Guidance

Chapter 1: Introduction

Updated 9 November 2021

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

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

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

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Who is this guidance 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

Why was it produced?

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. Five 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.

How was it produced?

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 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.

What has changed?

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, 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 coming immediately after the summary guidance tables (Chapter 2). This chapter includes contemporary behaviour change theory, supported with practical examples as clinical case studies.

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, whilst 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 toothbrushing last thing at night or before bedtime recognises that shift workers may be going to bed in the morning.

How can it be used?

Oral and dental diseases are widely prevalent, and whilst 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 drive 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.

Whilst individual patient’s health behaviour is important, it should be set within the context of the wider determinants of health (Figure 1.1) which are often referred to as ‘the causes of the causes’^{[footnote 6]}. 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 Figure 1.2. 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 or at 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 (Figure 1.3).

Consideration of risk also has implications for dental recall periods which should be assessed in line with 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(s) 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 1.1). This framework works particularly well for plaque induced periodontal diseases as presented in Chapter 5.

Table 1.1 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. NICE. Making every contact count London: National Institute for Health and Clinical Excellence; 2021 (24 April 2021). ↩

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

9. Local Government Association. Prevention London: LGA; 2020 (5 November 2020). ↩