fibrosis) has been established. The addition of tobacco to the quid significantly increases the risk of oral cancer (Moss S, Melia J, Rodrigues V, Tuomainen H: unpublished data 1997; Thomas et al. 1993).

The habit of betel quid chewing is extremely common in India and South East Asia, Eastern Melanasia and the East African Coast. There is evidence that this habit remains prevalent in UK immigrants from these areas (Farrand et al. 2001). In the UK it has been reported that 19% of Bangladeshi men and 26% of women use some form of ‘chewed tobacco’ (Department of Health 2001). Other authors have reported that this may be as high as 39% and 82% respectively, in some areas (Bedi et al. 1995). Between 2% and 6% of UK Indian and Pakistani community members use some form of chewed tobacco.

Certain dietary deficiencies have been shown to play a role in oral carcinogenesis. Case control studies have consistently shown that oral cancer patients have histories of diets low in fruit and vegetables (that is, a diet low in Vitamin A and C has been associated with an increased risk of oral cancer) (Moss S, Melia J, Rodrigues V, Tuomainen H: unpublished data 1997). Iron deficiency anemia in combination with dysphagia and esophageal webs (Plummer-Vinson syndrome) is associated with an elevated risk for development of carcinoma.

It is well established that outdoor workers (for example, those involved in farming, fishing and postal delivery) are at greater risk from lip cancer because of long-term exposure to ultra-violet light. The risk of developing cancer of the lip increases with both the duration and frequency of exposure to ultraviolet radiation and is cumulative over time (Casiglia et al. 2001).


Other factors have been associated with an increased risk for oral cancer but evidence is not conclusive on whether the relationship is causal. These factors include:

  • Previous carcinoma
  • Bacterial and viral infections
  • Genetics
  • Occupational risk
  • Poor oral hygiene
  • Mouthwashes with a high alcohol content
  • Immune Deficiency

3.3.4. The accuracy of clinical oral examinations in detecting oral cancer and potentially malignant conditions

The sensitivity and specificity of screening for oral cancer by clinical examination depend on such factors as the training of the individual performing the examination, and on the criteria used to determine which lesions are counted as ‘positive’ and warrant referral for further investigation. The yield and positive predictive value depend on the population screened (Rodrigues et al. 1998).

There have been a number of population-based studies of screening by clinical oral examination for oral cancer. These studies have generally found a relatively high specificity between 81 to 99%. However, the sensitivity has varied widely from 59 to 85%. The positive predictive values have varied from 31 to 87 % depending on the prevalence of oral cancer. Consequently, due to the low prevalence of oral cancer in developed countries, two significant issues for screening programmes are a low yield in the general population and a high proportion of false positive referrals (Hawkins et al. 1999).

In the UK, screening by clinical examination of the oral cavity has been reported to have a sensitivity ranging from 71 to 81% and a specificity of 99% or more when screening was carried out by general dental practitioners, with dental specialists' diagnosis as the gold standard (Rodrigues et al. 1998). A recent meta-analysis of measures of performance reported in oral cancer and precancer screening studies concluded that systematic visual examination of the oral mucosa has a high discriminatory ability (Moles et al. 2002). In the latter study a weighted pooled average for sensitivity was calculated as 0.796. The corresponding value for specificity was 0.977

3.3.5. Toluidine blue dye

The use of toluidine blue dye has been suggested as an adjunct to visual examination in the identification and management of oral cancer since the 1960s and Toluidine blue dye oral cancer screening kits have been marketed to General Dental Practitioners in the UK. However, a recent systematic review of the evidence found wide variation in the sensitivity and specificity of the test (Gray et al. 2000). The authors of this review concluded that although toluidine blue might pick up additional cancers in high risk patients in secondary care, there was no evidence to support the use of toluidine blue as an adjunct to screening in primary care. The policy implications of this systematic review are that the use of toluidine blue dye as a screening tool in primary care should be discouraged.

3.3.6. Potentially malignant lesions and conditions

Although oral cancer often apparently arises de novo from clinically normal mucosa, there are also a number of clinically identifiable precursor lesions, which constitute a detectable pre-clinical phase (Downer 1997). The percentage of oral cancers which arise from precursor lesions is not accurately known, but has been estimated as more than 75% in India (a high incidence region for oral cancer). Although there are suggestions that the percentage of oral cancer cases arising de novo from clinically normal mucosa is greater in the Western world as compared to India, it has been argued that there are insufficient data to provide firm evidence particularly in countries such as the UK (Moss S, Melia J, Rodrigues V, Tuomainen H: unpublished data 1997).

Clinically identifiable precursor lesions are a heterogenous group of (usually) asymptomatic oral pathological entities with malignant potential. This broad group is generally classified under ‘lesions’ and ‘conditions’ – the latter are more generalised and widespread with significant systemic involvement. There is a paucity of data on the prevalence and incidence of potentially malignant lesions and conditions in the UK. Potentially malignant lesions include leukoplakia and erythroplakia of varying clinical presentations (such as homogenous, verrucous, nodular or speckled) and mixed lesions.


Leukoplakia is usually defined as an adherent white patch that cannot be diagnosed as any other disease process. Leukoplakia is thus a clinical diagnosis of exclusion – if an oral white patch can be diagnosed as some other condition (for example, candidiasis, lichen planus) then the lesion should not be considered to be an example of leukoplakia. As there have been somewhat unsatisfactory definitions and changes in the definitions of leukoplakia over time, there has been a wide range of figures for prevalence and incidence reported in the international literature. Leukoplakia is the most common potentially malignant condition. The incidence and prevalence of oral leukoplakia in the UK are not known. However, outside the UK the prevalence has been estimated to range from 0.2 to 11.7%. The variation in prevalence between studies is likely to be due to varying methodology and clinical criteria used in the identification of leukoplakia as well as population differences in risk factor prevalence.

Data on malignant transformation of leukoplakia are limited and difficult to interpret because of variable follow up, disease definitions, diagnostic criteria and treatment interventions. Several clinical studies have been conducted in Europe and the US to assess the potential for malignant transformation of oral leukoplakia. The reported rates of malignant transformation in the international literature range from 0.3 to 17.5% (Rodrigues et al. 1998). Most of the earlier studies have reported a risk of malignant transformation in the range of 3.6 to 6 per cent. However, several more recent studies have reported malignant transformation rates ranging from 8.9 to 17.5 percent. Although the reason for these results is unclear, it may be due to a more restrictive definition of what is considered clinical leukoplakia and further underscores the seriousness of ‘true leukoplakia’ (Neville et al. 2002). Estimates of the percentage of leukoplakias that regress to normal vary between 4.6% per year in India to 28.6% in the USA.

The most common oral sites for leukoplakia are the buccal mucosa, alveolar mucosa, and lower lip. The location of leukoplakia has a significant correlation with the frequency of finding dysplastic or malignant changes at biopsy. Lesions on the floor of the mouth, lateral tongue, and lower lip are most likely to show dysplastic or malignant changes (Neville et al. 2002). Some leukoplakias occur in combination with adjacent red patches or erythroplakia. If the red and white areas are intermixed, the lesion is called a speckled leukoplakia or speckled erythroplakia. Speckled leukoplakia or mixed leukoplakia/erythroplakia are at greatest risk for showing dysplasia or carcinoma.

The risk of malignant transformation is also reported to vary with gender (higher among women), type of leukoplakia (higher among those that are idiopathic, non-homogenous, of a long duration), presence of Candida albicans, and presence of epithelial dysplasia. Leukoplakias in non-smokers are also more likely to undergo malignant transformation than leukoplakias in patients who do smoke. This should not be interpreted to detract from the well-established role of tobacco in oral carcinogenesis but may indicate that non-smokers who develop leukoplakia do so as a result of more potent carcinogenic factors (van der Waal et al. 1997).


Erythroplakia is a term used analogously to leukoplakia to designate oral mucosal lesions that present as red areas and cannot be diagnosed as any other definable lesion (Shah et al. 2003). The prevalence of erythroplakia is not known but it is less common than leukoplakia. Studies in India and Burma have found a prevalence of 0.02 and 0.1% respectively (Shah et al. 2003). Oral erythroplakia occurs most frequently in older men (sixth and seventh decades) and appears as a red macule or plaque with a soft, velvety texture which may be slightly depressed below the level of the oral mucosa. The floor of the mouth, lateral tongue, retromolar pad and soft palate are most common sites of involvement. There are no studies reporting follow-up of series of cases of erythroplakia, perhaps due to its relatively low prevalence or due to its more active management. The rate of malignant transformation is high: most studies of biopsied cases of erythroplakia have found that the majority show areas of epithelial dysplasia, carcinoma in situ or invasive cancer, leading most authors to conclude that erythroplakia has a high potential for malignant transformation. However, the role of erythroplakia as a precursor lesion, as opposed to an early sign of carcinoma in situ or invasive cancer, is not clear (Rodrigues et al. 1998).


Lichen planus is a relatively common mucocutaneous disorder estimated to affect 0.5% to 2% of the general population. Lichen planus affects primarily middle-aged adults and the prevalence is greater among women. The classic skin lesions of the cutaneous form of lichen planus can be described as purplish, polygonal, planar, pruritic papules and plaques. These skin lesions commonly involve the flexor surfaces of the legs and arms, especially the wrists. Given that 30 – 50% of patients with oral lesions also have cutaneous lesions, the presence of these characteristic cutaneous lesions can aid in the diagnosis of oral lichen planus.

The malignant potential of oral lichen planus has been the subject of controversy for some time (Shah et al. 2003). Some studies indicate an increased risk of squamous cell carcinoma in patients with oral lichen planus lesions. This increased risk appears most common with the erosive and atrophic forms and in cases of lesions of the lateral border of the tongue. Other studies suggest that in some cases of purported malignant transformation, the malignancy may not have developed from true lesions of oral lichen planus but may instead have arisen from areas of dysplastic leukoplakia with a secondary lichenoid inflammatory infiltrate. The role of oral lichen planus as a true precursor lesion remains unclear (Rodrigues et al. 1998).


Oral Submucous fibrosis (OSMF) is a chronic disease of the oral mucosa which manifests as a unique generalised fibrosis of the oral soft tissues. The condition is most frequently seen in South-East Asia, particularly in the Indian subcontinent and is strongly associated with the habit of betel quid chewing. Sporadic cases have been reported among non-Asians (Europeans) (Moss S, Melia J, Rodrigues V, Tuomainen H: unpublished data 1997).

3.4. Effectiveness of Dental Health Education and Oral Health Promotion

3.4.1. Summary of the Literature Reviewed

  • Dental health education advice should be provided to individual patients at the chairside as this intervention has been shown to be beneficial (in the short term).
  • The effectiveness of other means of delivering dental health education and oral health promotion is unclear since, despite its importance, some issues have been poorly researched and there are design challenges around the use of randomised controlled trials.
  • Although evidence may be insufficient on whether it changes behaviour, dentists arguably have an ethical obligation to deliver good oral hygiene, dietary and smoking cessation advice to patients.

3.4.2. General Oral Health Promotion

We found two recent general systematic reviews on the effectiveness of health promotion and dental education on improving oral health. A report commissioned by Health Promotion Wales concluded that there is clear evidence that oral health education can change people's knowledge and improve their oral health (Sprod et al. 1996). However, it also concluded that while one-to-one oral health education is capable of reducing plaque levels, evidence strongly suggests that the changes achieved are short-term and unsustainable.

The authors of the second review were able to reach few definitive conclusions given the paucity of rigorous, well-designed studies in this area (Kay et al. 1998). From the studies that were rigorous and well-designed, Kay and Locker (Kay et al. 1998) were able to conclude that:

  • Health promotion that leads to use of fluoride containing agents results in caries reduction
  • Simple instruction in oral hygiene could alter people's behaviour in the short term
  • School based health education aimed at improving oral hygiene has not been shown to be effective. One-to-one interventions are effective but are likely to be expensive due to professional costs (few studies looked at cost-benefit ratios or sustainability of programmes)
  • There is no evidence that mass media programmes significantly alter any oral health related outcomes

It should be noted that only studies published in English were included in this study thus the results may be subject to publication bias. Although Kay and Locker reviewed each paper separately, they also aggregated the results. The papers included in the review differed on intervention, design, population and outcomes and thus it could be argued that it was inappropriate for Kay and Locker to pool the results as they did.

3.4.3. Smoking Cessation

Recent UK-based guidelines from the Health Education Authority conclude that health professionals can play a significant role in helping smokers to give up the habit (West et al. 2000). More specifically, a recent Cochrane review concluded that smoking cessation counselling delivered on an individual basis can assist smokers to quit (Lancaster et al. 2002). Although few studies have examined the role of dental professionals in this role, Watt and Daly suggest their success rates could be comparable with those in other primary care settings (Watt et al. 2003a). The key conclusions on efficacy from the recent UK guidelines (West et al. 2000) on offering smoking cessation advice to patients are:

  • Brief advice (less than 5 minutes) can result in 1 to 3% of smokers quitting smoking each year
  • The cessation rate increases to 6% if advice is up to 10 minutes and nicotine replacement therapy is utilized.

With regard to implementation, the recent UK 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.

Smokers may be more receptive to advice if it is linked with an existing medical condition. The smoker must be ready to quit and once an attempt to quit has been made, then follow-up should occur. There is no suggestion of when first follow-up should be made and how often additional follow-ups should occur. Additionally, these guidelines assume that people will be visiting their GP once a year, which may not be the case.

However, as noted earlier, these conclusions are based on studies looking at health professionals outside of dentistry. While Watt and Daly suggest the recommendations may be applied to health professionals in dentistry (Watt et al. 2003a), authors of a recent study (Rikard-Bell et al. 2003) suggest that more research is needed to determine whether smoking cessation advice delivered by dentists is indeed effective. They cite only one well-designed study that demonstrated significant results in smoking cessation following advice from a dentist, and three well-designed studies that failed to demonstrate successful results.

Rikard-Bell et al's own study in this area focused on patient views of dentist-delivered smoking cessation advice in Australia. They found that while 77% of patients agreed that dentists should provide smoking cessation advice, less than one-third of all smokers would try to quit upon advice from their dentist. Furthermore, over one-third of patients had little confidence in their dentist's knowledge of helping smokers quit.

3.4.4. Dietary Advice

Kay and Locker (Kay et al. 1998) reviewed a number of studies that looked at modifying the consumption of food and drink that contained sucrose. However, all studies used behavioural intentions or reported behaviour as outcome measures rather than those of oral health. Watt and McGlone (Watt et al. 2003b) found little evidence on dietary interventions delivered in primary dental care settings, and thus could not conclude whether giving dietary advice is effective.

3.5. Factors Affecting Dental Attendance and Satisfaction with the Current Service

3.5.1. Summary of the Literature Reviewed

  • People will attend the dentist either for an Oral Health Review (‘check-up’) or for relief of symptoms. However, it is not clear from the literature reviewed here what the distribution of the population between these categories is, nor how stable it is.
  • One study reported that regular attendees cited keeping their teeth as their main reason for their more frequent attendance. A larger body of literature on irregular attendees reported that people overwhelmingly cited a lack of perceived need to explain their symptomatic attendance pattern. Additional reasons commonly cited by patients for non-attendance were fear, cost and time. The attendance pattern of dependant groups (children and dependant adults) is determined by the motivations and priorities of their parents, guardians or carers.
  • People are generally satisfied with their NHS dental service and consider interpersonal skills to be the most important quality of their dentist.

This chapter summarises the most recent and comprehensive literature on public views of NHS dentistry, specifically motivations for visiting the dentist, factors that affect attendance patterns and satisfaction with the current service. Our literature search found no evidence regarding the public's views on specific recall intervals or whether people follow their dentist's recommendations about when to return for a check-up. Due to substantial variation internationally in the provision of, and payment for, dental care, we limited the scope to studies conducted in England and Wales.

3.5.2. Motivation for visiting the dentist

As the patterns of dental attendance vary substantially in England and Wales, it was important to query a broad spectrum of the population on their motivation for visiting the dentist. Therefore, we included NHS registered patients, in addition to users of NHS dentistry who are not currently registered. This latter group may be regular attendees but having not attended for over 15 months, will have been deregistered. It is important to note that first, there may be a group of patients included in these studies who may not know their registration status and second, that all of the studies obtained findings from the self-reported attendance of patients and not their attendance from dental records.

Broadly speaking, there are two reasons a person will present to the dentist: either for an oral health review (‘check-up’) or for symptomatic relief. Their attendance pattern, however, can vary substantially and many studies have sought to classify different patterns. The most widely known terms in the UK for describing attendance are ‘regular attendees’, ‘occasional attendees’ and people who only attend when experiencing oral problems. These terms originated in the National Dental Health Survey 1968 but have different inclusion criteria from study-to-study (Newsome et al. 1999). Several authors however, have described the inadequacy of these terms. Newsome and coworkers for example, report that the terms ‘regular’ and ‘occasional check-up’ refers to both the frequency and reason for the visit, while the latter term refers only to the reason. As an alternative, the categories ‘symptomatic attendee’ and ‘asymptomatic attendee’ have recently been used to describe dental attendance. Asymptomatic attendees are defined as those people who have attended for a check-up at least twice in three years, although this definition can vary.

While information about self-reported attendance is collected through surveys such as the Office of Fair Trading (OFT), the ratio between symptomatic attendees and asymptomatic attendees will be more accurately reported using results from the dental records, as there will inevitably be some discrepancy between perceived self-reported attendance patterns versus real attendance. Within both of these sources however, there is an important issue with the stability of these categories; some people for example, will maintain a pattern of asymptomatic attendance before lapsing into larger periods of symptomatic attendance (Bullock et al. 2001).

3.5.3. Factors influencing the frequency with which NHS patients see their dentist

There was good evidence concerning factors influencing symptomatic attendance. However, obtaining factors that prompted asymptomatic people to attend the dentist was more difficult. In terms of factors that affect the dental attendance of the general population, Bullock and coworkers reports results from a case control study set in a General Dental Practice in Stoke-on-Trent (Bullock et al. 2001). Two hundred patients, were divided into regular attendees (patients 18 yrs or over who had attended for two dental examinations in the last 2 years) and causal attendees (patients 18 or over who had not attended for a dental examination for the past 2 years and who attended at time of questionnaire in response to a dental problem) each completing a self-administered questionnaire. The most frequent reason cited by regular attendees for their asymptomatic attendance was ‘to keep my teeth’ (96%), followed by a concern with the early diagnosis of problems and the cosmetic appearance of teeth, the avoidance of pain and to encourage their children to attend the dentist regularly. Fifty six per cent of irregular attendees reported a fear or a dislike of dental treatment, followed by concerns about cost (41%) and time (32%). The OFT survey however, reported the primary reason for not being registered with a dentist was overwhelmingly lack of perceived need (43%), in a similar cohort of patients. Fear or dislike of dentists was much less frequently reported (2%). This discrepancy over the primary reason for non-attendance could possibly be explained by exploring the circumstances in which the research took place; questionnaires in the Bullock and coworkers study were completed in the dentists waiting room, which may have exacerbated any fears of the dentist/dental treatment (Bullock et al. 2001).

The results of several studies that focus on attendance of specific demographic groups report similar results in many instances. A sub-group analysis of older people within the Bullock and co-workers study, revealed that the prime reason for non-attendance was lack of perceived need (Bullock et al. 2001). A study on non-attending dentate older adults conducted within three areas of Britain by Steele and co-workers also reported a perception that there was no need to attend as the most common factor for non-attendance. A significant proportion of respondents also had concerns over the high financial cost (22-37.5%) and a fear or dislike of the treatment (23.6-38.2%) (Steele et al. 1996).

In another study of expectant mothers (Rogers et al. 1991), the main factor for non-attendance was the same although fear was reported more frequently than the other reports, which again, could have been exacerbated as the research was conducted in a clinical setting (Rogers et al. 1991).

Studies that focus on dependent groups (children, adults with disabilities and frail older people) demonstrate the way in which their dental attendance depends on other individuals. Hendricks and co-workers for example, reported that asymptomatic dental attendance among children is based on the tension in the relationship between the mother's positive attitude towards preventative care versus the fear and dislike of pain or discomfort caused to their children (Hendricks et al. 1990). Mothers' past experience of dentistry also influenced attendance patterns, in addition to a lack of confidence or issues of trust. Newsome and co-workers also outlined however, the way in which childhood dental anxiety can also negatively impact on attendance (Newsome et al. 1999). In a study on reported barriers to dental care for dependent older adults by Lester and co-workers, responses by both carers and patients themselves were recorded and compared (Lester et al. 1998). While patients most frequently reported lack of perceived need and cost as the most influential factors affecting their attendance, the carers of this same group of patients cited transport, health, cost and lack of escort as the most significant reasons.

3.5.4. Satisfaction with NHS dental services in England and Wales

The scope of this search was limited to people who believed they were currently registered with an NHS dentist (although there may be a sub-set of these who were unknowingly deregistered) and to their satisfaction with the NHS dental service. It did not cover access to NHS dental services; however, this is currently being reviewed by the National Audit Office. In addition, it was important that the views of a nationally representative sample of the population were sought as findings from regional studies may be misleading as service provision varies within England and Wales.

The most recent and comprehensive survey that considered the satisfaction of the public with NHS dentistry was conducted by the Office of Fair Trading (OFT) in 2003. The Consumer's Experience of Dental Services (Office of Fair Trading 2003) comprises nearly 4,000 interviews with adults over 18 years of age, nearly 2,000 of whom said they were registered with an NHS dentist. The OFT survey was carried out by a company called Capibus who ensure their samples are nationally and regionally representative, from urban and rural areas of Great Britain. Newsome and co-workers also provides a review of studies from 1980 to 1997 that look at patient satisfaction, although it is not apparent if these studies were restricted to the NHS service (Newsome et al. 1999). Two additional reports published recently, Calnan and co-workers (Calnan et al. 1999) and Hancock and co-workers (Hancock et al. 1999), were conducted on a much smaller scale and there is substantial overlap in conclusions.

The OFT study concluded that NHS patients are generally positive about quality of service they receive, information provided, advice and value for money (Office of Fair Trading 2003) although with the exception of value of money, private patients rated their dentists significantly higher. Calnan at al's work on NHS dental patients reported that there was some evidence to suggest that older people value the service slightly higher compared with the younger population, although the effect is small (Calnan et al. 2003). Related to this, there is also an overall confidence in dentists, which seems to increase with age. Both private and NHS patients aged 15-24 are 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).

While the general trends reported by the OFT study are reliable, the design of such surveys are limited by their lack of flexibility in possible responses, the potential for poor interpretation of the questions/ answers and their intention, which may create suspicion by respondents. The review by Newsome and co-workers for example, recognised that studies seeking to explore patient satisfaction with NHS dentistry often explore patient's perceptions of various service quality attributes (Newsome et al. 1999). For instance, although some patients may acknowledge instances in which they have received poor treatment, it is unlikely that they will be able to assess all levels of clinical competence in dentistry, yet the OFT survey cited ‘bad treatment’ as being the strongest determinant of dental satisfaction. This illustrates how impressions of the service are usually formed from a number of other features. The Newsome and co-workers review suggests that interpersonal factors (including provision of information, a caring attitude and discussion with the patient over treatment options) are consistently reported by patients to be the most important factors in a dentist. Furthermore, the cost of treatment per se, is not a source of contention with patients who are within the NHS system, but the communication about fee (for example, ignorance of charge until after the treatment or anger about the way in which the final bill was presented).

In conclusion, patients are generally satisfied with their NHS dental service and they view interpersonal factors with the dentist as the most important aspect of this satisfaction.

Copyright © 2004, National Collaborating Centre for Acute Care.
Bookshelf ID: NBK54537


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