Guidance

Chapter 13: evidence base for recommendations in the summary guidance tables

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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Introduction

Strong recommendation

The Guideline Development Group (GDG) is confident that the benefits outweigh the harms of the intervention, typically based on high or moderate certainty evidence.

Conditional recommendation

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

Good practice

Clinical opinion suggests this advice is well established or supported. No robust underpinning research evidence exists. Good practice points are primarily based on extrapolation from research on related topics and/or clinical consensus, expert opinion and precedent, and not on research appropriate for rating the certainty or quality of the evidence.

Supporting evidence is graded as high, moderate, low or very low certainty. This grading is based on:

• the risk of bias in the primary studies included in a systematic review/guideline document
• the consistency of the findings across studies
• the applicability of the evidence to the specific question being addressed
• the precision around any estimate of effect
• whether the findings are at risk of publication bias

When a recommendation covers multiple components, each GDG considered the underlying evidence for each component and based the strength of recommendation on the main component.

Evidence base for dental caries tables

This evidence base refers to chapter 2: tables 1a, 1b, 1c, 1d, 1e, 1f and 1g.

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

Table 1: all children aged up to 3 years

Advice or professional intervention	Recommendation	Evidence base
Advice	Breastfed babies experience less tooth decay and breastfeeding provides the best nutrition for a baby’s overall health. Support mothers to: • breastfeed exclusively for around the first 6 months of a baby’s life • then continue breastfeeding, while introducing solids from around the age of 6 months	Strong Recommendation based on WHO guidelines, taking into account benefits of exclusive breastfeeding for first 6 months on overall health[footnote 1], as well as low certainty evidence of a dental caries-preventive effect[footnote 2][footnote 3]. Weaning advice is from UK Scientific Advisory Committee on Nutrition (SACN) guidelines[footnote 2]. Some very low certainty evidence of increase in dental caries risk beyond 12 months breastfeeding, but this was observed in children experiencing high frequency of nocturnal breastfeeding and may also be influenced by confounders that the studies did not assess, for example, sugar-sweetened food and drink consumption[footnote 3].
Advice	Parents or carers should brush their children’s teeth: • as soon as they erupt • twice a day • last thing at night or before bedtime and on one other occasion • with a toothpaste containing at least 1,000ppm fluoride • using only a smear of toothpaste	Strong Recommendation based on moderate certainty evidence for toothbrushing with fluoride toothpaste and concentration of 1,000ppm fluoride and above (the evidence for toothpaste 500 to 1,000ppm fluoride is inconclusive)[footnote 4]. Low to very low certainty evidence around initiation stage, frequency and timing[footnote 5]. Advice to use a smear only based on possible fluorosis risk (inconclusive evidence)[footnote 6].
Advice	Minimise consumption of sugar-containing foods and drinks.	Strong Recommendation based on moderate-certainty evidence that dental caries is lower when free-sugars intake is <10% and on very low certainty evidence that dental caries is lower when free-sugars intake is <5% energy[footnote 7], and in line with WHO[footnote 8] and SCAN guidelines[footnote 9].
Advice	For parents or carers feeding babies by bottle: • only breastmilk, infant formula or cooled boiled water should be given in a bottle • babies should be introduced to drinking from a free-flow cup from the age of 6 months • feeding from a bottle should be discouraged from the age of 1 year	Good practice[footnote 2]
Advice	Introduce solid foods (of different textures and flavours) at around the age of 6 months. Sugar should not be added to food or drinks given to babies and toddlers.	Good practice[footnote 2]
Advice	Use sugar-free versions of medicines if possible.	Good practice
Advice	Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost.	Conditional Recommendation based on very low certainty evidence for increased risk of dental caries associated with bedtime consumption of food and drinks containing free sugars (in children aged 3 years and older)[footnote 10].
Professional intervention	Assign a recall interval ranging from 3 to 12 months based on oral health needs and disease risk.	Conditional Recommendation based on very low certainty evidence[footnote 11]. Recommendation in line with NICE (CG19)[footnote 12].

Table 2: all children aged 3 to 6 years

Advice or professional intervention	Recommendation	Evidence base
Advice	Teeth should be brushed by a parent or carer. As the child gets older, a parent or carer should assist them to brush their own teeth: • on all tooth surfaces • at least twice a day • last thing at night (or before bedtime) and on at least one other occasion • with toothpaste containing at least 1,000ppm fluoride • using a pea-sized amount of the toothpaste • spitting out after brushing rather than rinsing, to avoid diluting the fluoride concentration	Strong Recommendation based on moderate certainty for toothbrushing with fluoride toothpaste[footnote 4], for fluoride concentration for permanent teeth[footnote 4] (evidence around primary teeth less clear) and spitting versus rinsing[footnote 5]. Evidence for frequency or timing is low certainty[footnote 5]. Advice to use pea-sized amount based on possible fluorosis risk[footnote 6].
Advice	Minimise amount and frequency of consumption of sugar-containing food and drinks.	Strong Recommendation based on moderate-certainty evidence that dental caries is lower when free-sugars intake is <10% and on very low certainty evidence that dental caries is lower when free-sugars intake is <5% energy[footnote 7] and in line with WHO[footnote 8] and SCAN guidelines[footnote 9].
Advice	Use sugar-free versions of medicines if possible.	Good practice
Advice	Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost.	Conditional Recommendation based on very low certainty evidence for increased risk of dental caries associated with bedtime consumption of food and drinks containing free sugars (in children aged 3 years and older)[footnote 10].
Professional intervention	Apply fluoride varnish (2.26% NaF) to teeth 2 times a year.	Strong Recommendation based on moderate certainty evidence[footnote 13].
Professional intervention	Assign a recall interval ranging from 3 to 12 months based on oral health needs and disease risk.	Conditional Recommendation based on very low certainty evidence[footnote 11]. Recommendation in line with NICE (CG19)[footnote 12].

Table 3: children aged 0 to 6 years giving concern because of dental caries risk

All the above, plus:

Advice or professional intervention	Recommendation	Evidence base
Advice	Use toothpaste containing 1,350 to 1,500ppm fluoride.	Strong Recommendation based on moderate certainty evidence of added benefit over 1,000ppm fluoride[footnote 4]
Advice	For children taking medication frequently or long term, choose or request sugar-free medicines if possible.	Good practice
Professional intervention	Apply fluoride varnish (2.26% NaF) to teeth 2 or more times a year.	Strong Recommendation based on moderate certainty evidence[footnote 13].
Professional intervention	Where the child is prescribed medication frequently or long term, liaise with medical practitioner to request that it is sugar free.	Good practice
Professional intervention	Investigate diet and assist adoption of good dietary practice in line with the Eatwell Guide.	Good practice[footnote 14]
Professional intervention	Assign a shortened recall interval based on dental caries risk.	Conditional Recommendation based on very low certainty evidence[footnote 11]. Recommendation in line with NICE (CG19)[footnote 12].

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

Table 4: all children from 7 years and young people up to 18 years

Advice or professional intervention	Recommendation	Evidence base
Advice	Brush teeth at least twice daily (with assistance from parent or carer if required): • last thing at night or before bedtime and on at least one other occasion • with toothpaste containing 1,350 to 1,500ppm fluoride • spitting out after brushing rather than rinsing with water, to avoid diluting the fluoride concentration	Strong Recommendation based on moderate certainty evidence[footnote 4] (timing is low certainty)[footnote 5].
Advice	Minimise amount and frequency of consumption of sugar-containing food and drinks.	Strong Recommendation based on moderate-certainty evidence that dental caries is lower when free-sugars intake is <10% and on very low certainty evidence that dental caries is lower when free-sugars intake is <5%[footnote 7] and in line with WHO[footnote 8] and SCAN guidelines[footnote 9].
Advice	Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost.	Conditional Recommendation based on very low certainty evidence for increased risk of dental caries associated with bedtime consumption of food and drinks containing free sugars (in children aged 3 years and older)[footnote 10].
Professional intervention	Apply fluoride varnish to teeth 2 times a year (2.26% NaF).	Strong Recommendation based on moderate certainty evidence[footnote 13].
Professional intervention	Assign a recall interval within the range of 3 to 12 months based on oral health needs and disease risk.	Conditional Recommendation based on very low certainty evidence[footnote 11]. Recommendation in line with NICE (CG19)[footnote 12].

Table 5: children from 7 years and young people up to 18 years giving concern because of dental caries risk

All the above, plus:

Advice or professional intervention	Recommendation	Evidence base
Advice	Parent or carer to assist and supervise toothbrushing if required.	Good practice[footnote 15]
Advice	Use a fluoride mouth rinse daily (0.05% NaF; 230ppm fluoride) at a different time to brushing.	Conditional Recommendation based on moderate certainty evidence from supervised school use in children and adolescents[footnote 16].
Professional intervention	Apply resin sealant to permanent teeth on eruption.	Strong Recommendation based on moderate certainty evidence of a benefit of resin‐based sealant maintained up to at least 48 months of follow‐up in both low risk and high risk populations[footnote 17].
Professional intervention	Apply fluoride varnish to teeth 2 or more times a year (2.26% NaF).	Strong Recommendation based on moderate certainty evidence[footnote 13]. Most studies used 2 applications per year. For guidance: manufacturers recommend application every 6 months, or a maximum of every 3 months.
Professional intervention	Where a child or young person is prescribed medication frequently or long term, liaise with medical practitioner to request that it is sugar free.	Good practice
Professional intervention	Investigate diet and assist adoption of good dietary practice in line with the Eatwell Guide.	Good practice[footnote 14]
Professional intervention	For those 8 years and above with active caries, consider recommending or prescribing daily fluoride mouth rinse (0.05% NaF; 230ppm fluoride), to be used at a different time from brushing, until dental caries risk is reduced.	Conditional Recommendation based on moderate certainty evidence from supervised school programmes[footnote 16]. Mouth rinse is available over the counter as well as on prescription.
Professional intervention	For those 10 years and above with active caries, consider prescribing 2,800ppm fluoride toothpaste until dental caries risk is reduced.	Conditional Recommendation based on there being no reliable evidence of superior effectiveness but some suggestion of a dose-response relationship (though it may not extend to concentrations this high)[footnote 4]. Recommendation in line with SDCEP 2018[footnote 18].
Professional intervention	For those 16 years and above with active caries, consider prescribing either 2,800ppm or 5,000ppm fluoride toothpaste until dental caries risk is reduced.	Conditional Recommendation based on there being no reliable evidence of superior effectiveness but some suggestion of a dose-response relationship (though it may not extend to concentrations this high)[footnote 4]. 5,000ppm fluoride only been studied in root caries[footnote 19].
Professional intervention	Assign a shortened recall interval based on dental caries risk.	Conditional Recommendation based on very low certainty evidence[footnote 11] Recommendation in line with NICE (CG19)[footnote 12].

Prevention of dental caries in adults

Table 6: all adults

Advice or professional intervention	Recommendation	Evidence base
Advice	Brush teeth at least twice daily: • last thing at night (or before bedtime) and on at least one other occasion • with toothpaste containing 1,350 to 1,500ppm fluoride • spitting out after brushing rather than rinsing with water, to avoid diluting the fluoride concentration	Strong Recommendation based on moderate certainty evidence for value of toothbrushing with fluoride toothpaste[footnote 4]. Moderate certainty from studies with children and adolescents for spitting versus rinsing[footnote 5]. Low-certainty evidence from children and adolescents for frequency and timing[footnote 5]. Evidence for the concentration is based on studies on immature permanent dentition in children and adolescents[footnote 4].
Advice	Minimise the amount and frequency of consumption of sugary food and drinks.	Strong Recommendation based on moderate-certainty evidence that dental caries is lower when free-sugars intake is <10% and on very low certainty evidence that dental caries is lower when free-sugars intake is <5% energy[footnote 7], and in line with WHO[footnote 8] and SCAN guidelines[footnote 9].
Advice	Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost.	Conditional Recommendation based on very low certainty evidence for increased risk of dental caries associated with bedtime consumption of food and drinks containing free sugars (in children aged 3 years and older)[footnote 10].
Professional intervention	Assign a recall interval ranging from 3 to 24 months, based on oral health needs and disease risk.	Conditional Recommendation based on moderate certainty evidence that recall interval can be varied on individual basis without negative effects for adults who regularly attend dentist[footnote 11]. Evidence not available for ‘hard-to-reach’ adults or those with more complex presentations. Recommendation in line with NICE (CG19)[footnote 12].

Table 7: adults giving concern because of dental caries risk

All the above, plus:

Advice or professional intervention	Recommendation	Evidence base
Advice	Support toothbrushing where required (for example carer assistance, specialised brush, non-foaming toothpaste).	Good practice[footnote 20]
Advice	Use a fluoride mouth rinse daily (0.05% NaF; 230ppm fluoride) at a different time to toothbrushing.	Conditional Recommendation based on moderate certainty evidence from supervised school use in children and adolescents[footnote 16].
Professional intervention	Apply fluoride varnish to teeth 2 times a year (2.26% NaF).	Strong Recommendation based on moderate certainty evidence from children and adolescents[footnote 13].
Professional intervention	Where a patient is prescribed medication frequently or long term, liaise with medical practitioner to request that it is sugar free.	Good practice
Professional intervention	Investigate diet and assist adoption of good dietary practice in line with the Eatwell Guide.	Good practice[footnote 14]
Professional intervention	For those with active coronal or root caries, consider recommending or prescribing daily fluoride rinse (0.05% NaF; 230ppm fluoride, to be used at a different time from toothbrushing) until dental caries risk is reduced.	Conditional Recommendation based on low certainty evidence[footnote 21].
Professional intervention	For those with obvious active coronal or root caries, consider prescribing 2,800 or 5,000ppm fluoride toothpaste until dental caries is stabilised and risk is reduced.	Conditional Recommendation based on there being no reliable evidence of superior effectiveness but some evidence of dose-response relationship, although it may not extend to concentrations this high[footnote 4]. Moderate-certainty evidence for effectiveness of 5,000ppm fluoride for root caries[footnote 19].
Professional intervention	Assign a shortened recall interval based on dental caries risk.	Conditional Recommendation based on moderate certainty evidence that recall interval can be varied on individual basis without negative effects for adults who regularly attend dentist[footnote 11]. Evidence not available for ‘hard-to-reach’ adults or those with more complex presentations. Recommendation in line with NICE (CG19)[footnote 12].

Evidence base for periodontal diseases tables

This evidence base refers to chapter 2: tables 2a, 2b, 2c and 2d.

Prevention of periodontal diseases - to be used in addition to caries prevention

Table 8: all patients

Advice or professional intervention	Recommendation	Evidence base
Advice	Toothbrush type: • use a manual or powered toothbrush	Strong Recommendation based on moderate certainty evidence that powered toothbrushes are probably more effective than manual for reducing gingival index score, but the benefit may not be clinically important[footnote 22][footnote 23]. Both types of toothbrush work and are recommended[footnote 24]. Not everyone can afford a powered toothbrush.
Advice	Self-care plaque removal: • remove plaque effectively using methods shown by the dental team. This will prevent gingivitis (gum bleeding or redness) and reduces the risk of periodontal disease	Good practice For example, SDCEP 2014 recommends: ‘Ensure that all patients are able to perform optimal plaque removal’[footnote 25].
Advice	Around orthodontic appliances and bridges, plaque control should be undertaken using the aids suggested by the dental professional.	Good practice
Advice	Self-care plaque removal: • daily, effective plaque removal is critical to periodontal health	Conditional Recommendation based on indirect evidence that professional intervention alone is insufficient to prevent periodontal disease starting or deteriorating[footnote 26][footnote 27].
Advice	Toothbrushing and toothpaste: • brush gum line and each tooth at least twice daily (last thing at night or before bedtime and on one other occasion)	Conditional Recommendation based on very low-certainty evidence that infrequent brushing is associated with periodontitis[footnote 28].
Advice	Toothbrush type: • use a small toothbrush head, medium texture	Conditional Recommendation based on low certainty evidence of gingival lesions when hard bristle brushes were used[footnote 29].
Professional intervention	Correct factors that impede effective plaque control including supra and subgingival calculus, open margins and restoration overhangs and contours, which prevent effective plaque removal.	Good practice For example, SDCEP 2014 recommends: ‘Ensure that local plaque retentive factors are corrected – for example, remove overhanging restorations or alter denture design’[footnote 25].
Professional intervention	For people with extensive inflammation, start with toothbrushing advice, followed by interdental plaque control.	Good practice
Professional intervention	Assess patient, parent or carer’s preferences for plaque control: • decide on manual or powered toothbrush • demonstrate methods and types of brushes • Assess plaque removal abilities and confidence with brushing • Patient sets goals for toothbrushing for next visit	Good practice For example, SDCEP 2014 recommends: ‘…Ask the patient to practise, that is, to clean his or her teeth in front of you. This provides an opportunity to correct the patient’s technique if required and ensures that the patient has really understood what he or she needs to do. Help the patient plan how to make effective plaque removal a habit…’[footnote 25].
Professional intervention	Advise best methods of plaque removal to prevent gingivitis and achieve lowest risk of periodontitis and tooth loss.	Conditional Recommendation based on very low certainty evidence for one-to-one oral hygiene advice reducing gingivitis and plaque[footnote 30].
Professional intervention	Use behaviour change methods with oral hygiene instruction.	Conditional Recommendation based on low certainty evidence that goal setting, self‐monitoring and planning improve oral hygiene‐related behaviour[footnote 31].

Table 9: all adults (and young people aged 12 to 17 years with evidence of periodontal disease)

Advice or professional intervention	Recommendation	Evidence base
Advice	Interdental plaque control: • clean daily between the teeth to below the gum line before toothbrushing • where there is space for an interdental or single-tufted brush, this should be used • for small spaces between teeth, use dental floss or tape	Conditional Recommendation based on low certainty evidence for an added benefit from flossing, though it is unclear if this benefit is clinically important[footnote 32]; EFP recommends floss only where gaps are too small for interdental brushes[footnote 33]. Low certainty evidence that use of interdental brushes is beneficial and that they are more effective than floss, but again the clinical importance of the difference is uncertain[footnote 32].
Professional intervention	Assess patient’s preferences for interdental plaque control: • decide on appropriate interdental aids • demonstrate methods and types of aids • assess plaque removal abilities and confidence with aids • patient sets goals for interdental plaque control	Good practice For example, SDCEP 2014 recommends: ‘Demonstrate, in the patient’s mouth while he or she holds a mirror, how to systematically clean each tooth using a toothbrush (manual or rechargeable powered) as well as how to use floss and/or interdental brushes…’[footnote 25].

Prevention of peri-implantitis

Table 10: all adults with dental implants

Advice or professional intervention	Recommendation	Evidence base
Advice	Dental implants require the same level of oral hygiene and maintenance as natural teeth.	Good practice For example, SDCEP 2014 recommends: ‘…Patients with a single implanted crown can be encouraged to treat the implant as they would their natural dentition and to clean it with a toothbrush, interdental brushes and implant floss…’[footnote 25].
Advice	Clean around and between implants carefully with interdental aids and toothbrushes.	Conditional Recommendation based on very low certainty evidence of benefit of manual and powered toothbrushes, dental floss and interdental brushes[footnote 34].
Advice	Attend for regular checks of the health of gum and bone around implants.	Conditional Recommendation based on low certainty evidence of supportive periodontal therapy improving implant success rate, and preventing peri‐implantitis in healthy people with one or more implants[footnote 35].
Professional intervention	Advise best methods for self-care plaque control, both toothbrushing and interdental cleaning.	Good practice For example, SDCEP 2014 recommends: ‘Patients with an implant-supported bridge or denture may require training in the use of interdental brushes and implant floss…’[footnote 25].

Control of specific risks for periodontitis

Table 11: tobacco

Advice or professional intervention	Recommendation	Evidence base
Professional intervention	Ask, Advise, Act: at every opportunity, ask patients if they smoke and record smoking status, advise on the most effective way of quitting and act on patient response, such as refer to local stop smoking support.	Strong Recommendation: moderate certainty evidence that interventions for smoking cessation improve periodontal health[footnote 36].

Table 12: diabetes

Advice or professional intervention	Recommendation	Evidence base
Advice	Patients with diabetes should try to maintain good diabetes control as they are: • at greater risk of developing serious periodontitis and • less likely to benefit from periodontal treatment if the diabetes is not well controlled	Conditional Recommendation based on low certainty evidence that poorly controlled diabetes substantially increases the risk or progression of periodontitis[footnote 37]. Moderate certainty evidence found that diabetic control improved periodontal health[footnote 36]. Moderate-certainty evidence found that periodontal treatment improved diabetic control[footnote 38].
Professional intervention	For patients with diabetes: • explain risk related to diabetes; ask about HbA1c (glycated haemoglobin) levels • assess and discuss clinical management.	Good practice For example, Siddiqi 2019 found almost three-quarters of diabetic patients were unaware of the link between diabetes and periodontal health[footnote 39].

Table 13: medications

Advice or professional intervention	Recommendation	Evidence base
Advice	Some medications can affect gingival health. Refer to British National Formulary.	Good practice
Professional intervention	For patients who use medications that cause dry mouth or gingival enlargement: • explain oral health findings and risk related to medication • assess and discuss clinical management	Good practice For example, SDCEP 2014 has this advice for doctors: ‘Certain types of medication can lead to gingival enlargement in some patients. These include the calcium channel blockers, phenytoin and ciclosporin. Good oral hygiene can minimise the risk of gingival enlargement in these patients. However, in severe cases, the patient’s dentist may contact you to discuss modification of the drug regimen’[footnote 25].

Evidence base for oral cancer tables

This evidence base refers to chapter 2: tables 3a, 3b, 3c, 3d and 3e.

Tobacco

Table 14: all adults and young people

Advice or professional intervention	Recommendation	Evidence base
Professional intervention	Ask, advise, act.	Strong Recommendation based on moderate certainty evidence evaluating tobacco cessation in dental settings and the effectiveness of brief opportunistic smoking cessation interventions[footnote 40][footnote 41].
Professional intervention	Ask At every opportunity, ask patients if they smoke and record smoking status (smoker, ex-smoker, never smoker).	No specific evidence regarding asking about smoking; however, it is an integral part of the Ask, Advise, Act pathway.

Table 15: for those who smoke

Ask, advise, act	Recommendation	Evidence base
Advise	Explain that a combination of behavioural support and varenicline, or short-acting with long-acting Nicotine Replacement Therapy, are likely to be most effective.	Strong Moderate certainty evidence from multiple systematic reviews[footnote 42][footnote 43][footnote 44][footnote 45][footnote 46][footnote 47], benefits considered to outweigh harms (adverse events for these interventions are mild and would not mitigate their use, although concerns been raised that varenicline may slightly increase cardiovascular events in people already at increased risk of those illnesses).
Act	Refer people who want to stop smoking to local stop smoking support, preferably where behavioural support and prescribed stop smoking medicines are available.	Strong Moderate certainty evidence. NICE guidance supports this recommendation as ‘evidence and expert opinion showed that support provided by these services is clinically effective and highly cost-effective in helping people to stop smoking’[footnote 47].
Act	Acknowledge that e-cigarettes may be helpful for some smokers for quitting or reducing smoking.	Conditional Recommendation based on low certainty evidence from one systematic review; insufficient evidence to demonstrate the long-term effects[footnote 48].

Smokeless tobacco

Table 16: adults and young people

Ask, advise, act	Recommendation	Evidence base
Ask	Ask patients if they use smokeless tobacco, using the names that the various products are known by locally. It may be helpful to show a picture of what the products look like (chapter 11).	Strong Recommendation: moderate certainty evidence evaluating tobacco cessation in dental settings and the effectiveness of brief opportunistic smoking cessation interventions[footnote 40]. Guidance on showing pictures of what products look like presented in NICE guidance[footnote 49].
Advise	If someone uses smokeless tobacco, ensure they are aware of the health risks and provide very brief advice.	Strong Moderate certainty evidence underpinning this NICE guidance statement[footnote 49].
Act	Refer patients who want to quit to specialist support services.	Strong Based on moderate certainty evidence ‘that support provided by these services is clinically effective and highly cost-effective in helping people to stop smoking’[footnote 47].

Alcohol

Table 17: all adults and young people

Ask, advise, act	Recommendation	Evidence base
Ask	Use the AUDIT-C tool (or similar) to assess a patient’s level of risk of alcohol harm by completing 3 consumption questions.	Strong Recommendation based on moderate certainty evidence from a systematic review showed that brief interventions can reduce alcohol consumption in those drinking hazardous or harmful amounts of alcohol when compared to minimal or no interventions[footnote 50].
Advise	If AUDIT C score is 4 or below, give positive feedback and encourage your patient to keep their drinking at lower risk levels. If score is 5 to 10, give brief advice to encourage a reduction in alcohol consumption and reduce the risk of alcohol harm.	Strong
Act	Feedback to the patient that their level of drinking is putting them at risk of developing a range of health problems (including cancers of the mouth, throat and breast) and this increases the more you drink and the more frequently you drink. Highlight ‘low risk’ guidelines for alcohol consumption from UK Chief Medical Officers: • to keep health risks from alcohol to a low level, it is safest not to drink more than 14 units a week on a regular basis • if you regularly drink as much as 14 units per week, it’s best to spread your drinking evenly over 3 or more days. • if you wish to cut down the amount you drink, a good way to help achieve this is to have several drink-free days a week Give a leaflet.	Strong
Act	For those who are pregnant or think they could become pregnant, the safest approach is not to drink alcohol at all, to remove the risk of alcohol-related harm to the baby.	Good practice A well conducted systematic review highlights the paucity of evidence evaluating light drinking in pregnancy compared with abstinence[footnote 51]. Based on this research, the CMO’s guidance supports a ‘precautionary’ approach[footnote 52].
Act	AUDIT-C score of 11 or above, refer to GP or community specialist alcohol service.	Good practice

Diet

Table 18: all patients

Advice or professional intervention	Recommendation	Evidence base
Advice	Promote increased consumption of non-starchy vegetables and fruit.	Good practice Most of the evidence underpinning recommendations concerning diet and cancer prevention comes from observational studies and laboratory or animal studies and is considered low certainty. The findings regarding increased fruit and vegetable consumption are, however, fairly consistent. A high-quality systematic review provides low certainty evidence that increasing fruit and vegetable intake reduces the risk of cancer and all-cause mortality[footnote 53].

Early detection

Table 19: all patients (with and without teeth)

Advice or professional intervention	Recommendation	Evidence base
Professional intervention	Obtain an updated medical, social and dental history and perform an intraoral and extraoral visual and tactile examination for all patients at each oral health assessment visit.	Good practice

Table 20: patients giving concern

Advice or professional intervention	Recommendation	Evidence base
Professional intervention	It’s not recommended to use vital staining, oral cytology or light‐based detection and/or oral spectroscopy for evaluating lesions for malignancy.	Strong Recommendation based on moderate certainty evidence from a well conducted systematic review of diagnostic accuracy of index tests for the detection of oral cancer and potentially malignant disorders of the lip and oral cavity, in patients presenting with clinically evident lesions[footnote 54].
Professional intervention	In line with national referral recommendations, patients should be referred on an urgent or suspected cancer pathway if they have any of the following: • an unexplained ulceration in the oral cavity lasting for more than 3 weeks • a persistent and unexplained lump in the neck • a lump on the lip or in the oral cavity consistent with oral cancer • a red patch in the oral cavity consistent with erythroplakia • a red and white patch in the oral cavity consistent with erythroleukoplakia • persistent unexplained hoarseness • persistent pain in the throat or pain on swallowing lasting for more than 3 weeks	Good practice NICE guidance found no evidence with regard to the positive predictive values of different symptoms of oral cancer in primary care[footnote 55]. The benefits of rapid referrals need balancing against the harms of over-referral[footnote 56].

Evidence base for tooth wear tables

This evidence base refers to chapter 2: tables 4a and 4b.

Table 21: all patients

Advice or professional intervention	Recommendation	Evidence base
Advice	Maintain standard oral hygiene practices. Brush teeth at least twice daily: • last thing at night and on one other occasion • with toothpaste containing fluoride (appropriate to age - see dental caries table) • spitting out after brushing, rather than rinsing with water, to avoid diluting the fluoride concentration	Good practice for preventing tooth wear Strong recommendation for preventing dental caries and conditional for periodontal disease.
Advice	Maintain good dietary practice in line with the Eatwell Guide including avoiding or minimising sugar sweetened drinks (especially carbonated) and fruit juice and/or smoothies (limited to 150ml per day)[footnote 57].	Good practice
Professional intervention	Assess tooth wear using a validated tool (for example Basic Erosive Wear Examination (BEWE)) at the start of any new course of treatment.	Good practice

Table 22: patients at higher risk (those with accelerated tooth wear)

Advice or professional intervention	Recommendation	Evidence base
Professional intervention	Identify possible sources of risk: intrinsic, extrinsic and mechanical.	Good practice For example, guidance on tooth wear diagnosis by Royal College of Surgeons[footnote 58].
Professional intervention	Support patient in risk reduction and management.	Good practice For example, guidance on tooth wear prevention and management by Royal College of Surgeons[footnote 58].

References

1. WHO Global Strategy for Infant and young child feeding 2003. ↩

2. Scientific Advisory Committee on Nutrition (SACN). Feeding in the first year of life. 2018. ↩ ↩² ↩³ ↩⁴

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4. Walsh T, Worthington HV, Glenny AM, Marinho VC, Jeroncic A. Fluoride toothpastes of different concentrations for preventing dental caries. Cochrane Database of Systematic Reviews 2019; (3). ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰

5. SIGN Guidelines 138. Dental interventions to prevent caries in children. 2014. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

6. Wong MCM, Glenny A-M, Tsang BWK, Lo ECM, Worthington HV, Marinho VCC. Topical fluoride as a cause of dental fluorosis in children. Cochrane Database of Systematic Reviews 2010; (1). ↩ ↩²

7. Moynihan PJ, Kelly SA. Effect on caries of restricting sugars intake: systematic review to inform WHO guidelines. Journal of Dental Research 2014 Jan;93(1):8-18. doi: 10.1177/0022034513508954. Epub 2013 Dec 9. PMID: 24323509; PMCID: PMC3872848 ↩ ↩² ↩³ ↩⁴

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