Guidance

Chapter 1: introduction

Updated 10 September 2025

This guidance is issued jointly by the Department of Health and Social Care, the Welsh Government, the Department of Health Northern Ireland and NHS England, 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.

While 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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Who this guidance is for

Dental teams providing frontline care are the principal audience for this evidence-based toolkit. Since its first edition in 2007^{[footnote 1]}, this guidance has been widely used and valued by dental professionals and colleagues across health and social care, both within the UK and beyond. Delivering Better Oral Health (DBOH) is for the benefit of everyone and, ultimately, patients.

Dental professionals recognise the importance of good oral health. This guidance underpins their important role as experts in promoting oral health and preventing oral disease as a fundamental pillar of contemporary healthcare.

DBOH is, therefore, of special relevance for all dental team members as it:

• supports primary care dental teams to routinely promote oral and general health
• facilitates the provision of optimal care, advice and support for patients in achieving and maintaining good oral health
• is an educational resource for dental schools, postgraduate deaneries and other providers and commissioners of dental teaching
• is equally appropriate to dental specialists and their teams
• may be used across health and social care
• allows commissioning bodies to implement preventive pathways of care
• will be supported by resources to facilitate continuing professional development

Purpose of the guidance

This resource was produced to help busy health professionals provide high-quality preventive care, which is patient centred and aligns with wider health advice, thus promoting general and oral health. As evidence on prevention grows, DBOH guidance makes sense of the growing body of published research evidence. From the outset there was a commitment to regularly review and update this guidance.

This fourth edition represents the work of a UK-wide collaboration of well-respected experts and frontline practitioners, including patient representatives. 5 Guideline Development Groups have come together to review the evidence on specific topics, in line with the published process^{[footnote 2]}. The work has been overseen by a Guideline Working Group, supported by national leaders across health policy and the dental professions through the Dental Oversight Group^{[footnote 2]}. It is intended for use throughout dentistry in the United Kingdom. We trust that this updated guidance will be welcomed by dental professionals who have been using DBOH for some time and provide an additional resource for those new to the toolkit.

Methodology

The guidance was revised using an agreed, published methodology^{[footnote 2]}. Recommendations are based on the identification of existing high-quality systematic reviews, guidelines and, as appropriate, policy documents or legislation. Searching focused on the period from 2010 onwards, unless a clear need for a broader or narrower search period was identified by the Guideline Development Groups. Primary studies were not used unless there was a clear gap in secondary sources of evidence.

To bring version 4 of this guidance in line with more recent advances in guideline development, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach has been used to assess the certainty of the evidence and the strength of the subsequent recommendations^{[footnote 3]}. This system rates the quality (or certainty) of evidence for a particular outcome across studies.

Updates

All existing evidence has been checked and updated as well as new evidence added^{[footnote 2]}. A greater emphasis has been placed on risk-based management including monitoring through appropriate dental recall and across the life course, with the first dental attendance within the first year of life ^{[footnote 4]}. This is reflected in the summary guidance tables in chapter 2, as well as across the narrative chapters. The content includes a greater consideration of older people and other vulnerable groups, often based on good practice, rather than available evidence given the paucity of research for these groups.

The importance of supporting behaviour change is acknowledged with this chapter (chapter 3) coming immediately after the summary guidance tables. This chapter includes contemporary behaviour change theory, supported with practical examples found in the clinical case studies appendix.

Regarding the dental disease chapters:

• the disease-based chapters on dental caries, periodontal disease, oral cancer and tooth wear are linked to the chapters which address the major risk factors for these oral diseases
• the chapter on periodontal diseases includes a greater emphasis on primary, secondary and tertiary prevention, and recognises changing terminology and assessment tools, while aligning the guidance with the commonly used Basic Periodontal Examination (BPE)
• the chapter on tooth wear includes a focus on accelerated tooth wear and is included in the summary guidance tables for the first time
• each chapter has a resources section that provides links to a range of resources to support the delivery of better oral health

There are also changes which recognise different patterns of living, for example saying ‘toothbrushing last thing at night or before bedtime’ recognises that shift workers may be going to bed in the morning.

How to use this guidance

Oral and dental diseases are widely prevalent, and while oral health has improved in recent decades, most people are at risk of developing some oral disease during their lifetime. The most common diseases are dental caries and periodontal diseases, with oral cancer being the most serious, and tooth wear an increasing concern. The impact of oral disease (most notably dental caries) includes pain, days lost from work and school, and adversely affects people’s quality of life.

Within healthcare generally, there is a push for greater emphasis on prevention of ill-health and reduction of inequalities in health by giving advice, provision of support to change behaviour and application of evidence-informed actions from birth and across the life course. Effective self-care, together with professional support, is important for good oral health. It is vital that dental team members, as well as other healthcare staff, provide consistent messages that are up to date and based on the best evidence.

Population advice and support on lowering risk

All patients should receive advice and support to lower their risk of oral and general disease and promote health. This generally involves some element of behaviour change as outlined in chapter 3, although there are professional interventions, such as applying fluoride varnish to all teeth, that reduce the risk of dental caries. This is reflected in the summary guidance tables (chapter 2) as advice or professional intervention for all patients. For those patients about whom there is greater concern, because they are at higher risk of oral disease, there are recommendations on increasing the intensity of general care and additional actions for dental teams and their patients to take (chapter 2).

Risk identification and management is essential for prevention

We all make risk-based decisions on a daily basis, avoiding or taking risks in order to gain benefits^{[footnote 5]}. Or we may have conditions or live in an environment that presents a risk to our personal health. Many risk factors for oral health are also risk factors for poor general health and thus in supporting and promoting oral health we are also effectively helping patients to care for their general health.

Risks and benefits must be ‘balanced’. A good example of this would be in discussions about eating fruit. Fruit is part of a healthy diet and beneficial to overall health and therefore advice to all patients would be to encourage its consumption. However, in a very limited, small minority of the population it may constitute a risk factor for tooth wear in those who overconsume. This is where we in the dental profession must promote a healthy diet for everyone, while also providing our patients with specific advice about the pattern and volume of acidic fruit consumption when there is accelerated tooth wear, and only when this has been identified as the most likely risk factor.

While an individual patient’s health behaviour is important, it should be set within the context of the wider determinants of health which are often referred to as ‘the causes of the causes’^{[footnote 6]}. Figure 1.1 below shows the range of factors which affect oral health. These include:

• wider determinants, including:
  • housing policy
  • culture
  • commercial determinants
  • healthcare
  • education system
  • neighbourhood and/or built environment
  • attitudes and/or societal norms
  • political system
  • public policies
• socioeconomic position and/or protected characteristics, including:
  • socioeconomic status
  • education
  • global factors
  • genetics
  • ethnicity
  • age
  • housing
  • physical and learning disabilities
  • oral health literacy and knowledge
  • employment status
  • gender
• personal determinants, including:
  • dental history, including factors such as:
    • fluoride exposure
    • dental attendance patterns
    • caries experience
    • restorations
    • prostheses and/or appliances
    • family history
    • missing teeth
  • medical history, including conditions and/or medications that may:
    • complicate the provision of dental treatment or ability to maintain oral health
    • increase the risk of developing dental disease
    • mean general health is at an increased risk if dental disease arises
  • behavioural history, including factors such as:
    • diet
    • tobacco use
    • oral hygiene practices
    • alcohol
• special investigations, including:
  • radiographs
  • diet history
  • international caries classification and management system (ICCMS)
  • BPE
  • basic erosive wear examination (BEWE)
  • alcohol use screen tests such as AUDIT C
• dental status, including:
  • caries
  • tooth wear
  • tooth loss
  • plaque retaining factors
  • periodontal disease
  • low saliva rate
  • poor oral hygiene
  • mucosal legions

Figure 1.1: factors which affect oral health

Oral health is influenced by a range of contextual societal issues which are outside the day-to-day control of patients and healthcare providers. Individual or patient-level advice and guidance provided in DBOH (downstream actions) also requires upstream policy and community level interventions to address the social determinants of health. This should not be taken as a reason to do nothing or assume that patients in challenging situations do not value their oral health or want to do something about it. The evidence suggests that we need to work steadily, in partnership with our patients, to support change. A few small changes can make a big difference over time.

Risk assessment of individual patients is generally a clinical judgement based on careful history taking, clinical examination and further investigations, addressing the factors outlined in figure 1.1. Early identification of risks and their management also requires integration across healthcare, as we ‘make every contact count for health’^{[footnote 7]}.

Assessing risk status

The range of oral diseases to which people are susceptible, and their personal risk factors, change across the life course as shown in tables 1.1 and 1.2.

Table 1.1: oral diseases, risk factors and healthy behaviours to promote for children of different ages

	0 to 2 years	3 to 6 years	7 to 17 years
Most common diseases and conditions	Dental caries	Dental caries Tooth wear	Dental caries Tooth wear Gingivitis
Major risk factors in this age group	Diet (food and drinks containing sugar) Lack of fluoride	Diet (food and drinks containing sugar) Lack of fluoride Poor oral hygiene	Diet (food and drinks containing sugar) Low or no fluoride Poor oral hygiene Tobacco commencing Alcohol commencing
What to actively promote for everyone in this age group	Healthy diet Parental toothbrushing Fluoride toothpaste	Healthy diet Parental toothbrushing and assistance Fluoride toothpaste Spit instead of rinse after brushing	Healthy diet Fluoride toothpaste Spit instead of rinse after brushing Good oral hygiene Avoid or stop tobacco Avoid alcohol
Monitoring and recall period	3 to 12 months	3 to 12 months	3 to 12 months

Table 1.2: oral diseases, risk factors and healthy behaviours to promote for adults of different ages

	18 to 65 years	Older or vulnerable adults
Most common diseases and conditions	Dental caries Tooth wear Periodontitis Oral cancer	Dental caries Tooth wear Periodontitis Oral cancer Dry mouth
Major risk factors in this age group	Diet (food and drinks containing sugar) Low or no fluoride Poor oral hygiene Tobacco Alcohol Polypharmacy Tooth loss Dentures	Diet (food and drinks containing sugar) Low or no fluoride Poor oral hygiene Tobacco Alcohol Polypharmacy Tooth loss Dentures
What to actively promote for everyone in this age-group	Healthy diet Good oral hygiene Fluoride toothpaste Spit instead of rinse after brushing Avoid or stop tobacco Avoid or minimise alcohol	Healthy diet Good oral hygiene, including dentures Fluoride toothpaste Spit instead of rinse after brushing Avoid or stop tobacco Avoid or minimise alcohol Dry mouth care
Monitoring and recall period	3 to 24 months	3 to 24 months

Children in their early years are most likely to be affected by dental caries, however the risk and the range of oral and dental conditions rises with age. The role of dental team members is, therefore, based on risk to provide the most relevant support, care and advice to patients throughout their life. Assessing and categorising each patient’s individual risk status should therefore be part of each course of care across the life course. In using this toolkit, it is easiest to consider whether patients are at:

• the general level of population risk, in which case they receive the general advice
• higher risk

The latter may be because of their disease history (medical or dental), the context in which they live or their health behaviours, and indicate that additional support is required (see tables 1.3a, 1.3b, 1.3c and 1.3d).

Table 1.3a: advice for children aged up to 3 years

Patient risk status	Recommended support and advice
General population	Brush teeth at least twice daily last thing at night or before bedtime and on one other occasion with a smear of fluoride toothpaste containing at least 1,000ppm fluoride Parents or carers should brush teeth as soon as they appear Promote breastfeeding exclusively from birth for the first 6 months then continue breastfeeding and introduce solids. Gradually introduce a wide variety of solid foods (of different textures and flavours) Sugar should not be added to food or drinks given to babies and toddlers Minimise consumption of sugar-containing food and drinks Avoid sugar-containing food and drink at bedtime Use sugar-free versions of medicines For parents feeding by bottle, only breastmilk, infant formula or cooled boiled water should be given Feeding from a bottle should be discouraged from the age of 1 year; babies should drink from a free-flow cup from 6 months Recall: 3 to 12 months; shorten recall interval when at higher risk
In addition to advice for the general population, those at higher risk of dental caries should:	Apply fluoride varnish 2 or more times a year Use toothpaste containing 1,350 to 1,500ppm fluoride Investigate diet and assist adoption of good dietary practice in line with the Eatwell Guide Liaise with medical practitioner to request that any long-term medication is sugar-free
In addition to advice for the general population, those at higher risk of periodontal diseases should:	Not applicable for this age group
In addition to advice for the general population, those at higher risk of oral cancer should:	Not applicable for this age group
In addition to advice for the general population, those at higher risk of tooth wear should:	Investigate possible risk factors and advise accordingly

Table 1.3b: advice for children aged 3 to 6 years

Patient risk status	Recommended support and advice
General population	Brush teeth at least twice daily last thing at night or before bedtime and on at least one other occasion with a pea-sized amount of fluoride toothpaste containing at least 1,000ppm fluoride Parents or carers should brush or assist toothbrushing up to 7 years Spit out after brushing, do not rinse Apply fluoride varnish twice yearly Promote healthy diet Minimise consumption of sugar-containing food and drinks Avoid sugar-containing food and drink at bedtime Use sugar-free versions of medicines Recall: 3 to 12 months; shorten recall interval when at higher risk
In addition to advice for the general population, those at higher risk of dental caries should:	Apply fluoride varnish 2 or more times a year Use toothpaste containing 1,350 to 1,500ppm fluoride Investigate diet and assist adoption of good dietary practice in line with the Eatwell Guide Liaise with medical practitioner to request that any long-term medication is sugar-free
In addition to advice for the general population, those at higher risk of periodontal diseases should:	Oral hygiene instruction
In addition to advice for the general population, those at higher risk of oral cancer should:	Not applicable for this age group
In addition to advice for the general population, those at higher risk of tooth wear should:	Investigate possible risk factors and advise accordingly

Table 1.3c: advice for children aged 7 to 17 years

Patient risk status	Recommended support and advice
General population	Brush teeth and the gum line effectively at least twice daily last thing at night or before bedtime and on at least one other occasion with toothpaste containing a standard 1,350 to 1,500ppm fluoride Parents or carers should assist toothbrushing if required Spit out after brushing, do not rinse Apply fluoride varnish to teeth 2 times a year Promote healthy diet Minimise amount and frequency of consumption of sugar-containing food and drinks Avoid sugar-containing food and drink at bedtime Avoid tobacco Avoid alcohol Recall: 3 to 12 months; shorten recall interval when at higher risk
In addition to advice for the general population, those at higher risk of dental caries should:	Apply fluoride varnish 2 or more times a year Recommend daily fluoride rinse (0.05% NaF) Consider prescribing higher fluoride toothpaste (short-term): (10 to 15 years 2,800ppm fluoride; over 16 years 2,800ppm fluoride or 5,000ppm fluoride) Dietary analysis and sugar reduction Apply fissure sealants Liaise with medical practitioner to request that any long-term medication is sugar-free
In addition to advice for the general population, those at higher risk of periodontal diseases should:	Oral hygiene instruction Promote interdental cleaning if evidence of disease Advise on methods for supporting tobacco cessation (very brief advice) Correct plaque retentive factors Consider general health including reduced salivary flow, diabetes and medications
In addition to advice for the general population, those at higher risk of oral cancer should:	Advise on methods for supporting tobacco cessation (very brief advice) Advise on alcohol use (Audit C)
In addition to advice for the general population, those at higher risk of tooth wear should:	Investigate possible risk factors and advise accordingly Advise on lowering risk Support with behaviour change

Table 1.3d: advice for all adults

Patient risk status	Recommended support and advice
General population	Brush teeth and the gum line effectively, 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 Spit out after brushing, do not rinse Promote healthy diet Minimise amount and frequency of consumption of sugar-containing food and drink and avoid at bedtime Avoid tobacco Avoid alcohol or drink at safer levels Recall: 3 to 24 months; shorten recall interval when at higher risk
In addition to advice for the general population, those at higher risk of dental caries should:	Support toothbrushing where required (for example carer assistance, specialised brush, non-foaming toothpaste) Apply fluoride varnish 2 times a year Recommend daily fluoride rinse (0.05% NaF) Consider prescribing higher fluoride toothpaste: 2,800ppm fluoride or 5,000ppm fluoride Dietary analysis and sugar reduction Liaise with medical practitioner to request that any long-term medication is sugar-free
In addition to advice for the general population, those at higher risk of periodontal diseases should:	Oral Hygiene Instruction Promote interdental cleaning if evidence of disease Advise on methods for supporting tobacco cessation (very brief advice) Correct plaque retentive factors Consider general health including reduced salivary flow, diabetes, medications
In addition to advice for the general population, those at higher risk of oral cancer should:	Advise on methods for supporting tobacco cessation (very brief advice) Advise on alcohol use (Audit C)
In addition to advice for the general population, those at higher risk of tooth wear should:	Investigate possible risk factors and advise accordingly Advise on lowering risk Support with behaviour change

Consideration of risk also has implications for dental recall periods which should be assessed in line with National Institute for Health and Care Excellence (NICE) guidance ^{[footnote 8]}, and shortened for those thought to be at higher risk. The shortest interval between oral health reviews for all patients should be 3 months, the longest interval between oral health reviews for patients younger than 18 years should be 12 months and for patients aged 18 years and older, 24 months.

When encountering patients who are at higher risk, it is an important to explore if they can be supported to lower their risk or need special preventive care for the rest of their life. For most people, with support and encouragement, it is possible to tackle at least some of their risk factors over time, rather than all at once. However, there are vulnerable children and adults of all ages for whom it may not always be possible to do so because of their condition, medication, frailty or context.

Working in partnership with patients to lower risk

This guidance acknowledges that dental team members should be aware that different choices will be appropriate for individual patients. Dental professionals should help each patient to agree on a personalised approach that respects their own values and preferences as well as their level of risk.

The challenge for dental professionals is to:

• ensure everyone receives universal preventive advice and support, in person or online
• identify patients who are at higher risk of dental disease or for whom dental care would be particularly difficult and provide additional preventive care and support

Some people find it helpful to think about whether prevention is primary, secondary or tertiary (table 1.4). This framework works particularly well for plaque induced periodontal diseases as presented in chapter 5.

Table 1.4: stages of prevention

Stage	Description
Primary	Reducing the incidence of disease and health problems within the population, either through universal measures that reduce lifestyle risks and their causes or by targeting high-risk groups.
Secondary	Detecting the early stages of disease and intervening before full symptoms develop.
Tertiary	Softening the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often complex health problems and injuries.

Source: Local Government Association^{[footnote 9]}

References

1. Department of Health, British Association for the Study of Community Dentistry, NHS. Delivering better oral health: An evidence-based toolkit for prevention. London: Department of Health; 2007. ↩

2. Public Health England. Improving oral health: guideline development manual. London: Public Health England; 8 January 2020. ↩ ↩² ↩³ ↩⁴

3. GRADE Working Group. GRADE 2016. ↩

4. NHS England. Starting Well Core 2015. ↩

5. Schenk L, Hamza KM, Enghag M, Lundegård I, Arvanitis L, Haglund K and others. Teaching and discussing about risk: seven elements of potential significance for science education. International Journal of Science Education. 2019;41(9):1271-86. ↩

6. Public Health England. Inequalities in oral health in England. London: PHE; 2021 ↩

7. NHS England. Making Every Contact Count (MECC) (viewed 15 April 2025) ↩

8. NICE. Dental recall guidelines. London: National Institute for Health and Clinical Excellence; 2004. Report No.: CG019. ↩

9. Local Government Association. Making the case for prevention: a must know for elected members; 2025 (15 April 2025). ↩