IMPORTANT Delivering Better Oral Health 2021

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Guidance and support
1. Home (https://www.gov.uk/)
2. Health and social care (https://www.gov.uk/health-and-social-care)
3. Public health (https://www.gov.uk/health-and-social-care/public-health)
4. Health improvement (https://www.gov.uk/health-and-social-care/health-improvement)
5. Oral health (https://www.gov.uk/health-and-social-care/oral-health)
6. Delivering better oral health: an evidence-based toolkit for prevention
(https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-
based-toolkit-for-prevention)
Department
of Health &
Social Care (https://www.gov.uk/government/organisations/department-of-health-and-social-
care)
NHS England (https://www.gov.uk/government/organisations/nhs-commissioning-board)
NHS Improvement (https://www.gov.uk/government/organisations/nhs-improvement)
Office for Health
Improvement
& Disparities (https://www.gov.uk/government/organisations/office-for-health-improvement-
and-disparities)
Guidance
Chapter 1: Introduction
Updated 9 November 2021
Contents
Who is this guidance for?

Why was it produced?
How was it produced?
What has changed?
How can it be used?
References
UK Dental Exams Masterclass by Dr Diana McPherson | www.ukdentalexams.com

https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-1-introduction 1/8
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health-an-evidence-based-toolkit-for-prevention/chapter-1-introduction

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.
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 (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 (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 (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 (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 (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 (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 (4).
This is reflected in the summary guidance tables (https://www.gov.uk/government/publications/delivering-
better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-2-summary-guidance-tables-for-dental-
teams), 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)
(https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-2-summary-guidance-tables-for-dental-teams). This chapter includes contemporary
behaviour change theory, supported with practical examples as clinical case studies
(https://khub.net/documents/135939561/516396401/DBOH+Behaviour+change+Case+studies.pdf/0a2d5b97-
b27c-83dd-f172-5164998e14aa).
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
UK Dental Examsare dental caries and
Masterclass byperiodontal
Dr Dianadiseases,
McPherson with oral cancer being the most
| www.ukdentalexams.com
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
prevention/chapter-3-behaviour-change), 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 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-
evidence-based-toolkit-for-prevention/chapter-2-summary-guidance-tables-for-dental-teams)) 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
prevention/chapter-2-summary-guidance-tables-for-dental-teams)).
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
(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
(https://khub.net/documents/135939561/516396401/Figure1.1+Holistic+assessment.png/2b0ba82b-c5f0-8eca-
5639-b8556630d7be)) which are often referred to as ‘the causes of the causes’ (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
(https://khub.net/documents/135939561/516396401/Figure1.1+Holistic+assessment.png/2b0ba82b-c5f0-8eca-
5639-b8556630d7be). Early identification of risks and their management also requires integration
across healthcare, as we ‘make every contact count for health’ (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
(https://khub.net/documents/135939561/516396401/Figure+1.2.+Oral+disease+across+the+life+course.pdf/d95
1f1fc-466b-2887-aeab-2d9a7fd582d1). 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
(https://khub.net/documents/135939561/516396401/Figure+1.3+Population+and+higher+risk+approaches+for+o
ral+health+by+age.pdf/03a087b4-985f-5550-f06f-a6a4e60c1acc)).
Consideration of risk also has implications for dental recall periods which should be assessed in line
with NICE guidance (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 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-
for-prevention/chapter-5-periodontal-diseases).
Table 1.1 Stages of prevention

Reducing the incidence of disease and health problems within the population, either
Primary 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.
Softening the impact of an ongoing illness or injury that has lasting effects. This is done
Tertiary
by helping people manage long-term, often complex health problems and injuries.
Source: Local Government Association (https://www.local.gov.uk/our-support/our-improvement-offer/care-

and-health-improvement/integration-and-better-care-fund/better-care-fund/integration-resource-
library/prevention) (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

(https://www.gov.uk/government/publications/improving-oral-health-guideline-development-manual). London:
Public Health England; 8 January 2020.
3. GRADE Working Group (http://www.gradeworkinggroup.org/#). GRADE 2016.
4. NHS England. Starting Well Core (https://www.england.nhs.uk/primary-care/dentistry/smile4life/) 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

(https://www.gov.uk/government/publications/inequalities-in-oral-health-in-england). London: PHE; 2021
7. NICE. Making every contact count London: National Institute for Health and Clinical Excellence
(https://stpsupport.nice.org.uk/mecc/index.html); 2021 (24 April 2021).
8. NICE. Dental recall guidelines (https://www.nice.org.uk/Guidance/CG19). London: National Institute for

Health and Clinical Excellence; 2004. Report No.: CG019.
9. Local Government Association. Prevention London: LGA (https://www.local.gov.uk/our-support/our-

improvement-offer/care-and-health-improvement/integration-and-better-care-fund/better-care-fund/integration-
resource-library/prevention); 2020 (5 November 2020).
All content is available under the Open Government Licence

v3.0, except where otherwise stated © Crown copyright

11/19/21, 8:31 PM Chapter 2: Summary guidance tables for dental teams - GOV.UK
GOV.UK

Department
of Health &
care)
Office for Health
Improvement
and-disparities)
Guidance
Chapter 2: Summary guidance
tables for dental teams
Contents
How to use these tables

Table 1: Prevention of dental caries
Table 2: Prevention of periodontal diseases
Table 3: Prevention of oral cancer
Table 4: Prevention of tooth wear
Resources
https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-2-summary-guidance-… 1/19
References


health-an-evidence-based-toolkit-for-prevention/chapter-2-summary-guidance-tables-for-dental-
teams

improvement policy.
How to use these tables

These summary tables list the advice and actions that should be provided for all patients to maintain
good oral health. They also outline the additional support that should be offered to people identified
as being at higher risk of dental disease. Recent thinking suggests that all patients should be given
the benefit of advice, care and support to improve their general and oral health, not just those thought
to be at risk.
Patients giving concern are those at higher risk of dental disease, or for whom dental disease, or its
management (such as requiring admission to hospital), would provide a significant challenge. They
may include:
children or adults presenting with current or past dental disease

children with siblings who have dental caries experience
children who have required dental treatment, including treatment under general anaesthetic or
sedation, or whose siblings have done so
children and adults with physical and learning disabilities
children or adults who are medically compromised, for example those with diabetes
mentally and physically frail older people including those with cognitive decline
people undergoing treatments or therapies that place them at additional risk, for example some
cancer treatments or drug therapy that results in dry mouth
people who are homeless
people who have contextual or environmental factors that may place them at additional risk for
example social disadvantage
people with specific conditions that may place them at additional risk of disease in specific teeth
for example hypoplasia or retained impacted third molars
people with vulnerabilities that would place them at additional risk from treatment for example
chemotherapy
Further details on assessing risk are outlined in Chapter 1

prevention/chapter-1-introduction). Each patient’s risk needs to be assessed at every dental recall visit
and monitored across the life course, as disease risk will change over time.
The grading of the quality (or certainty) of evidence and strength of recommendations in the following
summary tables is based on GRADE (Grading of Recommendations, Assessment, Development and
Evaluations) (https://www.gradeworkinggroup.org/). It reflects the extent to which the relevant disease-
based Guideline Development Group (GDG) (1) is confident that desirable effects of an intervention
outweigh undesirable effects across the range of patients for whom the recommendation is intended.
Strong recommendations – the GDG is highly confident that desirable consequences outweigh
undesirable or undesirable consequences outweigh desirable, typically based on high or moderate
certainty evidence.
Conditional recommendations – 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 (2 to 4).
It is important to recognise that where a recommendation is conditional rather than strong, this does
not mean that the intervention does not work but simply that the current evidence supporting it is not
of the highest certainty.
The following tables provide evidence in relation to the prevention of dental caries, periodontal
disease, oral cancer and tooth wear. Where appropriate, the tables provide advice according to age
and/or specific risk factors.
Table 1: Prevention of dental caries
Prevention of dental caries in children 0 to 6 years of age
All children aged up to 3 years
Strength of
Recommendation
recommendation
Advice
Breastfed babies experience less tooth decay and breastfeeding provides the
best nutrition for a baby’s overall health.
Support mothers to: Strong

• breastfeed exclusively for around the first 6 months of a baby’s life
• continue breastfeeding while introducing solids from around the age of 6
months
For parents or carers feeding babies by bottle:

• only breastmilk, infant formula or cooled boiled water should be given in a
bottle
Good practice
• 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
Gradually introduce a wide variety of solid foods (of different textures and
flavours) from around the age of 6 months. Sugar should not be added to food Good practice
or drinks given to babies and toddlers

Strength of
Recommendation
recommendation
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
Strong
• with a toothpaste containing at least 1000 ppm fluoride
• using only a smear of toothpaste
(https://www.gov.uk/government/publications/delivering-better-oral-health-an-
evidence-based-toolkit-for-prevention/chapter-9-fluoride#smear)
Minimise consumption of sugar-containing foods and drinks Strong
Use sugar-free versions of medicines if possible Good practice
Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced
Good practice
and buffering capacity is lost
Professional intervention
Assign a recall interval ranging from 3 to 12 months based on oral health needs
Conditional
and disease risk
All children aged 3 to 6 years
Strength of
Recommendation
recommendation
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 Strong
• with toothpaste containing at least 1,000 ppm fluoride
• using a pea-sized amount of the toothpaste
• spitting out after brushing rather than rinsing, to avoid diluting the fluoride
concentration
Minimise amount and frequency of consumption of sugar-containing food and

Strong
drinks
Use sugar-free versions of medicines if possible Good practice
Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced
Conditional
and buffering capacity is lost

Strength of
Recommendation
recommendation
Apply fluoride varnish (2.26% NaF) to teeth 2 times a year Strong
Assign a recall interval ranging from 3 to 12 months based on oral health needs
Conditional
and disease risk
Children aged 0 to 6 years giving concern because of dental caries risk
Strength of
Recommendation
recommendation
All the above, plus:
Advice
Use toothpaste containing 1,350 to 1,500 ppm fluoride Strong
For children taking medication frequently or long term, choose or request

Good practice
sugar-free medicines if possible
Apply fluoride varnish (2.26% NaF) to teeth 2 or more times a year Strong
Where the child is prescribed medication frequently or long term, liaise with
Good practice
medical practitioner to request that it is sugar free
Investigate diet and assist adoption of good dietary practice in line with the
Good practice
Eatwell Guide
Assign a shortened recall interval based on dental caries risk Conditional
Prevention of dental caries in children aged from 7 years and young people (up
to 18 years)
All children from 7 years and young people up to 18 years
Strength of
Recommendation
recommendation
Advice

Strength of
Recommendation
recommendation
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
Strong
• with toothpaste containing 1,350 to 1,500 ppm fluoride
• spitting out after brushing rather than rinsing with water, to avoid diluting
the fluoride concentration
Minimise amount and frequency of consumption of sugar-containing food

Strong
and drinks
Avoid sugar-containing foods and drinks at bedtime when saliva flow is

Conditional
reduced and buffering capacity is lost
Apply fluoride varnish to teeth 2 times a year (2.26% NaF) Strong
Assign a recall interval within the range of 3 to 12 months based on oral

Conditional
health needs and disease risk
Children from 7 years and young people up to 18 years giving concern because of dental
caries risk
Strength of
Recommendation
recommendation
Advice
Parent or carer to assist and supervise toothbrushing if required Good practice
Use a fluoride mouth rinse daily (0.05% NaF; 230 ppmF) at a different time to
Conditional
brushing
Apply resin sealant to permanent teeth on eruption Strong
Apply fluoride varnish to teeth 2 or more times a year (2.26% NaF) Strong
For those 8 years and above with active dental caries, consider recommending
or prescribing daily fluoride mouth rinse (0.05% NaF; 230ppm F), to be used at Conditional
a different time from brushing, until dental caries risk is reduced
For those 10 years and above with active dental caries, consider prescribing
Conditional
2,800ppm fluoride toothpaste until dental caries risk is reduced
Strength of
Recommendation
recommendation
For those 16 years and above with active dental caries, consider prescribing
either 2,800ppm or 5,000ppm fluoride toothpaste until dental caries risk is Conditional
reduced
Where a child or young person is prescribed medication frequently or long term,

Good practice
liaise with medical practitioner to request that it is sugar free
Good practice
Eatwell Guide
Prevention of dental caries in adults
All adults
Strength of
Recommendation
recommendation
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 Strong
• spitting out after brushing rather than rinsing with water, to avoid diluting
the fluoride concentration
Minimise the amount and frequency of consumption of sugar-containing food

Strong
and drinks
Avoid sugar-containing foods and drinks at bedtime when saliva flow is

Conditional
reduced and buffering capacity is lost
Assign a recall interval ranging from 3 to 24 months, based on oral health

Conditional
needs and disease risk
Adults giving concern because of dental caries risk
Strength of
Recommendation
recommendation
Advice

Strength of
Recommendation
recommendation
Support toothbrushing where required (for example carer assistance,

Good practice
specialised brush, non-foaming toothpaste)
Use a fluoride mouth rinse daily (0.05% NaF; 230 ppmF) at a different time to
Conditional
toothbrushing
Apply fluoride varnish to teeth 2 times a year (2.26% NaF) Strong
For those with active coronal or root caries, consider recommending or

prescribing daily fluoride rinse (0.05% NaF; 230 ppmF, to be used at a different Conditional
time from toothbrushing) until dental caries risk is reduced
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 Conditional
reduced
Where a patient is prescribed medication frequently or long term, liaise with

Good practice
medical practitioner to request that it is sugar free
Good practice
Eatwell Guide
Table 2: Prevention of periodontal diseases
Prevention of periodontal diseases – to be used in addition to dental caries

prevention
All patients
Strength of
Recommendation
recommendation
Advice
Self-care plaque removal:
• daily, effective plaque removal is critical to periodontal health Conditional
• remove plaque effectively using methods shown by the dental team. This will
prevent gingivitis (gum bleeding or redness) and reduces the risk of periodontal Good practice
disease

https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-2-summary-guidanc… 10/19
Strength of
Recommendation
recommendation
Toothbrushing and toothpaste:

• brush gum line and each tooth at least twice daily (last thing at night or before Conditional
bedtime and on at least one other occasion)
Toothbrush type
• use a manual or powered toothbrush Strong
• use a small toothbrush head, medium texture Conditional
Around orthodontic appliances and bridges, plaque control should be

Good practice
undertaken using the aids suggested by the orthodontic or dental team
Advise best methods of plaque removal to prevent gingivitis and achieve lowest
Conditional
risk of periodontitis and tooth loss
Use behaviour change methods with oral hygiene instruction Conditional
Correct factors that impede effective plaque control including supra and
subgingival calculus, open margins and restoration overhangs and contours, Good practice
which prevent effective plaque removal
For people with extensive inflammation, start with toothbrushing advice,

Good practice
followed by interdental plaque control
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
Good practice
• patient sets SMART goals (see chapter 3
(https://gov.uk/government/publications/delivering-better-oral-health-an-evidence-
based-toolkit-for-prevention/chapter-3-behaviour-change)) for toothbrushing for
next visit
All adults (and young people aged 12 to 17 years with evidence of periodontal disease)
Strength of
Recommendation
recommendation
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 Conditional
used
• for small spaces between teeth, use dental floss or tape
Strength of
Recommendation
recommendation
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
Good practice
• patient sets SMART goals (see chapter 3
based-toolkit-for-prevention/chapter-3-behaviour-change)) for interdental plaque
control
Prevention of peri-implantitis
All adults with dental implants
Strength of
Recommendation
recommendation
Advice
Dental implants require the same level of oral hygiene and maintenance as
Good practice
natural teeth
Clean around and between implants carefully with interdental aids and
Conditional
toothbrushes
Attend for regular checks of the health of gum and bone around implants Conditional
Advise best methods for self-care plaque control, both toothbrushing and
Good practice
interdental cleaning
Control of specific risks for periodontitis
Tobacco
Strength of
Recommendation
recommendation
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
Strong
response, such as refer to local stop smoking support (see Table 3 tobacco
section of oral cancer below for more detail)
Diabetes
Strength of
Recommendation
recommendation
Advice
Patients with diabetes should try to maintain good diabetes control as they are:
• at greater risk of developing serious periodontitis and
Conditional
• less likely to benefit from periodontal treatment if the diabetes is not well
controlled
For patients with diabetes:

• explain risk related to diabetic control; ask about HbA1c (glycated
haemoglobin) levels
Good practice
• assess and discuss clinical management (see Chapter 5
based-toolkit-for-prevention/chapter-5-periodontal-diseases))
Medications
Strength of
Recommendation
recommendation
Advice
Some medications can affect gingival health
For patients who use medications that cause dry mouth or gingival
enlargement:
• explain oral health findings and risk related to medication
Good practice
• assess and discuss clinical management (see Chapter 5
based-toolkit-for-prevention/chapter-5-periodontal-diseases))
Table 3: Prevention of oral cancer

Use of tobacco, both smoked (for example cigarettes, pipes, waterpipes or shisha) and smokeless
(for example paan, chewing tobacco, gutkha), seriously affects general and oral health. The most
significant risk is for oral cancer and pre-cancers. The combined use of tobacco and alcohol further
increases the risk of oral cancer. Encourage children and young people not to start smoking or using
tobacco.
Tobacco
All adults and young people

Strength of
Recommendation
recommendation
Professional intervention – Very Brief Advice (VBA)
Ask, advise, act Strong
Ask
Strong
At every opportunity, ask patients if they smoke and record smoking status
(smoker, ex-smoker, never smoker)
For those who smoke
Strength of
Recommendation
recommendation
Advise
Explain that a combination of behavioural support and the medication Strong

varenicline, or short-acting with long-acting Nicotine Replacement Therapy, are
likely to be most effective.
Act
Act on patient response:

• refer people who want to stop smoking to local stop smoking support Strong
(https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/),
preferably where behavioural support and prescribed stop smoking medicines
are available.
Acknowledge that e-cigarettes may be helpful for some smokers for quitting or
Conditional
reducing smoking.
Smokeless tobacco
(Predominantly used by those of South Asian origin)
Adults and young people
Strength of
Recommendation
recommendation
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 Strong
products look like (Chapter 11 (https://gov.uk/government/publications/delivering-
better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-11-smoking-and-
tobacco-use#figure1)).
Strength of
Recommendation
recommendation
Advise
Strong
If someone uses smokeless tobacco, ensure they are aware of the health risks
and provide very brief advice.
Act
Strong
Refer patients who want to quit to specialist support services
(https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/).
Alcohol
Regularly drinking more than 14 units of alcohol per week can adversely affect general and oral
health, with the most significant oral health impact being the increased risk of oral cancer. The
combined use of tobacco and alcohol further increases the risk of oral cancer.
Alcohol Identification and Brief Advice (IBA) uses the AUDIT-C tool (or similar) to ask and assess risk
and provide advice.
Strength of
Recommendation
recommendation
Professional intervention - Identification and Brief Advice (IBA)
Ask, advise, act Strong
Ask
Use the AUDIT-C tool

Strong
(https://khub.net/documents/135939561/516396401/scratch+card.png/bd822613-
a8a2-2f79-1d6e-7994a792e8c7) (or similar) to assess a patient’s level of risk of
alcohol harm by completing 3 consumption questions:
Scoring Your
Questions
system score
0 1 2 3 4
4 or
2 to 4 2 to 3
more
How often do you have a drink Monthly times times
Never times
containing alcohol? or less per per
per
month week
week

Scoring Your
Questions
system score
How many units of alcohol do you

10 or
drink on a typical day when you are 0 to 2 3 to 4 5 to 6 7 to 9
more
drinking?
How often have you had 6 or more Daily

Less
units if female, or 8 or more if male, or
Never than Monthly Weekly
on a single occasion in the last almost
monthly
year? daily
Advise and Act
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.
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. Strong
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 (https://app.box.com/v/CQUIN-structured-advice-tool)
For those who are pregnant or think they could become pregnant, the safest approach is Good
not to drink alcohol at all, to remove the risk of alcohol-related harm to the baby. practice
Good
AUDIT-C score of 11 or above, refer to GP or community specialist alcohol service.
practice
Diet
Increasing fruit and vegetable intake reduces the risk of cancers in general and contributes to overall
health.
All patients
Strength of
Recommendation
recommendation

Strength of
Recommendation
recommendation
Promote increased consumption of non-starchy vegetables and

Good practice
fruit.
Early detection
Oral cancer survival rates are strongly associated with the stage at diagnosis. Early detection is key
to improving oral cancer survival rates and quality of life.
All patients (with and without teeth)
Strength of
Recommendation
recommendation
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 Good practice
assessment visit.
Those giving concern
Strength of
Recommendation
recommendation
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 (inner or outer) or in the oral cavity consistent with oral
Good practice
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
It’s not recommended to use vital staining, oral cytology or light‐based

Strong
detection and/or oral spectroscopy for evaluating lesions for malignancy.
Table 4: Prevention of tooth wear
All patients

Strength of
Recommendation
recommendation
Maintain standard oral hygiene practices.

Good practice for
preventing tooth
Brush teeth at least twice daily:
wear
• last thing at night (or before bedtime) and at least on one other occasion
Strong
• with toothpaste containing fluoride (appropriate to age – see dental caries
recommendation
table)
for preventing
• spitting out after brushing, rather than rinsing with water, to avoid diluting the
dental caries
fluoride concentration
Maintain good dietary practice in line with the Eatwell Guide

(https://www.gov.uk/government/publications/the-eatwell-guide) including avoiding or
Good practice
minimising sugar sweetened drinks (especially carbonated) and fruit juice
and/or smoothies (limited to 150ml per day).
Assess tooth wear using a validated tool (for example Basic Erosive Wear
Good practice
Examination (BEWE)) at the start of any new course of treatment.
Patients at higher risk (those with accelerated tooth wear)
Identify possible sources of risk: intrinsic, extrinsic and mechanical (see Chapter 7)
Good
(https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-
practice
toolkit-for-prevention/chapter-7-tooth-wear).
Good
Support patient in risk reduction and management.
practice
Resources
E-learning for healthcare: Delivering Better Oral Health. Key oral health improvement messages for
families includes the evidence base that underpins these for use in practice by the clinical dental
team (https://portal.e-lfh.org.uk/Component/Details/603101) and for non-clinical staff (https://portal.e-
lfh.org.uk/Component/Details/603095).
E-learning for healthcare: Children’s oral health advice for all (https://www.e-
lfh.org.uk/programmes/childrens-oral-health/). This session aims to improve the knowledge of the general
public and early years healthcare workers regarding children’s oral health.
Dental teams can utilise Change4Life Top Tips for Teeth

(https://campaignresources.phe.gov.uk/resources/campaigns/69-top-tips-for-teeth/resources) dental toolkit and
resources.
Prevention: Key oral health messages and evidence (0 to 6 years) training guide for dental teams
(https://khub.net/documents/135939561/516396401/Key+oral+health+messages+and+evidence+0+to+6+years.
pdf/e403f4f2-0845-e700-882e-2d13a57208c8?t=1632138295143).

References
1. Public Health England. Improving oral health: guideline development manual
(https://www.gov.uk/government/publications/improving-oral-health-guideline-development-manual). London:
PHE; 8 January 2020.
2. Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, and others. GRADE
guidelines: 4. Rating the quality of evidence–study limitations (risk of bias). Journal of Clinical
Epidemiology. 2011;64(4):407-15.
3.Guyatt GH, Schünemann HJ, Djulbegovic B, Akl EA. Guideline panels should not GRADE good
practice statements. Journal of Clinical Epidemiology. 2015; 68(5),597-600.
4. Tugwell P, Knottnerus JA. When does a good practice statement not justify an evidence based
guideline? Journal of Clinical Epidemiology. 2015; 68(5),477-479.


11/19/21, 8:31 PM Chapter 3: Behaviour change - GOV.UK
GOV.UK

Department
of Health &
care)
Office for Health
Improvement
and-disparities)
Guidance
Chapter 3: Behaviour change
Contents
Introduction
Behaviours that support oral health
What is important for behaviour change to occur?
What can dental professionals do?
Examples of behaviour change interventions
Training
Resources
References
https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-3-behaviour-change 1/11

health-an-evidence-based-toolkit-for-prevention/chapter-3-behaviour-change

improvement policy.
Introduction
Given the right circumstances, most oral diseases can be prevented or managed by ‘healthy
behaviours’ such as enjoying a healthy balanced diet and cleaning teeth and gums effectively. Each
day, members of the dental team provide guidance to patients of all ages about health-related
behaviours as part of contemporary person-centred care (1). Helping patients to improve their oral
health involves providing tailored advice, teaching new skills, answering questions and regularly
reinforcing key messages (2), whilst understanding that the ability to change is influenced by a range
of individual, environmental and socioeconomic factors as outlined in Chapter 1
prevention/chapter-1-introduction).
The field of behavioural science has changed significantly in recent years. There have been
considerable advances in understanding why individuals behave in certain ways as well as how
behaviour change interventions can support, and sustain, change (3 to 5). It is a journey, rarely an
event.
In this chapter, the latest guidance on approaches to supporting individuals to change their health
behaviours is summarised (1, 2, 5 to 7) and applied to dental professionals and oral health
behaviours. It suggests how recent advances in behavioural science can be used by all dental team
members, to enhance existing knowledge and skills. This includes an overview of important
considerations when supporting individual patients through the process or cycle of change. Practical
case studies
b27c-83dd-f172-5164998e14aa) are available to illustrate how the guidance may be used in practice.
Behaviours that support oral health

Research highlights the oral health behaviours that dental professionals may need to support their
patients to change through brief interventions (1):
improving oral hygiene (Chapter 8) (https://www.gov.uk/government/publications/delivering-better-oral-

health-an-evidence-based-toolkit-for-prevention/chapter-8-oral-hygiene)
optimising exposure to fluoride (Chapter 9) (https://www.gov.uk/government/publications/delivering-
better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-9-fluoride)
reducing sugar intake and healthier eating (Chapter 10)
prevention/chapter-10-healthier-eating)

stopping smoking and tobacco use through very brief advice (Chapter 11
prevention/chapter-11-smoking-and-tobacco-use))
reducing harmful alcohol consumption through identification and brief advice (Chapter 12
prevention/chapter-12-alcohol))
Many dental professionals will admit to having felt confused or frustrated when patients did not make
behaviour changes that were recommended. However, we know that whilst the provision of health
information alone may increase knowledge, this will not achieve sustained changes in behaviour for
most people.
Even when providing more in-depth support, many health professionals will have experienced how
lengthy, and difficult, the process of supporting patients to change their behaviour can be. They will
also have seen first-hand how many attempts are required before a new behaviour is maintained,
overcoming barriers and resistance.
To understand the complexity of behaviour change, we need to consider the broader influences on
patient’s lives. A patient’s ability to change their behaviour is influenced by an array of individual,
social and environmental factors, with socio-economic circumstances being a major influence
(Chapter 1 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-
toolkit-for-prevention/chapter-1-introduction)). This explains why multiple unhealthy behaviours, such as
smoking, alcohol misuse, and lack of tooth brushing, may cluster together in particular groups of
people.
While some individuals with well-developed social networks and supportive living environments are
more likely to succeed, others may find changing a specific behaviour or group of behaviours
particularly challenging. We also know that at certain times in people’s lives, they may find changes
in behaviour easier (or harder) to sustain. Furthermore, fear and cost are common barriers to dental
care and may make it more difficult to support patients in behaviour change. This means that some
patients face multiple barriers when attempting to change their behaviours. Indeed, these different
barriers to behaviour change may lead to a widening of health inequalities between groups in society.
Bearing in mind the huge potential for oral and general health gain, some of the general principles to
best achieve oral health-related behaviour change over time are provided below.
What is important for behaviour change to occur?

Within the field of behavioural science there are many different theories, models and frameworks that
can help health professionals support their patients to change their behaviour (1, 2, 5 to 7). One of
the most helpful recent models is COM-B (3, 8). This model proposes that for behaviour change to
occur, a person must have Capability, Opportunity and Motivation to change Behaviour as outlined
below:
Capability
The person must have the physical or psychological ability to change to the desired behaviour. This
includes a person’s knowledge of what the desired behaviour is and why it is important, the skills
required to make the change and the self-control needed to start and maintain that desired behaviour
over the long-term.
Consider, for example, what you could do to help a patient trying to reduce the sugar in their diet.
How can you help them to:
understand why it is important for their health and oral health to reduce their sugar intake?
choose a healthier alternative they like instead?
keep on choosing healthier alternatives when their initial enthusiasm wears off?
Opportunity
This refers to the environment in which the person lives, which may include the social environment
required to support the behaviour, for example, their income; the physical environment; or the
facilities available. In the section above, we have already described how socio-economic
circumstances can be a major barrier to behaviour change.
Consider, for example, helping a patient to give up smoking and how you can take account of the
following:
if they are struggling to cope with stressful events in their lives such as unemployment, disability,
or homelessness
if they live or work with others who smoke around them
how they can access nicotine replacement therapy or local stop smoking support
Motivation
This relates to the person’s motivation to adopt new behaviour, which would require the desire, and
intention, to change and to stop or adapt their existing habits.
Consider, for example, what you could do to help a patient routinely brush their teeth with a fluoride
toothpaste twice every day. How can you help them to:
find a time in their daily schedule when tooth brushing would work for them
think through how to maintain the habit and what to do if they revert to their previous infrequent
brushing
Some patients will need support and help across all three areas of the COM-B model, while others
might experience specific issues around capability, opportunity and/or motivation. The COM-B model
is not a solution to all behaviour change challenges, but it can offer dental professionals a
comprehensive framework, when working with patients to better understand what is going on. It is
also very helpful in considering when, and how, to facilitate change. This COM-B model has been
used to develop a range of techniques that can be employed to change health behaviour. These are
described more fully in the next section.
What can dental professionals do?

Dental professionals working with patients can help them to build their motivation to change and
support them to act when they are ready. This involves building rapport and empathy, providing
support in an appropriate format, and considering the right timing (Figure 3.1
(https://khub.net/documents/135939561/516396401/Figure+3.1+How+to+support+patients+to+change+their+or
al+health+behaviours.pdf/8285ca1b-01cd-952c-04bc-d82f89749737)).
Changing behaviour should be considered as a cycle. It may start with patients being unaware of the
issue, through a time when they are thinking about making a change, to when they are actively
preparing to change by planning and setting goals, to when they are ready to act, and then trying to

maintain the change avoiding relapse. As the stages of change need not be linear, dental team
members should start wherever the patient currently is on the cycle (9). This process should not be
considered as having discrete steps and may include the following aspects.
Raising the issue and building motivation
Dental professionals can start conversations with patients by providing information about the specific
behaviour which needs to be addressed, and its link to oral and general health (Figure 3.1
al+health+behaviours.pdf/8285ca1b-01cd-952c-04bc-d82f89749737)). They should help their patients
understand the short, medium, and longer-term consequences of their oral health-related behaviours.
This can also mean discussing what will happen if the person does (or does not) perform the
behaviours. To build motivation further, the dental team members can help patients feel positive
about the benefits of changing one or more of these behaviours.
Assessing readiness to change
It is important to assess a patient’s readiness to take action to change (Figure 3.1

al+health+behaviours.pdf/8285ca1b-01cd-952c-04bc-d82f89749737)). This can be facilitated by discussing
the advantages and disadvantages of making (or not making) a change, and listening for verbal clues
about their desire, ability, and reasons for change.
Whilst there may be several oral health behaviours you may wish to tackle with a patient, for general
or oral health reasons, it is helpful to recognise that this cannot be achieved all at once. In this
situation, it is important to discuss with the patient which behaviour they feel most ready to change,
and work with this, even if it is not what you as a health professional would prioritise.
Patients may express resistance to change if they feel the change is too difficult or not right for them
at that time. In this case, trying to persuade the patient to change is unlikely to help. Instead, dental
professionals should show empathy, discuss the patient’s views, provide support, and keep the
opportunity for further discussions open for the future.
Supporting patients to take the next step
If a patient is ready to act, one or more of the behaviour change techniques described below can be
used:
working with the patient to show them how to perform the behaviour and provide tailored
instruction
work out a plan together in terms of simple tasks over time, using SMART goals:
Specific – clear and precise goals provide focus and clarity of purpose
Measurable – goals that can be easily measured and quantified
Achievable – goals that are challenging, but within the patient’s reach – this will increase
their self-confidence in making these changes (setting unachievable goals merely
demotivates people)
Relevant – to the patient’s circumstances, motivations and needs
Timely – check that it is the right time to work on the goal. Setting a clear time frame is also
important to help maintain motivation and to monitor progress
help identify barriers to making changes and how they might be overcome
plan together how they might cope if there is a relapse in their behaviour
provide encouragement and praise the patient’s efforts at subsequent appointments

help identify motivating rewards for any progress achieved to help maintain motivation
signpost or refer patients to other local services or digital resources
Adapted from NICE Behaviour change overview (https://pathways.nice.org.uk/pathways/behaviour-change)

(7).
Dental team members already use many of these techniques every day, while some may be less
familiar. Examples of these techniques are described in the accompanying patient case studies
b27c-83dd-f172-5164998e14aa).
Delivering successful behaviour change
When using behaviour change techniques and delivering behaviour change interventions, consider
the source of the intervention (who delivers it), the mode of delivery (how it is delivered) and the
schedule (timing – when it is delivered) (5).
Source
The source of an intervention is the person who will deliver the intervention with a patient. In dental
practices, this may be one dental professional, or several working together and providing a consistent
message. To help patients achieve successful behaviour change, dental team members need to build
rapport and empathy with their patients to ensure a good relationship (4). This rapport is important so
that conversations with patients about their oral health behaviours can be supportive and conducive
to change.
Effective communication during brief interventions uses a range of skills, which can be remembered
using the acronym ‘OARS’ (10), as shown in Figure 3.1
al+health+behaviours.pdf/8285ca1b-01cd-952c-04bc-d82f89749737):
Open questions to explore patients’ feelings and values

Affirmations that you as the dental professional can see the patient’s point of view, understand
the difficulties involved and recognise the patient’s successes
Reflective listening and clarifications
Summarising the patient’s thoughts and feelings about making changes to their oral health
behaviours
Adapted from NHS Scotland (10).
Mode
The mode of delivery, how the behaviour change intervention is to be delivered, should also be
considered. Different modes of delivery are appropriate for different patient groups, disease
severities and behaviours. Dental team members may need to use more than one mode of delivery
or adapt to the needs and preferences of the individual patient.
The most common mode is a face-to-face conversation, but this may be supplemented with printed
resources (for example, leaflets, scratch cards or digital resources, such as links to websites, sending
of text messages and recommendation of specific apps) (6). The NHS app library includes apps

which have been assessed to meet a required standard. New forms of delivery are emerging in the
digital arena with the use of remote consultations and emails. Patient acceptability of online
communication is growing and may also be helpful for oral health.
Schedule
Scheduling behaviour change interventions includes consideration of their frequency, duration, and
timing. In terms of frequency, all healthcare providers, including dental team members, have a role in
making every contact count to improve the health, (including the oral health) of patients. The ‘Making
Every Contact Count’ approach (11), requires health professionals to make use of every encounter
with patients. For dental professionals, recall appointments offer the ideal opportunity to highlight
behaviours to change with patients or reinforce earlier interventions. Equally, for patients who do not
attend regularly, visits for urgent care can also be utilised as they provide an opportunity to establish
a positive relationship (6), with the option of follow-up care.
The duration of interventions may vary from very brief advice (VBA) or brief advice (BA) through to
more in-depth interventions, such as motivational interviewing, which requires additional training.
The timing of behaviour change discussions is important because, as previously mentioned,

assessing the patient’s readiness to change will influence the type of support the professional
provides. Readiness to change may be more likely at certain key points in the life course, such as
pregnancy or new parenthood, leaving school, starting a new relationship, or entering retirement. It is
also important to recognise that behaviour change takes time and patients may not complete the
whole cycle at their first attempt. There is some evidence to suggest it takes anywhere from 2 to 9
months to develop a new habit depending on the patient and the nature of the habit.
Dental professionals can also provide an environment that is supportive of health behaviour change,
for example:
using the physical space to provide family and breastfeeding-friendly facilities

(https://www.unicef.org.uk/babyfriendly/accreditation/maternity-neonatal-health-visiting-childrens-centres/)
and using displays to support campaigns such as Smile Month
(https://www.dentalhealth.org/national-smile-month), Mouth Cancer Action month
(https://www.dentalhealth.org/mouthcancer), Stoptober (https://thestoptober.co.uk/) and Dry January
(https://alcoholchange.org.uk/get-involved/campaigns/dry-january)
using digital technology, such as the dental practice website, apps, video conferencing, links to
self-help websites or social media to provide information, reinforce key messages and provide
reminders. Patients can be recommended to use these resources in preparation for or following
their appointments. However, it is important to be aware of the need to provide paper resources
for patients who are not able or do not want to rely on digital technology
Examples of behaviour change interventions

In addition to the general principles and techniques described above, specific behaviour change
interventions have been developed for some oral health-related behaviours:
oral hygiene for plaque removal (Chapter 8 (https://www.gov.uk/government/publications/delivering-

better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-8-oral-hygiene)) – OH-TIPPS – a
behaviour change strategy for patients to feel more confident in their ability to perform effective
plaque removal and help them plan how and when they will look after their teeth and gums
regular use of fluoride (Chapter 9) (https://www.gov.uk/government/publications/delivering-better-oral-

health-an-evidence-based-toolkit-for-prevention/chapter-9-fluoride) – resources to support behaviour
change conversations with parents of young children to promote parental supervision of tooth
brushing with a fluoride toothpaste as part of oral hygiene (Chapter 8)
prevention/chapter-8-oral-hygiene)
reducing sugar as part of a healthier diet (Chapter 10)
prevention/chapter-10-healthier-eating) – use of diet diaries and other resources, for example Food
Scanner App)
tobacco – Very Brief Advice pathway for smoking (Chapter 11
prevention/chapter-11-smoking-and-tobacco-use))
alcohol – Identification and Brief Advice (IBA) (Chapter 12
These specific techniques and approaches can, and should, be used alongside the wider and more
general techniques described above. Patient case studies highlighting common pitfalls and
suggested ways to overcome them are provided within the case studies
b27c-83dd-f172-5164998e14aa).
Training
While some of the techniques are familiar to dental professionals, additional training may be required
to support behaviour change in general or specific oral health behaviour change interventions. A list
of helpful publications (1 to 11) and e-learning training programmes has been provided at the end of
this chapter and dental team members should be supported to undertake the training for the roles
delegated to them and to keep up to date as new programmes become available.
The dental team has an important role in helping to promote healthy behaviours with all patients.
Changing behaviour is not an easy task, patient’s desires and circumstances need to be central to
the endeavour and different approaches may be needed for different behaviours. It is important that
dental team members understand the principles of behaviour change and the various influences on
change to enable the provision of the best possible support to patients. The field of behavioural
science is rapidly expanding, with many different sources of guidance published. By considering this
guidance, and how it can be applied, dental teams can better help patients achieve their oral health
goals.
Resources
E-learning for healthcare: behaviour change conversations with parents of young children with
accompanying videos (https://portal.e-lfh.org.uk/Catalogue/Index?
HierarchyId=0_42302_44735&programmeId=42302).
Leeds School of Dentistry: Rolling with resistance videos including techniques on re-framing and
reflection (https://www.youtube.com/playlist?list=PLI3a4dw4MiWVMDs8qaGQqMYH31SD3gtSz).

OARS (https://www.nhsggc.org.uk/about-us/professional-support-sites/cdm-local-enhanced-services/health-
determinants/approaches-to-brief-intervention/skills-oars/#): open questions, affirming, reflecting and
summarising skills to enable you to build up a partnership with the client and to guide the
conversation.
E-learning for healthcare: alcohol identification and brief advice in dental settings (https://www.e-
lfh.org.uk/programmes/alcohol/).
E-learning for healthcare: alcohol and tobacco brief interventions (https://www.e-

lfh.org.uk/programmes/alcohol-and-tobacco-brief-interventions/).
The National Centre for Smoking Cessation and Training (NCSCT) Very Brief Advice on Smoking for
Dental Patients (https://www.ncsct.co.uk/publication_dental_vba.php).
Oral Hygiene TIPPS video (http://www.sdcep.org.uk/published-guidance/periodontal-management/). Oral

Hygiene TIPPS is a behaviour change strategy which aims to make patients feel more confident in
their ability to perform effective plaque removal and help them plan how and when they will look after
their teeth and gums.
Starting conversations with patients and supporting health-related behaviour change

(http://www.tentpegs.info/toothpicks.html).
Behaviour change development framework – Health Education England

(https://behaviourchange.hee.nhs.uk/).
References
1. NICE. Oral health promotion: general dental practice NG30 (https://www.nice.org.uk/guidance/ng30).
London: NICE; 15 December 2015.
2. NICE. Behaviour change: individual approaches PH49 (https://www.nice.org.uk/Guidance/PH49).

London: NICE; 2 January 2014.
3. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising
and designing behaviour change interventions. Implementation Science 2011;6:42.
4. Prochaska JO, DiClemente CC, editors. The transtheoretical approach. 2nd edition. New York:
Oxford University Press; 2005.
5. Public Health England. Achieving behaviour change. A guide for local government and partners
(https://www.gov.uk/government/publications/behaviour-change-guide-for-local-government-and-partners).
London: Public Health England; 2019. Report Number: GW-834.
6. NICE. Behaviour change: digital and mobile health interventions NG183

(https://www.nice.org.uk/guidance/NG183). London: National Institute for Health and Care Excellence;
2020.
7. NICE. Behaviour Change Overview (https://pathways.nice.org.uk/pathways/behaviour-change). London:

NICE; 2019.
8. Michie S, van Stralen MM, West R. The behaviour change wheel: a guide to designing
interventions. 1st edition. London: Silverback Publishing 2014.
9. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an
integrative model of change. Journal of Consulting and Clinical Psychology. 1983;51(3):390-5.

10. NHS Greater Glasgow and Clyde. Skills-OARS Glasgow (https://www.nhsggc.org.uk/about-

us/professional-support-sites/cdm-local-enhanced-services/health-determinants/approaches-to-brief-
intervention/skills-oars/). NHS Scotland; 27 June 2020.
11. NICE. Making every contact count (https://stpsupport.nice.org.uk/mecc/index.html). London: National

Institute for Health and Clinical Excellence; 24 April 2021.


11/19/21, 8:31 PM Chapter 4: Dental caries - GOV.UK
GOV.UK

Department
of Health &
care)
Office for Health
Improvement
and-disparities)
Guidance
Chapter 4: Dental caries
Contents
Introduction
Epidemiology
Dental caries risk
Risk and protective factors
Early detection and management pathways
Resources
References

https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-4-dental-caries 1/11

health-an-evidence-based-toolkit-for-prevention/chapter-4-dental-caries

improvement policy.
Introduction
Dental caries is one of the most prevalent non-communicable diseases nationally (1, 2) and globally
(3). The disease is caused by dietary sugars that are broken down by micro-organisms in the biofilm
on a tooth surface, which produces acids that, over time, demineralise tooth enamel (4, 5).
The process of de- and re-mineralisation is dynamic (4). In the early stages of the disease, dental
caries can be reversed. However, when factors promoting demineralisation exceed those favouring
remineralisation, dental caries progresses (unless checked) into dentine to a point where the tooth
surface breaks down and ultimately a cavity forms (5).
Effective patient care involves first diagnosing the presence and recording the extent of disease,
using contemporary dental caries management tools such as the International Caries Classification
and Management System (ICCMS) (6), encouraging a reduction of factors that cause
demineralisation, notably sugar consumption; and, enhancement of those favouring remineralisation,
particularly the availability of fluoride and mineral ions. This may be achieved by a combination of
preventive actions taken by patients, patient carers and healthcare professionals, supported by
higher-level actions that promote policies and active change to facilitate a less cariogenic social
environment.
Epidemiology
The prevalence of dental caries in children in the UK has reduced dramatically over the past 5
decades (7). This is generally attributed to the introduction of fluoride-containing toothpaste in the
early 1970s (4). Other factors such as changed social attitudes, access to dental care, developments
in preventive dental materials, together with health promoting and clinical practices have also
contributed to these changes over time. Yet dental caries, which is largely preventable, remains
prevalent and inequalities are marked (8).
Surveys of oral health in adults within the UK (9) suggest that there are 3 cohorts in the population:
the oldest cohort, who have lost all their teeth, and wear complete dentures
a middle cohort, who retain most of their teeth, but do so largely because of the efforts of the
dental profession who have restored and maintained teeth in those who grew up before fluoride
toothpaste became widely available
the youngest cohort, many of whom are caries-free in their early years
In the immediate future, the number of edentulous people will continue to fall. Therefore, more adults
will enter older age with some or all of their natural teeth, many of which will be heavily restored.
Dental caries is not just a disease of children and young people, new carious lesions can develop at
any age. Dental professionals therefore need to be vigilant and take appropriate action to support all
patients, irrespective of age, based on their dental caries risk.
Root caries is increasingly a cause for concern and lifelong coronal caries experience is a risk factor
for root surface caries experience (10). Root caries increases with age and amongst independently
living older adults, factors such as poor plaque control, xerostomia, coronal decay and having
exposed root surfaces are indicators of risk (11).
Like many common chronic lifestyle-associated diseases, the prevalence of dental caries is linked
with social and economic circumstances (12, 13), and ethnicity, with the prevalence of dental caries
higher in some ethnic groups. It is, however, recognised that there is a complex interplay between
these determinants. Whilst some of the variation in disease levels can be accounted for by
deprivation (circa 41% amongst 5 year olds) (12), it is not the only risk factor and dental team
members play an important role in identifying modifiable risks and helping individuals to recognise
and minimise these risks, and enhance protective factors.
Dental caries risk

Assessing the level of dental caries risk for an individual patient is key to tailoring appropriate
preventive care as outlined in Chapter 2: Table 1 (https://www.gov.uk/government/publications/delivering-
teams#table1). Based on extensive research, dental caries risk assessment tools have been
developed, but these can be complex and time consuming to administer. Risk identification based on
a single risk or protective factor has limitations due to the multifactorial nature of dental caries. The
presence of dental caries in the past is a good predictor of dental caries experience in the future, and
the overall clinical judgement of a dental professional who has a general sense of an individual’s
lifestyle and life-circumstances is vital (14).
Dental professionals should consider which patients are at higher risk of dental caries. People at
higher risk include children presenting with tooth decay; children who have had dental caries in their
primary dentition and first permanent molars and those who have been admitted to hospital for
removal of their teeth; as well as certain children who are medically compromised or have a disability.
Amongst adults, people with medically compromising conditions or disabilities and older adults,
particularly as they become physically or cognitively impaired, are at higher risk as well as people
with active caries. This includes people for whom the treatment of dental caries can be difficult or
present a risk to health.
Additionally, there may be patients with specific teeth or areas of their mouth at higher risk of
developing dental caries. For example, hypomineralised teeth are at increased risk of dental caries in
children (15). Also, adults with partially erupted third molars are at higher risk of developing dental
caries in the impacted third molar itself or in the case of mesioangular impacted third molars, on the
distal surface of the preceding second molar tooth (16 to 19). These risks should be clearly identified
and explained to patients.
Oral healthcare professionals should work with patients to assess their dental caries risk and support
them to manage their oral health effectively as part of person-centred care.
The challenge for oral healthcare professionals is to:
ensure everyone receives universal preventive advice and support

identify those children and young people who are at higher risk of dental caries and provide
additional preventive care
identify and provide additional support to those at higher risk in an ageing population with
UK existing
Dentalrestorations, advanced prostheses and the co-morbidities that come with old age
Exams Masterclass by Dr Diana McPherson | www.ukdentalexams.com
identify individuals for whom dental care would be particularly difficult

identify specific teeth which would benefit from specific preventive action and support
Risk and protective factors

The main modifiable risk factors for dental caries are diet, consuming too much cariogenic sugar too
often, and lack of optimal fluoride.
The key recommendations and good practice points to prevent dental caries are in the summary
guidance (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-
for-prevention/chapter-2-summary-guidance-tables-for-dental-teams#table1) (Chapter 2: Table 1) with further
details in the following chapters:
Fluoride (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-
toolkit-for-prevention/chapter-9-fluoride) and Oral hygiene
prevention/chapter-8-oral-hygiene) (Chapters 9 and 8)
Healthier eating (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-
based-toolkit-for-prevention/chapter-10-healthier-eating) (Chapter 10)
Other dental caries risk and protective factors, including addressing medicine containing sugars or
reducing salivary flow, placing fissure sealants, chewing sugar-free gum and using topical
remineralising agents and varnishes, are addressed below.
Medicines
Liquid, chewable or soluble medications containing sugars, either provided on prescription or bought
over the counter, may contribute to the frequency, and possibly volume, of an individual’s sugar
intake. This presents a challenge as people who are likely to be taking long-term medications in liquid
format are likely to be at increased risk of dental caries or from dental treatment that may be
required, most notably children with chronic illnesses, people with special needs, or vulnerable older
adults.
Children with chronic conditions such as epilepsy may require liquid medication for a long time.
Frequent liquid medications can also be taken for common conditions including pain relief, infections,
coughs and colds. There is some evidence that due to generic prescribing, a large proportion of the
medications dispensed for possible long-term use in older adults are sugar-containing liquid oral
medicines (20).
Sugar-free medicines, where available, may play an important role in the long-term care of such
patients. Products that do not contain fructose, glucose or sucrose are listed as being sugar-free.
Preparations containing artificial sweeteners such as hydrogenated glucose syrup, lycasin, maltitol,
sorbitol or xylitol are also listed as sugar-free, since there is evidence that they are non-cariogenic
(21).
Where a patient is on a long-term liquid or soluble medication that is not sugar-free, clinical teams
are advised to check the British National Formulary (BNF) – NICE (https://bnf.nice.org.uk/) to determine
if sugar-free alternatives are available.
Where a sugar-free version is available, the clinician should write to the patient’s general medical
practitioner to ask if they can change the prescription to the sugar-free version, explaining the reason
for the request.
Patients that are dentate and on long-term medication that is not sugar-free, and where sugar-free
alternatives are not available, should be advised where possible to try to take medications at
mealtimes. This may not be realistic if there are specific instructions such as taking medications on
an empty stomach, or carers are only permitted to distribute medicines at specific times.
Parents should also be advised to discuss with pharmacists if sugar-free versions of over the counter
liquid medications are available for their children.
Methadone, used in the rehabilitation of drug users, is available as a sugar-free preparation.

However, the sugar-based version is most often used (22, 23) due to issues of cost and practicalities.
Whilst clinicians have raised concerns about the risk of developing dental caries, empirical research
has not been undertaken. High-quality studies are required to assess the adverse effects of
methadone on oral health (24).
It is increasingly recognised that certain medicines may reduce salivary flow, which therefore raises
patient risk of developing dental caries. Again, it is helpful to discuss these issues with patients and
where appropriate, liaise with their medical practitioner or specialist.
In older adults, polypharmacy leading to xerostomia is a significant risk factor for dental caries, as
well as sugared oral nutritional supplements. This includes therapeutic foods which may be in
milkshake type liquids which are extremely common within care homes to provide vitamins, minerals
and calories to prevent further weight loss. There is a general trend towards more liquid medication,
particularly in relation to end-of-life care. Analysis of recent NHS prescribing data
(https://khub.net/documents/135939561/516396401/Oral_liquid_prescribing_NHS_England.xlsx/edf3d686-d265-
8951-521e-0eb2b6e3cfce) (in England) is available online. It will not always be practical, or appropriate,
to consider alternatives to these sugar-based supplements and medications because of more
pressing health concerns; and, in such cases, dental professionals are encouraged to place greater
emphasis on risk management using fluoride (Chapter 9)
prevention/chapter-9-fluoride).
People prescribed liquid medications are likely to be in dependent sections of the population
including young children, people with special needs and older adults. Whether the use of the
medication is short-term or long-term, it is vital to take their general health and wellbeing into account
on prescribing these medications. The top 5 most prescribed medications in England include
lactulose and morphine sulphate oral solutions, both of which contain sugar (see list of oral liquid
prescribing medication
(https://khub.net/documents/135939561/516396401/Oral_liquid_prescribing_NHS_England.xlsx/edf3d686-d265-
8951-521e-0eb2b6e3cfce)). These are commonly used to manage short and long term illnesses:
constipation, hepatic encephalopathy and acute or chronic pain and palliative care in older people. If
the medication use is long-term, then recognition of sugar-containing oral liquid medication is
important. It is important to explore with patients, and their carers or medical team, whether sugar-
free options are available and can be tolerated. Alternatively it will be helpful to find ways in which the
protective effects of fluoride may be optimised to manage dental caries risk and maintain the patient’s
overall health.
Pit and fissure sealants
Pit and fissure sealants have been used in the prevention and control of dental caries on permanent
teeth for decades (25). A range of materials and techniques exist, with new ones continuing to
emerge. Materials include resin-based, glass ionomer, polyacid-modified resin and resin-modified
glass-ionomer cements.

When compared with unsealed teeth, there is moderate-certainty evidence that resin-based fissure
sealants are effective in preventing and arresting dental caries for up to 48 months (26). The
evidence for glass-ionomer based sealants is inconclusive (26).
In line with the philosophy that children at increased risk of dental caries should receive additional
preventive interventions, it is strongly recommended that resin-based sealants be applied on eruption
of permanent teeth, particularly molar teeth, if a child is judged by the clinician to be at higher risk of
dental caries.
Whilst there is limited research evidence on the benefits of proximal sealants, it would seem best
practice to seal a surface if it is exposed and at risk. For example, the mesial surface of a first
permanent molar may be sealed when the deciduous molar has been lost; or when a surface is
exposed, whilst carrying out an interproximal restoration on an adjacent tooth.
The placement of sealants is highly technique-sensitive, with poor operative technique and/or a
challenging environment affecting the retention of the sealant and therefore its success (27). It is
important to check sealants for wear, integrity and leakage at every visit and re-seal where necessary
to maintain their role in caries prevention.
Sugar-free chewing gum
The use of sugar-free chewing gum (SFG) has been suggested as a dental caries-inhibiting activity.
A recent systematic review provided tentative evidence that chewing SFG reduces dental caries
increment compared to ‘not chewing’ (28). However, there was a considerable degree of variability in
the effect and the trials included were generally of moderate quality. The review concluded that there
is a need for future research to explore the acceptability and feasibility of the use of SFG as a public
health intervention (28). The National Institute for Health and Care Excellence (NICE) guidance on
oral health for adults in care homes does include SFG as an option for dental caries risk
management amongst dentate frail older adults in care homes (29).
Remineralising agents other than fluoride
Topical remineralising agents have been available, either on prescription from dentists or over-the-
counter, for several years now. They are mainly used for patients with high dental caries risk, as an
adjunct to normal therapies, including high-concentration fluoride dentifrices. It is suggested that
these agents are effective in remineralising early enamel lesions in high risk patients (30). Typical
constituents include casein phosphopeptide (an amorphous calcium phosphate) that helps bind the
remineralising ions to the biofilm as well as modulating biofilm pH and bacterial colonisation.
Chlorhexidine varnish
Further research in this area is required, but it may be helpful to consider chlorhexidine varnish
(CHX-V) in circumstances where fluoride (Chapter 9)
prevention/chapter-9-fluoride) is not possible. There is currently limited evidence regarding the use of
CHX-V for the prevention of root caries in older people and adults with xerostomia. A recent
systematic review (31), involving just 3 studies, evaluated CXH-V in relation to a placebo. They
reported weak evidence that CHX-V, applied by a professional to exposed roots (3 monthly
application; 1% and 10%), reduces the initiation of root caries lesions and the dental caries activity of
existing lesions.
Early detection and management pathways

Given that dental caries can be identified and is reversible at an early stage, lesions should be
identified at an early stage and managed. There is no evidence that a specific dental recall interval
influences dental caries development or progression.
The time between dental check-ups should be based on risk, as assessed by the clinician, working
with patients (and where appropriate parents or guardians) and will be influenced by preventive care
needed. The recall period will change across the life course (32, 33), as shown in Chapter 1
prevention/chapter-1-introduction). For example, in children it is good practice for the recall period to be
set so that they can obtain optimal prevention through treatments such as the application of fluoride
varnish.
For older adults in care homes, having an oral health assessment on entry to the care home is
recommended in NG48 by NICE (29), supported by access to professional care on a regular basis.
Given that these people will be at higher risk of most oral diseases and conditions, shortened recall
periods are likely to be the norm.
Resources
NHS Education for Scotland. Prevention and Management of Dental Caries in Children Scotland
(https://www.sdcep.org.uk/published-guidance/caries-in-children/): NES; 2018 [Second Edition].
Oral health for adults in care homes NICE guideline (https://www.nice.org.uk/guidance/ng48) [NG48].
NICE guidance: Dental checks: intervals between oral health reviews

(https://www.nice.org.uk/Guidance/CG19), Clinical guideline [CG19], National Institute for Health and
Clinical Excellence; 2004. Report No. CG019.
Widget health. Easy read and communication support for healthcare and medical professionals to
help patients with learning difficulties with a visit to the dentist (https://widgit-
health.com/downloads/dental-procedures.htm).
References
1. NHS Digital. Report 2: Dental Disease and Damage in Children: England, Wales and Northern
Ireland. (https://files.digital.nhs.uk/publicationimport/pub17xxx/pub17137/cdhs2013-report2-dental-disease.pdf)
London: The Health and Social Care Information Centre; 2015 Published 19 March 2015.
2. NHS Digital. Adult Dental Health Survey 2009 – Summary report and thematic series
(http://www.hscic.gov.uk/pubs/dentalsurveyfullreport09) [NS] London: The Health and Social Care
Information Centre; 2011.
3. Marcenes W, Kassebaum NJ, Bernabé E, Flaxman A, Naghavi M, Lopez A, and others. Global
Burden of Oral Conditions in 1990-2010: A Systematic Analysis. Journal of Dental Research.
2013;92(7):592-7.
4. Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, and others. Dental
Caries. Nature Reviews Disease Primers. 2017;3:17030.
5. Machiulskiene V, Campus G, Carvalho JC, Dige I, Ekstrand KR, Jablonski-Momeni A, and others.
Terminology of Dental Caries and Dental Caries Management: Consensus Report of a Workshop
Organized by ORCA and Cariology Research Group of IADR. Caries Research. 2020;54(1):7-14.

6. ICCMS Collaboration. ICCMS: International Caries Detection and Assessment System (ICDAS)
and its International Caries Classification and Management System (ICCMS) – methods for staging
of the caries process and enabling dentists to manage caries 2020 (https://www.iccms-
web.com/content/icdas) [updated 2020].
7. NHS Digital. Child Dental Health Survey: England, Wales and Northern Ireland.
(https://digital.nhs.uk/data-and-information/publications/statistical/children-s-dental-health-survey/child-dental-
health-survey-2013-england-wales-and-northern-ireland) London: The Health and Social Care Information
Centre; 2015.
8. Public Health England. Inequalities in oral health in England.

(https://www.gov.uk/government/publications/inequalities-in-oral-health-in-england) London: PHE; 2021
19.03.2021. Contract No.: GW-1921.
9. NHS Digital. Adult Dental Health Survey 2009, England, Wales and Northern Ireland.
(https://digital.nhs.uk/data-and-information/areas-of-interest/public-health/adult-dental-health-survey) London:
NHS Digital; 2011.
10.Thomson WM, Broadbent JM, Foster Page LA, Poulton R. Antecedents and Associations of Root
Surface Caries Experience among 38-Year-Olds. Caries Research. 2013;47(2):128-34.
11. Hayes M, Da Mata C, Cole M, McKenna G, Burke F, Allen PF. Risk indicators associated with root
caries in independently living older adults. Journal of Dentistry. 2016;51:8-14.
12. Public Health England. Oral health survey of 5 year old children 2019 London
(https://www.gov.uk/government/statistics/oral-health-survey-of-5-year-old-children-2019). 2020 (updated 19
March 2020).
13. Public Health England. Oral health survey of 3 year old children 2020 London
(https://www.gov.uk/government/statistics/oral-health-survey-of-3-year-old-children-2020). 2021.
14. Fontana M, Gonzalez-Cabezas C. Evidence-Based Dentistry Caries Risk Assessment and

Disease Management. Dental Clinics of North America. 2019;63(1):119-28.
15. Wuollet E, Laisi S, Alaluusua S, Waltimo-Sirén J. The Association between Molar-Incisor

Hypomineralization and Dental Caries with Socioeconomic Status as an Explanatory Variable in a
Group of Finnish Children. International Journal of Environmental Research Public Health.
2018;15(7).
16. Faculty of Dental Surgery. Parameters of care for patients undergoing mandibular third molar
surgery. (https://www.rcseng.ac.uk/dental-faculties/fds/publications-guidelines/clinical-guidelines/) London:
RCSEng; 2020.
17. Toedtling V, Coulthard P, Thackray G. Distal caries of the second molar in the presence of a
mandibular third molar – a prevention protocol. British Dental Journal. 2016;221(6):297-302.
18. McArdle LW, McDonald F, Jones J. Distal cervical caries in the mandibular second molar: an
indication for the prophylactic removal of third molar teeth? Update. British Journal of Oral and
Maxillofacial Surgery. 2014;52(2):185-9.
19. McArdle LW, Jones J, McDonald F. Characteristics of disease related to mesio-angular

mandibular third molar teeth. British Journal of Oral Maxillofacial Surgery. 2019;57(4):306-11.
20. Baqir W, Maguire A. Consumption of prescribed and over-the-counter medicines with prolonged
oral clearance used by the elderly in the Northern Region of England, with special regard to generic
prescribing, dose form and sugars content. Public Health. 2000;114(5):367-73.
21. European Food Standards Agency on Dietetic Products NaAN. Scientific Opinion on the
substantiation of health claims related to intense sweeteners and contribution to the maintenance or
achievement of a normal body weight (ID 1136, 1444, 4299), reduction of post-prandial glycaemic
responses (ID 4298), maintenance of normal blood glucose concentrations (ID 1221, 4298), and
maintenance of tooth mineralisation by decreasing tooth demineralisation (ID 1134, 1167, 1283)
pursuant to Article 13(1) of Regulation (EC) No 1924/2006. European Food Standards Agency
Journal. 2011;9:2229 [26pp].
22. Nathwani NS, Gallagher JE. Methadone: dental risks and preventive action. Dental Update.
2008;35(8):542-4, 7-8.
23. Brondani M, Park PE. Methadone and oral health–a brief review. Journal of Dental Hygiene.
2011;85(2):92-8.
24. Tripathee S, Akbar T, Richards D, Themessl-Huber M, Freeman R. The relationship between

sugar-containing methadone and dental caries: a systematic review. Health Education Journal. 2012.
25. Wright JT, Crall JJ, Fontana M, Gillette EJ, Nový BB, Dhar V, and others. Evidence-based clinical
practice guideline for the use of pit-and-fissure sealants: A report of the American Dental Association
and the American Academy of Pediatric Dentistry. The Journal of the American Dental Association.
2016;147(8):672-82.e12.
26. Ahovuo‐Saloranta A, Forss H, Walsh T, Nordblad A, Mäkelä M, Worthington HV. Pit and fissure
sealants for preventing dental decay in permanent teeth. Cochrane Database of Systematic Reviews.
2017(7).
27. NHS Education for Scotland. Prevention and Management of Dental Caries in Children Scotland
(https://www.sdcep.org.uk/published-guidance/caries-in-children/). NES; 2018 [Second].
28. Newton JT, Awojobi O, Nasseripour M, Warburton F, Di Giorgio S, Gallagher JE, and others. A
Systematic Review and Meta-Analysis of the Role of Sugar-Free Chewing Gum in Dental Caries.
Journal of Dental Research Clinical Translational Research. 2019:2380084419887178.
29. NICE. Oral health for adults in care homes NG48. (https://www.nice.org.uk/guidance/ng48) London:
NICE; 2016.
30. González-Cabezas C, Fernández CE. Recent Advances in Remineralization Therapies for Caries
Lesions. Advances in Dental Research. 2018;29(1):55-9.
31. Meyer-Lueckel H, Machiulskiene V, Giacaman RA. How to Intervene in the Root Caries Process?
Systematic Review and Meta-Analyses. Caries Research. 2019;53(6):599-608.
32. NICE. Dental recall guidelines. (https://www.nice.org.uk/Guidance/CG19) London: National Institute

for Health and Clinical Excellence; 2004. Report No.: CG019.
33. NICE. Surveillance report 2018 – Dental checks: intervals between oral health reviews (2004)
NICE guideline CG19. (https://www.nice.org.uk/guidance/cg19/resources/surveillance-report-2018-dental-
checks-intervals-between-oral-health-reviews-2004-nice-guideline-cg19-4898003869/chapter/Surveillance-
decision?tab=evidence) London: National Institute for Health and Clinical Excellence; 2018 21.06.2018.
Report No.: CG019.



11/19/21, 8:31 PM Chapter 5: Periodontal diseases - GOV.UK
GOV.UK

Department
of Health &
care)
Office for Health
Improvement
and-disparities)
Guidance
Chapter 5: Periodontal diseases
Contents
Introduction
Definitions
Epidemiology
Risk or susceptibility and protective factors
Primary prevention of periodontitis
Secondary prevention of periodontitis
Tertiary prevention of periodontitis
Mouthrinses, mouthwashes and sprays
Peri-implant
UK health Masterclass by Dr
Dental Exams Diana McPherson | www.ukdentalexams.com
https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-5-periodontal-diseases 1/22
Resources
References


health-an-evidence-based-toolkit-for-prevention/chapter-5-periodontal-diseases

improvement policy.
Introduction
Whilst several conditions may affect the tooth-supporting tissues referred to as the periodontium or
gums, the following sections focus on the most common forms of periodontal diseases, called
‘gingivitis’ (inflammation of the gums that can be reversed) and ‘periodontitis’ (inflammation that
results in loss of periodontal attachment) (1). The early stages of disease may be symptom-free, but
the impact on peoples’ lives of later stage disease are more serious (1), particularly as the disease is
irreversible.
Gingivitis and periodontitis are separate conditions, although both are initiated by plaque in
susceptible people. Gingivitis is a risk factor for periodontitis, although not all people or sites with
gingivitis go on to develop periodontitis. The prevention and management of periodontitis is
described here in terms of primary, secondary, and tertiary prevention as shown in Chapter 1 (Table
1.1) (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-1-introduction#table1). Because both conditions are initiated by plaque, the primary
prevention of periodontitis will also prevent gingivitis.
As the use of dental implants to replace missing teeth has increased, 2 new conditions, peri-implant
mucositis and peri-implantitis, have become apparent (2). These conditions may be analogous to
gingivitis and periodontitis. Additional advice for the prevention of these conditions is provided at the
end of this chapter.
Definitions
The 2017 World Workshop classification of periodontal and peri-implant conditions (3, 4), can be
summarised as follows.
Periodontal health
Periodontal health is the absence of clinically detectable inflammation (<10% of sites bleeding on
probing), on an intact periodontium, or a reduced periodontium where attachment loss has resulted
from anything other than periodontitis.
Gingivitis
Gingivitis is an inflammatory condition resulting from interactions between the dental plaque and the
host’s immune response, which remains contained within the gingiva and does not extend to the
periodontal attachment (cementum, periodontal ligament, and alveolar bone). Such inflammation is
reversible by reducing levels of dental plaque at and below the gingival margin.
Periodontitis
Periodontitis is a microbially-associated, host-mediated inflammation that results in loss of

periodontal attachment. A patient is said to have periodontitis if:
interdental clinical attachment loss (CAL) is detectable at ≥2 non-adjacent teeth
or
buccal or oral CAL ≥3 mm with pocketing ≥3 mm is detectable at ≥2 teeth, where the lost clinical
attachment cannot be ascribed to another cause
Periodontitis causes progressive destruction of the tooth‐supporting tissues. Signs of the disease
include clinical attachment loss, manifested as interdental recession and/or periodontal pocketing
and alveolar bone loss (4). This chronic and inflammatory disease is caused by a complex interplay
of risk factors, with dental plaque being the most important (4).
Epidemiology
Some level of irreversible periodontitis affects almost half of UK adults (5), although this might
underestimate true disease levels.
Similar levels of periodontal diseases are present globally, with the latest evidence suggesting that
around 10% of the world’s population (8.2 to 11.4% age standardised) has evidence of severe
disease (6). The peak in prevalence occurs between 60 and 64 years of age (6), and there are
marked inequalities by socio-economic status. About half of all adults have some evidence of
moderate disease and thus, it is one of the most common chronic inflammatory diseases globally.
Age need not be a barrier to good periodontal health (7 to 11), particularly when people can
undertake the necessary self-care and are able to visit the dental team.
Risk or susceptibility and protective factors

In addition to plaque build-up, tobacco (smoking or chewing) and alcohol use, several general health
conditions are risk factors for periodontal diseases. Conversely, there are risks to general health
resulting from having active periodontal diseases.
Some systemic disorders, such as diabetes and cardiovascular diseases, share similar genetic
and/or environmental influences with periodontal diseases, thus affected people may have signs of
either or both conditions (12, 13).
International consensus of joint dental and medical experts, based upon evidence from systematic
reviews, recommends the importance of periodontal therapy in reducing the risks of diabetes and its
complications (14).
There is ongoing debate about the role of periodontitis in cardiovascular diseases (15, 16), but at
present no firm conclusions can be drawn. Also, there is insufficient information to determine the true
relationship between rheumatoid arthritis and periodontitis. (17) Likewise, the evidence linking
lifestyle factors such as stress (18, 19), poor diet (20, 21), being overweight (22), or cannabis use
(23), is insufficient to suggest a clear association with periodontal diseases.
Plaque
Dental plaque is a highly organised and specialised film of bacteria in an organic matrix that forms on
the teeth. The intercellular matrix consists of various micro‐organisms and their by‐products. The
bacteria mutually support each other, using chemical messengers, in a complex and highly evolved
community, that can protect them from an individual’s immune system and chemical agents.
Normally, small amounts of bacteria cause only minimal inflammation, but a disruption in the balance
(dysbiosis) between the plaque and person’s immune system can lead to the initiation of gingivitis
and progression to periodontitis (1).
Tobacco
Tobacco smoking and use of smokeless tobacco products have a profound effect on the risk of
developing periodontitis (24, 25). They also impair the treatment response. Cessation of tobacco use
can prevent further deterioration of periodontal health (Chapter 2: Table 2
prevention/chapter-2-summary-guidance-tables-for-dental-teams#table2); Chapter 11
prevention/chapter-11-smoking-and-tobacco-use)).
Vaping
Evidence suggests that although not risk free, using an e-cigarette (vaping), is far less harmful to
health than smoking. Findings about the impact of vaping on periodontal health are inconsistent but
suggest people who vape are at greater risk for periodontal diseases compared to non-smokers (26).
However, it is helpful to recognise that most people who vape are former smokers and will have
experienced the effect of smoking on their periodontal health. It will take time to build a clear picture
of their longer-term periodontal health through longitudinal research. E-cigarettes may, however,
have a lower risk of periodontitis than tobacco and therefore provide a helpful transition to cessation
for smokers (Chapter 11 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-
evidence-based-toolkit-for-prevention/chapter-11-smoking-and-tobacco-use)).
Alcohol
There is emerging low-certainty evidence that alcohol consumption is associated with periodontitis
(27, 28). Possible mechanisms of action may be related to alcohol’s negative impact on bone density
and saliva secretion. Advice on managing alcohol risk reduction is presented in Chapter 12: Alcohol
prevention/chapter-12-alcohol).
Diabetes
Glycaemia in those without a diagnosis of diabetes, and hyperglycaemia in those with diabetes are
both risk factors for poor periodontal health (29) and also impair the response to its treatment. While
well-controlled diabetes is not a risk factor, many people oscillate between different levels of control.
Therefore, it is best to assume an increased risk of periodontal diseases for anyone who has
diabetes (30).
Medications
Several medications may affect periodontal health, which underlines the importance of a
comprehensive and up-to-date medical history.
Medications may cause:
dry mouth – antidepressants (31), and other drugs can cause dry mouth

gingival enlargement – most commonly seen with calcium channel blockers for cardiovascular
disease (32), although other drugs can also have this effect
Therefore, it is good practice to check the possible side-effects of patient medications in a formulary.
Primary prevention of periodontitis
Risk factor control
The primary prevention of periodontitis and gingivitis involves control of any risk factors. An overview
of risk factors and their management is presented in Chapter 2: Table 2
prevention/chapter-2-summary-guidance-tables-for-dental-teams#table2). As gingivitis is a predictor of
developing periodontitis (33), and thereafter tooth loss (34), its prevention also helps in the primary
prevention of periodontitis. Importantly, risk factor control is also the mainstay of the management of
established gingivitis and periodontitis (that is, secondary and tertiary prevention (35, 36)).
In view of the chronic nature of the disease and risk of the irreversible bone-loss, self-care is vitally
important. For everybody, the primary preventive goals are to develop good plaque removal skills and
to avoid tobacco. Effective and regular toothbrushing from infancy and interdental plaque removal
from 18 years of age (beforehand if evident disease) are therefore the main skills required from an
early age (Chapter 8 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-
based-toolkit-for-prevention/chapter-8-oral-hygiene)). All dental team members play a major role in
assessing, coaching, and supporting patients with self-care. Whilst professional intervention plays an
important role for people with advanced disease, no clinical benefits of ‘routine scale and polish’ have
been demonstrated for adults with good periodontal health (37).
Plaque control
The central role of plaque in the pathogenesis of periodontitis means that its control is essential in the
maintenance of periodontal health. Comprehensive advice on oral hygiene instruction (OHI) is
outlined in Chapter 8 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-
based-toolkit-for-prevention/chapter-8-oral-hygiene) on oral hygiene.
The importance of behaviour change approaches in support of plaque control is increasingly

recognised (38, 39) within periodontal care. Contemporary approaches encourage patients to
understand how oral hygiene might benefit them, to develop confidence in their oral hygiene abilities,
to set targets for change that they feel able to achieve and to challenge perceived barriers to
performance. Some of these methods address common barriers to an effective oral hygiene routine
that may have been missed during traditional instruction.
Useful resources include the Oral Hygiene TIPPS video (https://www.sdcep.org.uk/published-

guidance/periodontal-management/oral-hygiene-tipps-video/) (40), which was devised by the Scottish
Dental Clinical Effectiveness Programme. Oral Hygiene TIPPS (Talk, Instruct, Practice, Plan,
Support) is a behaviour change strategy for dental teams helping them to increase patients’
confidence in their ability to perform effective plaque removal and help them plan how and when they
will look after their teeth and gums. Behaviour change is covered in detail in Chapter 3
prevention/chapter-3-behaviour-change), which has case studies
b27c-83dd-f172-5164998e14aa) relating to managing patient self-care.

Whilst brief behaviour change interventions have the potential to improve plaque control over
traditional oral hygiene instruction alone (41, 42), the evidence to date is not robust (41). There is low
to moderate certainty evidence that motivational methods, involving plaque disclosure and repeated
OHI reduce plaque (39); and, very low to low certainty evidence that motivational methods reduce
gingivitis. Amongst teenagers receiving orthodontic care, there is moderate certainty evidence that
reminders reduce plaque and gingivitis in the short term, and very low certainty evidence that they do
so over a 3-month period (43, 44).
The potential for m-Health (mobile phone messages) to support oral hygiene in mothers, children and
orthodontic patients is being tested, but to date there is insufficient evidence to make firm
recommendations (45, 46).
Removal of plaque retention factors
In sites where calculus and overhanging restorations with ledges prevent plaque removal (BPE Code
2), the retentive factor can be removed. This may not be necessary where there are no signs of
gingivitis but may be required if there is evidence of disease.
Smoking cessation
Cessation of tobacco use can prevent further deterioration of periodontal health. Information about
checking patients’ smoking status and for helping people to quit is provided in the chapter on tobacco
and smoking (Chapter 11 (https://www..gov.uk/government/publications/delivering-better-oral-health-an-
evidence-based-toolkit-for-prevention/chapter-11-smoking-and-tobacco-use)). Smoking should be managed
by Asking, Advising and Acting in line with the strong evidence on brief interventions outlined in the
oral cancer text to be found in Chapter 2: Table 4 (https://www.gov.uk/government/publications/delivering-
teams#table4).
Alcohol risk reduction
To keep health risks from alcohol to a low level it is safer not to drink more than 14 units a week on a
regular basis (see Chapter 12: Alcohol (https://www.gov.uk/government/publications/delivering-better-oral-
health-an-evidence-based-toolkit-for-prevention/chapter-12-alcohol)). (47).
Diabetes control
The following actions are advised (13, 30).
In addition to usual good practice for periodontal diseases prevention, people with diabetes should be
informed of the implications for their periodontal health.
Discuss how diabetes control affects periodontal health and ask about their level of glycaemic
control, also known as HbA1c. Levels consistently below 7.0% (8.6 mmol/L) indicate good control.
The target HbA1c value for most people with diabetes is 6.5% or below in line with IFCC
(International Federation of Clinical Chemistry) or 48mmol/mol (or below) DCCT (diabetes control
and complications trial). Units are increasingly calculated in mmmol/mol
(https://www.diabetes.co.uk/downloads/files/HbA1c%20units%20DCCT%20to%20IFCC.pdf). It is worth noting
that people may be set different threshold units by their team; thus dental teams should explore this
with each patient (48).
Encourage people to maintain good diabetes control (including diet, medication, exercise and so on)
and to follow up with the diabetes physician regularly.

Write to the diabetes physician for guidance on a patient’s diabetes status and health, particularly
HbA1c levels. Download template letter
(https://khub.net/documents/135939561/516396401/Template+letter+for+clinician+to+contact+diabetes+physicia
n.odt/4369be79-e902-45be-0e51-1e9fa89e77be).
Inform the physician about the patient’s periodontitis status, which may help the physician to tailor
diabetes care and advice appropriately and support the person with diabetes in maintaining more
effective control.
Periodontal treatment may improve diabetes control among affected people and it is associated with
reduced complications of diabetes (14).
Medication management
Members of the dental team will be used to enquiring about their patients’ medications as part of a
medical history. Specific assessments and actions are relevant to periodontal health.
Ask
Ask people on medication if they experience dry mouth or swollen gums.
Assess
Assess the oral cavity for any impact of medication, for example, dry mouth, mucosal changes,
caries, extensive plaque deposits or candida infection or gum swelling.
Action
You should:
explain findings and assess possible need to change medication

contact physician to request consideration for medication change where appropriate regarding
gingival enlargement – download template letter
(https://khub.net/documents/135939561/516396401/Template+letter+for+clinician+to+contact+physician+a
bout+gingival+enlargement.odt/07f64644-510f-1127-cb4f-507b366f0823)
consider short-term use of chlorhexidine mouthrinse in addition to usual plaque control methods
consider increasing frequency of reviews and of scaling (professional mechanical plaque
removal)
Secondary prevention of periodontitis
Early detection and management pathways: basic periodontal examination
Early detection and treatment of periodontitis increases the likelihood of tooth retention (49). One
screening tool that is well known and quick to use is the Basic Periodontal Examination (BPE) (50).
The BPE uses the WHO BPE probe and is suitable for routine assessment of all dentate adults
(Table 5.1).
Table 5.1. BPE codes

Code Observation
0 Healthy gingival condition with no bleeding on probing
1 Bleeding on probing
2 Plaque retention factor present (for example calculus, overhanging restoration)
Black band extending 3.5mm to 5.5mm is partially obscured (indicates pocket 4mm to
3
5.5mm)
Black band extending 3.5mm to 5.5mm is completely obscured (indicates pocket of 6mm or
4
greater)
* Furcation involvement
Detailed advice on the use of the BPE is provided in the Greater Manchester Local Dental Network’s
(2019) Healthy Gums Do Matter (51) and the British Society for Periodontology and Implant Dentistry
(BSP) BPE guidelines (50). It is important to note that the BPE does not provide a diagnosis, nor
does it assess the response to treatment, as pockets do not always reduce, even in successful
treatment.
The BPE has also been adapted for early detection of periodontal diseases in children, as
periodontitis can manifest in childhood and adolescence, but is difficult to detect without probing (52).
Therefore, all children from the age of 7 years onwards should be examined with a modified BPE.
The BSP summary guidance indicates how to do this in 2 age bands: 7 to 11 years and 12 to 17
years as presented in Table 5.2.
Table 5.2. BPE summary guidance for children and adolescents (British Society of
Periodontology, 2012) (52)
Age Teeth to assess
6 1/ 6[footnote 1]
7 to 11 Gum disease is difficult to 6 /1 6
years identify unless looked for
BPE codes to use: 0,1,2 (only)
6 1/ 6[footnote 1]
6 /1 6
BPE codes to use: 0,1,2,3,4 and *
12 to 17 Gum disease is difficult to BPE = 0-2 as above

years identify unless looked for
BPE = 3 in 1 or more sextant: treat and review after 3
months
BPE = 4 or * in any sextant: full periodontal

assessment and normally arrange referral

Managing periodontitis
As for any disease, the management of periodontitis will depend on its extent, severity and rate of
progression. An overview of risk factors and their management is presented in Chapter 2: Table 2
prevention/chapter-2-summary-guidance-tables-for-dental-teams#table2).
Patients with BPE scores of 0 to 2 are deemed not to have periodontitis and therefore only require
primary prevention. As periodontitis and gingivitis have common risk factors, prevention of one will
prevent the other. As set out above, primary prevention involves plaque control, the removal of
plaque retention factors and management of other risk factors that either increase the risk of
developing periodontitis or complicate its successful care.
Patients with BPE scores of 3 or 4 may have periodontitis. Preventive care may therefore involve
secondary (detecting the early stages of periodontitis and intervening before full symptoms develop)
or tertiary prevention (softening the impact of periodontitis by helping people manage its long-term
consequences with Supportive Periodontal Care (SPC)).
Secondary prevention will involve more detailed periodontal charting to identify affected sites, as
patients with these BPE codes will have pockets of ≥4mm or ≥6mm respectively (50). Plaque scores
may identify areas with specific oral hygiene problems to be managed (53).
The European Federation of Periodontology has developed S3 level evidence-based clinical practice
treatment guidelines for periodontitis, which have been adapted and adopted by the BSP for
implementation in the UK (53). Once the patient has an established diagnosis of periodontitis, it may
be managed by a stepwise approach to therapy as outlined in the guidance (53).
Sextants coded 3 should receive initial therapy including self-care advice (oral hygiene instruction
and risk factor control). After the patient has had time to respond to this, a 6-point pocket chart
should be recorded in the affected sextant to monitor progress and advise the patient accordingly.
If there is a code 4 in any sextant then record a 6-point pocket chart to identify affected sites
throughout the entire dentition. Tertiary prevention in patients who have undergone initial therapy for
periodontitis, and who are now in the maintenance phase of care will require full probing depths
throughout the entire dentition recorded at least annually. It is important to support patients with clear
advice as part of supportive periodontal care Chapter 2: Table 2
prevention/chapter-2-summary-guidance-tables-for-dental-teams#table2).
The 2017 World Workshop on Classification of Periodontitis (3), is useful in classifying the stage and
speed of breakdown of periodontitis as part of the detailed assessment required in patients with the
disease.
New classification of periodontitis
The new classification of periodontitis (3, 54) describes the historical degree of periodontal
breakdown (stage) and the speed of the breakdown (grade) (54). It was adapted for implementation
in the UK healthcare system by the BSP (55). An overview is presented in Table 5.3.
The BSP adaptation classifies the disease into 4 stages based on severity (I, II, III or IV) and 3
grades based on disease susceptibility (A, B or C). The stage of periodontitis cannot reduce,
because the bone loss is largely irreversible, but may increase (54).
Table 5.3. Staging and grading of periodontitis

Staging of
periodontitis
Stage I Stage II Stage III Stage IV

(early/mild) (moderate) (severe) (very severe)
Interproximal Coronal third Mid third of Apical third

<15% or <2 mm**
bone loss* of root root of root
Describe as:
• localised (up to 30% of
teeth)
Extent
• generalised (more than
30% of teeth)
• molar/incisor pattern
Grading of
periodontitis
Grade A Grade B Grade C

(slow) (moderate) (rapid)
% bone loss / age <0.5 0.5–1.0 >1.0
*Maximum bone loss in percentage of root length.

**Measurement in mm from cemento-enamel junction (CEJ) if only bitewing radiograph available
(bone loss) or no radiographs clinically justified (CAL).
Sources: (54, 55).
Notes:
If a patient has interproximal attachment loss but BPE codes of only 0, 1 and 2, (for example, a
previously treated, stable periodontitis patient), and radiographs are not available or justifiable,
staging and grading should be performed on the basis of measuring attachment loss in mm from the
CEJ and estimation of concomitant bone loss.
If a patient is known to have lost teeth due to bone loss likely to have been within the apical third of
the root, stage IV may be assigned.
Tertiary prevention of periodontitis
Supportive periodontal care (SPC) after treatment for periodontitis
Periodontitis is a chronic disease that will recur and worsen without good plaque control (8, 56). This
is the basis for providing SPC, which involves a long-term commitment from the patient and an
intensive level of support, monitoring and care from the dental team. Trials have compared different
types of SPC, with inconclusive results, but to date there have been no randomised controlled trials
comparing SPC to no SPC (57). The evidence for the clinical efficacy of subgingival air polishing
compared with ultrasonic debridement for systemically healthy patients in periodontal maintenance is
still limited and remains inconclusive (58). Some patients preferred ultrasonic compared to hand
instrumentation
UK Dental Exams because it took less time.
Masterclass by Dr Diana McPherson | www.ukdentalexams.com
Components of SPC include: (59, 60):
setting expectations – advice about the importance of SPC and the commitment required and
need for patient adherence
regular monitoring of
plaque and gingival inflammation to guide oral hygiene advice
probing depths and bleeding on probing to guide:
evaluation of health and stability
treatment
oral hygiene advice Chapter 8 (https://www.gov.uk/government/publications/delivering-better-oral-
health-an-evidence-based-toolkit-for-prevention/chapter-8-oral-hygiene) and behaviour change Chapter
3 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-3-behaviour-change) intervention as appropriate (covered above)
debridement or professional mechanical plaque removal (PMPR):
removal of supra and subgingival plaque and calculus (PMPR)
root surface debridement of pockets 5mm and deeper with bleeding on probing
Patient adherence to plaque control is central to periodontal care as removal of supra and
subgingival plaque and calculus is of limited value in the absence of high standards of plaque control
(37).
In patients with type 2 diabetes, there is moderate certainty evidence that SPC improves metabolic
control and reduces systemic inflammation (61). These findings have been supported by several
systematic reviews. However, the certainty of the evidence and the amount of reduction in HbA1c
varies (62 to 64); there is insufficient evidence to determine if this effect is maintained beyond 4
months.
Findings for any benefit of periodontal therapy on hypertension remain inconclusive (65).
Management of periodontitis: summary
Table 5.4 summarises the possible management options for periodontitis in adults in relation to BPE
scores.
Table 5.4. BPE and possible management options in adults
Code Observation Management
Healthy gingival Risk factor control

0
condition Recalls as low risk
Bleeding on Risk factor control

1
probing Recalls as low risk depending on extent of bleeding
Plaque retention Consider removing retention factor

2
factors Recalls as low risk depending on extent of bleeding

Code Observation Management
Risk factor control

Remove retention factors
Pockets 4mm to Detailed assessment, including pocket charting in affected segments,
3
5.5mm radiographs, classification, and grading
Active treatment
Supportive Periodontal Care
As Code 3 above and additionally

Pockets of 6mm
4 Detailed assessment, including full-mouth pocket charting,
or greater
radiographs, classification, and grading
Furcation
* As Code 4 above
involvement
Mouthrinses, mouthwashes and sprays

There is a range of mouthrinses, mouthwashes and sprays available to the public, in addition to
mechanical plaque control with dentifrices, for longer or short-term use.
The body of available evidence suggests that of the products evaluated, there is high certainty
evidence for the use of chlorhexidine mouthrinse to reduce dental plaque and gingivitis (66, 67). Both
0.1 and 0.2% chlorhexidine gluconate mouthwashes are effective for preventing plaque formation
and reducing gingival inflammation during the early healing period after periodontal and implant
surgery (66). Plaque scores (very low certainty evidence) and gingivitis scores (moderate certainty
evidence) are reduced to a similar degree, whether using chlorhexidine mouthrinse containing
sodium fluoride or chlorhexidine alone (67). It is important to note that chlorhexidine gluconate may
be incompatible with some ingredients in toothpaste and therefore it is important to rinse the mouth
thoroughly with water between using toothpaste and chlorhexidine-containing products. Longer term
use of chlorhexidine mouthrinse has adverse effects including extrinsic tooth staining; taste
disturbance or alteration; effects on the oral mucosa including soreness, irritation, mild
desquamation, and mucosal ulceration or erosions; general burning sensation or a burning tongue.
This product is, therefore, advised for short-term use.
There is very little reliable evidence available to draw conclusions about effects of chlorhexidine
antiseptic sprays on plaque and gingivitis (68). There is, however, low to moderate certainty evidence
that adjunctive antiseptics in mouthrinses, including essential oils and cetylpyridinium chloride (CPC)
provide statistically significant reductions in gingival, bleeding and plaque indices when compared to
mechanical plaque control alone (69). Similar results were shown for other reviews involving herbal
(70), aloe vera (71, 72), green tea (73), and polyphenol (74) rinses.
Peri-implant health
Dental implants may be used to replace missing teeth. However, the soft tissues and bone around
dental implants (75), are at the same risk of inflammation and progressive disease as those around
natural teeth (38). Among patients with implants the prevalence of peri-implant mucositis and peri-
implantitis are approximately 43% and 22% respectively (76).
Superficial inflammation (peri-implant mucositis) and true breakdown (peri-implantitis) around dental
implants are common (75), and evidenced by bleeding on gentle probing, erythema, swelling and/or
suppuration (2).
Poor oral hygiene, a history of periodontitis, smoking, diabetes, and lack of supportive care appear to
be risk factors for peri-implant disease (2, 77, 78). Whilst previous systematic reviews have shown
limited or conflicting evidence regarding the role of smoking as a risk factor for peri-implantitis (78,
79), a more recent systematic review provides low certainty evidence from 8 cross-sectional surveys
of a significant association (OR 1.7, 95% CI 1.25‐2.3) (80). There is also low certainty evidence that
the placement of implants in smokers is associated with implant failure, postoperative infection, and
marginal bone loss (81).
Definitions
Peri-implant health
The main clinical characteristics of peri-implant health is an absence of clinical signs of inflammation,
absence of bleeding and/or suppuration on gentle probing, no increase in probing depth compared to
previous examinations and absence of bone loss beyond crestal bone level changes resulting from
initial bone remodelling (4, 82).
Peri-implant mucositis
The main clinical characteristic of peri‐implant mucositis is bleeding on gentle probing. Erythema,
swelling and/or suppuration may also be present (82). The diagnosis is based on the presence of
bleeding and/or suppuration on gentle probing with or without increased probing depth compared to
previous examinations and absence of bone loss beyond crestal bone level changes resulting from
initial bone remodelling (4, 82).
Peri-implantitis
Peri‐implantitis is a plaque‐associated disease of the tissues around dental implants, characterised

by inflammation of the mucosa and progressive loss of supporting bone (2, 82). Diagnosis of peri-
implantitis includes presence of bleeding and/or suppuration on gentle probing, increased probing
depth compared to previous examinations and the presence of bone loss beyond crestal bone level
changes resulting from initial bone remodelling.
In the absence of data from a previous examination the diagnosis of peri‐implantitis is based on a
‘combination of presence of bleeding and/or suppuration on gentle probing, probing depths of ≥6 mm
and bone levels ≥3 mm apical of most coronal portion of intraosseous part of implant’ (2).
The principles of prevention around implants are the same as for teeth and focus on effective control
of plaque and management of other risk factors (83, 84). However, plaque control around implants is
more challenging due to the circumferential nature of peri-implantitis lesions, as well as plaque
retention around cemented restorations and the design of super-structures that hinder access to the
implant surface for brushing. An overview of risk factors and their management is presented in
Chapter 2: Table 2 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-
based-toolkit-for-prevention/chapter-2-summary-guidance-tables-for-dental-teams#table2).
Monitoring of implants includes regular checking of soft tissue health visually and by probing.
Radiographs are required to monitor bone stability over time (82). Unresponsive pockets with
bleeding, pus and/or progressive bone loss (as indicated by presence of bone loss beyond crestal
bone level changes resulting from initial bone remodelling) indicate peri-implantitis (82).
At each visit:
monitor plaque and marginal inflammation

monitor probing depths and compare them to baseline (following placement of prosthesis) and
previous visits, bleeding, and presence of pus
take appropriate radiographs as indicated and compare with the time of prosthesis placement
and subsequent films
debride all supra and submucosal plaque and calculus
consider early referral to specialist for unresponsive deepened pockets with bleeding, or pus
and progressive bone loss
decide on recall interval based on peri-implant and periodontal status
There is low certainty evidence that SPC can potentially maintain peri‐implant health measured in
terms of implant success rates, and prevent peri‐implant mucositis, and/or peri‐implantitis (85, 86).
Resources
Greater Manchester Local Dental Network. Healthy Gums do Matter
(https://www.bsperio.org.uk/professionals/healthy-gums-do-matter-toolkit). Practitioner’s Toolkit. 2019.
Second Edition.
BSP Clinical Guidelines (https://www.bsperio.org.uk/professionals/publications) including flowchart

implementing the 2017 classification of periodontal diseases.
BSP UK version of the S3 Treatment Guidelines for Periodontitis

(https://www.bsperio.org.uk/professionals/bsp-uk-clinical-practice-guidelines-for-the-treatment-of-periodontitis).
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1. The teeth to assess are all 4 permanent first molars, the upper right first permanent incisor and
the lower left first permanent incisor.


11/19/21, 8:31 PM Chapter 6: Oral cancer - GOV.UK
GOV.UK

Department
of Health &
care)
Office for Health
Improvement
and-disparities)
Guidance
Chapter 6: Oral cancer
Contents
Definitions
Epidemiology
Risk factors
Early detection and management pathway
Prevention post-treatment for oral cancer
Resources
References

https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-6-oral-cancer 1/12

health-an-evidence-based-toolkit-for-prevention/chapter-6-oral-cancer

improvement policy.
Definitions
In this guideline, oral cancer is defined as cancerous lesions of 3 distinct sites: oral cavity (mouth),
oropharynx (throat) and lip (outer) (1), although these cancers can, and do, cross anatomical
boundaries.
The International Classification of Diseases and Related Health Problems 10th Revision
(https://icd.who.int/browse10/2016/en#/C00-C14) (World Health Organization (WHO), 2016), defines
these lesions as follows:
mouth (oral cavity) cancer: inner lip (C00.3–C00.9), other and unspecified parts of the tongue
(C02) (excluding lingual tonsil C2.4), gum (C03), floor of the mouth (C04), palate (C05), and
other and unspecified parts of the mouth (C06)
oropharyngeal cancer: base of the tongue (C01), lingual tonsil (C2.4), tonsil (C09), oropharynx
(C10), and other (C14: pharynx unspecified, Waldeyer’s ring, overlapping sites of oral cavity and
pharynx)
lip cancer: outer lip (C00.0; C00.1; C00.2)
Epidemiology
In 2016, 3,744 people in the UK were diagnosed with mouth cancer (Table 6.1) (2). The risk of oral
cancer increases with age. Age-standardised incidence rates of mouth cancer are higher in Scotland
than the rest of the UK, and are rising in England and Wales (2). Mouth cancer is much more
common among males than females with a ratio of approximately 2:1; more common among older
age groups, with the peak age for diagnosis being 66 to 70 years (3, 4).
Data from Scotland reveal wide socioeconomic inequalities in the incidence of oral cancer with those
from lowest socioeconomic groups having a near 3-fold greater incidence risk ratio than those from
the highest socioeconomic groups (4); while data from London suggests some South East Asian
ethnic groups have higher incidence rate ratios of mouth cancer than their white counterparts (5).
Oropharyngeal cancer
Oropharyngeal cancer incidence rates are rising rapidly in all 4 UK countries, with 2,977 people in
England diagnosed with oropharyngeal cancer in 2016 (2). In Wales, oropharyngeal cancer now
exceeds oral cavity cancer rates (Table 6.1) (2), and has been reported as the fastest rising incidence
of any cancer in Scotland (6). The risk of oropharyngeal cancer is more than 3 times higher among
men than women, and over 3-fold higher among those from more deprived socioeconomic areas
than less deprived areas (4). There is some evidence that people with human papilloma virus (HPV)-
related (7) cancers (such as oropharyngeal cancer) are diagnosed at a younger age (8), although this
is not substantially younger than oral cavity cancer, with the peak age for oropharyngeal cancer
diagnosis being 61 to 65 years (4).
Lip cancer
Lip cancer (outer) is far less common (Table 6.2) than cancers of the oral cavity (which includes the
inner lip) and oropharyngeal cancer. The rates among men are slightly higher than among women.
Table 6.1: UK Cancer registry data: latest numbers (n) and (European) age-standardised
incidence rates per 100,000 person-years, by sex
Oral cavity cancer (OCC) Oropharyngeal cancer (OPC) Year
Country Incidence rate N Incidence rate N Date
England 2016
Females 4.8 per 100,000 1309 2.7 per 100,000 712
Males 7.3 per 100,000 1779 9.1 per 100,000 2265
Northern Ireland 2016
Females 3.9 per 100,000 34 2.1 per 100,000 18
Males 5.9 per 100,000 46 6.8 per 100,000 55
Scotland 2016
Females 5.6 per 100,000 160 2.7 per 100,000 77
Males 10.0 per 100,000 240 9.7 per 100,000 247
Wales 2015
Females 3.7 per 100,000 64 2.9 per 100,000 48
Males 7.4 per 100,000 112 10.5 per 100,000 159
Source: UK Cancer Registry (2)
Table 6.2: England Cancer Registry data: latest numbers (n) and (European) age-standardised
incidence rates (EASR) per 100,000 person-years, by sex
Site Cases (n) EASR
Oral cavity
Females 1,332 4.8 per 100,000

Site Cases (n) EASR
Males 1,776 7.2 per 100,000
Total 3,108 6.0 per 100,000
Oropharyngeal
Females 731 2.7 per 100,000
Males 2,324 9.2 per 100,000
Total 3,055 5.9 per 100,000
Outer lip
Females 48 0.2 per 100,000
Males 68 0.3 per 100,000
Total 116 0.2 per 100,000
Source: National Cancer Registration and Analysis Service (NCRAS), Oral cancer incidence data
request 2019 (NCRAS, 2019) (9).
Mortality
Survival rates are improving but remain poor overall. Just over half of all people (56%) diagnosed
with mouth cancer between 2009 and 2013 in England survived for 5 years or more (10). The
prognosis for oropharyngeal cancer is a little better, with 66% of people diagnosed with
oropharyngeal cancer during 2009 to 2013 surviving for 5 years or more. Earlier detection can
improve prognosis.
Risk factors
The major risk factors for oral cancers are tobacco use (Chapter 11
prevention/chapter-11-smoking-and-tobacco-use)) and alcohol consumption (particularly in excess)
toolkit-for-prevention/chapter-12-alcohol)), and in combination with one another. Infection with the human
papilloma virus is an important risk for oropharyngeal cancer (7), possibly in combination with
tobacco and alcohol (7). Excessive exposure to ultra violet (UV) light is a risk factor for outer lip
cancer. There is limited evidence in relation to dietary risk factors associated with oral cancer
toolkit-for-prevention/chapter-10-healthier-eating)). An overview of risk factor management is presented in
the toolkit in Chapter 2, table 3 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-
evidence-based-toolkit-for-prevention/chapter-2-summary-guidance-tables-for-dental-teams#table3).
Compared with zero tobacco use and alcohol consumption, the risks of mouth and oropharyngeal
cancer increase with any level of tobacco use or alcohol consumption – there are no safe lower limits
(11).
While most of the available evidence focuses on smoking tobacco, a growing body of evidence
shows that use of smokeless (chewing) tobacco, often used as a component of betel quid, and betel
quid without tobacco (for example betel quid and areca nut), is associated with increased risk of oral
cavity cancer (12).
Smoking duration is more important than frequency as a risk for oral cancer (as with lung cancer);
thus, fewer cigarettes per day over a longer number of years has a higher level of risk for oral cancer
than more cigarettes per day over fewer years. In contrast, frequency of alcohol consumption is more
important than duration; thus, higher consumption (more than three drinks per day) over a few years
has a higher risk for oral cancer than a lower intake over many years (13).
Using both tobacco and alcohol increases the risk of oral cancer exponentially for individuals. It is
estimated that people who both drink and smoke heavily have an over 10-fold increased risk of
developing oral cancer than those people who abstain from both products (14). Prevention
approaches for smoking and tobacco use are addressed more fully in Chapters 11
prevention/chapter-11-smoking-and-tobacco-use) and 12
prevention/chapter-12-alcohol) respectively.
Oral HPV infection is a major risk factor for oropharyngeal cancer in particular (15, 16). The effects
on the primary prevention of oropharyngeal cancer of extending the school-based HPV vaccination
programme to include boys as well as girls will take several decades to become apparent. HPV may
be spread through sexual contact, particularly oral sex (17). In theory the risk of HPV-related
oropharyngeal cancer may be reduced by changes in sexual behaviour and adoption of safer sexual
practices. However, as the natural history, prevalence, persistence and determinants of oral HPV
infection and oropharyngeal cancer are poorly understood, the strongest preventive approach is,
therefore, to recommend vaccination for young people, both boys and girls.
UV light is a known risk factor (https://www.who.int/uv/health/solaruvradfull_180706.pdf) for all skin

cancers, including cancer of the outer lip (18). It is advisable to avoid the use of sunbeds and tanning
salons (19). Sun exposure is necessary for production of vitamin D, but dental teams may want to
familiarise themselves with NICE guideline 34 Sunlight exposure
(https://www.nice.org.uk/guidance/NG34): risks and benefits, which recommends avoiding getting
sunburnt, for example, by seeking shade when outside for a prolonged period, especially in the
middle of the day (11am to 3pm) and wearing sun-protective clothing (such as hats, sunglasses and
limb-covering close-weave clothing) (20).
Diets low in fruit and non-starchy vegetables are deleterious for general health. Fruit and non-starchy
vegetables are rich in fibre, vitamins, minerals, antioxidants and phytochemicals, which help to
protect against cancer in general (Chapter 10 (https://www.gov.uk/government/publications/delivering-
better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-10-healthier-eating)). There is limited new
evidence in relation to dietary risk factors associated with oral cancers (21). Obesity is increasingly
being associated with many cancers (22), but oral cancers seem to be an exception with oral cancer
risk associated with those with low body mass index (BMI) (23). Overall the evidence supports
promoting increased consumption of non-starchy vegetables and fruit as part of a healthy diet (24 to
26).
Associations between the risk of oral cancers and poor oral health are emerging. After adjusting for
smoking and alcohol consumption, having few missing teeth, regular dental attendance, and daily
toothbrushing are associated with a reduced risk of mouth and oropharyngeal cancers, but wearing a
denture was not associated with increased risks (27, 28). There seems to be little evidence to show
increased risks for oral cancer with mouthwash use (29). Management of the risk factors for oral
cancer, is outlined in Chapter 1 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-
evidence-based-toolkit-for-prevention/chapter-1-introduction).
Early detection and management pathway

Dentists, and other members of the clinical dental team, are the only dedicated professionals
regularly examining a patients’ mouth. Early identification, diagnosis and management of oral
cancers can achieve better outcomes for patients. Dental teams have a pivotal role in the early
detection of oral cancer and oral potentially malignant disorders or pre-cancers (30), including
cancers and conditions that can precede the onset of invasive cancer. These may present as solitary
lesions or be multifocal or widespread conditions within the oral cavity such as leukoplakia (31). A
pathway of care for the early detection and prevention of oral cancer is outlined below.
All patients
1. Ask
Explore risk factors, especially tobacco use.
Use Audit-C questionnaire or scratch card for alcohol consumption.
Record advice given and patient’s response in the clinical notes.
2. Examine
Extraoral: lips, neck, nodes (visual and tactile).
Intraoral: soft tissues (visual and tactile).
High-risk patients
1. Advise
Share the best approaches to changing modifiable risk factors in line with tobacco (Chapter 11
prevention/chapter-11-smoking-and-tobacco-use)) and alcohol pathways (Chapter 12
prevention/chapter-12-alcohol)).
2. Act
If a patient is interested in quitting smoking and/or reducing drinking, act to assist them to address
these risk factors by:
providing information leaflets (https://app.box.com/v/CQUIN-structured-advice-tool)

referring tobacco users to local stop smoking support, GP or pharmacist
considering referral of patients with higher risk alcohol consumption, particularly in combination
with tobacco use to their GP or community specialist alcohol treatment service (Chapter 12
encouraging them on their journey and building their confidence
If the patient is not interested in quitting smoking and/or reducing alcohol consumption:

make a simple statement, for example: ‘That’s fine, but help is available. Let me know if you
change your mind’
record advice given and patient’s response in the clinical notes
keep asking and advising – it can make a difference
Support patients with a diagnosis of oral cancer or potentially premalignant oral epithelial lesions.
Ongoing dental care is particularly important for this group of patients, particularly those who have
had radiotherapy. They are at a higher risk of a range of conditions including dental caries, oral
mucositis and osteonecrosis (32).
It is good practice for clinical dental teams to take an up-to-date medical, social and dental history
and perform an intraoral and extraoral conventional visual and tactile examination in all adults at
each patient visit (33). This may identify possible risk factors for oral cancer, and potentially
malignant disorders and oral cancers. This is in line with the UK’s national regulatory body’s
recommendations (34).
Extra-oral examinations during routine check-ups provide a good opportunity for members of the
dental team to identify potential lip cancers. Most symptomless mouth cancers can be detected by
means of a visual examination by clinicians (35).
Signs and symptoms of oral potentially malignant disorders
Signs and symptoms of an oral malignancy or potentially malignant disorders are as follows:
unexplained ulceration or swelling and/or induration in the oral cavity lasting for more than 3
weeks
a persistent and unexplained lump in the head or neck
a lump on the lip or in the oral cavity
a red patch in the oral cavity consistent with erythroplakia
a red and white patch in the oral cavity consistent with erythroleukoplakia (‘speckled
leukoplakia’)
persistent (not intermittent) hoarseness lasting for more than 3 weeks (if other symptoms are
present to suggest suspicion of lung cancer, refer via lung cancer guideline)
persistent pain in the throat or pain on swallowing lasting for more than 3 weeks
Sources: National Collaborating Centre for Cancer (2015) Suspected cancer: recognition and
referral, NICE (https://cks.nice.org.uk/head-and-neck-cancers-recognition-and-referral#!scenario) (36).
Scottish referral guidelines for suspected cancer (https://www.gov.scot/publications/scottish-referral-
guidelines-suspected-cancer-january-2019/) (37).
Less common but important signs and symptoms may include:
unexplained tooth mobility not associated with periodontal disease

delayed healing of an extraction site
fixation of lesion
regional lymph node enlargement
dysphagia
weight loss
cranial neuropathies
Urgent referrals
For adult patients with a clinically evident suspicious mucosal lesion, or symptom(s) suggestive of
oral malignancy, clinicians should provide immediate referral to a specialist (33). Dental team
members must therefore use an ‘urgent suspected cancer pathway referral’ (for an appointment
within 2 weeks) for those with any of the above symptoms (38). General medical practitioners (GPs)
have an established system for making such rapid referrals and dental team members should also
ensure that they are familiar with, and can refer in accordance with, local head and neck cancer
policies and procedures to ensure that a patient is seen by the correct specialist team (38). It is vitally
important that the dental team is aware of this guidance and facilitate the necessary appointment so
that this does not lead to patient delays in receiving care (39), should they require it.
The gold standard for diagnosis is a scalpel biopsy and histological assessment (40), which is best
carried out by the specialist head and neck cancer team in line with national guidance. There is no
evidence currently to support the use of diagnostic adjuncts such as vital staining or light-based
detection methods for the evaluation of potentially premalignant oral epithelial lesions among adult
patients with clinically evident, seemingly innocuous, or suspicious lesions (40).
Further guidance on patient support, and the diagnostic process is available in NICE guidance on
recognition and referral (41).
Prevention post-treatment for oral cancer

In advance of their cancer treatment and therapies, patients should have received appropriate care to
manage and stabilise their other oral diseases such as dental caries and periodontal diseases.
Afterwards, it is important that patients who have received surgery, radiotherapy and/or
chemotherapy in the head and neck area make regular visits for dental care. They should be made
aware that they are now at increased risk of a range of oral conditions including dental caries,
periodonitis/peri-implantitis, mucositis and osteoradionecrosis (42). It is particularly important that
dental teams provide appropriate additional preventive care and support for these patients who may
have long-term or lifelong limited opening and reduced salivary flow (42).
Resources
Suspected cancer: recognition and referral. NICE guideline [NG12]
(https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-on-patient-support-safety-netting-and-the-
diagnostic-process).
CRUK and BDA Oral Cancer Recognition Toolkit

(https://www.doctors.net.uk/eClientopen/CRUK/oral_cancer_toolkit_2015_open/).
Mouth Cancer Foundation (https://www.mouthcancerfoundation.org/).
RCS Clinical Guidelines: The Oral Management of Oncology Patients Requiring Radiotherapy,
Chemotherapy and/or Bone Marrow Transplantation (https://www.rcseng.ac.uk/dental-
faculties/fds/publications-guidelines/clinical-guidelines/).
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10. Muller P, Belot A, Morris M, Rachet B. Net survival and the probability of cancer death from rare
cancers (http://csg.lshtm.ac.uk/rare-cancers/), London: London School of Hygiene and Tropical
Medicine; 2016
11. Lubin JH, Muscat J, Gaudet MM, Olshan AF, Curado MP, Dal Maso L, and others. An
examination of male and female odds ratios by BMI, cigarette smoking, and alcohol consumption for
cancers of the oral cavity, pharynx, and larynx in pooled data from 15 case-control studies. Cancer
Causes and Control. 2011;22(9):1217-31.
12. Gupta B, Johnson NW. Systematic review and meta-analysis of association of smokeless
tobacco and of betel quid without tobacco with incidence of oral cancer in South Asia and the Pacific.
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13. Lubin JH, Purdue M, Kelsey K, Zhang ZF, Winn D, Wei Q, and others. Total exposure and
exposure rate effects for alcohol and smoking and risk of head and neck cancer: a pooled analysis of
case-control studies. American Journal of Epidemiology. 2009;170(8):937-47.
14. Hashibe M, Brennan P, Chuang SC, Boccia S, Castellsague X, Chen C, and others. Interaction
between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the
International Head and Neck Cancer Epidemiology Consortium. Cancer epidemiology, biomarkers
and prevention: a publication of the American Association for Cancer Research, cosponsored by the
American Society of Preventive Oncology. 2009;18(2):541-50.
15. Anantharaman D, Abedi-Ardekani B, Beachler DC, Gheit T, Olshan AF, Wisniewski K, and others.
Geographic heterogeneity in the prevalence of human papillomavirus in head and neck cancer.
International Journal of Cancer. 2017;140(9):1968-75.
16. Lingen MW, Xiao W, Schmitt A, Jiang B, Pickard R, Kreinbrink P, and others. Low etiologic
fraction for high-risk human papillomavirus in oral cavity squamous cell carcinomas. Oral Oncology.
2013;49(1):1-8.

17. NHS, Sexual activities and risk (https://www.nhs.uk/live-well/sexual-health/sex-activities-and-risk/), NHS

2018 (updated 17 November 2018).
18. Lucas R MT, Smith W, Armstrong B. Solar ultraviolet radiation: global burden of disease from
solar ultraviolet radiation (https://www.who.int/uv/health/solaruvradfull_180706.pdf.) No. 13. 2006 [cited
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19. McWhirter E, Souter LH, Rumble RB, Rosen CF, Tenkate T, McLaughlin J, and others. The use of
indoor tanning devices and the risk of developing cutaneous malignant melanoma: a systematic
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Contract No.: 8.
20. NICE. Sunlight exposure: risks and benefits [NG34] (https://www.nice.org.uk/guidance/NG34).

London: National Institute for Clinical Excellence; 2016 09 February 2016. Contract No.: NG 34.
21. Edefonti V, Hashibe M, Ambrogi F, Parpinel M, Bravi F, Talamini R, and others. Nutrient-based
dietary patterns and the risk of head and neck cancer: a pooled analysis in the International Head
and Neck Cancer Epidemiology Consortium. Annals of Oncology: official journal of the European
Society for Medical Oncology. 2012;23(7):1869-80.
22. Arnold M, Leitzmann M, Freisling H, Bray F, Romieu I, Renehan A, and others. Obesity and
cancer: An update of the global impact. Cancer Epidemiology. 2016;41:8-15.
23. Gaudet MM, Olshan AF, Chuang SC, Berthiller J, Zhang ZF, Lissowska J, and others. Body mass
index and risk of head and neck cancer in a pooled analysis of case-control studies in the
International Head and Neck Cancer Epidemiology (INHANCE) Consortium. International Journal of
Epidemiology. 2010;39(4):1091-102.
24. Chuang S-C, Jenab M, Heck JE, Bosetti C, Talamini R, Matsuo K, and others. Diet and the risk of
head and neck cancer: a pooled analysis in the INHANCE consortium. Cancer Causes and Control.
2012;23(1):69-88.
25. World Cancer Research Fund, American Institute for Cancer Research. Food, Nutrition, Physical
Activity, and the Prevention of Cancer: a Global Perspective. Washington, DC: AICR; 2007.
26. World Cancer Research Fund, American Institute for Cancer Research. Wholegrains, vegetables
and fruit and the risk of cancer. 2018. Contract No.: Third.
27. Ahrens W, Pohlabeln H, Foraita R, Nelis M, Lagiou P, Lagiou A, and others. Oral health, dental
care and mouthwash associated with upper aerodigestive tract cancer risk in Europe: the ARCAGE
study. Oral Oncology. 2014;50(6):616-25.
28. Hashim D, Sartori S, Brennan P, Curado MP, Wunsch-Filho V, Divaris K, and others. The role of
oral hygiene in head and neck cancer: results from International Head and Neck Cancer
Epidemiology (INHANCE) consortium. Annals of oncology: official journal of the European Society for
Medical Oncology. 2016;27(8):1619-25.
29. Gandini S, Negri E, Boffetta P, La Vecchia C, Boyle P. Mouthwash and oral cancer risk
quantitative meta-analysis of epidemiologic studies. Annals of Agricultural and Environmental
Medicine. 2012;19(2):173-80.
30. Awadallah M, Idle M, Patel K, Kademani D. Management update of potentially premalignant oral
epithelial lesions. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2018;125(6):628-
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31. Warnakulasuriya S. Clinical features and presentation of oral potentially malignant disorders. Oral
Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2018;125(6):582-90.
32. Kumar N, Brooke A, Burke M, John R, O’Donnell A, Soldani F. The oral management of oncology
patients requiring radiotherapy, chemotherapy and/or bone marrow transplantation. Faculty Dental
Journal. 2013;4(4):200-3.
33. Lingen MW, Abt E, Agrawal N, Chaturvedi AK, Cohen E, D’Souza G, and others. Evidence-based
clinical practice guideline for the evaluation of potentially malignant disorders in the oral cavity: A
report of the American Dental Association. The Journal of the American Dental Association.
2017;148(10):712-27.e10.
34. General Dental Council. Oral Cancer - Improving Early Detection. London: GDC; 2012.
35. Walsh T, Liu JLY, Brocklehurst P, Glenny AM, Lingen M, Kerr AR, and others. Clinical assessment
to screen for the detection of oral cavity cancer and potentially malignant disorders in apparently
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(https://www.gov.scot/publications/scottish-referral-guidelines-suspected-cancer-january-2019/). 2019.
38. National Institute of Clinical Excellence (NICE). Head and neck cancer
(https://cks.nice.org.uk/topics/head-neck-cancers-recognition-referral/). 2017 March.
39. Grimes D, Patel J, Avery C. New NICE referral guidance for oral cancer: does it risk delay in
diagnosis? British Journal of Oral and Maxillofacial Surgery. 2017;55(4):404-6.
40. Macey R, Walsh T, Brocklehurst P, Kerr AR, Liu JLY, Lingen MW, and others. Diagnostic tests for
oral cancer and potentially malignant disorders in patients presenting with clinically evident lesions.
Cochrane Database of Systematic Reviews. 2015(5).
41. NICE. Head and neck cancers - recognition and referral NG12
(https://www.nice.org.uk/guidance/ng12/) (updated) 2015.
42. RCSEng, BSDH. The Oral Management of Oncology PatientsRequiring Radiotherapy,

Chemotherapy and/or Bone Marrow Transplantation Clinical Guidelines. London: RCSEng and
BSDH; 2018.


11/19/21, 8:32 PM Chapter 7: Tooth wear - GOV.UK
GOV.UK

Department
of Health &
care)
Office for Health
Improvement
and-disparities)
Guidance
Chapter 7: Tooth wear
Contents
Definitions
Identifying and monitoring tooth wear in clinical practice
The Basic Erosive Wear Examination (BEWE) index
Tooth wear in the UK
General population advice for patients
Risk factors
Risk factor management: professional action for high risk patients
Monitoring tooth wear
Resources
https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-7-tooth-wear 1/15
References


health-an-evidence-based-toolkit-for-prevention/chapter-7-tooth-wear

improvement policy.
Definitions
Tooth wear is the cumulative loss of mineralised tooth substance due to chemical and/or mechanical
factors (1).
Its components are:
dental erosion (chemical loss due to exposure to either intrinsic or extrinsic non-bacterial acids)
dental attrition (physical loss due to tooth-to-tooth contact)
dental abrasion (physical loss caused by objects other than teeth, such as a toothbrush, hard
object, or the tongue)
The term dental abfraction (a notched out area of the tooth at the gingival edge, associated with
vigorous brushing) has been used to describe micro-stress fractures of the tooth due to occlusal
loading, although there is a lack of clinical evidence that this is a separate cause of tooth wear, and
so the term is not recommended.
Tooth wear is normally multi-factorial (2, 3); it involves a combination of erosion, attrition and
abrasion, leading to a change in shape or form of the tooth. It is now commonly accepted that dental
erosion is a more complex process than merely chemical wear (1).
By definition, dental erosion is the dissolution of tooth mineral where plaque is not involved in its
aetiology (4). Remineralisation is possible only in enamel, provided there is no corresponding
mechanical loss; once tissue is lost, tooth wear becomes irreversible (5). As the condition
progresses, which is not inevitable, visible changes to the tooth shape occur (6). On the occlusal
surfaces of molars, discrete lesions exposing dentine appear, which can merge to create a wider and
deeper lesion, thus causing the crown height to reduce. On anterior teeth, attritional wear combined
with erosion on the incisal surface is common. On the buccal/facial surface flattening of the contour
can, without prevention, lead to loss of crown height if it merges with incisal wear.
Tooth wear terminology has developed in recent years. The use of the term ‘tooth surface loss’ in the
clinical situation is now discouraged (1).Terms such as non-age-related tooth wear and accelerated
tooth wear are used to reflect a more nuanced holistic approach to this condition. Erosive tooth wear
(that is, tooth wear with erosion as its primary aetiological factor) is used in recognition that severe
tooth wear rarely happens without a contributing acidic aetiology. Since a range of terms is commonly
used, and this can be confusing, this document uses the generic term tooth wear, which is
internationally recognised (1).
Identifying and monitoring tooth wear in clinical practice

Tooth wear is a natural part of ageing and so the extent and seriousness of any wear must be judged
against a patient’s age (1). It can occur in children, and in primary as well as permanent teeth.
Severe tooth wear may lead to poor aesthestics and a reduced lifespan of the teeth involved.
Sensitivity is not necessarily an indication of progression. Sensitivity occurs when there is stimuli of
patent dentinal tubules, and this can occur with minimal wear, particularly in the cervical region.
Sensitivity is a common complaint (60% report concerns) among those attending specialist care for
tooth wear (7).
Secondary prevention is therefore key to management of tooth wear. This means identifying ‘non-
age-related tooth wear’ as early as possible and focusing on identifying and preventing the risk
factors that can lead to progress in affected individuals. In doing so, dental team members may
identify people with eating disorders and medical conditions for which they require additional support
for their overall health and wellbeing.
The Basic Erosive Wear Examination (BEWE) index

Several indices have been developed to measure and monitor tooth wear (1), (8 to 11). For example,
the Tooth Wear Index by Smith and Knight (10), which proposes a distinction of pathological levels of
wear based on a patient’s age, is widely used – although limitations in the index have been
recognised, and adaptations subsequently developed (9). There is also the Tooth Wear Evaluation
System (TWS), which is now in its second version (8).
The BEWE is a simple screening tool based on the principles of the Basic Periodontal Examination
(BPE). The BEWE records the most severely affected surface for each sextant, which means it
entails a similar clinical procedure to the BPE’s sextant approach. The BEWE is a 4 point scale from
0 to 3, with 1 representing early change, 2 less than 50% and 3 more than 50% of the surface
involved. All teeth are examined and the surface with the highest score in a sextant is recorded. The
cumulative score highlights the extent of the condition and can assist in the management of the
condition for the practitioner (11). This tool has been validated for use (12), including in primary
dental care (13). It provides evidence to inform discussions with affected patients and its use is
recommended during all patients’ routine examinations (14). A BEWE score of 3 (wear affecting over
50% of a surface) present in every sextant justifies further investigation and multiple level 3 scores
indicate severe wear.
BEWE Score 1
First tooth wear signs. Initial loss of surface texture (brightness loss, opaque surface or ‘frosted glass’
appearance) but with a discrete area on the buccal (facial) surface and minimal loss of the incisal
edge.
BEWE Score 2
Distinct defect. Hard tissue loss less than 50% of the surface area. Dentine is often involved. Loss of
clinical crown height less than 50% from the buccal aspect.
BEWE Score 3
Hard tissue loss signs, with more than 50% of the surface area. Dentine is often involved but is not a
prerequisite for a BEWE score of three. For restored teeth, the tooth wear can only be scored
provided that the size of the restoration does not exceed 50%.
Source: (14).

Tooth wear in the UK

The 2009 national (England, Wales and Northern Ireland) survey of dentate adults found that 2% had
severe tooth wear (exposing the pulp or secondary dentine), 15% had moderate wear (exposing a
large area of dentine on any surface) and 77% had some wear present (15, 16). This varied with age,
since damage is cumulative: 44% of dentate adults aged 75 to 84 years had some moderate wear
compared with 4% of 16 to 24 year olds. Moderate wear was more common in men (19%) than
women (11%) (15, 16).
Prevalence of tooth wear amongst adults had increased slightly since the 1998 survey, when 11% of
adults had moderate wear. The increase was greatest in younger adults: in 2008, 4% of 16 to 24 year
olds had moderate tooth wear, compared with only 1% in 1998 (17).
Tooth wear is present in primary as well as permanent teeth. The 2013 national survey of children
(England, Wales and Northern Ireland) found that one-third (33%) of 5 year olds had evidence of
tooth wear on one or more of the buccal surfaces of their primary upper incisors, although only 4% of
5 year olds had wear which involved dentine or pulp (18). The 2013 child survey also looked for tooth
wear on permanent upper incisors and first permanent molars of 12 and 15 year olds. Although some
evidence of tooth wear was common: 38% of 12 year olds and 44% of 15 year olds had some tooth
wear on the lingual surfaces of incisors, only 2% and 4% respectively had tooth wear involving the
dentine or pulp (18). Amongst children, tooth wear involving dentine or pulp in these index teeth was
similar to the prevalence reported in the 2003 survey data for these age groups. Tooth wear is more
common on lingual surfaces of upper central incisors than buccal surfaces, and more common on
buccal than lingual surfaces of premolars.
A study in Ireland measured tooth wear at 5 years of age, and again when the children were 12 years
old (19). There was a significant association between the presence of tooth wear with dentine
exposed in the primary dentition, and tooth wear on the occlusal surfaces of the first permanent
molars at 12 years old. Screening for tooth wear in younger children is therefore important, to enable
early preventive advice and support to be given (19).
General population advice for patients

Although the prevalence of tooth wear may be increasing and we are more aware of the condition,
most people do not have accelerated tooth wear. General oral health advice for patients without
visible signs of accelerated tooth wear is shown in Chapter 2: Table 4
prevention/chapter-2-summary-guidance-tables-for-dental-teams#table4) and is the same as in the dental
caries and periodontal disease tables. It includes the adoption of good dietary practice enjoying a
healthy diet (Chapter 10 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-
evidence-based-toolkit-for-prevention/chapter-10-healthier-eating)), and cleaning teeth effectively (Chapter
8 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-8-oral-hygiene)), with a standard fluoride toothpaste (Chapter 9
prevention/chapter-9-fluoride)).
Research at population level increasingly highlights the role of acidic beverages, particularly soft
drinks (20 to 22) and fruit juices (22). Whilst concerns have also been raised about fruit (23), national
surveys within the UK over the past 9 years show that the majority of children and adults do not
consume enough fruit and vegetables for a healthy diet (24). The vast majority of the population,
therefore, are not at risk of accelerated tooth wear because of excessive fruit consumption and
should not be given advice to reduce the volume or frequency of fruit consumption which is beneficial
for general health. Snacking on fruit should not be discouraged amongst the general population.
Risk factors
Tooth wear is multifactorial. Much of the available evidence to date relates to epidemiological and
laboratory research, together with professional advice. The former involving cross-sectional studies
of associations at population level and from higher risk groups attending specialist services, suggest
that increased tooth wear is associated with extrinsic acid (from food, drink and medications), as well
as intrinsic acid (from the stomach due to gastro-oesophageal reflux, rumination, vomiting and eating
disorders), or a mixture of factors.
Unlike demineralisation in dental caries, there is no clear-cut critical pH for dental erosion to occur,
because other influences such as a drink’s mineral content may moderate its erosive action. For
example, the calcium content in calcium enriched drinks may reduce the erosive effect of those
drinks (25). Furthermore, saliva plays an important role in diluting and buffering acids and facilitating
their clearance through swallowing (26).
Increased erosive potential of extrinsic acids occurs when there is:
lower pH value
lower salivary flow
lower buffering capacity (takes longer for saliva to neutralise the acid)
higher titratable acidity (more available H+ ions in solution)
lower calcium and phosphate content in saliva (influences degree of saturation)
lower fluoride content
higher temperature (that is, if drinks are warmed, erosive potential is increased) (26 to 29)
The ‘erosive potential’ of a wide range of food, drinks and medicines is measured by laboratory
findings which suggest that drinks, juices, fruits, and some medications and alcoholic drinks cause a
significant decrease in pH of enamel samples (27, 29).
It is generally accepted that acidic drinks are the most common unhealthy type of drinks in respect to
acid erosion (27, 29, 30), as outlined in Table 7.1.
Carbonated water, with fruit flavouring or lemon has been shown to have high erosive potential (28),
as have ‘fruit juices’ or fruit teas (30 to 32). Multiple products are marketed as fruit juices. It is
therefore increasingly important to distinguish between fruit juice and fruit drinks. Fruit juice is a drink
that is prepared by mashing the pulp of the fruit, while a fruit drink is a sugary solution that contains
the colour and flavour of the fruit but not the real fruit juice. Some fruit drinks do contain a little of the
fruit juice, but the rest is essentially flavour and colour.
Unflavoured water (still and sparkling), milk, tea and coffee have the ‘lowest erosive potential’ (27).
Although carbonated mineral water is more acidic than still water, it is fine for teeth, as long as it is
unflavoured (27, 31).
Whether the erosive potential translates into tooth wear depends on patient factors and exposure
conditions (33), including the length of time involved (27), and number of acidic attacks per day (30,
32).
There is also likely to be individual variation in response to the erosive effects of acids, due to:
the quantity and quality of saliva

features of the pellicle

individual habits which might include swishing, swilling, rinsing or holding drinks in the mouth
before swallowing (retention may prolong the effect and overwhelm any protective capacity of
saliva) (29)
the presence of calcium and phosphate in associated beverages and foods (29)
lower frequency of toothbrushing with a fluoride toothpaste (34)
individual susceptibility, for example, tooth anatomy and structure (5, 34)
The most important aspect of patient care, once the presence of tooth wear has been identified, is to
identify all possible sources of risk, chemical and/or mechanical, recognising that acids may be
extrinsic or intrinsic, healthy or unhealthy.
Current evidence suggests that in individuals who do not have a medical condition or consume
carbonated drinks, there may be other sources of acid; which highlights the importance of detailed
and careful dietary investigation as part of risk factor identification. It may therefore be helpful to use
the example diet diary
(https://khub.net/documents/135939561/516396401/Example+of+a+diet+diary.pdf/ad68124b-edf1-7fa3-71f4-
02e81149f5f1?t=1631880301380).
Whilst fruit is a possible healthy dietary risk factor, it has mainly been identified amongst adults
referred for specialist management of erosion in dental hospitals, where eating fruit over an extended
period was one of the risk factors for severe erosive tooth wear (30).
Table 7.1 provides a list of possible factors which increase the risk of tooth wear to explore with high
risk patients. Several caveats are important. Firstly, it has been compiled based on expert opinion
and the best evidence available on risks and their management. Secondly, further research is
required to better understand risk factors which may be multifactorial and build evidence for their
management. Thirdly, it is not a definitive or exhaustive list.
Table 7.1 Possible sources of chemical and mechanical wear to explore with high risk patients
with signs of tooth wear
Possible actions to consider (related to the specific

Chemical wear: extrinsic sources of acid
risk for an individual patient)
Drinks:
• carbonated drinks (except non-flavoured

sparkling water) Limit carbonated and acidic drinks to meal-times.
• wine (white and red)
• alcopops and designer drinks Substitute with plain water or non-flavoured sparkling
• fortified wines with fruity flavours water.
• smoothies
• energy drinks Drink regular tea or coffee (without sugar).
• drinks containing citric acid, including
natural fruit juices – such as orange, Reduce the temperature of fruit teas or other hot
grapefruit, lemon, blackcurrant erosive drinks – this slows the erosion, but it’s
• fruit teas (excluding non-fruit flavoured preferable to swap to a safer alternative.
herbal teas such as camomile or
peppermint)
• sports drinks


Chemical wear: extrinsic sources of acid
Foods:
Limit if consumed frequently.
• vinegar-based foods, including pickles
• fruit-based sauces
Confectionary:
Avoid, or, for patients with reduced salivary flow,
• acidic sweets, for example sour jelly-
replace with sugar free alternatives that have neutral
based sweets, acid drops, sherbet
pH and/or are designed for dry mouth and saliva
lemons, and so on
stimulation.
• fruit-based sugar and certain sugar free
sweets
Fruit eating should not be discouraged unless identified

as a risk factor.
Fruit (healthy acids):
Avoid grazing on fruit (only if this is identified as a risk
factor).
• acidic fresh fruit, particularly in high
quantities
Substitute acidic fruit with vegetables, bananas or
• lemons, oranges and grapefruit are the
avocados, particularly between meals and ensure a wide
most acidic fruit acids (most fruits may be
variety of vegetables.
erosive, other than banana and avocado)
Address any higher risk habits such as holding against
teeth.
Medication: Replace with tablets which may be swallowed.
• chewable vitamin C tablets Consider replacement of medication with non-acidic

• aspirin alternatives.
• asthmatic inhalers
• some iron preparations Discuss options with pharmacist or GP as appropriate.
Reduced saliva: Consider saliva substitutes (toothpastes,

mouthwashes, gels).
• conditions which reduce salivary flow
including intense sport and anxiety Discuss options with pharmacist, GP or specialist as
• saliva reducing medications appropriate.
Chemicals:
Consider alternatives for whitening in dental practice.
• tooth whitening materials
Other rare sources:
• occupational exposure to acid, for Explore possibilities to remove risk factor, where
example mists in the workplace air, wine possible.
tasters
• swimming


Chemical wear: intrinsic sources of acid
Gastric acid reflux including GORD (gastro

oesophageal reflux disease).
Seek medical advice and support to control the reflux.
Laryngopharyngeal reflux (LPR).
Avoid brushing after vomiting and rinse mouth with

water.
Chronic vomiting in pregnancy.
Apply fluoride toothpaste with finger to improve taste
in mouth or use fluoride mouthwash.
Support patient to seek medical advice and support.
Avoid brushing after vomiting.

Eating disorders including Bulimia
Nervosa. Rinse mouth with water.
Apply fluoride toothpaste with finger to improve taste

in mouth or use fluoride mouthwash.
Possible actions to consider (related to the

Mechanical wear: intrinsic sources of acid
specific risk for an individual patient)
High abrasive toothpastes (for example smokers

Use standard or low abrasive toothpaste.
toothpastes – more common in the US).
Filing teeth.
Avoid trauma to teeth.
Opening objects with teeth.
Advise on adapting brushing technique and

Brushing aggressively or inappropriately.
using a soft-medium brush.
Piercings. Advise on removal of piercings.
Increase awareness of bruxism – consider

Bruxism.
stress-related factors.
Suggest workers use available PPE for

Workplace particulate.
protection in workplace.
Note: the quality of evidence is low. All the above findings are based on weak clinical evidence or
laboratory studies.
Sources informing expert opinion: Lussi and others (27, 28); O’Toole and others (30); Saads
Carvalho (29); Ganss and others (35); Goswami and others (36); Sovik and others (37); Souza and
others (38); Vertuan (39); Buzalaf and others (26, 40).
Risk factor management: professional action for high risk patients

Secondary prevention for patients with tooth wear should focus on identifying, minimising or
removing the source of risk, ideally at an early stage as outlined in Chapter 2: Table 4
prevention/chapter-2-summary-guidance-tables-for-dental-teams#table4). It is important to note that there
are few clinical studies assessing the prevention of tooth wear, particularly dental erosion, with the
majority of the evidence being of low certainty.
Patients should be active participants in identifying the main sources of risk and in discussions about
managing them. These conversations can be sensitive and take time, since they may involve
exploring lifestyle and even expose possible mental health issues which require supportive referral.
This provides the basis for the provision of tailored, specific advice for each individual patient, to
manage their risks of tooth wear. Chapter 3 (https://www.gov.uk/government/publications/delivering-better-
oral-health-an-evidence-based-toolkit-for-prevention/chapter-3-behaviour-change) on behaviour change
provides important tools for the dental team.
Professional consensus suggests that tackling intrinsic and extrinsic sources of acid is more
important than relying on adjustments relating to toothpastes and toothbrushing. For high risk
patients displaying signs of accelerated tooth wear, focus on the main risk(s) of tooth wear such as
diet, medications and general health and help the patient to understand that such changes will be of
greater benefit than possible sources of protection such as specialised pastes. Evidence from insitu
and invitro (laboratory) studies suggests that specialised toothpastes containing fluoride, or fluoride
plus a stannous-based ingredient, can play a supplementary role in managing erosive wear (41).
Diet (including drinks)
Where there is evidence of dietary risk responsible for tooth wear, patients should be advised to
reduce the frequency of intake of the identified acidic foods or drinks.
Keep the identified acidic food and drinks to mealtimes and explore safe alternatives, particularly
between meals.
Advise against methods of drinking that promote tooth wear such as swilling and swishing.
Promote a healthy diet as outlined in Chapter 10 (https://www.gov.uk/government/publications/delivering-

better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-10-healthier-eating).
Toothbrushing
Use toothpaste containing an age-relevant fluoride content twice daily as outlined in Chapters 8
prevention/chapter-8-oral-hygiene) and 9 (https://www.gov.uk/government/publications/delivering-better-oral-
health-an-evidence-based-toolkit-for-prevention/chapter-9-fluoride).
Avoid using high abrasive toothpaste.
Consider the use of specialised pastes containing fluoride or fluoride plus a stannous-based
ingredient.
There is no strong evidence to suggest that the timing of toothbrushing is of great importance.
For people who experience vomiting on a frequent basis and wish to refresh their mouth after
vomiting, it may be helpful good practice to rinse the mouth and apply fluoride toothpaste, or a
fluoride mouthrinse.
General health
Medical advice and/or referral to their GP should be considered, if required, for management of
intrinsic sources of acid involving reflux or eating disorders, or medications.
Medications
Many people are on long-term medication which suppresses salivary flow. It is important to be aware
of medications that reduce the flow of saliva, and thus impact on the clearance of acids and ensure
regular medication is acid free.
Saliva
Saliva may be a very important biological factor affecting the progression of dental erosion (26),
playing a role in dilution, buffering (chemically lessening the impact) and clearance of dietary acids
and supporting remineraliation after an erosive challenge. Patients with reduced salivary flow, of any
aetiology, may therefore be at increased risk of tooth wear. Active encouragement in seeking medical
support and considering saliva or medication substitutes will be important.
Given the potential for erosive drinks to be a risk factor for tooth wear, the use of drinking straws may
be considered as part of risk management. Current professional guidelines recommend the use of a
wide bore straw, plus avoidance of holding acidic drinks in the mouth (42). There is some weak
evidence that straws are more likely to be beneficial if positioned to the back of the mouth to
minimise contact between the drink and the tooth surfaces (40). However, there is insufficient
evidence to know whether drinking through a straw does lead to a reduction in the risk of tooth
erosion given that people generally want to enjoy the taste of a drink. Thus, any benefit is likely to
depend upon drinking behaviour and positioning of the straw.
Monitoring tooth wear

Tooth wear is generally a slow process and may be episodic. Tools to help monitor tooth wear
progression include clinical assessment using indices if it is early tooth wear; and if more severe,
study models and photographs.
It is important to recognise that we do not yet have accurate methods for measuring tooth wear over
time; however, rapid advancement of digital technologies such as intra-oral scans and registration
may result in adjuncts for monitoring tooth wear progression in clinical practice alongside history
taking and clinical judgement (43).
Where accelerated tooth wear and its aetiology have been identified, it may be helpful to consider a
shortened dental recall period to support behaviour change and to monitor progress of the condition.
Resources
Recommendations and guidelines for dentists using the basic erosive wear examination index
(BEWE). (https://www.nature.com/articles/s41415-020-1246-y)
RCS Clinical Guidelines: Diagnosis, Prevention and Management of Dental Erosion.

(https://www.rcseng.ac.uk/dental-faculties/fds/publications-guidelines/clinical-guidelines/)
References

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2. Shellis RP, Addy M. The interactions between attrition, abrasion and erosion in tooth wear.
Monographs of Oral Science. 2014;25:32-45.
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increasing knowledge. Monographs in oral science. 2014;25:1-15.
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Chemical and Histopathological Aspects. Caries Research. 2011;45(suppl 1)(Suppl. 1):2-12.
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taxonomy based on the revised version of the Tooth Wear Evaluation System (TWES 2.0). Journal of
Oral Rehabilitation. 2020:10.
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Aetiology, Diagnosis and Prevention. Dental Update. 2018;45:3–10.
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scientific and clinical needs. Clinical oral investigations. 2008;12 Suppl 1(Suppl 1):S65-S8.
12. Olley RC, Wilson R, Bartlett D, Moazzez R. Validation of the Basic Erosive Wear Examination.
Caries Research . 2014;48(1):51-6.
13. Dixon B, Sharif MO, Ahmed F, Smith AB, Seymour D, Brunton PA. Evaluation of the basic erosive
wear examination (BEWE) for use in general dental practice. British Dental Journal. 2012;213(3):E4.
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guidelines for dentists using the basic erosive wear examination index (BEWE). British Dental
Journal. 2020;228(3):153-7.
15. NHS Digital. Adult Dental Health Survey 2009, England, Wales and Northern Ireland. London:
NHS Digital; 2011.
16. HSCIC. Adult Dental Health Survey 2009 – Summary report and thematic series
17. HSCIC. 2. Disease and related disorders – a report from the Adult Dental Health Survey 2009
(https://files.digital.nhs.uk/publicationimport/pub01xxx/pub01086/adul-dent-heal-surv-summ-them-the2-2009-
rep4.pdf) London: The Health and Social Care Information Centre; 2011.
18. NHS Digital. Report 2: Dental Disease and Damage in Children: England, Wales and Northern
Ireland. London: The Health and Social Care Information Centre; 2015 Published 19 March 2015.
19. Harding MA, Whelton HP, Shirodaria SC, O’Mullane DM, Cronin MS. Is tooth wear in the primary
dentition predictive of tooth wear in the permanent dentition? Report from a longitudinal study.
Community Dental Health. 2010;27(1):41-5.
20. Al-Zwaylif LH, O’Toole S, Bernabe E. Type and timing of dietary acid intake and tooth wear
among American adults. Journal of Public Health Dentistry. 2018;78(3):214-20.
21. Li H, Zou Y, Ding G. Dietary Factors Associated with Dental Erosion: A Meta-Analysis. PLOS
ONE. 2012;7(8):e42626.
22. Salas MMS, Nascimento GG, Vargas-Ferreira F, Tarquinio SBC, Huysmans MCDNJM, Demarco
FF. Diet influenced tooth erosion prevalence in children and adolescents: Results of a meta-analysis
and meta-regression. Journal of Dentistry. 2015;43(8):865-75.
23. Bartlett DW, Lussi A, West NX, Bouchard P, Sanz M, Bourgeois D. Prevalence of tooth wear on
buccal and lingual surfaces and possible risk factors in young European adults. Journal of Dentistry.
2013;41(11):1007-13.
24. Public Health England, Food Standards Agency, NatCen, MRC. National Diet and Nutrition
Survey: Years 1 to 9 of the Rolling Programme (2008/2009 – 2016/2017): Time trend and income
analyses. London: Public Health England,; 2019.
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2012;51:39-48.
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substances and medications. British Journal of Nutrition. 2012;107(2):252-62.
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substances and medications. British Journal of Nutrition. 2012;107(2):252-62.
33. Schlueter N, Amaechi BT, Bartlett D, Buzalaf MAR, Carvalho TS, Ganss C, and others.
Terminology of Erosive Tooth Wear: Consensus Report of a Workshop Organized by the ORCA and
the Cariology Research Group of the IADR. Caries Research. 2020;54(1):2-6.
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erosion: no correlation with dietary variables? Journal of Clinical Pediatric Dentistry. 2005;29(2):157-
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in American adolescents and young adults. Journal of Asthma. 2020:1-7.
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patient-related risks factors. British Dental Journal. 2018;224(5):371-8.
41. Abdelwahed AG, Temirek MM, Hassan FM. Antierosive Effect of Topical Fluorides: A Systematic
Review and Meta-Analysis of In Situ Studies. Open Access Maced Journal of Medical Science.
2019;7(9):1523-30.
42. British Society for Restorative Dentistry. Tooth wear Guidance for the BSRD
(https://www.bsrd.org.uk/File.ashx?id=15192). London: BSRD; 2019.
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2020;93:103282.


11/19/21, 8:33 PM Chapter 8: Oral hygiene - GOV.UK
GOV.UK

Department
of Health &
care)
Office for Health
Improvement
and-disparities)
Guidance
Chapter 8: Oral hygiene
Contents
Oral hygiene practices in the UK

Oral hygiene principles for oral health
Oral hygiene advice
Specific oral hygiene issues for vulnerable children and adults
Powered versus manual toothbrushes
Interdental cleaning
Sustainable toothbrushes
Resources
References
https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-8-oral-hygiene 1/12

health-an-evidence-based-toolkit-for-prevention/chapter-8-oral-hygiene

improvement policy.
Oral hygiene practices in the UK

Oral hygiene practices include toothbrushing and the use of other aids for cleaning teeth.
Toothbrushing is widely practiced across the UK. In a 2009 national survey of adults
(https://digital.nhs.uk/data-and-information/publications/statistical/adult-dental-health-survey/adult-dental-health-
survey-2009-summary-report-and-thematic-series) (1), more women reported cleaning their teeth at least
twice a day than men (82% compared with 67%). Three quarters (76%) of dentate adults reported
using toothpaste with 1,350 to 1,500 parts per million level of fluoride and a further 18 per cent used
a brand with a medium (1,000 to 1,350 parts per million) fluoride level. Most dentate adults (58%)
used additional products as well as a standard toothpaste and brush, the most common of which
were mouthwash (31%), powered toothbrushes (26%) and dental floss (21%). Women and middle-
aged adults were more likely to use additional products than men, younger and very old adults (85
years and over).
A 2013 national survey (2) found that only a quarter of children benefited from having their teeth
brushed before they were 6 months of age, whereas about 50% had commenced between 6 months
and one year of age. Overall about 90% of children (aged 5 to 8 years) are reported as having
started toothbrushing by 2 years of age (2). Overall, 77% of 12-year-olds and 81% of 15-year-olds
reported that they brushed their teeth twice daily or more. Mouthwash was the most common aid
other than a toothbrush (manual or powered) and toothpaste. As expected, the use of mouthwashes,
dental floss (the only interdental cleaning method investigated) and sugar-free gum was generally
higher in older children. Approximately 40% of the school children surveyed used a powered
toothbrush.
Oral hygiene principles for oral health

Toothbrushing is important throughout life. The overall goal is to achieve and maintain good oral
hygiene as follows:
clean all tooth surfaces, and the gum line, thoroughly with a toothbrush and fluoride-containing
toothpaste at least twice a day (last thing at night or before bed and one other time), spitting out
the excess toothpaste
use additional cleaning aids to reach interproximal surfaces, as appropriate
The risk of dental caries (Chapter 4) (https://gov.uk/government/publications/delivering-better-oral-health-an-

evidence-based-toolkit-for-prevention/chapter-4-dental-caries) and periodontal diseases (Chapter 5)
prevention/chapter-5-periodontal-diseases) can both be reduced by the practice of regular careful oral
hygiene involving toothbrushing with fluoride toothpaste. The particular benefit in preventing dental
caries, relates to the fluoride in toothpaste (Chapter 9)
prevention/chapter-9-fluoride). Good oral hygiene reduces the risk of periodontal diseases; however,
periodontal health also requires effective interproximal plaque removal. Oral hygiene advice for the
population in general, and specific advice for those at higher risk, are presented below for each oral
condition.
Dental caries
For caries prevention, it is the application of fluoride in toothpaste that is the most important aspect of
brushing, as fluoride helps prevent, control, and arrest caries (Chapter 2: Table 1
prevention/chapter-2-summary-guidance-tables-for-dental-teams#table1)). Higher concentration of fluoride
in toothpaste leads to better caries control. Family or standard fluoride toothpaste at 1,350 to 1,500
parts per million fluoride (ppmF) is recommended, although in very young children, where the ability
to control swallowing is limited, a toothpaste containing a lower amount (at least 1,000 ppmF) can be
used (3, 4). Frequency of brushing is important. Brushing should occur twice daily as a minimum, the
guidance being to clean teeth last thing at night or before bed, and at least one other time each day.
The term ‘before bed’ may be used as an alternative to ‘last thing at night’ for shift workers to sleep at
another time of day.
Early introduction to the habit of toothbrushing is important. Parents should brush their children’s
teeth as soon as they erupt. From 3 to 6 years of age there is a transition with the child and adult
both brushing. Adult involvement ensures the correct amount of toothpaste is used, enables them to
prevent children eating or licking toothpaste from the tube and that all teeth are brushed thoroughly.
From 7 years of age, many children can brush their own teeth but will still require prompting,
supervision, and motivation. Parents may still need to provide help with toothbrushing for some
children, depending on risk and capability.
Gingivitis
Physical removal of plaque is the important element of toothbrushing for preventing or controlling
periodontal (gum) diseases for the general population (Chapter 2: Table 2
prevention/chapter-2-summary-guidance-tables-for-dental-teams#table2)). Self-care is important to maintain
healthy gums and manage any gingivitis; it reduces inflammation of the gingivae. It is important to
advise and instruct patients on good plaque removal from, and just into, the gingival crevice,
including interdental areas, which takes around 2 minutes. There is no high-quality evidence
regarding the best times of the day to brush in order to maintain healthy gums; however, it is good
practice to suggest last thing at night or before bedtime and one other time in line with caries
prevention (3).
Periodontitis
Self-care is vitally important to prevent and manage plaque-induced periodontitis (5) (Chapter 2:
Table 2 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-2-summary-guidance-tables-for-dental-teams#table2)). For people with periodontal
diseases this becomes vitally important throughout the rest of life and good oral hygiene may take
longer than the recommended 2 minutes. The patient’s existing method of brushing may need to be
modified to clean all tooth surfaces systematically, maximise plaque removal and to brush the gum
line carefully (6). No particular technique has been shown to be better than another (7). Disclosing
tablets can help to indicate areas that are being missed. For people with extensive inflammation, it is
good practice to start with toothbrushing advice, followed by interdental plaque control (8).
Cleaning between teeth, ideally with interdental brushes, is recommended prior to toothbrushing as a
habit-forming approach, which is considered to be good practice (9), through adult life.
Based on current evidence, no strong conclusions can be drawn concerning any specific oral hygiene
devices as adjuncts to toothbrushing for patient self-care in periodontal maintenance (5, 10), or
method of providing oral hygiene advice (11).
Tooth wear
General population advice
For the general population, advice on toothbrushing follows the generic advice on oral health for
prevention of dental caries and periodontal diseases (Chapter 2: Table 4
prevention/chapter-2-summary-guidance-tables-for-dental-teams#table4)). Although concerns have been
raised, there is no strong evidence to suggest that the timing of toothbrushing is of great importance
in preventing tooth wear or that all patients should delay brushing until after meals involving erosive
food and drinks (12).
Higher risk of tooth wear
For those at higher risk, changing to a low abrasive toothpaste or specially reformulated toothpaste
for tooth wear alone may be considered, but will not be sufficient to fully address tooth wear (Chapter
7) (https://gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-7-tooth-wear). There have been debates over whether to recommend manual or
powered toothbrushes. Many brushes now have sensors to indicate when the user is brushing too
hard. However, when it comes to tooth wear, there is no evidence to suggest that powered
toothbrushes are any better, or worse, than manual toothbrushes (13). Patient preference is therefore
the most important factor over whether a powered or manual toothbrush is used.
Oral hygiene advice

Effective toothbrushing with a fluoride toothpaste is important to support oral health. The physical
action of brushing removes plaque, which prevents gingivitis and periodontitis, and the fluoride in
toothpaste is effective against tooth decay. The following key messages for the population include
when and how to brush, specific habits associated with brushing, and, where necessary, assistance
with brushing. There may be adaptations of toothbrushes, such as special grip handles, that are
helpful to people who have limited manual dexterity.
Advice for the population (primary prevention)
Advice to prevent oral disease in general should, therefore, focus on the following points (3, 4):
brush all tooth surfaces at least twice a day (last thing at night or bedtime and on at least one
other occasion), with fluoride toothpaste
ensure that every surface of each tooth and the junction between the gum and tooth (gumline)
are cleaned carefully
for young people and adults, the patient’s existing method of brushing may need to be modified
to maximise plaque removal, emphasising the need to systematically clean all tooth surfaces
both powered and manual toothbrushes are effective for plaque control (14)
there is low-certainty evidence that medium and soft bristle brushes are less likely to cause
gingival lesions than hard bristle toothbrushes (15); for most patients, an appropriate brush will
be a small-headed toothbrush with medium texture bristles
the type of toothbrush filament does not appear to be clinically important in plaque removal (15,
16)
daily interproximal plaque removal should have started by age 18 years, or younger, if gingival
inflammation is present
thorough cleaning may take at least 2 minutes (3); the main rationale for this time period is to
ensure that sufficient time is taken for all tooth surfaces to be cleaned effectively (17)
timers, which range from simple ‘egg-timers’ to clocks incorporated into toothbrushes and
downloadable ‘apps’, can be helpful to assist with the length of time toothbrushing (3, 17)
disclosing agents can help to indicate areas of the mouth that are being missed and guide the
person to more effective brushing
Advice for children in the population (primary prevention)
Advice should include the following:
brushing should start as soon as the first primary tooth erupts using toothpaste containing at
least 1,000 ppmF (3, 4)
parents or carers should use no more than a smear of toothpaste
(https://gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-9-fluoride#smear) (a thin film of paste covering less than three-quarters of the
child’s brush) for children below 3 years of age (17)
parents or carers should use no more than a pea-sized amount of toothpaste
(https://gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-9-fluoride#blob) for children between 3 and 6 years (18)
parents or carers should brush their young children’s teeth. In the absence of evidence from
home settings, expert opinion suggests that they need to be helped and supervised by an adult,
when brushing, until at least 7 years of age (based on findings from supervised brushing at
schools which show significant caries reduction) (19)
parental supervision in the early years can also ensure that children do not eat or lick toothpaste
from the tube (or brush), use the correct amount of toothpaste, and brush in a systematic pattern
around the mouth (20)
as soon as they are able (usually around the age of 3 years), children should be encouraged to
spit out excess toothpaste, and not to rinse with water after brushing
from 7 years of age, many children can brush their own teeth but will still require supervision,
motivation, and possibly assistance
for children at higher risk of oral disease, a family fluoride toothpaste (1,350 to 1,500 ppmF) is
indicated for maximum caries control, except where children cannot be prevented from eating
toothpaste (3, 4)
Advice for those with evidence of periodontitis or higher risk (secondary and
tertiary prevention)
Advice should include the following:
cleaning at the gum level is particularly important for people with experience of periodontitis
interdental cleaning aids help reach interproximal surfaces (8), and it may possibly be helpful to
use them before toothbrushing (9)
in general, people with, or treated for, periodontitis will have larger interdental spaces due to
tissue loss, and should use interdental brushes, which are more effective than dental floss or
tape (21)
the interdental brush should fit snuggly in the interdental space; therefore, many people with
periodontitis will require different sizes for smaller and larger spaces – where the teeth are
closer together, floss or tape can be used for interdental cleaning (5)
regular re-evaluation of oral hygiene will be helpful for some patients with appropriate level of
support from dental professionals (5, 22)
Additional considerations
partially dentate older adults would particularly benefit from additional attention to oral hygiene,
particularly those wearing partial dentures (23), as they increase plaque retention
good denture hygiene is important for those with partial and/or complete dentures as
demonstrated in mouthcare matters (https://mouthcarematters.hee.nhs.uk/)
Specific oral hygiene issues for vulnerable children and adults

Vulnerable children and adults, particularly those lacking manual dexterity and mental capacity, may
require assistance and support with toothbrushing as part of their daily self-care. Oral hygiene care
and advice for people who have learning disabilities should be based on professional expertise and
the needs and preferences of the individual and their carers (24). They may benefit from using a
powered brush (24), and some will require modifications such as a grip handle to assist with
toothbrushing. The latter may also be useful for people with physical disabilities. There is low/very
low certainty evidence for the effectiveness of triple-headed manual toothbrushes for reducing plaque
compared to single-headed brushes (25). Carers of people lacking the ability to undertake their
personal oral hygiene may consider some of these products helpful and they are likely to require
training and support from the dental team. It is worth noting that some studies reported participant
difficulties with, or fears of, using the powered or the 3-headed manual toothbrushes (24); thus, they
won’t be helpful for some patients.
NICE guidance on oral health for adults in care homes stresses the importance of ensuring care staff
provide residents with daily support to meet their mouth care needs and preferences, as set out in
their personal care plan after their oral health assessment (26).
This should include:
providing daily oral care for full or partial dentures (such as brushing, removing food debris, and
removing dentures overnight)
using their choice of cleaning products for dentures if possible
using their choice of toothbrush, either manual or powered
daily use of mouth care products prescribed by dental clinicians (for example, this may include a
high fluoride toothpaste or a prescribed mouthwash or rinse (27)
Powered versus manual toothbrushes

There is moderate-certainty evidence to suggest that powered toothbrushes reduce plaque and
gingivitis more than manual toothbrushing in the short and long term, and supporting their safety (28).
Findings are consistent across reviews, favouring powered brushes but the clinical relevance of the
results is unclear (14), (29 to 31). This is particularly important to note as many people will not be
able to afford a powered toothbrush and it should be stressed that teeth can be cleaned effectively
with either type of toothbrush (32). Additionally, the evidence is insufficient to conclude that any
particular mode of action of powered brush is superior (for example, sonic, rotatory) (33). There is no
evidence regarding the role of powered versus manual toothbrushes in preventing caries.
Interdental cleaning
Periodontal health
There is low to very low-certainty evidence that using some dental cleaning aids in addition to tooth
cleaning (for example, interdental brushes and floss) reduce gingivitis and plaque, but the clinical
importance of the effect sizes is uncertain (8). The findings suggest that interdental brushes may be
more effective than floss and the evidence for tooth cleaning sticks and oral irrigators is limited and
inconsistent (8). Daily cleaning is recommended between the teeth to below the gum line (8). Ideally
this should take place throughout adult life and start earlier if there are signs of gingivitis. Since
toothbrushing is a daily routine for the majority of people, carrying out interdental oral hygiene first
may help to link these activities and develop regularity (9).
Dental caries
Recommendations relating to interdental brushing and flossing are based on trials at unclear or high
risk of bias that focus on the reporting of plaque and/or gingivitis, rather than caries. Thus, there is no
evidence to determine whether interdental cleaning aids reduce caries, or not, when compared with
toothbrushing alone (8).
Sustainable toothbrushes
The sustainability agenda, which is an important aspect of public health action, has implications for
the prevention or oral diseases. It is increasingly influencing the nature of new products arriving on
the market, some of which have relatively little underpinning research.
For example, switching from traditional plastic toothbrushes to replaceable-head plastic or bamboo
has been suggested as being environmentally more sustainable. However, all choices have trade-
offs which should be considered carefully. Bamboo toothbrushes are manufactured in different parts
of the world, and although they have been shown to have a reduced carbon footprint (34), they have
also been shown to have high planetary harm, due to the need for land, and volume of water required
to grow the product. Furthermore, there is currently little evidence on their effectiveness. On the other
hand, plastic has been considered the most hygienic option for decades. Additionally, all
toothbrushes, whether normal plastic, bamboo, and biodegradable plastic (PLA or polylactic acid),
have brush heads containing metal and/or nylon, so it is currently not possible to recycle the heads.
Further innovative new products will emerge, and it will be important for health professionals to be
aware of these changes and consider the clinical effectiveness of sustainable products. Integrating
oral health and sustainability is attractive, and continually recycled plastic, rather than bioplastic or
bamboo, will be the most environmentally sustainable toothbrush model (35). Practices may wish to
encourage patients to recycle toothbrushes as best as possible. As a compromise, it may be possible
for people to remove or chop off the brush head and recycle the handle. Some dental practices
already have an arrangement with companies to recycle any type of toothbrush and toothpaste
tubes.
Resources
Oral Hygiene TIPPS video (http://www.sdcep.org.uk/published-guidance/periodontal-management/oral-
hygiene-tipps-video/). Oral Hygiene TIPPS is a behaviour change strategy which aims to make patients
feel more confident in their ability to perform effective plaque removal and help them plan how and
when they will look after their teeth and gums.
HABIT resources to support oral health conversations between health visitors and parents
(https://www.toothbrushinghabit.com/).
eBUG toothbrushing demonstration video for 7(+) years (https://e-bug.eu/junior_pack.aspx?

cc=eng&ss=2&t=Oral%20hygiene).
Dental Check By One (https://dentalcheckbyone.co.uk/).
Scottish Dental Clinical Effectiveness Programme. Prevention and Management of Dental Caries in
Children (https://www.sdcep.org.uk/published-guidance/caries-in-children/): SDCEP; 2018 (Second Edition).
How To Clean a Denture Animation:
How To Clean a Denture Animation - Mouth Care …
Wales Designed to Smile (https://www.designedtosmile.org/info/).
Scotland Childsmile (http://www.child-smile.org.uk/).
Northern Ireland Happy Smiles (http://www.hscboard.hscni.net/our-work/integrated-care/dental-

services/happy-smiles/).
NHS apps library (https://www.nhs.uk/apps-library/). Includes Brush DJ which plays two minutes of your
music so you brush your teeth for the right amount of time. The app has short videos on how to brush
your teeth and how to clean in between them using an interdental brush or floss.
Public Health England: Oral health toolkit for adults in care homes
(https://www.gov.uk/government/publications/adult-oral-health-in-care-homes-toolkit/oral-health-toolkit-for-adults-
in-care-homes).

References
1. NHS Digital. Adult Dental Health Survey 2009 - Summary report and thematic series
(https://digital.nhs.uk/data-and-information/publications/statistical/adult-dental-health-survey/adult-dental-health-
survey-2009-summary-report-and-thematic-series) [NS] London: The Health and Social Care Information
Centre; 2011.
2. NHS Digital. Child Dental Health Survey: England, Wales and Northern Ireland. London: The
Health and Social Care Information Centre; 2015.
3. SIGN. Sign 138. Dental interventions to prevent caries in children. Health Improvement Scotland;
2014.
4. Walsh T, Worthington HV, Glenny AM, Marinho VCC, Jeroncic A. Fluoride toothpastes of different
concentrations for preventing dental caries. Cochrane Database of Systematic Reviews. 2019(3).
5. Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Beglundh T, and others. Treatment of stage
I-III periodontitis-The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology.
2020;47 Supplement 22:4-60.
6. Zimmermann H, Zimmermann N, Hagenfeld D, Veile A, Kim TS, Becher H. Is frequency of

toothbrushing a risk factor for periodontitis? A systematic review and meta-analysis. Community
Dentistry and Oral Epidemiology. 2015;43(2):116-27.
7. Janakiram C, Taha F, Joe J. The Efficacy of Plaque Control by Various Toothbrushing Techniques-
A Systematic Review and Meta-Analysis. Journal of Clinical and Diagnostic Research. 2018;12.
8. Worthington HV, MacDonald L, Poklepovic Pericic T, Sambunjak D, Johnson TM, Imai P, and
others. Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and
controlling periodontal diseases and dental caries. Cochrane Database of Systematic Reviews.
2019;4(4):Cd012018.
9. Mazhari F, Boskabady M, Moeintaghavi A, Habibi A. The effect of toothbrushing and flossing

sequence on interdental plaque reduction and fluoride retention: A randomized controlled clinical trial.
Journal of Periodontology. 2018;89(7):824-32.
10. Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Beglundh T, and others. Treatment of
Stage I-III Periodontitis –The EFP S3 Level Clinical Practice Guideline. Journal of Clinical
Periodontology in Europe. 2020.
11. Soldani FA, Lamont T, Jones K, Young L, Walsh T, Lala R, and others. One-to-one oral hygiene
advice provided in a dental setting for oral health. Cochrane Database of Systematic Reviews.
2018;10(10):Cd007447.
13. Van der Weijden FA, Campbell SL, Dorfer CE, Gonzalez-Cabezas C, Slot DE. Safety of
oscillating-rotating powered brushes compared to manual toothbrushes: a systematic review. Journal
of Periodontology. 2011;82(1):5-24.
14. Grender J, Adam R, Zou Y. The effects of oscillating-rotating powered toothbrushes on plaque
and gingival health: A meta-analysis. American Journal of Dentistry. 2020;33(1):3-11.

15. Ranzan N, Muniz FWMG, Rösing CK. Are bristle stiffness and bristle end-shape related to
adverse effects on soft tissues during toothbrushing? A systematic review. International Dental
Journal. 2019;69(3):171-82.
16. Hoogteijling F, Hennequin-Hoenderdos NL, Van der Weijden GA, Slot DE. The effect of tapered
toothbrush filaments compared to end-rounded filaments on dental plaque, gingivitis and gingival
abrasion: a systematic review and meta-analysis. Internationa Journal of Dental Hygiene.
2018;16(1):3-12.
17. NHS Education for Scotland. Prevention and Management of Dental Caries in Children Scotland
(https://www.sdcep.org.uk/published-guidance/caries-in-children/): NES; 2018 Second.
18. Wong MCM, Glenny AM, 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).
19. Marinho VCC, Higgins J, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries
in children and adolescents. Cochrane Database of Systematic Reviews. 2003(1).
20. Dos Santos APP, de Oliveira BH, Nadanovsky P. A systematic review of the effects of supervised
toothbrushing on caries incidence in children and adolescents. International Journal of Paediatric
Dentistry. 2018;28(1):3-11.
21. Slot DE, Valkenburg C, Van der Weijden GA. Mechanical plaque removal of periodontal
maintenance patients: A systematic review and network meta-analysis. Journal of Clinical
Periodontology. 2020;47(S22):107-24.
22. Tonetti MS, Eickholz P, Loos BG, Papapanou P, van der Velden U, Armitage G, and others.
Principles in prevention of periodontal diseases. Journal of Clinical Periodontology. 2015;42(S16):S5-
S11.
23. Wong FMF, Ng YTY, Leung WK. Oral Health and Its Associated Factors Among Older
Institutionalized Residents—A Systematic Review. International Journal of Environmental Research
and Public Health. 2019;16(21):4132.
24. Waldron C, Nunn J, Mac Giolla Phadraig C, Comiskey C, Guerin S, van Harten MT, and others.
Oral hygiene interventions for people with intellectual disabilities. Cochrane Database of Systematic
Reviews. 2019(5).
25. Kalf-Scholte SM, Van der Weijden GA, Bakker E, Slot DE. Plaque removal with triple-headed vs
single-headed manual toothbrushes-a systematic review. International Journal of Dental Hygiene.
2018;16(1):13-23.
26. NICE. Oral health for adults in care homes NICE guideline [NG48]. NICE; 2016 5th July 2016.
27. NICE. Managing medicines in care homes [SC1]. London: NICE; 2014 December 2017.
28. Yaacob M, Worthington HV, Deacon SA, Deery C, Walmsley AD, Robinson PG, and others.
Powered versus manual toothbrushing for oral health. Cochrane Database of Systematic Reviews.
2014(6).
29. Clark-Perry D, Levin L. Systematic review and meta-analysis of randomized controlled studies
comparing oscillating-rotating and other powered toothbrushes. Journal of the American Dental
Association. 2020;151(4):265-75.e6.
30. Wang P, Xu Y, Zhang J, Chen X, Liang W, Liu X, and others. Comparison of the effectiveness
between power toothbrushes and manual toothbrushes for oral health: a systematic review and
meta-analysis.
UK Dental ExamsActa Odontologica
MasterclassScandinavica.
by Dr Diana2020;78(4):265-74.
McPherson | www.ukdentalexams.com
31. Elkerbout TA, Slot DE, Rosema NAM, Van der Weijden GA. How effective is a powered
toothbrush as compared to a manual toothbrush? A systematic review and meta-analysis of single
brushing exercises. International Journal of Dental Hygiene. 2020;18(1):17-26.
32. West N, Chapple I, Claydon N, D’Aiuto F, Donos N, Ide M, and others. BSP implementation of
European S3 - level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical
practice. Journal of Dentistry. 2021;106:103562.
33. Deacon SA, Glenny AM, Deery C, Robinson PG, Heanue M, Walmsley AD, and others. Different
powered toothbrushes for plaque control and gingival health. Cochrane Database of Systematic
Reviews. 2010(12).
34. Lyne A, Ashley P, Saget S, Porto Costa M, Underwood B, Duane B. Combining evidence-based
healthcare with environmental sustainability: using the toothbrush as a model. British Dental Journal.
2020;229(5):303-9.
35. Duane B, Ashley P, Saget S, Richards D, Pasdeki-Clewer E, Lyne A. Incorporating sustainability

into assessment of oral health interventions. British Dental Journal. 2020;229(5):310-4.


11/19/21, 8:33 PM Chapter 9: Fluoride - GOV.UK
GOV.UK

6. Delivering better oral health: an evidence-based toolkit for prevention (https://www.gov.uk/government/publications/delivering-
better-oral-health-an-evidence-based-toolkit-for-prevention)
Department
of Health &
Social Care (https://www.gov.uk/government/organisations/department-of-health-and-social-care)
Office for Health
Improvement
& Disparities (https://www.gov.uk/government/organisations/office-for-health-improvement-and-disparities)
Guidance
Chapter 9: Fluoride
Contents
Fluoride and dental caries prevention

Water fluoridation
Milk fluoridation
Increasing fluoride availability
Fluorides and the risk of dental fluorosis
Deciding on fluoride delivery options
Other dental caries-preventive agents
Resources
References

https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-9-fluoride 1/11
This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives,
Kew, London TW9 4DU, or email: psi@nationalarchives.gov.uk.
Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.
This publication is available at https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-

prevention/chapter-9-fluoride

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.
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.
Fluoride and dental caries prevention

Fluorides are widely found in nature and in products such as tea, fish, beer and in some natural water supplies. The link between
fluoride in public water supplies and reduced levels of dental caries was first documented early in the last century. Since then fluoride
has become more widely available, most notably in toothpaste, and recognised as having improved oral health in the UK. The decline
of dental caries worldwide over recent decades is largely attributed to the daily use of fluoride toothpaste (1).
There is abundant evidence that increasing fluoride availability to individuals and communities is effective at reducing dental caries
levels (Chapter 2: Table 1 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-2-summary-guidance-tables-for-dental-teams#table1); Chapter 4 (https://www.gov.uk/government/publications/delivering-better-
oral-health-an-evidence-based-toolkit-for-prevention/chapter-4-dental-caries)). For example, moving from brushing once a day to twice a day
lowers an individual’s risk of developing dental caries by 14% (2).
Regular exposure to fluoride maintains a concentration in the plaque biofilm that encourages remineralisation of the tooth surface. This
can be achieved by a range of methods, but similar principles apply to all. Fluoride delivery using vehicles that can be incorporated into
aspects of everyday living are more likely to be effective and they avoid increasing inequalities.
The risk of ingesting too much fluoride leading to fluorosis should be considered for young children during tooth formation (3). A
balance has to be achieved, whereby, most benefit can be gained from this naturally occurring substance, whilst at the same time
minimising the risk of fluorosis.
Water fluoridation
Currently, approximately 10% of England’s population, or about 6 million people, have a fluoridatated water supply. In terms of
population coverage, the West Midlands is the most extensively fluoridated area, followed by parts of the North East of England (Figure
9.1).
There are no fluoridation schemes in Scotland, Wales and Northern Ireland, however, there are some localised areas of naturally
occurring fluoride in the water. To check if the water supply in a given area is fluoridated, information can be obtained from the local
water supplier by quoting the residential postcode. Many water companies have an online function to allow consumers to check the
level of fluoride.

Figure 9.1. Map of fluoridated areas in England
Milk fluoridation
There are a few community schemes in England which supply children with fluoridated milk at early years and school settings. They are
provided in areas that are not fluoridated and where levels of dental caries are high. In 2016 an evidence review and guide for local
authorities commissioning programmes such as fluoridated milk classified these as of limited value for oral health (4).
Increasing fluoride availability

Information on how fluoride availability can be increased on an individual basis to improve oral health follows below. This can involve a
range of behaviours and modes of delivery, linking closely, but not exclusively, to oral hygiene practices. Concentration, frequency and
mode of delivery of fluoride are important, together with practical action to ensure that fluoride stays in the oral cavity and is not rinsed
away.
Fluoride toothpaste
Toothpaste is the most common delivery system for fluoride and comes in a range of strengths, flavours and formulations. For further
details on toothbrushing please see Chapter 8 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-
toolkit-for-prevention/chapter-8-oral-hygiene) on oral hygiene . There is moderate to high-certainty evidence that fluoride toothpaste of 1,000
ppm fluoride or above prevents dental caries in both the permanent and primary dentition (5). For children at higher risk, 1,350 to 1,500
ppm is advocated and also for children from 7 years upwards (5).
The formulation of fluoride in toothpaste varies and can take various forms, for example, sodium fluoride, sodium monofluorophosphate,
stannous fluoride, or a combination of these. However, currently, there is insufficient evidence to confidently recommend one over
another. It is the strength in parts per million fluoride (which can be found on the packaging) that is important (5), along with
consideration of wider dental caries risk factors, particularly sugar in the diet.
It is important to brush at least twice a day with fluoride toothpaste, last thing at night or before bedtime and one other time (5, 6). It is
also helpful to recognise that a combination of health behaviours such as using higher fluoride paste, brushing twice a day and avoiding
rinsing after brushing appears to be associated with reducing the dental caries increment in adolescents (2).
Types of over-the-counter toothpastes by fluoride concentration level
A table of currently available toothpastes and their fluoride content

(https://khub.net/documents/135939561/516396401/Fluoride_content_of_toothpastes.xlsx/747e70d8-bb73-df61-5d72-15fb930cd25a?
t=1632213336398) is provided for information. The list is not an endorsement of any particular brand. Whilst every effort has been made
to ensure the list is comprehensive, and correct at the time (January 2020), it may not represent all brands of toothpaste available in the
UK. Analysis of toothpastes suggested that almost one-third (31%) of available toothpastes contained no fluoride and 4% had an
unrecorded concentration (7). Information is not available about levels of fluoride in brands bought from places such as single price
stores, markets, websites and car boot sales, which may be special imports or, on occasion counterfeit, and not contain any fluoride.
Such toothpaste may not offer protection against dental caries. There is increasing diversity in the toothpaste market with greater
emphasis on whitening, natural, and holistic health products. This trend highlights the importance of dental professionals taking time to
recognise the changing market, explore with patients what toothpastes they are using, and why, in order to assist them in selection of
an appropriate product.
Higher dose fluoride toothpaste
The maximum concentration of fluoride-containing toothpaste that can be purchased over the counter in the UK is 1,500 ppm fluoride.
Higher dose toothpastes are available on prescription from a dentist. Evidence on the efficacy of higher dose fluoride toothpastes is
limited (5) and available studies focus on root caries (8). Dentists may wish to consider higher concentration fluoride toothpastes for
vulnerable young people and adults susceptible to dental caries (9). Dental caries risk should be reviewed at routine oral health
assessments and high fluoride toothpaste only continued for those who are unable to reduce their susceptibility to dental caries.
Prescribing higher dose fluoride toothpaste
The following sections provide information and advice on fluoride prescription including examples of prescription scripts. It is important
to avoid chronic and/or acute ingestion of fluoride; however, occurrences of excessive fluoride ingestion in adults from high fluoride
toothpastes are very rare (10). Adults should be advised to follow the instructions under which these medications are licensed which
recommends a 2cm ribbon on toothbrush head 3 times daily. As with children, adults should be encouraged to spit out excess
toothpaste and avoid rinsing. Adults with limited capacity should be supported in toothbrushing to ensure that they use the
recommended amount only.
Sodium fluoride 2,800 ppm fluoride toothpaste
Indications for use include high dental caries risk patients aged 10 years and over. This includes those with dental caries present, a
high cariogenic diet or cariogenic medication. Whilst this approach may be helpful as dental caries risk is tackled, most patients will
benefit from reducing their sugar intake in the longer term. However, it may be necessary to continue with high fluoride toothpaste
where patients are unable to reduce their susceptibility to dental caries. For example of a prescription, please see Figure 9.2 below.
Figure 9.2. Prescription for higher dose fluoride toothpaste 2800ppm
Sodium fluoride 5,000 ppm toothpaste

Indications for use include high dental caries risk patients aged 16 years and over. This includes those with root or coronal caries
present or risk factors such as dry mouth, overdentures, those with a highly cariogenic diet or cariogenic medication and those who
have received head and neck radiotherapy and chemotherapy (5, 11). Again, this should be used in conjunction with reducing sugar
intake, subject to review and not normally for the long term, except in specific circumstances. For example of a prescription please see
Figure 9.3 below.
Figure 9.3. Prescription for higher dose fluoride toothpaste 5000ppm
Toothpaste taste, texture and foaming
The taste of toothpaste varies between brands and countries and is influenced by the target market. While fruit flavoured toothpastes
aimed at children are available, as the majority of family toothpastes are mint flavoured, it is recommended to start young children on a
mild mint family toothpaste. If fruit flavoured toothpastes are chosen, extra care must be taken to ensure that children do not eat or
swallow the toothpaste because they like the taste. Transition to mint flavoured paste should therefore be encouraged as soon as the
child will tolerate this taste.
Toothpaste taste can be a barrier to regular use, particularly in children with sensory sensitivities, including autism and learning
disabilities who may benefit from a paste that is less flavoured or foaming.
People who have a vulnerable airway, for example if they have experienced a stroke or are on a ventilator, or some adults and children
with special needs (such as sensory sensitivities, dysphagia, dry mouth, cognitive decline, having nil by mouth) will benefit from a
toothpaste that produces less foam (12, 13). Thus they would benefit from toothpaste that is free from sodium lauryl sulphate.
Examples of such products can be found in the Mouthcare Matters product list (http://mouthcarematters.hee.nhs.uk/wp-
content/uploads/2018/03/Order-Information-rollout-MCM.pdf).
Fluoride varnish
Fluoride varnish is one of the best options for increasing the availability of topical fluoride regardless of the levels of fluoride in any
water supply (14). This should happen when a child visits a dental surgery and is strongly recommended (14). The dental caries-
preventive effectiveness of fluoride varnish in both permanent and primary dentitions is clear (14, 15). Several systematic reviews
conclude that applications twice a year produce an average reduction in dental caries increment of 37% in the primary and 43% in the
permanent dentition (14). Much of the evidence of effectiveness is derived from studies which have used sodium fluoride 22,600 ppm
(2.26% NaF) varnish for application.
Fluoride varnish for use as a topical treatment has several practical advantages. It is well accepted and safe for most patients (see
exceptions below). Furthermore, the application of fluoride varnish is simple and can be applied by trained and competent members of
the oral healthcare team including dental nurses. While a thorough prophylaxis is not essential prior to application, removal of gross

plaque is advised. Dental nurses can be trained to apply fluoride varnish to the prescription of a dentist and this use of team skill mix
can assist a practice to become more preventively orientated (16). A detailed protocol for the application of fluoride varnish is currently
available from the Scottish Childsmile Manual (17, 18).
The use of fluoride varnish is contraindicated in patients with ulcerative gingivitis and stomatitis (19). There is a very small risk of allergy
to one component (colophony) of the most commonly used fluoride varnish. Check any medical history with the parent, specifically
check for allergy to sticking plaster or severe allergy or asthma that has required hospitalisation (17), the use of colophony containing
varnish application is contraindicated for these cases. Other brands of varnish may have different constituents.
Some fluoride varnishes contain alcohol. Because they are being used as a medicament and are not an intoxicant, it has been agreed
(on the authority of the West Midlands Shari’ah Council) that they are suitable for use by Muslims, provided that they are used in small
amounts, well below that which would intoxicate, and they are not being used for reasons of vanity.
Clinicians should be aware that many fluoride varnishes on the market are not licensed for dental caries control, although they may
have similar formulations, and take this into consideration with respect to their prescribing responsibilities. Practitioners need to be
aware of their responsibilities when prescribing off-licence, and should ensure that they are in the best interests of the patient and
taking account of product availability (20).
Whilst most of the focus on fluoride varnish use has been on dental caries prevention in children, it is increasingly important to consider
its use with adults at higher risk, particularly frail older people, who have maintained their natural teeth. Fluoride varnish has the
advantage of being professionally applied and does not have aesthetic challenges.
Fluoride mouthwashes
Fluoride mouthwashes or mouthrinses (0.05% w/v; 230 ppm) can be considered for patients aged 8 years and above, for daily use, in
addition to twice daily brushing with toothpaste containing at least 1,350 ppm fluoride (21). Rinses require patient compliance and
should be used at a different time to toothbrushing to maximise the topical effect which enhances the bioavailability of fluoride in the
plaque biofilm (22). They are likely to be most useful in higher dental caries risk patients.
There is moderate-certainty evidence that fluoride mouthrinses prevent dental caries in the permanent dentition, although the evidence
is derived from supervised use at school (21). There are no trials of the effect of mouthrinses on the primary dentition.
Overall, there is insufficient evidence to support daily (230ppm) versus weekly (circa 900ppm) mouthwash use as superior, in terms of
dental caries prevention (21). The available evidence coming from school-based programmes where children are supervised suggests
that regular use of fluoride mouthrinse results in a large reduction in tooth decay in the permanent teeth of children and adolescents.
The benefit of fluoride mouthrinse is likely to be present even if children use fluoride toothpaste or live in water‐fluoridated areas (21).
For an example of a prescription, please see Figure 9.4 below.
Figure 9.4. Prescription for fluoride rinses

Fluorides and the risk of dental fluorosis

A potential side effect of using fluoride as a dental caries-preventive measure is the occurrence of dental fluorosis, which can occur if a
child is exposed to excess ingested fluoride during the period of tooth formation (23).
The risks of fluorosis damaging the appearance of permanent incisors are relevant only to ingestion of fluoride by those under 3 years
old (17, 24), as calcification of the crowns of permanent incisor teeth is complete by 30 months.
Risks of aesthetically challenging fluorosis to premolars are only relevant to those aged under 6 years as calcification of the crowns of
these teeth is complete by this age. To minimise risk of fluorosis, while still using the optimum concentration of fluoride in toothpaste (5),
the best approach is to use very small quantities for children aged 6 years and below, whilst teeth are still calcifying.
Children aged under 3 years
Parents of children aged under 3 years are advised to have only a smear of fluoride toothpaste (3), when toothbrushing (Chapter 8
(https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-8-oral-hygiene)) while
their incisors are forming, as shown in Figure 9.5a below.
If a smear of 1,000 ppm toothpaste is used, this amounts to 0.1ml of paste by volume which contains 0.1mg of fluoride.
When 1,500 ppm paste is used the ‘smear’ (0.1ml) of paste contains 0.15mg of fluoride.
Overall, this results in an absorbable fluoride dose of only 0.007 to 0.01mg per kg body weight if swallowed, for a child weighing 15kg
(17).
Figure 9.5a. Toothpaste amounts for infants and young children. Smear: up to 3 years.
Children aged 3 to 6 years
Children aged 3 to 6 years should use only a pea-sized blob of toothpaste (3) when teeth are being brushed (Chapter 8
(https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-8-oral-hygiene)) as shown
in Figure 9.5b below.
If a pea-sized blob of 1,000 ppm toothpaste is used, this amounts to 0.25ml of toothpaste containing 0.25mg of fluoride.
When 1,500 ppm paste is used the ‘pea’ (0.25ml) of toothpaste contains 0.375mg of fluoride.
Overall this results in an absorbable fluoride dose of only 0.02 to 0.025mg per kg body weight if swallowed, for a child weighing 15kg
(17).
Figure 9.5b. Toothpaste amounts for infants and young children. Pea-sized blob: 3 to 6 years.
Deciding on fluoride delivery options

Fluoride should form part of the standard tools to tackle dental caries and reduce risk. Standard, age-appropriate advice should be
given to everyone, that is, toothbrushing with fluoride toothpaste (1,350 to 1,500 ppm) (5). Additional action for patients who are at
higher risk of dental caries should involve careful consideration based on their history, area of residence, clinical examination and
special investigations such as diet diary. Higher fluoride paste (over 1,500 ppm toothpaste) should ideally be a short-term risk reduction
measure whilst the level of sugar in the diet is reduced. Exceptions will include patients who are at higher long-term risk of dental
caries. This may be because of reduced salivary flow, physical or learning disability or medical conditions.
Other dental caries-preventive agents
Novel and emerging products
New toothpastes and equivalent products are emerging on the market. They include toothpaste tablets (7), albeit supported by limited
or no evidence regarding their effectiveness. Some of these products do not contain fluoride and are driven by a desire for natural
products and also environmental sustainability (7). It is likely that more products will emerge, and oral healthcare professionals are
encouraged to check them on a regular basis, particularly to check if they contain fluoride. Where patients have elected to use a non-
fluoride toothpaste, it is important to highlight the loss of dental caries preventive effect and the increased need to manage their sugar
intake to prevent dental caries.
Fluoride in combination with other preventive agents
One systematic review focused on preventive dental regimes and/or one or more chemical agents applied by a dental professional to
reduce the initiation of root caries lesions or render them inactivate (11). It highlighted that dentifrice containing 5,000 ppm fluoride, and
professionally applied chlorhexidine or silver diamine fluoride varnish, may inactivate existing decay and/or reduce the initiation of root
caries lesions (low-certainty evidence). However, the results should be interpreted with caution, due to the low numbers of clinical trials
for each agent, the high risk of bias within studies, and the limiting grade of evidence.
Recent reviews have highlighted the benefits of Silver diamine fluoride (SDF) in dental caries management (25, 26), albeit the quality of
evidence is low. Silver diamine fluoride, however, is licensed in the UK for management of dentine hypersensitivity, not the prevention
or arrest of dental caries. An emerging body of evidence suggests that it is a useful vehicle for fluoride delivery with the evidence
consistently supporting SDF’s effectiveness for arresting coronal caries in the primary dentition and root caries in older adults for all
comparators (26). SDF can arrest established carious lesions, especially in primary teeth (25, 26); however, it blackens teeth and so
has challenging aesthetic properties. There is also emerging evidence that it may be beneficial in preventing further root caries in older
people (25, 26).
Further high quality research is therefore required to determine its potential beyond its current product licence, including investigating its
primary preventive properties and the most beneficial time intervals for its use. Thus, whilst there is some suggestion that SDF is
effective in dental caries prevention as an agent in young children (25), and possibly for root caries in older adults, current evidence
essentially focuses on caries arrest.
Resources
BSPD resources to support SDF application in children for the arrest of caries in the primary dentition
(https://www.bspd.co.uk/Professionals/Resources).
Simple communication tool to support fluoride varnish application (https://widgit-health.com/downloads/dental-procedures.htm) (In the
Dentist’s Room).
References
1. Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F and others. Dental caries. Nature Reviews Disease
Primers. 2017;3:17030.
2. Chesters RK, Huntington E, Burchell CK, Stephen KW. Effect of oral care habits on caries in adolescents. Caries Research.
1992;26(4):299-304.
3. Wong MCM, Glenny AM, 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).
4. Public Health England. Local authorities improving oral health: commissioning better oral health for children and young people: An
evidence-informed toolkit for local authorities. London: Public Health England; 2014.
5. Walsh T, Worthington HV, Glenny AM, Marinho VCC, Jeroncic A. Fluoride toothpastes of different concentrations for preventing
dental caries. Cochrane Database of Systematic Reviews. 2019(3).
6. SIGN. Sign 138. Dental interventions to prevent caries in children. Health Improvement Scotland; 2014.
7. Gupta A, Godson J, Chestnutt IG, Gallagher J. Formulation and fluoride content of dentifrices: A review of current patterns. British
Dental Journal. in press.
8. Wierichs RJ, Meyer-Lueckel H. Systematic Review on Noninvasive Treatment of Root Caries Lesions. Journal of Dental Research.
2014;94(2):261-71.
9. Public Health England. Commissioning better oral health for children and young people: An evidence-informed toolkit for local
authorities. London: Public Health England; 2018.
10. Randall C. Fluoride toothpaste – what are the dangers of chronic ingestion in adults? In: Service SP, editor. Dentistry 2019.
11. Wierichs RJ, Meyer-Lueckel H. Systematic review on noninvasive treatment of root caries lesions. Journal of Dental Research.
2015;94(2):261-71.
12. Smith CJ, Horne M, McCracken G, Young D, Clements I, Hulme S and others. Development and feasibility testing of an oral
hygiene intervention for stroke unit care. Gerodontology. 2017;34(1):110-20.
13. Prendergast V, Kleiman C, King M. The Bedside Oral Exam and the Barrow Oral Care Protocol: translating evidence-based oral
care into practice. Intensive and Critical Care Nursing. 2013;29(5):282-90.
14. Marinho VCC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental caries in children and adolescents.
15. Mishra P, Fareed N, Battur H, Khanagar S, Bhat MA, Palaniswamy J. Role of fluoride varnish in preventing early childhood caries: A
systematic review. Dental Research Journal (Isfahan). 2017;14(3):169-76.
16. Chief Dental Officer England. Avoidance of Doubt-Application of Fluoride Varnish by Dental Nurses. In: Officer OotCD, editor.
London: NHS England; 2016.
17. NHS Scotland, Healthier Scotland. Programme Manual for Childsmile Staff. Glasgow: University of Glasgow; 2016. Contract No.:
4531.
18. NHS Scotland - Childsmile (http://www.child-smile.org.uk/)
19. Colgate. Colgate Duraphat Varnish: product leaflet 2020 (https://www.colgateprofessional.com.au/products/products-list/colgate-duraphat-

varnish)
20. MHRA. Off-label or unlicensed use of medicines: prescribers’ responsibilities: UK Govenment; 2014 [updated 11 December 2014].
21. Marinho VCC, Chong LY, Worthington HV, Walsh T. Fluoride mouthrinses for preventing dental caries in children and adolescents.

22. Weyant RJ, Tracy SL, Anselmo TT, Beltrán-Aguilar ED, Donly KJ, Frese WA and others. Topical fluoride for caries prevention:
executive summary of the updated clinical recommendations and supporting systematic review. Journal of the American Dental
Association. 2013;144(11):1279-91.
23. Buzalaf M, Levy S. Fluoride Intake of Children: Considerations for Dental Caries and Dental Fluorosis. Monographs in oral science.
2011;22:1-19.
24. Wright JT, Hanson N, Ristic H, Whall CW, Estrich CG, Zentz RR. Fluoride toothpaste efficacy and safety in children younger than 6
years: a systematic review. Journal of the American Dental Association. 2014;145(2):182-9.
25. Oliveira BH, Rajendra A, Veitz-Keenan A, Niederman R. The Effect of Silver Diamine Fluoride in Preventing Caries in the Primary
Dentition: A Systematic Review and Meta-Analysis. Caries research. 2019;53(1):24-32.
26. Seifo N, Cassie H, Radford JR, Innes NPT. Silver diamine fluoride for managing carious lesions: an umbrella review. BMC Oral
Health. 2019;19(1):145.
All content is available under the Open Government Licence v3.0, except where otherwise
stated © Crown copyright

11/19/21, 8:33 PM Chapter 10: Healthier eating - GOV.UK
GOV.UK

Department
of Health &
Office for Health
Improvement
Guidance
Chapter 10: Healthier eating
Contents
Diet in the UK
Free sugars in the diet
Sugar consumption and dental caries
Diet and cancer
Diet and tooth wear
General good dietary practice guidelines
Key messages for a healthier diet
Changing to a healthier diet
Diet in the early years
Bedtime routines
Teething
Vulnerable groups
Resources
References

https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-10-healthier-eating 1/12

prevention/chapter-10-healthier-eating

Diet in the UK
A healthy diet is important for oral and general health. Surveys consistently highlight that the population of the United Kingdom is eating
too many ‘free sugars’ (see below), too much saturated fat and salt, and not enough fruit, vegetables, fibre and oily fish.
Defining free sugars
The term ‘Free sugars’ includes all sugars (monosaccharides and disaccharides) added to foods and drinks by the manufacturer, cook
or consumer, as well as sugars naturally present in honey, syrups, smoothies, and fruit juices.
It does not include sugars found naturally in whole fresh fruit and vegetables and those naturally present in milk and milk products.
Also included as free sugars are the following:
all the sugars naturally present in fruit and vegetable juices, concentrates, smoothies, purées, pastes, powders and extruded fruit
and vegetable products
all sugars in drinks except for lactose and galactose naturally present in milk and other dairy-based drinks including:
• all sugars in unsweetened fruit and vegetable juices, fruit and vegetable juice concentrates and smoothies
• all sugars in alcoholic drinks
• all sugars naturally present in dairy-alternative drinks such as soya, rice, oat and nut-based drinks
lactose and galactose added as an ingredient to foods or drinks, including lactose in whey powder.
Sources: Scientific Advisory Committee on Nutrition, 2015 (1); Swan and others, 2018 (3); NHS Eatwell Sugar: the facts, 2019
Some people choose not to have milk and dairy products in their diet for a variety of reasons, for example, if they are unable to digest
lactose (lactose intolerance), have an allergy to cow’s milk protein or are following a vegan diet. There are a number of plant-based
foods and drinks now available on the market, which can contain free sugars and individuals are advised to look at the labelling and
choose unsweetened (lower sugar) versions and those which are fortified with vitamins and minerals such as calcium.
Free sugars in the diet

Free sugars, if consumed, should only be consumed in small amounts. It is recommended that the average population intake of free
sugars should not exceed 5% of total dietary energy for age groups from 2 years upwards (1). The recommended upper ‘threshold’ of
free sugars intake, by age, is presented in Figure 10.1 below and can be accessed on the NHS Change4Life website
(https://www.nhs.uk/change4life/food-facts/sugar).

Figure 10.1. Visualisation of sugar recommendations: recommended maximum threshold. One cube is 4g of sugar. Source (2)
Age Maximum daily amounts of added sugar
4 to 6 years 5 cubes (19 grams)
7 to 10 years 6 cubes (24 grams)
11 years and over 7 cubes (30 grams)
In 2016 to 2019, free sugars intake exceeded the government recommendation of providing no more than 5% of total energy intake (4).
Amongst children and young people, girls aged 11 to 18 years and boys aged 4 to 10 years had the highest mean free sugars intakes
as a percentage of total energy (12.5% and 12.4% of total energy respectively); whilst children aged 1.5 to 3 years had the lowest mean
intake (9.7%) (4).
Amongst adults, the reported mean intake of free sugars, as a percentage of total energy intake, was 9.9% for those of working age (19
to 64 years) and 9.4% for those aged 65 years and over; thus, exceeding the recommended threshold (4). Amongst adults, men aged
75 years and over had the highest mean intake at 10.9% of total energy (4).
Some encouraging dietary trends have been emerging. National research suggests that the intake of free sugars is reducing over time
in children (less so in adults), although it remains above recommended thresholds (no more than 5% of total energy) (5). Fewer children
and young people report drinking sugar-sweetened beverages, and those drinking them are consuming less (5). Nonetheless, they
remain a significant source of sugar and it should be noted that they get most of their free sugars intake from the foods presented in
Figure 10.2 below and on NHS – Change4Life (https://www.nhs.uk/change4life/food-facts/sugar), most of which have little nutritional value.

Figure 10.2. Common sources of free sugar in the diet of children and young people. Data from the National Diet and Nutrition Survey,
2018. Source (2)
The main sources of free sugars consumed by children are:
soft drinks and fruit drinks

cereal and cereal products
sugar, preserves and confectionery (6)
In contrast there has been little change in the intake of fruit and vegetables over the past decade which provide a healthy alternative to
free sugars. All age and sex groups have an average intake of fruit and vegetables below the minimum recommendation of having ‘At
least 5 A Day’ (5). Thus, healthier eating advice should routinely be provided to promote good oral and general health for patients.
The main impact of the consumption of sugar-containing foods and drinks to oral health is dental caries in both adults and children;
however, there is some evidence of dietary links with tooth wear and cancers.
Sugar consumption and dental caries

Sugar intake and the frequency of intake of sugars is particularly relevant for dental caries. The Stephan curve of pH in the oral cavity
demonstrates why frequency is important. It illustrates how demineralisation (area coloured yellow) of tooth surfaces occurs after every
sugar intake and the subsequent drop in pH that takes place in the mouth as oral bacteria convert sugar to acid (Figure 10.4a). This
process stops as the buffering action of saliva returns the pH to normal (20 to 40 minutes). Saliva production varies across a 24-hour
day, being stimulated at mealtimes whereas it is much reduced during sleep.
The impact of frequent sugar intakes is illustrated in Stephan’s curve in Figure 10.4b. In this case sugar intakes are experienced on
many occasions during the day, so demineralisation occurs more often and the time between drops in pH is not long enough for
effective remineralisation to take place. When sugar intakes are spaced some hours apart, there is a good opportunity for
remineralisation, which is also more effective in the presence of fluoride.

Figure 10.4. Effect of repeated sugars consumption on plaque biofilm pH. Reproduced from Chestnutt IG, Dental Public Health at a
Glance, Wiley Blackwell, with permission. (a) The pH of fluid in the plaque biofilm falls rapidly on eating sugar (within one minute).
Slowly recovers over 20 to 40 minutes as pH rises due to buffering and washing effect of saliva, sugar used up. (b) Repeated intakes of
sugar mean that pH remains for prolonged period below the point which favours demineralisation.
Prospective cohort studies conducted in children and adolescents indicate that higher consumption (that is, the amount) of sugars,
sugar-containing foods and sugar-sweetened beverages is associated with a greater risk of dental caries in the deciduous and
permanent dentitions (1). There is less available evidence on adults (7). A higher frequency of consumption of free sugar-containing
foods and beverages, but not total sugars, is also associated with greater risk of dental caries in the deciduous and permanent
dentitions (1). There is evidence that drinking sugar-sweetened beverages on a daily basis is related to greater dental caries risk in
adults (8).
Recommendations to prevent tooth decay are as follows:
minimise the amount and frequency of consumption of sugar-containing foods and drinks
avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced, and buffering capacity is reduced
All food and drink containing sugars should be consumed as part of a meal and not as a between-meal snack. It is important to
recognise that honey, fruit smoothies, fresh fruit juice and dried fruit all contain cariogenic sugars and should not be consumed as a
between-meal snack. Neither should fruit in sugary syrup. Fresh fruit (or alternatively frozen fruit, or fruit canned in juice) are
recommended snacks between meals.
Fizzy drinks, soft drinks, juice drinks and squashes sweetened with sugar have no place in a child’s daily diet (1).
Most free sugars in the diet are contained in processed and manufactured foods and drinks. Consumers should check labels carefully
to find out how much sugar a product contains. NHS Eatwell (https://www.nhs.uk/live-well/eat-well/top-sources-of-added-sugar/) (9),
Change4Life (https://www.nhs.uk/change4life) (10), and the Change4Life food scanner App are helpful resources.
Similar messages should be reinforced throughout life and this is particularly important as people enter later life when diet and health
behaviours change, and risks increase under a variety of influences.
Diet and cancer

As a population, we would benefit from eating a variety of fruit and non-starchy vegetables, consuming at least 5 portions per day.
Whilst there is evidence that those whose diets are low in fresh fruit and vegetables have a moderately increased risk of cancers in
general (11), there is little evidence that poor diet is a risk factor for oral cancer, compared with using tobacco and particularly when
tobacco and alcohol consumption are combined.

Diet and tooth wear

In general, patients should be encouraged to eat a healthy balanced diet. Only where there is evidence of tooth wear should possible
dietary risk factors be identified and patients advised to reduce the frequency of intake of acidic foods or drinks; keep acidic food and
drinks to mealtimes and explore alternatives, particularly between meals. It is also important to advise against methods of drinking that
promote tooth wear such as swilling and swishing.
General good dietary practice guidelines

Below are some of the main healthy eating messages aimed at helping people make healthier dietary choices.
The 2 most important elements of a healthy diet include:
eating the right amount of food, relative to how active a person is to be a healthy weight
eating a range of different types of foods in line with the Eatwell Guide (https://www.gov.uk/government/publications/the-eatwell-guide)
The Eatwell Guide (https://www.gov.uk/government/publications/the-eatwell-guide) (12) is a key tool that defines the government’s
recommendations on a healthy diet for children and adults. Of note the guide contains lots of flexibility for culturally diverse foods. It
does not apply to children under 2 years of age because they have different nutritional needs. Furthermore, between the ages of 2 and
5 years, children should gradually move to eating the same foods as the rest of the family, in proportions shown in the Eatwell Guide
(https://www.gov.uk/government/publications/the-eatwell-guide). It makes healthy eating easier to understand by providing a visual
representation of the proportions in which different types of foods are needed to have a well-balanced and healthy diet. The proportions
shown are representative of food consumption over the period of a day, or even a week, not necessarily each mealtime. A balanced
diet contains foods from all 5 major food groups.
The Eatwell Guide (https://www.gov.uk/government/publications/the-eatwell-guide) encourages us to:
eat at least 5 portions of a variety of fruit and vegetables every day

base meals on potatoes, bread, rice, pasta and other starchy carbohydrates, choosing wholegrain versions where possible
have some dairy or dairy alternatives (such as soy drinks); choosing lower fat and lower sugar options
eat some beans, pulses, fish, eggs, meat and other proteins (including 2 portions of fish every week, 1 of which should be oily)
choose unsaturated oils and spreads and eat in small amounts
drink 6 to 8 cups or glasses of fluid a day
if consuming foods and drinks high in fat, salt or sugar, have these less often and in small amounts
Key messages for a healthier diet

Whilst those at higher risk of disease may require specific advice, everyone has the potential to benefit from a healthier diet. You may
find it helpful to refer patients to the Eatwell Guide booklet (https://www.gov.uk/government/publications/the-eatwell-guide), which is available
online, as this can be emailed to patients (13).
Eat at least 5 portions of a variety of fruit and vegetables every day
Eat at least 5 portions of a variety of fruit and non-starchy vegetables every day. Starchy vegetables such as potatoes only count
towards carbohydrate intake. A portion of fruit or vegetables is 80g. Fresh, frozen, canned, dried and juiced all count. One portion of
dried fruit is only 30g which could be 3 dried apricots or one tablespoon of raisins. It is important to limit fruit juice and smoothies to a
combined total of 150ml per day. Just one portion of fruit juice or smoothie (150ml) counts as one of (at least) 5-a-day.
There is evidence to suggest that people who eat lots of fruit and vegetables are less likely to develop chronic diseases such as
coronary heart disease and some types of cancer.
Potatoes, bread, rice, pasta and other starchy carbohydrates
Base meals on starchy carbohydrates, including potatoes, bread, rice and pasta. Choose wholegrain varieties, or keep the skins on
potatoes, for more fibre, vitamins and minerals.
Dairy and alternatives
Eat some dairy or dairy alternatives but choose lower fat options when possible. For products such as yoghurt, people should be
encouraged to check the label and choose those lower in fat and sugars.
Beans, pulses, fish, eggs, meat and other proteins
Eat some beans, pulses, fish, eggs, meat and other proteins. Eat at least 2 portions (2 x 140g) of fish each week, one of which is oily.
Limit processed meats such as sausages, bacon and cured meats. People who eat more than 90g per day of red or processed meats
should try to reduce the amount to no more than an average of 70g per day.
Oils and spreads

People should be encouraged to use these products sparingly as they are high in fat. Cutting down on these types of foods could help
to control your weight as they are high in calories.
Foods high in fat, salt and sugar
These foods are not required as part of a healthy, balanced diet. If included, they should only be consumed infrequently and in small
amounts. Most people need to cut down on the amount of high fat, salt and sugar-containing foods and drinks consumed.
Cut down on saturated fat
Cutting down on saturated fat can lower blood cholesterol and reduce the risk of heart disease. Most people in the UK eat too much
saturated fat. An average man should have no more than 30g saturated fat a day. The average woman should have no more than 20g
saturated fat a day. Children should have less saturated fat than adults. A low-fat diet is not suitable for children under 5 years.
One of the easiest ways to cut down on saturated fat is to compare the labels on similar products and choose the one lower in
saturated fat. Patients should be encouraged to watch out for foods that are high in saturated fat, including fatty cuts of meat, sausages,
butter, cream, cheese, chocolate, pastries, cakes and biscuits. It is not necessary to stop eating these foods altogether; but eating too
much of these can result in people having more than the recommended maximum amount of saturated fat.
Cut down on the amount and frequency of sugar containing foods and drinks
As stated earlier in this chapter, recommendations in order to reduce dental caries advocate minimising or reducing the amount and
frequency of sugar-containing foods and drinks. Regularly consuming foods and drinks high in free sugars increases the risk of dental
caries and obesity. Ideally, no more than 5% of total energy intake should come from free sugars.
All patients and, in the case of children, their parents, are encouraged to ‘sugar swap (https://www.nhs.uk/change4life/food-facts/sugar/sugar-
swaps-for-kids)’. It is particularly helpful to swap drinks containing free sugars for water, lower fat milk or sugar-free alternatives, including
tea and coffee. Alcohol has a high calorific content and limiting its intake to within 14 units per week helps keep health risks low for both
men and women (14). When advising adults, do also highlight the sugar and calories in alcoholic as well as non-alcoholic drinks.
Cut down on salt
Eating too much salt can raise blood pressure, which increases the risk of developing heart disease or stroke. Adults should eat no
more than 6g of salt a day (6g of salt is about a teaspoonful) and children should have less salt. Most of the salt eaten is already in
everyday foods such as bread, breakfast cereal, pasta sauce, soups and starchy snacks.
Drink plenty of fluids
Drinking about 6 to 8 glasses of fluids every day is recommended to prevent dehydration. Water, lower fat milk and sugar-free drinks
including tea and coffee all count. Fruit juices and smoothies count towards fluid consumption but are a source of free sugars and so
consumption should be limited to no more than a combined total of 150 ml a day and consumption with meals should be recommended.
Changing to a healthier diet

There is very little reliable evidence available to draw conclusions about the effects of dietary interventions in the dental setting for
reducing sugar consumption or making other beneficial dietary changes. This reflects the paucity of high quality research in the field;
however, more promising results are emerging as outlined below:
1. A systematic review suggests interactive dietary counselling with 11 to 12 year olds may increase their use of xylitol products (15),
as an alternative to free sugar.
2. A trial involving a tailored 30-minuted structured conversation with parents and children (5 to 7 year olds) who required extraction
of primary teeth due to dental caries, achieved promising results in caries management (16). This trial, informed by motivational
interviewing, aiming to prevent future dental caries, involved setting preventive goals and having a review appointment with the
child’s general dental practitioner, who was advised to treat the child as being at high dental caries risk (16).
When giving dietary advice to minimise consumption of sugars, it is good practice to assess the overall pattern of eating to establish the
following information:
the number of intakes of food and drinks per day

the number of intakes that contain sugars and how many were consumed between normal mealtimes
whether any intakes containing sugars were taken before bedtime – this is important as reduced salivary flow overnight reduces
dental caries protective effects
An example of one type of diary (https://khub.net/documents/135939561/516396401/Example+of+a+diet+diary.pdf/ad68124b-edf1-7fa3-71f4-

02e81149f5f1) is available to download.
Overall, it is important to use contemporary theory and evidence on behaviour change in general to inform preventive practice as
explored further in Chapter 3 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-3-behaviour-change). A diet modification approach should be used in conjunction with actions to increase fluoride
availability. However, lowering the amount and frequency of free sugars consumed will have wider health benefits, preventing weight
gain and obesity which in turn will reduce the risk of heart disease, type 2 diabetes and some cancers.
Diet in the early years
Breastfeeding
Breastfeeding makes an important contribution to infant and lifelong health and represents the physiological norm for infant feeding for
around the first 6 months of life. It provides the best start in life and continuing breastfeeding beyond 6 months
(https://app.box.com/s/1vywgq45v82s0u23rvomip2epttob8be) has beneficial effects for both mother and child. The additional benefits for
infants include a reduced risk of dental caries (17 to 19), and being less likely to develop malocclusions compared with ‘never breastfed’
children (20).
Infants should be exclusively breastfed for around the first 6 months of life (21) (Chapter 2: Table 1
(https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-2-summary-guidance-
tables-for-dental-teams#table1)). The available evidence indicates that breastfeeding up to 12 months of age is associated with a
decreased risk of dental caries and may offer some protection when compared with infant formula (18). The evidence on breastfeeding
after one year is not straightforward because much of the research is observational and does not adjust for confounders such as dietary
factors, oral hygiene practices and use of fluoride containing products. Further well-designed research is needed (17, 22).
Once teeth begin to appear, parents may raise the dilemma of when to brush a child’s teeth if they fall asleep at the breast. Parents
should be encouraged to brush childrens’ teeth as close to bedtime as possible and follow the general guidelines, rather than wake a
child to brush their teeth.
Bottle feeding
Families may choose to bottle feed their babies or mothers may be unable to breastfeed. They should be supported if, after being given
advice, information and support, they opt to bottle feed using formula milk. Only breast milk, infant formula or cooled boiled water
should be given in a bottle. Sugar, honey or any other sugar-containing products or drinks must not be added to bottles. From the age
of 6 months babies should be encouraged to drink from a free-flow cup (rather than one with a valve which requires a child to suck) and
feeding from a bottle should be discouraged from the age of one year (20).
Infant feeding: Moving on to solids
Children’s food preferences and eating habits are formed early in life and so it is important to support the development of healthy eating
habits in young children. From around 6 months, infants should be introduced to a wide range of foods, including iron-containing foods,
in an age-appropriate form and at a time and in a manner to suit both family and individual child (13). The transition to include solid
foods should occur when infants are developmentally ready. Solids should be introduced alongside continued breastfeeding or infant
formula; these, and water, should be the only drinks offered as infants move on to solids (20).
A wide variety of solid foods with different flavours and textures should gradually be introduced to diversify the infant diet and to help
ensure nutritional requirements are met. Examples of first solid foods include blended, mashed, or soft-cooked vegetables (for example
parsnip, broccoli, potato, yam, sweet potato, carrot) and fruit (for example apple or pear). Batons (sticks) of vegetables provide healthy
‘finger food’ as children begin to feed themselves. Example menus for early years settings provide lots of practical menu suggestions
(24), along with the Start4Life website (https://www.nhs.uk/start4life) (25). It is important to encourage parents to try a range of healthy
foods with children to find which ones they enjoy. This way parents can establish the basis of healthy eating in life.
Commercial baby foods
Commercial baby foods and drinks aimed at children up to 36 months may provide infants’ first non-milk taste experiences and form a
substantial proportion of their diet. Labelling may be confusing for parents particularly when the terms natural or organic sugars are
used – they are still cariogenic. A recent review found that there are inconsistencies between national recommendations on infant and
young child feeding and the types of products available, their ingredients, nutrition composition and product labelling and marketing
(26).
Some commercial baby foods have added sugar or salt or contain ingredients that are high in sugar or salt. This is more common in
commercial baby finger-foods, which are often marketed as snacks. Sweet finger foods (including biscuits, wafers, puffs, bars, bites,
fruit shapes) make up two-thirds of the baby finger-food market.
The highest sugar content is found in processed dried fruit products, which are often marketed as ‘healthy snacks’ due to their fruit
content, but the sugar in these products is often free sugars as they contain ingredients such as fruit juices, purees and concentrates.
Fruit and vegetables are recommended first foods for infants and young children. Advice is to start feeding infants with single
vegetables and fruits, and vegetables that are less sweet. However, the balance of products on the market is mainly fruit, particularly
mixed fruit; a less sweet product mix would better prepare babies to accept a wide range of different, less sweet tastes and protect
dental health.
More than one-third of baby meals are marketed at children under 6 months, despite government advice that solid foods should be
introduced (alongside breast milk or infant formula) at around 6 months of age.
Nearly three-quarters of fruit juice-based baby drinks are marketed at infants under 12 months, which is inconsistent with advice to offer
only breast milk, infant formula or water as drinks between 6 and 12 months of age.
Public Health England (2019) (26).
Feeding patterns and practices

Feeding practices are continually changing and raise questions for the oral healthcare team. When new products are introduced, you
may be required to give advice on products and practices for which there is not specific research evidence. As a helpful guide, it is
worth reflecting on their sugar content and the principles of sugar frequency and consumption. Recent examples which encourage
grazing include ‘nets’ or ‘pacifier-type’ feeding devices into which carers insert selected foods. Commercially produced ‘pouches’ of
food are increasingly common. Around one-third of commercial baby foods and drinks are packaged in pouches, many of which have
nozzles (26). Although some companies provide advice (on the back of the pack or website) on how to feed these products (from a
spoon), this is not consistent across the market. Whilst there is no specific research evidence of the impact for developing teeth it is
likely that these foods can be consumed ‘on the go’ and over longer periods of time; therefore, having prolonged contact with teeth and,
if sugar containing, more likely to increase the risk of dental caries. It is increasingly important to discuss how products are consumed
as well as their sugar content.
Bedtime routines
The importance of bedtime routines and defining what constitutes a bedtime routine have recently been the subject of professional
deliberations and research (27, 28). The frequency and amount of food and drinks containing free sugars should be as low as possible
in the first year of life (20). Only plain milk or water should be provided between meals for young children and baby juices or sugary
drinks discouraged, particularly at bedtime (20). A recent systematic review confirms a consistent positive association between caries
risk and free sugars ingestion around bedtime across three age-groups (3 to 5 years, 6 to 11 years, 12 to 16 years) (28). The certainty
of evidence was very low and that is perhaps not surprising, given the challenges of conducting this type of research. However, the
recommendation to avoid food and drinks containing free sugars before bedtime in children, (and, of course, overnight), is based on a
sound physiology and good practice for everyone.
Teething
A variety of interventions, gels and solutions are used by parents to manage teething, generally unsupported by clinical evidence (29).
However, it is important to note that some teething products may include sugar (29) and the Medicines and Healthcare products
Regulatory Agency (MHRA) has ensured that products should carry this warning (29). There is helpful information for parents on the
NHS website on a range of methods to manage teething including teething rings, painkillers, breadsticks and fresh fruit or vegetable
sticks. Tips for helping your teething baby (https://www.nhs.uk/conditions/baby/babys-development/teething/tips-for-helping-your-teething-baby/).
Vulnerable groups
Dietary advice for vulnerable groups experiencing medical, physical and mental health challenges needs to be tailored to their specific
circumstances (Chapter 4) (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-4-dental-caries) and may involve close working with colleagues across health and social care. It may require greater
use of protective factors including fluoride (Chapter 9) (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-
based-toolkit-for-prevention/chapter-9-fluoride).
Resources
The Eatwell Guide (https://www.gov.uk/government/publications/the-eatwell-guide).
Start4Life (https://www.nhs.uk/start4life): trusted NHS help and advice during pregnancy, birth and parenthood. Includes content on
breastfeeding and weaning.
Change4Life (https://www.nhs.uk/change4life): easy ways to eat well and move more. Includes content on sugar swaps for kids, food
labelling and quick and easy snack ideas.
WHO: breastfeeding (https://www.who.int/nutrition/topics/exclusive_breastfeeding/en/).
Feeding in the first year of life: SACN report (https://www.gov.uk/government/publications/feeding-in-the-first-year-of-life-sacn-report).
Commercial infant and baby food and drink: evidence review (https://www.gov.uk/government/publications/commercial-infant-and-baby-food-
and-drink-evidence-review): a report setting out the evidence for action on food and drink product ranges targeted at babies and young
children, and Public Health England (PHE)’s advice to government.
Infant feeding (https://www.gov.uk/government/publications/infant-feeding-commissioning-services): information to support the commissioning of

local infant feeding services.
NHS: tips for helping your teething baby (https://www.nhs.uk/conditions/baby/babys-development/teething/tips-for-helping-your-teething-baby/).
NHS: What to feed young children (https://www.nhs.uk/conditions/pregnancy-and-baby/understanding-food-groups/).
Snack ideas for children (http://www.child-smile.org.uk/parents-and-carers/healthy-snack-ideas.aspx).
Example menus for early years settings in England (https://www.gov.uk/government/publications/example-menus-for-early-years-settings-in-

england): example menus and useful guidance for early years settings to help meet the Early Years Foundation Stage requirements for
food and drink.
NHS: Food labelling (https://www.nhs.uk/live-well/eat-well/how-to-read-food-labels/).
Change4Life Food Scanner (https://apps.apple.com/gb/app/change4life-food-scanner/id1182946415).

PHE: Sugar Reduction Programme (https://publichealthengland.exposure.co/sugar-reduction-programme): progress made by industry in the
first year. Includes a suite of sugar and calorie reduction infographics.
References
1. SACN. Carbohydrates and health. London: TSO; 2015.
2. NHS. Change for life: Sugar (https://www.nhs.uk/change4life/food-facts/sugar). London: PHE; 2021.
3. Swan GE, Powell NA, Knowles BL, Bush MT, Levy LB. A definition of free sugars for the UK. Public Health Nutrition.
2018;21(9):1636-8.
4. Public Health England. National Diet and Nutrition Survey. London: Public Health England; 2020.
5. Public Health England, Food Standards Agency, NatCen, MRC. National Diet and Nutrition Survey: Years 1 to 9 of the Rolling
Programme (2008/2009 to 2016/2017): Time trend and income analyses. London: Public Health England; 2019.
6. Public Health England, Food Standards Agency, NatCen, MRC. National Diet and Nutrition Survey: results from years 7 and 8
(combined). London: Public Health England; 11 April 2018.
7. Bernabé E, Vehkalahti MM, Sheiham A, Lundqvist A, Suominen AL. The Shape of the Dose-Response Relationship between Sugars
and Caries in Adults. Journal of Dental Research. 2016;95(2):167-72.
8. Bernabé E, Vehkalahti MM, Sheiham A, Aromaa A, Suominen AL. Sugar-sweetened beverages and dental caries in adults: a 4-year
prospective study. Journal of Dentistry. 2014;42(8):952-8.
9. NHS. Eat well: Sugar the facts (https://www.nhs.uk/live-well/eat-well/top-sources-of-added-sugar/). London: NHS; 2018 [updated 29
January 2019].
10. NHS. Change4Life (https://www.nhs.uk/change4life). London: NHS; 2020.
11. Walsh T, Liu JLY, Brocklehurst P, Glenny AM, Lingen M, Kerr AR and others. Clinical assessment to screen for the detection of oral
cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database of Systematic Reviews. 2013(11).
12. Public Health England. The Eatwell Guide (https://www.gov.uk/government/publications/the-eatwell-guide). London: Public Health
England; 2016.
13. Public Health England. The Eatwell Guide booklet (https://www.gov.uk/government/publications/the-eatwell-guide). London: Public Health
England; 2016.
14. UK Chief Medical Officers’. UK Chief Medical Officers’ Low Risk Drinking Guidelines 2016. London: Department of Health England,
Welsh Government, Department of Health Ireland, Scottish Government; 2016 25.08.2016.
15. Harris R, Gamboa A, Dailey Y, Ashcroft A. One‐to‐one dietary interventions undertaken in a dental setting to change dietary
behaviour. Cochrane Database of Systematic Reviews. 2012(3).
16. Pine CM, Adair PM, Burnside G, Brennan L, Sutton L, Edwards RT and others. Dental RECUR Randomized Trial to Prevent Caries
Recurrence in Children. Journal of Dental Research. 2020;99(2):168-74.
17. Tham R, Bowatte G, Dharmage SC, Tan DJ, Lau MX, Dai X and others. Breastfeeding and the risk of dental caries: a systematic
review and meta-analysis. Acta Paediatricia. 2015;104(467):62-84.
18. Avila WM, Pordeus IA, Paiva SM, Martins CC. Breast and Bottle Feeding as Risk Factors for Dental Caries: A Systematic Review
and Meta-Analysis. PLoS One. 2015;10(11):e0142922.
19. Cui L, Li X, Tian Y, Bao J, Wang L, Xu D and others. Breastfeeding and early childhood caries: a meta-analysis of observational
studies. Asia Pacific Journal of Clinal Nutrition. 2017;26(5):867-80.
20. SACN. Scientific Advisory Committee on Nutrition (SACN) Feeding in the first year of life. London: TSO; 2018.
21. World Health Organization. Breastfeeding. Geneva: WHO; 2019.
22. Peres KG, Nascimento GG, Peres MA, Mittinty MN, Demarco FF, Santos IS and others. Impact of Prolonged Breastfeeding on
Dental Caries: A Population-Based Birth Cohort Study. Pediatrics. 2017;140(1).
23. Public Health England. Breastfeeding and dental health (https://www.gov.uk/government/publications/breastfeeding-and-dental-

health/breastfeeding-and-dental-health). London: PHE; 2019 [updated 30 January 2019].
24. HM Government. Examples Menus for Early Years Settings. London; 2017.
25. NHS. Start4Life (https://www.nhs.uk/start4life). London: NHS; 2020.
26. Public Health England. Commercial infant and baby food and drink: evidence review. London: PHE; 2019.
27. Kitsaras G, Goodwin M, Allan J, Pretty IA. Defining and measuring bedtime routines in families with young children – A DELPHI
process for reaching wider consensus. PLOS ONE. 2021;16(2):e0247490.
28. Baghlaf K, Muirhead V, Moynihan P, Weston-Price S, Pine C. Free Sugars Consumption around Bedtime and Dental Caries in
Children: A Systematic Review. Journal of Dental Research Clinical Translational Research. 2018;3(2):118-29.
29. Monaghan N. Teething issues. British Dental Journal. 2019;227(10):883.

11/19/21, 8:33 PM Chapter 11: Smoking and tobacco use - GOV.UK
GOV.UK

Department
of Health &
Office for Health
Improvement
Guidance
Chapter 11: Smoking and tobacco use
Contents
Smoking in the UK
Chewing tobacco and other tobacco products
Effective interventions to support patients to quit smoking
Implementation and delivery in dental practice
Resources
References

https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-11-smoking-and-toba… 1/13

prevention/chapter-11-smoking-and-tobacco-use

Smoking in the UK
Smoked tobacco in the form of cigarettes, pipes and cigars, together with all other forms of tobacco, present a major risk to oral health.
The overall goal of the dental team is to help eliminate all forms of tobacco use. It’s worth highlighting at the outset that much of the
tobacco research has been conducted in relation to cigarette smoking in adults and therefore this may be reflected in the terminology
used, where evidence is presented in the summary tables (Chapter 2: Table 3 (https://www.gov.uk/government/publications/delivering-better-
oral-health-an-evidence-based-toolkit-for-prevention/chapter-2-summary-guidance-tables-for-dental-teams#table3)) and in the text below.
Despite fewer people smoking, it remains the leading cause of preventable death and disease in the UK (1). Between 2016 and 2018,
77,600 deaths were attributable to smoking per year in England with comparable estimates of 5,000 deaths each year in Wales, 10,000
in Scotland and 2,300 in Northern Ireland (1). Furthermore, exposure to second-hand smoke (passive smoking) can lead to a range of
diseases, many of which are fatal, with children especially vulnerable to the effects of passive smoking (2).
Smoking and other forms of tobacco have a significant impact on ill health and health inequalities. Tobacco use, including both smoked
and smokeless tobacco, seriously affects oral health as well as general health. The most significant risk is for oral cancer and pre-
cancer. It is also the most common risk factor for periodontal disease.
In 2019, amongst adults in the UK:
14.1% were current smokers (6.9 million) with the population of England reporting lower levels (13.9%) compared with Northern
Ireland (15.6%) Wales (15.5%) and Scotland (15.4%)
15.9% of men smoked compared with 12.5% of women
younger adults (aged 25 to 34 years) continued to have the highest proportion of current smokers (19.0%)
prevalence was 2.5 times higher in people in routine and manual occupations than in people in managerial and professional
occupations: whereas around 1 in 4 people (23.2%) in routine and manual occupations smoked, compared with just 1 in 10 people
(10.2%) in managerial and professional occupations
since 2014, there have been statistically significant declines in the proportion of current smokers among all socio-economic
groups; however, inequalities have increased
most people take up smoking in their teens or early twenties
Source: Office for National Statistics (ONS), 2020

(https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/201
9).
The prevalence of smoking also varies within countries (https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-women-s-

smoking-status-at-time-of-delivery-england/statistics-on-women-s-smoking-status-at-time-of-delivery-england-quarter-3-2017-18), and changes over
time so it may be helpful to check local rates for your area as listed in the resources at the end of this section.
Smoking rates in people with alcohol and other drug dependencies are 2 to 4 times those of the general population (4).
Smokers are less likely to report having very good health

8) (3), when compared with those who have never smoked (1, 5); reporting bad or very bad general health was more than 2.5 times as
common in current smokers than those who have never smoked (12.2% and 4.7%, respectively) (5).
In Great Britain, more than half (52.7%) of people aged 16 years and above who currently smoked said they wanted to quit
9) and 62.5% of those who have ever smoked said they had quit (1). Most cigarette smokers report that they would like to stop and
make many attempts to quit. Currently, around half of all smokers quit using willpower alone (6). However, receiving support can greatly
increase a person’s chances of quitting successfully.
People are 3 times as likely to quit successfully if they use a combination of stop smoking aids (including e-cigarettes) together with
specialist help and support (https://www.nhs.uk/smokefree/help-and-advice) (6, 7).
Supporting smokers in contact with the healthcare system to quit is a prevention priority in the NHS Long Term Plan
(https://www.longtermplan.nhs.uk/) and every health care professional has a role to play (https://www.gov.uk/government/publications/e-
cigarettes-and-heated-tobacco-products-evidence-review/evidence-review-of-e-cigarettes-and-heated-tobacco-products-2018-executive-summary) (8
to 10).

Recent research evidence has focused on interventions during hospital care. A Cochrane Review by Rigotti and others
(https://pubmed.ncbi.nlm.nih.gov/22592676/) (11) found that hospital based stop smoking interventions that begin during a hospital stay and
include counselling with follow-up support for at least one month after discharge are effective in increasing quit rates. Such programmes
are effective when administered to all hospitalised smokers, regardless of their reason for admission. Adding nicotine replacement
therapy (NRT) to a counselling programme increases the success rate (https://pubmed.ncbi.nlm.nih.gov/22592676/) of a programme for
hospitalised smokers (11). Hospital based programmes that include behavioural support, pharmacotherapy and follow-up have also
been shown to reduce all-cause re-admissions and mortality (https://pubmed.ncbi.nlm.nih.gov/27225016/) at one and 2-year follow-up (12).
As many of the adverse effects of tobacco use on the oral tissues are reversible, stressing their impact on oral health may provide a
useful means of motivating patients to quit. Quitting smoking is the best thing a smoker can do for their health, and the benefits of
stopping begin almost immediately.
The greatest benefits to oral health relate to preventing periodontal diseases (Chapter 5
(https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-5-periodontal-diseases))
and oral cancer (Chapter 6 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention/chapter-6-oral-cancer)). The most significant harms of tobacco use on the oral cavity are oral cancers and pre-cancers,
increased severity and extent of periodontal diseases, tooth loss and poor wound-healing post-operatively (13, 14). Reducing tobacco
use (https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/) is a key priority for the NHS across the 4 nations of the
UK.
Chewing tobacco and other tobacco products

Dental team members should be aware of the various alternative forms of tobacco and alternative forms of use such as chewing rather
than smoking and that these are associated with oral cancer (https://pubmed.ncbi.nlm.nih.gov/25411778/), other oral pathologies and
negative health effects (15). Data on the use of other tobacco products within the UK is more limited than smoking; however, a recent
oncology paper (https://pubmed.ncbi.nlm.nih.gov/30942182/) highlights that the use of smokeless tobacco is becoming a global concern
(16). Smokeless tobacco is responsible for a large number of deaths worldwide with the South East Asian region bearing a substantial
share of the burden (https://pubmed.ncbi.nlm.nih.gov/27903956/) (17).
The use of betel quid (paan) with areca nut, with or without the addition of smokeless tobacco, is especially common within South Asian
culture and mouth cancer is very common in the Indian sub-continent (18). Its social and cultural use is observed across the UK
(https://pubmed.ncbi.nlm.nih.gov/18620935/) (19), with some evidence that it is impacting on the risk
(https://pubmed.ncbi.nlm.nih.gov/27185184/) of oral cancer (20, 21).
Shisha smoking (also known as hookah, water pipe, narghile or hubble bubble) is a traditional method of tobacco use, especially in the
Eastern Mediterranean region, but its use is observed across the world. Many people wrongly perceive waterpipe smoking as less
harmful than smoking because of the perception that water filters out the harmful substances in the smoke. However, it’s associated
with many of the same risks as cigarette smoking. Like smoking, shisha smoking produces significant levels of noxious chemicals
(https://pubmed.ncbi.nlm.nih.gov/30609154/) including tar, carbon monoxide (CO), nitric oxide and various carcinogens
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7546025/) (22, 23).
Nasal snuff made from pulverised tobacco leaves is a dry form of tobacco which is inhaled or ‘snuffed’ into the nasal cavity. Moist snuff
typically used in Scandinavia is known as Snus. Snus can be loose or pre-packaged in small teabag-like sachets. Other countries have
different forms of dried or moist tobacco (https://www.fda.gov/tobacco-products/products-ingredients-components/smokeless-tobacco-products-
including-dip-snuff-snus-and-chewing-tobacco) used for sniffing, dipping or chewing (24, 25). Chewed tobacco comes in a number of forms,
loose-leaf, dip, plug, twist and chew bags.
New products are continually emerging such as ‘Heat-not-burn’ tobacco products (HnB); these are electronic devices that heat process
tobacco instead of combusting it to supposedly deliver an aerosol with fewer toxicants than in cigarette smoke (26). Evidence is
primarily drawn from tobacco industry data and lacks research on long-term HnB use effects on health (26).
All forms of tobacco that are legal in the UK present an oral cancer risk
(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005549.pub3/full) and users of tobacco in any form can be helped to quit
through smoking cessation interventions (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005084.pub3/information) (27 to 29).
It’s important to ask people if they use smokeless tobacco, using the names that the various products are known by locally. If
necessary, show them a picture of what the products look like (https://untobaccocontrol.org/kh/smokeless-tobacco/paan-betel-quid-
tobacco/#lal), using visual aids (28) as shown below (Figure 11.1), or by using this link (https://untobaccocontrol.org/kh/smokeless-
tobacco/paan-betel-quid-tobacco/#lal).

Figure 11.1: Nicotine tobacco products adapted from City of Bradford MDC
Common names for products containing tobacco include:
waterpipes, shisha, hookah, hubble-bubble (containing tobacco and flavourings)

zarda (tobacco often added to paan)
gutkha (processed tobacco with added sweeteners)
scented chewing tobacco (tobacco with added flavours)
naswar, nas, niswar (tobacco with slaked lime, indigo, cardamom, oil, menthol, water)
chillam (heated tobacco)
paan (tobacco, areca nut or ‘supari’, slaked lime, betel leaf)
snuff, snus (powdered or ground tobacco)
khaini (tobacco, slaked lime paste, sometimes areca nut)
This may be necessary if the person’s first language does not include English or if the terms are unfamiliar. Although there has been
less research on smokeless tobacco use (https://www.nice.org.uk/guidance/ph39), a similar approach to delivering very brief advice is
recommended (Table 2.3) for patients who are users (30). Advising of the health risks, using the same brief intervention and referring
patients who want to quit to specialist support services is recommended. The outcome then needs to be recorded in the patient notes,
as with all tobacco use.
Effective interventions to support patients to quit smoking

Healthcare practitioner advice, provided across a variety of healthcare settings, helps people stop smoking
(https://pubmed.ncbi.nlm.nih.gov/23152200/) (31).
Research suggests (https://pubmed.ncbi.nlm.nih.gov/2792621/) that 95% of patients expect to be asked about smoking and a short
intervention can make all the difference (32). Smokers are more likely to expect to be asked about tobacco use
(https://pubmed.ncbi.nlm.nih.gov/22399549/) and recognise the need to change than people with other risk behaviours (33).
Dental teams are in a unique position to provide opportunistic advice to many ‘healthy’ people who need professional support to stop
their tobacco use and reduce their risk of oral disease. The first stage is to establish if the patient is a smoker, of any form of tobacco.
Dental teams across primary care, community and hospital services routinely investigate tobacco use as part of standard patient care.
Advice can then be given about effective methods of quitting smoking involving behavioural and pharmacological approaches as
outlined in Figure 11.2: Very brief advice pathway: 30 second discussion
(https://khub.net/documents/135939561/516396401/smoking+pathway.png/143e2360-8d5a-56e9-2310-f444b42764af).

Very Brief Advice
Very Brief Advice (VBA) from the dental team (https://pubmed.ncbi.nlm.nih.gov/22175545/) (28, 29, 34), as outlined in the evidence tables
(Chapter 2, Table 3 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-2-
summary-guidance-tables-for-dental-teams)), has been shown to increase a patient’s motivation to quit
(https://pubmed.ncbi.nlm.nih.gov/22696348/) and can double a patient’s success with quitting smoking (28, 29). Dental professionals can
successfully deliver tobacco cessation interventions (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005084.pub4/full) to
increase the chances of achieving long‐term tobacco‐use abstinence; this includes single and multi‐session behavioural support, and
behavioural support with the addition of NRT or e‐cigarettes (29). Many people will, however, need VBA on a number of occasions
before they are ready to act. Keep asking and advising because it will make a difference (https://www.e-lfh.org.uk/programmes/alcohol-and-
tobacco-brief-interventions/) (35).
Ask about smoking
All patients (adolescents and adults) should have their smoking status (current smoker, ex-smoker, never smoked) established at the
beginning of a course of dental care, recorded, and checked at every opportunity. This is part of a normal medical history routine in a
dental setting and should be explored during the consultation.
Do you smoke?
The member of the dental team who elicits this information should ensure this information is recorded in the patient’s clinical notes.
For those with or at risk of oral disease, most notably oral cancer, pre-cancer or periodontal disease, due to smoking or tobacco use, it
is important to give VBA.
Advise on the best way of quitting
Inform patients that the best way of quitting is with a combination of specialist support and medication
(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008286.pub3/full) (36).
Advice involves making a simple statement such as:
The best way to stop smoking is with a combination of behavioural support and stop smoking aids, which can significantly
increase the chance of stopping.
Medications that improve the chances (https://pubmed.ncbi.nlm.nih.gov/27734465/) of adults quitting smoking include combination nicotine
replacement therapy (NRT) (https://pubmed.ncbi.nlm.nih.gov/27158893/), varenicline, and bupropion (37 to 40).
E-cigarettes or vapes are not risk free but are far less harmful than cigarettes and there is growing evidence
(https://www.nice.org.uk/guidance/ng92) that they can help smokers to stop smoking (41 to 43).
The traditional approach to advice has been to warn a smoker of the dangers of smoking and advise them to stop. This is deliberately
left out of VBA for 2 reasons: first, it can immediately create a defensive reaction and raise anxiety levels and, second, it takes time and
can generate a conversation about smoking use, which is more appropriate during a dedicated stop smoking consultation.
Act according to the patient’s motivation
For those who wish to stop, refer to specialist support services where these are available (42). If not available, it will be important to
actively refer (not signpost) them to their GP or pharmacist:
Would you like me to refer you for specialist stop-smoking advice and support?
For those who are not ready to stop, affirm that this opportunity will remain open to them with:
That is fine, but help is available. Let me know if you change your mind.
A summary of the smoking-pathway (https://khub.net/documents/135939561/516396401/smoking+pathway.png/143e2360-8d5a-56e9-2310-

f444b42764af), which is useful for all forms of tobacco, is presented in Figure 11.2.
Harm reduction
Ceasing smoking reduces harm, ideally stopping permanently, or temporarily for example preceding an operation. Other people may
reduce in stages and then stop. People who are not ready or willing to stop smoking completely may wish to consider using a nicotine-
containing product to help them reduce their smoking en route to harm reduction. Dental team members should familiarise themselves
with the NICE guidance on Smoking: harm reduction (https://www.nice.org.uk/guidance/ph45) (44) and the recommendations in NICE
Guidance NG92 (https://www.nice.org.uk/guidance/ng92) (42. Almost all of the harm from smoking is caused by other components in
tobacco smoke, not by the nicotine. Smoking is highly addictive, largely because it delivers nicotine very quickly to the brain and this
makes stopping smoking difficult. Nicotine-containing products are an effective way of reducing the harm from tobacco for both the
person smoking and those around them. It is less harmful to use alternative nicotine-containing products
(https://pubmed.ncbi.nlm.nih.gov/27734465/) than to smoke (40).
Local services

Expert support from local stop smoking providers, combined with the use of stop smoking aids gives smokers the best chance of
quitting for good. Depending on the area, services can be based in a range of settings including integrated lifestyle services, community
pharmacies and GP surgeries further information can be found on the NHS website (https://www.nhs.uk/better-health/quit-smoking/).
Stop smoking support is free (with the exception of prescription charges where applicable) and offers a choice of one-to-one or group
behavioural support from a trained stop smoking advisor together with pharmacotherapy. Smokers who receive this package of support
are 3 times as likely to quit successfully as those who try to quit unaided or with over the counter NRT.
Dental team members should find out what specialist stop smoking providers (https://www.nhs.uk/better-health/quit-smoking/) (ideally local
stop smoking support) are available locally for their patients. Referral to local providers for support can be made quicker and easier by
adding a template into your existing data management system.
Where none is available then patients should be directed towards their GP or pharmacist. Furthermore, it is helpful to be aware if there
are specific local programmes such as voucher schemes for pregnant women to stop smoking, given that dental care is free during
pregnancy this presents an ideal opportunity to support smoking cessation. A trial conducted in one centre showed that women in
Glasgow were 2.63 times more likely not to be smoking at the end of pregnancy when incentives were provided for supported smoking
cessation (https://www.bmj.com/content/350/bmj.h134) (45).
Overview of quitting methods
1. Local stop smoking services
They offer the best chance of success. Combining stop smoking aids with expert behavioural support makes someone 3 times as likely
to quit as using willpower alone.
2. Using a stop smoking medicine
A stop smoking medicine prescribed by a GP, pharmacist or other health professional doubles a person’s chances of quitting.
3. Using over-the-counter nicotine replacement
NRT such as patches, gum or e-cigarettes makes it one and a half times as likely a person will succeed.
4. Using willpower alone
This is the least effective method.
Figure 11.3. Quitting methods

Pharmacotherapy
Pharmacotherapy is particularly effective when used in conjunction with behavioural support. Many of these products are available over
the counter in a pharmacy or other retail outlets.
Most of the research involves adults and is related to cigarette smoking. Whilst the dental team may not be involved in prescribing
these products, patients may choose to either obtain them elsewhere on prescription or purchase them. So it is helpful to be aware of
the evidence (https://www.gov.uk/government/publications/health-matters-stopping-smoking-what-works/health-matters-stopping-smoking-what-
works) and to boost patients’ confidence in using them.
NRT, varenicline and bupropion have all been shown to improve the chances of quitting smoking in adult smokers.
Evidence suggests that:
combination NRT (a patch combined with a fast-acting product) or varenicline are equally effective as quitting aids
(https://pubmed.ncbi.nlm.nih.gov/23728690/) (38)
all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets or lozenges) can help
people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting
(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000146.pub5/full) by 50% to 60%, regardless of setting (46)
combination NRT is more effective with regard to long term quit rates
(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013308/full) than a single form of NRT in adults who are motivated to quit
(39)
higher dose (21 mg/24-hour) nicotine patches result in higher quit rates
(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013308/full) than lower dose (14 mg/24-hour) nicotine patches in those
motivated to stop smoking (39)
there is no evidence of a difference (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013308/full) between fast-acting
NRT, such as gum and lozenge, and nicotine patches in those motivated to stop smoking (based on high quality evidence) (39)
varenicline may be more effective (https://pubmed.ncbi.nlm.nih.gov/27158893/) than bupropion with regard to quit rate and relapse (37)
varenicline improves abstinence compared with bupropion or NRT, however it is more likely than placebo to lead to nausea,
insomnia, abnormal dreams, headaches and serious adverse events. The lack of comparative adverse effects assessment of
varenicline with bupropion or NRT means that firm conclusions of the overall comparative effects
(https://www.cochranelibrary.com/cca/doi/10.1002/cca.1502/full) of these interventions cannot be drawn (47)
NRT may increase the chances of quitting during pregnancy however, evidence is low certainty
(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010078.pub3/full) (48). There is no evidence that NRT is harmful in
pregnancy and licensed NRT medication is routinely used to aid cessation
Whilst patients may be prescribed varenicline or bupropion, the drug of choice is most likely to be varenicline
(https://www.uptodate.com/contents/pharmacotherapy-for-smoking-cessation-in-adults) unless there are medical contra-indications (49).
Varenicline reduces cravings for nicotine (https://www.gov.uk/government/publications/smoking-and-tobacco-applying-all-our-health/smoking-and-
tobacco-applying-all-our-health) by blocking the reward pathway and by reinforcing effects of smoking which take place in the brain (50).
Bupropion (Zyban) reduces urges to smoke (https://www.gov.uk/government/publications/smoking-and-tobacco-applying-all-our-health/smoking-
and-tobacco-applying-all-our-health) and helps with withdrawal symptoms (50).
Considering the specific safety concerns, contraindications (for example, bupropion is contraindicated in patients who have seizures),
and comorbidities, the choice of agent is based largely on patient preference (https://www.uptodate.com/contents/pharmacotherapy-for-
smoking-cessation-in-adults) after discussion with a clinician (49). Current evidence suggests
(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009329.pub2/full) that adverse events for these interventions are mild and
would not mitigate their use, although concerns have been raised that varenicline may slightly increase cardiovascular events
(https://pubmed.ncbi.nlm.nih.gov/27158893/) in people already at increased risk of these illnesses (37, 38).
There is a growing body of evidence evidence that behavioural interventions combined with nicotine replacement, provided by dental
professionals, may increase tobacco abstinence rates in cigarette smokers (29).
Clinical trials have largely been conducted among adults; thus, in children, there is no evidence to support the use of pharmacological
interventions (https://pubmed.ncbi.nlm.nih.gov/29148565/) (51). NRT is licensed for use in children over 12 years of age in the UK.
Reducing smoking
If a patient indicates interest in cutting down their smoking, the healthcare professional should inform them that health benefits come
from stopping smoking altogether. Any benefits of simply reducing are unclear.
However, the clinician should advise them that if they reduce their smoking now, they are more likely to stop smoking in the future,
particularly if they use licensed nicotine-containing products (https://pubmed.ncbi.nlm.nih.gov/27734465/) to help reduce the amount they
smoke (40).
People who reduce the amount they smoke without supplementing their nicotine intake with a licensed nicotine product tend to
compensate by drawing smoke deeper into their lungs, exhaling later and taking more puffs. Therefore, use of a licensed nicotine-
containing product to provide ‘therapeutic’ nicotine is recommended.
Alongside the strong safety profile of NRT, the benefits of advising smokers unwilling or unable to quit smoking to reduce their smoking
using NRT are likely to outweigh any disadvantages (https://pubmed.ncbi.nlm.nih.gov/27734465/), given that the alternative is likely to be no
action (40).
The Stoptober campaign during the month of October provides an opportunity for smokers to quit, as people who stop smoking for 28
days are 5 times more likely to quit for good (https://www.nhs.uk/better-health/quit-smoking/) (52).
Safety of nicotine: evidence and misconceptions
While nicotine is the addictive substance in cigarettes, it is relatively harmless (https://www.gov.uk/government/publications/e-cigarettes-and-

heated-tobacco-products-evidence-review) (9).
In fact, almost all of the harm from smoking comes from the thousands of other chemicals in tobacco smoke, many of which are toxic.
Despite this, research finds that among smokers and ex-smokers in the UK (22):
only 6 in 10 think that NRT is less harmful than smoking cigarettes

only 4 in 10 incorrectly think nicotine in cigarettes causes most of the smoking-related cancer
Given these misconceptions, advising smokers on the relative safety of nicotine containing products compared to smoked tobacco is an
integral part of supporting them to quit.
People should be advised to use NRT, or an e-cigarette if they choose as it will help them to manage their cravings when they stop
smoking.
Vaping (e-cigarettes)
E-cigarettes, also known as vapes, are the most popular stop smoking aid in England (https://www.gov.uk/government/publications/e-
cigarettes-and-heated-tobacco-products-evidence-review), with 2.5m users in 2019 (https://www.gov.uk/government/publications/vaping-in-england-
evidence-update-march-2020) (9, 53).
There are many different types of e-cigarette product and this market is rapidly changing.
E-cigarettes are electronic devices that heat a liquid, usually containing nicotine, to create an aerosol for inhalation. At present, there is
no medicinally licensed e-cigarette product available on the UK market. However, the UK has some of the strictest regulation for e-
cigarettes in the world. Under the Tobacco and Related Products Regulations 2016 (54), e-cigarette products are subject to minimum
standards of quality and safety, as well as packaging and labelling requirements to provide consumers with the information they need to
make informed choices.
All e-cigarette products must be notified by manufacturers to the UK Medicines and Healthcare products Regulatory Agency (MHRA),
with detailed information including the listing of all ingredients. Leading UK health and public health organisations including the Royal
College of General Practice, British Medical Association and Cancer Research UK now agree that although not risk-free, e-cigarettes
are far less harmful than smoking (50).
Only a very small proportion of young people, who have never smoked, report that they vape (<1%) (55). More than half of current
vapers have managed to stop smoking completely and it is estimated that e-cigarettes may help over 50,000 smokers a year in
England to quit smoking, who would not have done so by other means (56).
E-cigarettes are particularly effective when combined with a structured programme of behavioural support. A major UK clinical trial
found that, when combined with expert face-to-face support, people who used e-cigarettes to quit were twice as likely to succeed than
people who used other nicotine replacement products such as patches or gum (57). People who have completely switched to vaping
should be recorded as non-smokers in dental records.
NICE guidance NG92 (42) sets out the following recommendations for health and social care workers in primary and community
settings.
For people who smoke and who are using, or are interested in using, a nicotine-containing e‑cigarette on general sale to quit smoking,
explain that:
although these products are not licensed medicines, they are regulated by the Tobacco and Related Products Regulations 2016
(54)
many people have found them helpful to quit smoking cigarettes
people using e‑cigarettes should stop smoking tobacco completely, because any smoking is harmful
the evidence suggests that e‑cigarettes are substantially less harmful to health than smoking but are not risk free
the evidence on e-cigarettes is still developing, including evidence on their long-term health impact
In summary, there is growing evidence that e-cigarettes are helping many thousands of smokers in England to quit. The available
evidence from research trials suggests that their effectiveness is broadly similar to prescribed stop smoking medicines and better than
NRT products if these are used without any professional support. E-cigarettes are particularly effective when combined with expert help
from a local stop smoking service.
Implementation and delivery in dental practice

The National Centre for Smoking Cessation and Training (https://www.ncsct.co.uk/) (NCSCT) has developed a simple form of advice
designed to be used opportunistically in less than a minute in almost any consultation with a smoker.

All dental team members should be encouraged to undertake the NCSCT training (https://www.ncsct.co.uk/pub_training.php) as part of
regular continuing professional development, therefore ensuring all dental team members are competent to deliver VBA and brief
interventions in smoking cessation.
The most common intervention dental teams will be involved in is delivering ASK, ADVISE, ACT in line with VBA to smokers (Figure
11.2 (https://khub.net/documents/135939561/516396401/Figure+11.2+Smoking+pathway.png/143e2360-8d5a-56e9-2310-f444b42764af?
t=1631875111806)). Use of the evidence-informed pathway will increase the chance of a successful quit attempt. It just takes 30 seconds
and can give patients the motivation to gain professional help which will increase their chances of quitting. It is important to be aware of
policies, services and routes of access in your local healthcare system as these vary across the UK. A similar approach can be followed
with all tobacco users.
The best outcomes occur when those who are interested in stopping take-up a referral for specialist support. Timing is crucially
important: the quicker the contact by a local stop smoking service, the greater the motivation and interest from the individual. Dental
patients who express a desire to stop should be referred to their local specialist stop smoking support (ideally a local stop smoking
service) to receive the best opportunity to stop smoking.
Dental teams and the local stop smoking services can work collaboratively in a variety of ways. As a first step, it’s important that all
members of a dental team are fully aware of the services offered locally and of how these operate. Arranging a meeting with a
representative of a local provider could provide a useful opportunity for dental teams to learn about the service offer and the best ways
of referring dental patients.
It’s important that no matter who makes the referral, the patient’s progress in stopping is assessed and is recorded in their clinical notes
at each subsequent dental appointment.
Stopping tobacco use can be a difficult process and is often associated with a range of unpleasant, short-term withdrawal symptoms,
some of which, such as ulcers, directly affect the oral cavity.
Reassurance and advice from dental team members may help patients deal more effectively with these problems, thereby increasing
their chances of quitting successfully.
The Cochrane review on tobacco cessation interventions (58) provided during substance abuse treatment or recovery is particularly
helpful in managing patients who may have more than one addiction. Current evidence suggest that providing tobacco cessation
interventions targeted to smokers in treatment and recovery for alcohol and other drug dependencies increases tobacco abstinence.
Resources
NCSCT Very Brief Advice on Smoking for Dental Patients (https://www.ncsct.co.uk/publication_dental_vba.php).
e-Learning for healthcare: Alcohol and Tobacco Brief Interventions programme (https://www.e-lfh.org.uk/programmes/alcohol-and-tobacco-
brief-interventions/).
NHS – Quit Smoking (https://www.nhs.uk/live-well/quit-smoking/).
Find your Local Stop Smoking Service (LSSS) (https://www.nhs.uk/better-health/quit-smoking/find-your-local-stop-smoking-service/).
Smoking and tobacco: applying All Our Health (https://www.gov.uk/government/publications/smoking-and-tobacco-applying-all-our-

health/smoking-and-tobacco-applying-all-our-health).
Health matters: stopping smoking – what works? (https://www.gov.uk/government/publications/health-matters-stopping-smoking-what-

works/health-matters-stopping-smoking-what-works).
Stop smoking options: guidance for conversations with patients (https://www.gov.uk/government/publications/stop-smoking-options-guidance-

for-conversations-with-patients/stop-smoking-options-guidance-for-conversations-with-patients).
E-Cigarettes policy, regulation and guidance (https://www.gov.uk/government/collections/e-cigarettes-and-vaping-policy-regulation-and-guidance).
ASH: Action on Smoking and Health (ASH) is a public health charity that works to eliminate the harm caused by tobacco
(https://ash.org.uk/home/).
Local Tobacco Control Profiles (https://fingertips.phe.org.uk/profile/tobacco-control).
The case for delivering Very Brief Advice on smoking YouTube video:

https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-11-smoking-and-tob… 10/13
30 SECONDS - A short lm about saving a life
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54. HM Government. The Tobacco and Related Products Regulations 2016. London: Public Health England,; 2016. Contract Number:
SI507.
55. McNeill A, Brose L, Calder R, Bauld L, Robson D. Vaping in England: an evidence update February 2019
(https://www.gov.uk/government/publications/vaping-in-england-an-evidence-update-february-2019). London: Public Health England; 2019.
56. Beard E, West R, Michie S, Brown J. Association of prevalence of electronic cigarette use with smoking cessation and cigarette
consumption in England: a time–series analysis between 2006 and 2017. Addiction. 2020;115(5):961-74.
57. Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N and others. A Randomized Trial of E-Cigarettes versus
Nicotine-Replacement Therapy. New England Journal of Medicine. 2019;380(7):629-37.
58. Apollonio D, Philipps R, Bero L. Interventions for tobacco use cessation in people in treatment for or recovery from substance use
disorders. Cochrane Database of Systematic Reviews. 2016(11).

11/19/21, 8:33 PM Chapter 12: Alcohol - GOV.UK
GOV.UK

Department
of Health &
Office for Health
Improvement
Guidance
Chapter 12: Alcohol
Contents
Alcohol misuse
Alcohol and health
Alcohol consumption
What is a unit of alcohol?
Guidelines on alcohol
Interventions which most effectively support patients to reduce alcohol consumption
Other relevant issues
Resources
References

https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-12-alcohol 1/10

prevention/chapter-12-alcohol

Alcohol misuse
In England, among people aged 15 to 49 years, alcohol is the leading cause of ill-health, disability, and death (1, 2). Alcohol misuse
across the UK is a significant public health problem with major health, social and economic consequences, estimated at between £21
and £52 billion a year (3). Each year there are over 1 million admissions to hospital for alcohol-related conditions (4).
Alcohol consumption is a public health issue across Europe, which has the highest per capita consumption of alcohol of all regions
globally, and the highest level of alcohol-related harms (5). Harmful use of alcohol contributes not only to the burden of non-
communicable diseases (NCDs), but also to the burden of communicable diseases, as well as violence and injuries (6).
This chapter will highlight the extent of the problem and summarise the links between alcohol and oral health. It will outline brief advice
and the use of a screening tool which dental team members can use to support their patients who drink alcohol, to lower their risk in
relation to general and oral health.
Alcohol and health

The UK Chief Medical Officers (CMOs) advise that to keep the risk from alcohol low, adults should not regularly drink more than 14
units of alcohol per week. Alcohol adversely affects health in a range of ways and there is no definitively ‘safe’ lower limit – no level of
regular alcohol consumption improves health. There is a significantly increased risk of oral cancers among drinkers, particularly when
combined with smoking or any form of tobacco use. These behaviours are linked; it is therefore important to recognise that drinking
alcohol during an attempt to stop smoking can potentially reduce the chances of effectively quitting and this needs to be considered
carefully (7). Alcohol has a wide range of health impacts including cardiovascular disease, cancers (breast, bowel, throat and mouth),
and drinking during pregnancy can lead to long-term harm to the baby (3).
For alcohol, frequency of consumption is more important than duration in years – higher consumption over a few years has a higher risk
for oral cancer than a lower intake over many years (8), although duration is still important as a risk factor for other chronic diseases like
cardiovascular disease. There is some variation by site, with evidence by head and neck cancer sites that drink-years are associated
with more pharyngeal/oral cavity site cancer when compared with laryngeal cancer (8).
Alcohol consumption
Around 21% of the adult population in England and 24% of adults in England and Scotland, regularly drink at levels that increase their
risk of ill health (increasing risk and higher risk drinkers) (9). The latest health survey for England, in 2018, suggested that more than
twice as many men than women drank at levels of increasing risk in a usual week (25% and 11% respectively); and, similarly at higher
risk levels (5% of men drank over 50 units and 3% of women drank over 35 units) (10). Adults living in the least deprived areas were
more likely to drink over 14 units of alcohol in a usual week than those living in the most deprived areas (27% compared with 18%) (10).
Whilst younger adults are less likely to drink than any other age group, when they do drink, the evidence suggests that consumption on
their heaviest drinking day tends to be higher than that of older people (9). There is emerging evidence that people who have a dry
month such as ‘Dry January’ subsequently reduce their drinking (11).
What is a unit of alcohol?

One unit equals 10ml or 8g of pure alcohol, which is around the amount of alcohol the average adult liver can break down in an hour,
although this will vary from person to person. If a wine label says ‘12% ABV’ or ‘alcohol by volume 12%’, it means 12% of the volume of
that drink is pure alcohol (12). To work out how many units there are in any drink, multiply the total volume of a drink (in ml) by its ABV
(measured as a percentage) and divide the result by 1,000. Figures 12.1 and 12.2 provide visual representation of drinks in relation to
their units of alcohol.

Figure 12.1. Alcohol unit reference. Source: (13)
One unit of alcohol is: one half pint of ‘regular’ beer, lager or cider, half a small glass of wine, one single measure of spirits, one small
glass of sherry, one single measure of aperitifs. Drinks that are more than a single unit are: one pint of ‘regular’ beer, lager or cider (2),
one pint of ‘strong’ or ‘premium’ beer, lager or cider (3), one Alcopop or a 275ml bottle of regular lager (1.5), one 440 ml can of ‘regular’
lager or cider (2), one 440 ml can of ‘super strength’ lager, one 250 ml glass of 12% wine (3), one 75cl bottle of 12% wine (9).

Figure 12.2. Alcohol unit guide. Source: (12)
The number of units you are drinking depends on the size and strength of your drink.
Wine 11% ABV wine 14% ABV wine Beer 3.8% ABV lager 5.2% ABV lager
125ml glass 1.4 units 1.8 units 284ml half pint 1.1 units 1.5 units
175ml glass 1.9 units 2.4 units 440ml can 1.7 units 2.3 units
250ml glass 2.8 units 3.5 units 568ml pint 2.2 units 3 units
750ml bottle 8.2 units 10.5 units 660ml bottle 2.5 units 3.4 units
Guidelines on alcohol
The UK CMOs’ low risk guidelines for alcohol consumption in 2016 provide clear recommendations on alcohol (15 to 17).
All adults
To keep health risks to a low level, it is safest not to drink more than 14 units per week. For adults who drink as much as 14 units per
week, it is best to spread this evenly over 3 days or more.
Young people
An alcohol-free childhood is the healthiest and safest option.
Pregnant women
The safest approach for women who are pregnant, or planning a pregnancy, is not to drink alcohol at all, to keep risks to your baby to a
minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk. The risk of harm
to the baby is likely to be low if a woman has drunk only small amounts of alcohol before she knew she was pregnant or during
pregnancy.
Cutting down alcohol consumption

A good way to help achieve this is to have several drink-free days each week.
Drinking risk categories
The term low risk drinking implies that no level of alcohol consumption is completely safe. Furthermore, the context can determine the
level of risk, for example drinking and driving, in conjunction with medication or where there is pre-existing chronic illness.
The guidelines state the following.
Low risk drinking
‘Low risk’ is not regularly exceeding 14 units per week, spread evenly over the week. This level of consumption represents a low risk of
long term or short-term health harm for a healthy adult.
Increasing risk drinking
Increasing risk means drinking in a way that raises the risk of ill health from drinking alcohol. For both men and women, this means
regularly drinking more than the low risk guideline of 14 units per week and up to 35 units for women and 50 units for men.
Higher risk drinking
Higher risk drinking for women is regularly drinking more than 35 units per week and for men regularly drinking more than 50 units per
week. People in this group are likely to already be experiencing health damage from their alcohol use, even if it is not yet evident.
Binge drinking
Binge drinking really means drinking enough on a single occasion to get drunk (The technical definition of binge drinking is drinking 6+
units (women) or 8+ units (men) in a single session) (18). Drunkenness can lead to risky behaviour and an increased risk of injury.
Sources: (15, 19)
Alcohol dependent drinking
Alcohol dependence is a disorder of regulation of alcohol use arising from repeated or continuous use of alcohol (20). The characteristic
feature is a strong internal drive to use alcohol, which is manifested by impaired ability to control use, increasing priority given to use
over other activities and persistence of use despite harm or negative consequences. These experiences are often accompanied by a
subjective sensation or urge or craving to use alcohol. Physiological features of dependence may also be present, including tolerance
to the effects of alcohol, withdrawal symptoms following cessation or reduction in use of alcohol, or repeated use of alcohol or
pharmacologically similar substances to prevent or alleviate withdrawal symptoms. The features of dependence are usually evident
over a period of at least 12 months but the diagnosis may be made if alcohol use is continuous (daily or almost daily) for at least one
month (20). Adults identified as misusing alcohol encompasses a very wide pathology: people drinking above low risk but who are not
dependent; and people with mild, moderate and severe dependence.
Interventions which most effectively support patients to reduce alcohol consumption

Supporting patients with brief interventions for alcohol is important in relation to the prevention of oral cancer and in particular, when
combined with tobacco use (Chapter 2: Table 4 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-
toolkit-for-prevention/chapter-2-summary-guidance-tables-for-dental-teams#table4); Chapter 11
(https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-11-smoking-and-tobacco-
use)). In addition to the benefits for general health, there is also some evidence that patients with periodontal disease may have the
potential to benefit from reducing alcohol intake (Chapter 5 (https://www.gov.uk/government/publications/delivering-better-oral-health-an-
evidence-based-toolkit-for-prevention/chapter-5-periodontal-diseases)).
Identification and Brief Advice (IBA)
A significant proportion of the healthy general population visit a dentist on a regular basis. There is evidence that identifying patients’
alcohol health risk, and feeding it back to them along with some advice on cutting down, is effective in reducing alcohol consumption
(21).
Behavioural counselling for adults
Whereas for non-dependent drinkers IBA is helpful in risk reduction (19), NICE guidance suggests that adults who are dependent
drinkers require behavioural counselling using motivational interviewing or cognitive behavioural therapy (CBT) as part of a package of
care (22). There is moderate to low quality evidence that behavioural counselling interventions improve outcomes such as alcohol
consumption, heavy drinking episodes, and drinking above the low risk threshold in adults who have been identified by screening in
primary care settings as misusing alcohol (21). The evidence for effectiveness of behavioural interventions amongst pregnant women is
inconclusive (21).
Brief interventions can reduce alcohol consumption for hazardous and harmful drinkers compared to minimal or no intervention (23).
Longer duration interventions probably have little additional benefit (23).

Children and young adults
There is insufficient evidence currently on the role of behavioural counselling interventions in reducing alcohol consumption, heavy
drinking episodes, and drinking above recommended amounts in adolescents who have been identified by screening in primary care
settings as misusing alcohol (21).
Dental teams are in a good position to identify people at risk and provide brief advice and support to those who are drinking above the
low risk levels (Figure 12.3).
The primary goal of IBA is to reduce alcohol consumption by showing the patient the following.
1. Their drinking might be putting their health at risk (they may be completely unaware).
2. What the patient can do about it.
Figure 12.3. Alcohol pathway: IBA (https://khub.net/documents/135939561/516396401/Alcohol+pathway.png/2e917707-7c70-7978-37fb-

14d41f2dd14a).
Screening tool (Ask)
The AUDIT (Alcohol Use Disorders Identification Test for Consumption) screening tool
(https://khub.net/documents/135939561/424776527/AUDIT-C+scratch+card.png/04c9be0a-4f90-50e2-1d51-bcdd3b767174?t=1613394095431) was
originally developed by the World Health Organization as a simple method of screening for excessive drinking and to assist in brief
assessment (24). Its shortened form, AUDIT-C, outlined in the previous version of Delivering Better Oral Health (DBOH) is now widely
used as a screening tool and is shown in Figure 12.4. It is also available as a patient scratch card. There is evidence that this brief
alcohol screening tool can be successfully used in general dental practice to identify patients at risk of harm from excessive alcohol
consumption (25, 26).
Figure 12.4. Audit C scratch card. Source: (13)
Advise
Advise the patient of the level of alcohol health risk indicated by their score.
Provide feedback and information relevant to their level of risk, and give a patient information leaflet (https://app.box.com/v/CQUIN-
structured-advice-tool).
Score 4 or below
Low risk: it’s good practice to give positive feedback and encourage your patient to keep their drinking at low-risk levels.
Score 5 to 10
Increasing or higher risk: it’s suggested to give brief advice to highlight the risk of harms caused by alcohol and the benefits of cutting
down. 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 risk increases the more you drink and how frequently you drink (23).
Highlight the recommendations from the CMOs. For example, you can say that:
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
Score 11 or 12
Drinking could be becoming a problem, explore the option of referral to a specialist alcohol addiction service (https://www.nhs.uk/service-
search/Alcohol-addiction/LocationSearch/1805) or to a GP. Do not merely advise these patients to stop drinking as they may require support
to do so safely. They may need to be referred for a full assessment by a specialised service who can advise on appropriate support. It
can be dangerous for some dependent drinkers to withdraw without medical supervision (19).
Other relevant issues
Vulnerable people
Alcohol use is higher among certain groups in society, such as homeless people, who may also have other conditions or circumstances
that exacerbate the risk from alcohol; they may therefore have additional support needs (27).
Combined behaviours: tobacco and alcohol
Tobacco and alcohol are linked behaviours, whereby around one quarter of smokers drink above low risk guidelines (7). Alcohol
increases the level of ‘feel-good’ chemicals produced in the brain by nicotine. Nicotine changes how the brain responds to alcohol,
which means more alcohol is needed before people get the same feel-good response as a non-smoker after a couple of drinks.
The available training suggests that there is no harm in talking to patients about both their smoking and alcohol consumption in one
session (7). The most important issue is to deliver person-centred advice and support and therefore the best option may be to offer the
chance to explore both issues and let the patient decide which to start with. Some health professionals prefer to talk to their patients
about smoking before raising the issue of alcohol consumption, while others will prefer to let their patient decide whether to talk about
tobacco or alcohol use first. Both approaches are perfectly fine (7).
It is worth being aware that if a patient is stopping smoking, they may need to think carefully about their alcohol consumption, as once
they have had a few units of alcohol to drink, their willpower to maintain tobacco cessation may be reduced (7).
Apps to assist with alcohol monitoring
There are now free apps that some patients may find useful for monitoring their alcohol consumption such as:
Drink Free Days (https://www.nhs.uk/oneyou/apps/)

Dry January (https://alcoholchange.org.uk/alcohol-facts/interactive-tools/the-dry-january-app-1)
Further evaluation is required on the effectiveness of using technology for reducing alcohol consumption.
Resources
E-learning for healthcare: Alcohol Identification and Brief Advice programme (https://www.e-lfh.org.uk/programmes/alcohol/). This includes
useful videos which demonstrate practising AUDIT-C.
E-learning for healthcare: Alcohol and Tobacco Brief Interventions programme (https://www.e-lfh.org.uk/programmes/alcohol-and-tobacco-
brief-interventions/).
Health Matters: tobacco and alcohol CQUIN (https://www.gov.uk/government/publications/health-matters-preventing-ill-health-from-alcohol-and-

tobacco/health-matters-preventing-ill-health-from-alcohol-and-tobacco-use). This includes links to infographics resources, the AUDIT-C scratch
card and a structured alcohol advice patient information leaflet.
Screening and brief advice for alcohol and tobacco use in inpatient settings (https://www.gov.uk/government/publications/preventing-ill-health-
commissioning-for-quality-and-innovation)
Alcohol and drug misuse prevention and treatment guidance (https://www.gov.uk/government/collections/alcohol-and-drug-misuse-prevention-

and-treatment-guidance).
Alcohol use screening tests (includes the AUDIT-C tool) (https://www.gov.uk/government/publications/alcohol-use-screening-tests).

Alcohol Change UK (https://alcoholchange.org.uk/): a leading UK alcohol charity formed from the merger of Alcohol Concern and Alcohol
Research UK. This includes a dry January app and alcohol unit calculator.
One you: Drink less (https://www.nhs.uk/oneyou/for-your-body/drink-less/).
Local Alcohol Profiles for England (https://fingertips.phe.org.uk/profile/local-alcohol-profiles).
References
1. Alcohol Change UK. Alcohol Statistics: Alcohol Research UK (https://alcoholchange.org.uk/alcohol-facts/fact-sheets/alcohol-statistics)
2. Public Health England. The Burden of Disease in England compared with 22 peer countries: executive summary
(https://www.gov.uk/government/publications/global-burden-of-disease-for-england-international-comparisons/the-burden-of-disease-in-england-
compared-with-22-peer-countries-executive-summary) London: Public Health England; 2020 (updated 17 January 2020).
3. Public Health England. The public health burden of alcohol: evidence review. London: Public Health England; 2016.
4. NHS Digital. Statistics on Alcohol (https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-alcohol/2020/part-1) London:

NHS Digital; 2020 (updated 4 February 2020).
5. World Health Organization. Alcohol in the European Union Consumption, harm and policy approaches. Copenhagen: WHO Regional
Office for Europe; 2012.
6. World Health Organization. Time to Deliver in Europe Meeting noncommunicable disease targets to achieve the Sustainable
Development Goals: Outcome report from the WHO European High-level Conference on Noncommunicable Diseases
(http://www.euro.who.int/__data/assets/pdf_file/0006/413259/WHO-TKM-Outcome-Report-WEB.pdf). Ashgabat, Turkmenistan, 9–10 April 2019
Copenhagen: WHO Regional Office for Europe; 2019
7. NHS England, Health Education England, Public Health England. Alcohol and Tobacco Brief Interventions Programme (https://www.e-
lfh.org.uk/programmes/alcohol-and-tobacco-brief-interventions/): NHS England; 2019
8. Lubin JH, Purdue M, Kelsey K, Zhang ZF, Winn D, Wei Q and others. Total exposure and exposure rate effects for alcohol and
smoking and risk of head and neck cancer: a pooled analysis of case-control studies. American journal of epidemiology.
2009;170(8):937-47.
9. UK government National Statistics, Statistics on Alcohol, England 2020 (https://alcoholchange.org.uk/alcohol-facts/fact-sheets/alcohol-

statistics).
10. National Statistics, NHS Digital. Health Survey for England: Adult health related behaviours. 2019.
11. de Visser RO, Robinson E, Bond R. Voluntary temporary abstinence from alcohol during ‘Dry January’ and subsequent alcohol use.
Health Psychology. 2016;35(3):281-9.
12. NHS England. Alcohol Units (https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/) London: National Health Services
England; 2019 (updated 13 April 2018).
13. UK government. Alcohol use disorders identification test consumption (AUDIT C)

(https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684828/Fast_alcohol_use_screening_test__FAST_
_.pdf#:~:text=Alcohol%20unit%20reference%20One%20unit%20Hof%20alcohol%20Drinks,Bottle%20%E2%80%9Csuper%20strength%E2%80%9D
%204%20Pint%20of%20%E2%80%9Cregular%E2%80%9D%20beer%2C). London: UK Gov; 2019.
14. NHS. STOPTOBER: quit smoking with Stoptober London: NHS; 2019 (updated 13.04.2018). Available from:
https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/.
15. Department of Health England, Welsh Government, Department of Health Ireland, Scottish Government. UK Chief Medical Officers’
Low Risk Drinking Guidelines 2016. London: Departments of Health; 2016.
16. Donaldson L. Guidance on the Consumption of Alcohol by Children and Young People. London: Department of Health; 2009.
17. Mamluk L, Edwards HB, Savović J, Leach V, Jones T, Moore THM and others. Low alcohol consumption and pregnancy and
childhood outcomes: time to change guidelines indicating apparently ‘safe’ levels of alcohol during pregnancy? A systematic review and
meta-analyses. BMJ Open. 2017;7(7):e015410.
18. Office of National Statistics. Adult drinking habits in Great Britain: 2017. London: ONS; 2018.
19. NICE. Alcohol-use disorders: prevention PH24. London: NICE; 2010 02.10.2010. Contract No.: PH24.
20. World Health Organization. ICD-11 for Mortality and Morbidity Statistics 6C40.2 Alcohol dependence. Geneva: WHO; 2020.
21. Jonas DE, Garbutt JC, Amick HR, Brown JM, Brownley KA, Council CL and others. Behavioral Counseling After Screening for
Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force. Annals of
Internal Medicine. 2012;157(9):645-54.
22. NICE. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol
dependence CG115. London: NICE; 2011 23.02.2011. Contract No.: CG115.
23. Kaner EFS, Beyer FR, Muirhead C, Campbell F, Pienaar ED, Bertholet N and others. Effectiveness of brief alcohol interventions in
primary care populations. Cochrane Database of Systematic Reviews. 2018(2).
24. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: The Alcohol Use Disorders Identification Test Guidelines for Use
in Primary Care, Geneva: World Health Organization; 2001.
25. Ntouva A, Porter J, Crawford MJ, Britton A, Gratus C, Newton T and others. Alcohol Screening and Brief Advice in NHS General
Dental Practices: A Cluster Randomized Controlled Feasibility Trial. Alcohol and Alcoholism. 2019;54(3):235-42.
26. Venturelli R, Ntouva A, Porter J, Stennett M, Crawford MJ, Britton A and others. Use of AUDIT-C alcohol screening tool in NHS
general dental practices in North London. British Dental Journal. 2021.
27. Apollonio D, Philipps R, Bero L. Interventions for tobacco use cessation in people in treatment for or recovery from substance use
disorders. Cochrane Database of Systematic Reviews. 2016(11).

11/19/21, 8:34 PM Chapter 13: Evidence base for recommendations in the summary guidance tables - GOV.UK
GOV.UK

Department
of Health &
care)
Office for Health
Improvement
and-disparities)
Guidance
Chapter 13: Evidence base for
recommendations in the
summary guidance tables
Contents
Introduction
Evidence base for Table 1: Dental caries
References
Evidence base for Table 2: Periodontal diseases
https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-13-evidence-base-for… 1/30
References
Evidence base for Table 3: Oral cancer
References
Evidence base for Table 4: Tooth wear
References


health-an-evidence-based-toolkit-for-prevention/chapter-13-evidence-base-for-recommendations-in-
the-summary-guidance-tables

improvement policy.
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 and 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 Table 1: Dental caries
Prevention of dental caries in children 0 to 6 years of age
All children aged up to 3 years
Recommendation Evidence base
Advice

Breastfed babies
experience less
tooth decay and
breastfeeding
provides the best
nutrition for a
baby’s overall Strong
health.
Recommendation based on WHO guidelines, taking into account benefits of
Support mothers exclusive breastfeeding for first 6 months on overall health (1), as well as low
to: certainty evidence of a dental caries-preventive effect (2, 3). Weaning advice is
• breastfeed from UK SACN guidelines (2). Some very low certainty evidence of increase in
exclusively for dental caries risk beyond 12 months breastfeeding, but this was observed in
around the first 6 children experiencing high frequency of nocturnal breastfeeding and may also
months of a baby’s be influenced by confounders that the studies did not assess, for example,
life sugar-sweetened food and drink consumption (3).
• then continue
breastfeeding,
while introducing
solids from around
the age of 6
months
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
Good practice (2)
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

Introduce solid
foods (of different
textures and
flavours) at around
the age of 6
months. Sugar Good practice (2)
should not be
added to food or
drinks given to
babies and
toddlers.
Parents or carers
should brush their
children’s teeth:
• as soon as they
erupt Strong
• twice a day
• last thing at night Recommendation based on moderate certainty evidence for toothbrushing
or before bedtime with fluoride toothpaste and concentration of 1,000 ppm F and above (the
and on one other evidence for toothpaste 500 to 1,000 ppm F is inconclusive) (4). Low to very
occasion low certainty evidence around initiation stage, frequency and timing (5).
• with a toothpaste Advice to use a smear only based on possible fluorosis risk (inconclusive
containing at least evidence) (6).
1,000 ppm fluoride
• using only a
smear of
toothpaste
Strong
Minimise
consumption of Recommendation based on moderate-certainty evidence that dental caries is
sugar-containing lower when free-sugars intake is <10% and on very low certainty evidence that
foods and drinks. dental caries is lower when free-sugars intake is <5% energy (7), and in line
with WHO (8) and SCAN guidelines (9).
Use sugar-free
versions of
Good practice
medicines if
possible.
Avoid sugar-
containing foods
Conditional
and drinks at
bedtime when
Recommendation based on very low certainty evidence for increased risk of
saliva flow is
dental caries associated with bedtime consumption of food and drinks
reduced and
containing free sugars (in children aged 3 years and older) (10).
buffering capacity
is lost.

Professional
intervention
Assign a recall
interval ranging Conditional
from 3 to 12
months based on Recommendation based on very low certainty evidence (11).
oral health needs Recommendation in line with NICE (CG19) (12).
and disease risk.
All children aged 3 to 6 years
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 Strong
• last thing at night (or
before bedtime) and on at Recommendation based on moderate certainty for toothbrushing with
least one other occasion fluoride toothpaste (4), for fluoride concentration for permanent teeth
• with toothpaste (4) (evidence around primary teeth less clear) and spitting versus
containing at least 1,000 rinsing (5). Evidence for frequency or timing is low certainty (5). Advice
ppm fluoride to use pea-sized amount based on possible fluorosis risk (6).
• using a pea-sized
amount of the toothpaste
• spitting out after
brushing rather than
rinsing, to avoid diluting
the fluoride
concentration
Strong
Minimise amount and
frequency of
Recommendation based on moderate-certainty evidence that dental
consumption of sugar-
caries is lower when free-sugars intake is <10% and on very low certainty
containing food and
evidence that dental caries is lower when free-sugars intake is <5%
drinks.
energy (7) and in line with WHO (8) and SCAN guidelines (9).
Use sugar-free versions of

Good practice
medicines if possible.

Avoid sugar-containing Conditional

foods and drinks at
bedtime when saliva flow Recommendation based on very low certainty evidence for increased
is reduced and buffering risk of dental caries associated with bedtime consumption of food and
capacity is lost. drinks containing free sugars (in children aged 3 years and older) (10).
Professional
intervention
Apply fluoride varnish Strong

(2.26% NaF) to teeth 2
times a year. Recommendation based on moderate certainty evidence (13).
Assign a recall interval

Conditional
ranging from 3 to 12
months based on oral
Recommendation based on very low certainty evidence (11).
health needs and disease
Recommendation in line with NICE (CG19) (12).
risk.
Children aged 0 to 6 years giving concern because of dental caries risk
Advice
Strong
Use toothpaste containing 1,350 to 1,500 ppm fluoride. Recommendation based on moderate
certainty evidence of added benefit over
1,000 ppm F (4)
For children taking medication frequently or long term,

Good practice
choose or request sugar-free medicines if possible.
Strong
Apply fluoride varnish (2.26% NaF) to teeth 2 or more
times a year. Recommendation based on moderate
certainty evidence (13).
Where the child is prescribed medication frequently or

long term, liaise with medical practitioner to request Good practice
that it is sugar free.
Investigate diet and assist adoption of good dietary

Good practice (14)
practice in line with the Eatwell Guide.
Conditional
Assign a shortened recall interval based on dental caries Recommendation based on very low
risk. certainty evidence (11).
Recommendation in line with NICE
(CG19) (12).
Prevention of dental caries in children aged from 7 years and young people (up
to 18 years)
All children from 7 years and young people up to 18 years
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
Strong
least one other occasion
• with toothpaste
Recommendation based on moderate certainty evidence (4) (timing is
containing 1,350 to 1,500
low certainty) (5).
ppm fluoride
• spitting out after brushing
rather than rinsing with
water, to avoid diluting the
fluoride concentration
Strong
Minimise amount and
frequency of consumption Recommendation based on moderate-certainty evidence that dental
of sugar-containing food caries is lower when free-sugars intake is <10% and on very low
and drinks. certainty evidence that dental caries is lower when free-sugars intake
is <5% (7) and in line with WHO (8) and SCAN guidelines (9).
Avoid sugar-containing Conditional

foods and drinks at
bedtime when saliva flow is Recommendation based on very low certainty evidence for increased
reduced and buffering risk of dental caries associated with bedtime consumption of food and
capacity is lost. drinks containing free sugars (in children aged 3 years and older) (10).
Apply fluoride varnish to Strong

teeth 2 times a year (2.26%
NaF). Recommendation based on moderate certainty evidence (13).

Assign a recall interval

Conditional
within the range of 3 to 12
months based on oral
Recommendation based on very low certainty evidence (11).
health needs and disease
risk.
Children from 7 years and young people up to 18 years giving concern because of dental
caries risk
Advice
Parent or carer to assist and supervise

Good practice (15)
toothbrushing if required.
Conditional
Use a fluoride mouth rinse daily (0.05% NaF;
Recommendation based on moderate certainty
230 ppmF) at a different time to brushing.
evidence from supervised school use in children and
adolescents (16).
Strong
Apply resin sealant to permanent teeth on Recommendation based on moderate certainty

eruption. 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 (17).
Strong

Apply fluoride varnish to teeth 2 or more
evidence (13). Most studies used 2 applications per
times a year (2.26% NaF).
year. For guidance: manufacturers recommend
application every 6 months, or a maximum of every 3
months.
Conditional
For those 8 years and above with active
caries, consider recommending or
prescribing daily fluoride mouth rinse (0.05%
evidence from supervised school programmes (16).
NaF; 230ppm F), to be used at a different
time from brushing, until dental caries risk is
Mouth rinse is available over the counter as well as
reduced.
on prescription.

https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-13-evidence-base-fo… 10/30
Conditional
For those 10 years and above with active Recommendation based on there being no reliable
caries, consider prescribing 2,800ppm evidence of superior effectiveness but some
fluoride toothpaste until dental caries risk is suggestion of a dose-response relationship (though
reduced. it may not extend to concentrations this high) (4).
Recommendation in line with SDCEP 2018 (18).
Conditional
For those 16 years and above with active
Recommendation based on there being no reliable
caries, consider prescribing either 2,800ppm
evidence of superior effectiveness but some
or 5,000ppm fluoride toothpaste until dental
suggestion of a dose-response relationship (though
caries risk is reduced.
it may not extend to concentrations this high) (4).
5,000 ppm F only been studied in root caries (19).
Where a child or young person is prescribed

medication frequently or long term, liaise
Good practice
with medical practitioner to request that it is
sugar free.
Investigate diet and assist adoption of good

dietary practice in line with the Eatwell Good practice (14)
Guide.
Conditional
Assign a shortened recall interval based on
Recommendation based on very low certainty
dental caries risk.
evidence (11)
Prevention of dental caries in adults
All adults

Brush teeth at
least twice daily:
• last thing at night
(or before
bedtime) and on at
least one other Strong
occasion
• with toothpaste Recommendation based on moderate certainty evidence for value of
containing 1,350 toothbrushing with fluoride toothpaste (4). Moderate certainty from studies
to 1,500ppm with children and adolescents for spitting versus rinsing (5). Low-certainty
fluoride evidence from children and adolescents for frequency and timing (5). Evidence
• spitting out after for the concentration is based on studies on immature permanent dentition in
brushing rather children and adolescents (4).
than rinsing with
water, to avoid
diluting the
fluoride
concentration
Minimise the Strong

amount and
frequency of Recommendation based on moderate-certainty evidence that dental caries is
consumption of lower when free-sugars intake is <10% and on very low certainty evidence that
sugary food and dental caries is lower when free-sugars intake is <5% energy (7), and in line
drinks. with WHO (8) and SCAN guidelines (9).
Avoid sugar-
containing foods
Conditional
and drinks at
bedtime when
Recommendation based on very low certainty evidence for increased risk of
saliva flow is
dental caries associated with bedtime consumption of food and drinks
reduced and
containing free sugars (in children aged 3 years and older) (10).
buffering capacity
is lost.
Professional
intervention
Conditional
Assign a recall
interval ranging
Recommendation based on moderate certainty evidence that recall interval
from 3 to 24
can be varied on individual basis without negative effects for adults who
months, based on
regularly attend dentist (11). Evidence not available for ‘hard-to-reach’ adults
oral health needs
or those with more complex presentations. Recommendation in line with NICE
and disease risk.
(CG19) (12).
Adults giving concern because of dental caries risk

Advice
Support toothbrushing where required

(for example carer assistance, specialised Good practice (20)
brush, non-foaming toothpaste).
Conditional
Use a fluoride mouth rinse daily (0.05%
NaF; 230 ppmF) at a different time to Recommendation based on moderate certainty
toothbrushing. evidence from supervised school use in children and
adolescents (16).
Strong
Apply fluoride varnish to teeth 2 times a
year (2.26% NaF). Recommendation based on moderate certainty
evidence from children and adolescents (13).
For those with active coronal or root

caries, consider recommending or
Conditional
prescribing daily fluoride rinse (0.05%
NaF; 230 ppmF, to be used at a different
Recommendation based on low certainty evidence (21).
time from toothbrushing) until dental
caries risk is reduced.
Conditional
For those with obvious active coronal or
Recommendation based on there being no reliable
root caries, consider prescribing 2,800 or
evidence of superior effectiveness but some evidence of
5,000ppm fluoride toothpaste until
dose-response relationship, although it may not extend
dental caries is stabilised and risk is
to concentrations this high (4). Moderate-certainty
reduced.
evidence for effectiveness of 5,000 ppm F for root
caries (19).
Where a patient is prescribed medication

frequently or long term, liaise with
Good practice
medical practitioner to request that it is
sugar free.
Investigate diet and assist adoption of

good dietary practice in line with the Good practice (14)
Eatwell Guide.

Conditional

evidence that recall interval can be varied on individual
Assign a shortened recall interval based
basis without negative effects for adults who regularly
on dental caries risk.
attend dentist (11). Evidence not available for ‘hard-to-
reach’ adults or those with more complex presentations.
References
1. WHO Global Strategy for Infant and young child feeding 2003
(https://www.who.int/publications/i/item/9241562218).
2. Scientific Advisory Committee on Nutrition (SACN). Feeding in the first year of life
(https://www.gov.uk/government/publications/feeding-in-the-first-year-of-life-sacn-report). 2018.
3. Tham R, Bowatte G, Dharmage SC, Tan DJ, Lau MX, Dai X and others. Breastfeeding and the risk
of dental caries: a systematic review and meta-analysis (https://www.ncbi.nlm.nih.gov/pubmed/26206663).
Acta Paediatrica 2015 Dec;104(467):62-84.
4. Walsh T, Worthington HV, Glenny AM, Marinho VC, Jeroncic A. Fluoride toothpastes of different
concentrations for preventing dental caries
(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007868.pub3/full). Cochrane Database of
Systematic Reviews 2019; (3).
5. SIGN Guidelines 138. Dental interventions to prevent caries in children

(https://www.scottishdental.org/library/dental-interventions-to-prevent-caries-in-children-sign-138/). 2014.
6. Wong MCM, Glenny A-M, Tsang BWK, Lo ECM, Worthington HV, Marinho VCC. Topical fluoride as
a cause of dental fluorosis in children
7. Moynihan PJ, Kelly SA. Effect on caries of restricting sugars intake: systematic review to inform
WHO guidelines (https://journals.sagepub.com/doi/abs/10.1177/0022034513508954). Journal of Dental
Research 2014 Jan;93(1):8-18. doi: 10.1177/0022034513508954. Epub 2013 Dec 9. PMID:
24323509; PMCID: PMC3872848
8. WHO Sugar Recommendations (https://www.ages.at/en/topics/nutrition/who-sugar-recommendations/).
9. Scientific Advisory Committee on Nutrition (SACN). Carbohydrates and health

(https://www.gov.uk/government/publications/sacn-carbohydrates-and-health-report). 2015.
10. Baghlaf K, Muirhead V, Moynihan P, Weston-Price S, Pine C. Free sugars consumption around
bedtime and dental caries in children: a systematic review (https://pubmed.ncbi.nlm.nih.gov/30931774/).
Journal of Dental Research Clinical and Translational Research 2018 Apr;3(2):118-129. doi:
10.1177/2380084417749215.

11. Fee PA, Riley P, Worthington HV, Clarkson JE, Boyers D, Beirne PV. Recall intervals for oral
health in primary care patients
12. NICE (CG 19) Dental checks: intervals between dental health reviews
(https://www.nice.org.uk/guidance/cg19). 2004.
13. Marinho VCC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental
caries in children and adolescents
14. Public Health England. Eatwell Guide (https://www.gov.uk/government/publications/the-eatwell-guide).

2016.
15. Dos Santos, APP, de Oliveira, BH, Nadanovsky, P. A systematic review of the effects of
supervised toothbrushing on caries incidence in children and adolescents
(https://www.ncbi.nlm.nih.gov/pubmed/28940755). International Journal of Paediatric Dentistry 2018;28,3-
11.
16. Marinho VCC, Chong LY, Worthington HV, Walsh T. Fluoride mouthrinses for preventing dental
caries in children and adolescents
17. Ahovuo‐Saloranta A, Forss H, Walsh T, Nordblad A, Mäkelä M, Worthington HV. Pit and fissure
sealants for preventing dental decay in permanent teeth
18. SDCEP Dental Clinical Guidance. Prevention and management of dental caries in children
(https://www.sdcep.org.uk/published-guidance/caries-in-children/). 2018.
19. Wierichs RJ, Meyer-Lueckel H. Systematic review on noninvasive treatment of root caries lesions
(https://www.ncbi.nlm.nih.gov/pubmed/25398366). Journal of Dental Research 2015 Feb;94(2):261-71.
20. Waldron C, Nunn J, Mac Giolla Phadraig C, Comiskey C, Guerin S, van Harten MT and others.
Oral hygiene interventions for people with intellectual disabilities
(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012628.pub2/full?cookiesEnabled). Cochrane
Database of Systematic Reviews 2019; (5).
21. Weyant RJ, Tracy SL, Anselmo TT, Beltrán-Aguilar ED, Donly KJ, Frese WA and others.
American Dental Association Council on Scientific Affairs Expert Panel on topical fluoride caries
preventive agents. Topical fluoride for caries prevention: executive summary of the updated clinical
recommendations and supporting systematic review (https://www.ncbi.nlm.nih.gov/pubmed/24177407).
Journal of American Dental Association 2013 Nov;144(11):1279-91. Review. Erratum in: Journal of
American Dental Association 2013 Dec;144(12):1335. Dosage error in article text. PubMed PMID:
24177407; PubMed Central PMCID: PMC4581720.
Evidence base for Table 2: Periodontal diseases
Prevention of periodontal diseases – to be used in addition to caries prevention
All patients
Advice
Self-care plaque removal:
Conditional
• daily, effective plaque removal is
Recommendation based on indirect evidence that professional
critical to periodontal health
intervention alone is insufficient to prevent periodontal disease
starting or deteriorating (1, 2).
• remove plaque effectively using

methods shown by the dental Good practice
team. This will prevent gingivitis
(gum bleeding or redness) and For example, SDCEP 2014 recommends: ‘Ensure that all
reduces the risk of periodontal patients are able to perform optimal plaque removal’ (3).
disease
Toothbrushing and toothpaste:

Conditional
• brush gum line and each tooth
at least twice daily (last thing at
Recommendation based on very low-certainty evidence that
night or before bedtime and on
infrequent brushing is associated with periodontitis (4).
one other occasion)
Toothbrush type
Strong
Recommendation based on moderate certainty evidence that

• use a manual or powered powered toothbrushes are probably more effective than manual
toothbrush for reducing gingival index score, but the benefit may not be
clinically important (5, 6). Both types of toothbrush work and
are recommended (7). Not everyone can afford a powered
toothbrush.
Conditional
• use a small toothbrush head,
medium texture Recommendation based on low certainty evidence of gingival
lesions when hard bristle brushes were used (8).
Around orthodontic appliances

and bridges, plaque control
should be undertaken using the Good practice
aids suggested by the dental
professional.

Advise best methods of plaque Conditional

removal to prevent gingivitis and
achieve lowest risk of Recommendation based on very low certainty evidence for one-
periodontitis and tooth loss. to-one oral hygiene advice reducing gingivitis and plaque (9).
Conditional
Use behaviour change methods
Recommendation based on low certainty evidence that goal
with oral hygiene instruction.
setting, self‐monitoring and planning improve oral hygiene‐
related behaviour (10).
Correct factors that impede

Good practice
effective plaque control including
supra and subgingival calculus,
For example, SDCEP 2014 recommends: ‘Ensure that local
open margins and restoration
plaque retentive factors are corrected – for example, remove
overhangs and contours, which
overhanging restorations or alter denture design’ (3).
prevent effective plaque removal.
For people with extensive

inflammation, start with
Good practice
toothbrushing advice, followed by
interdental plaque control.
Assess patient, parent or carer’s

preferences for plaque control: Good practice
• decide on manual or powered
toothbrush For example, SDCEP 2014 recommends: ‘…Ask the patient to
• demonstrate methods and types practise, that is, to clean his or her teeth in front of you. This
of brushes provides an opportunity to correct the patient’s technique if
• Assess plaque removal abilities required and ensures that the patient has really understood
and confidence with brushing what he or she needs to do. Help the patient plan how to make
• Patient sets goals for effective plaque removal a habit…’ (3).
toothbrushing for next visit
All adults (and young people aged 12 to 17 years with evidence of periodontal disease)
Advice

Interdental plaque
control:
Conditional
• clean daily between
the teeth to below the
Recommendation based on low certainty evidence for an added benefit
gum line before
from flossing, though it is unclear if this benefit is clinically important (11);
toothbrushing
EFP recommends floss only where gaps are too small for interdental
• where there is space
brushes (12).
for an interdental or
single-tufted brush,
Low certainty evidence that use of interdental brushes is beneficial and that
this should be used
they are more effective than floss, but again the clinical importance of the
• for small spaces
difference is uncertain (11).
between teeth, use
dental floss or tape
Professional
intervention
Assess patient’s
preferences for
interdental plaque
control:
• decide on
appropriate Good practice
interdental aids
• demonstrate For example, SDCEP 2014 recommends: ‘Demonstrate, in the patient’s
methods and types of mouth while he or she holds a mirror, how to systematically clean each
aids tooth using a toothbrush (manual or rechargeable powered) as well as how
• assess plaque to use floss and/or interdental brushes…’ (3).
removal abilities and
confidence with aids
• patient sets goals
for interdental plaque
control
All adults with dental implants
Advice
Good practice
Dental implants require
the same level of oral For example, SDCEP 2014 recommends: ‘…Patients with a single
hygiene and maintenance implanted crown can be encouraged to treat the implant as they would
as natural teeth. their natural dentition and to clean it with a toothbrush, interdental
brushes and implant floss…’ (3).

Conditional
Clean around and between
implants carefully with
Recommendation based on very low certainty evidence of benefit of
interdental aids and
manual and powered toothbrushes, dental floss and interdental
toothbrushes.
brushes (17).
Conditional
Attend for regular checks
of the health of gum and Recommendation based on low certainty evidence of supportive
bone around implants. periodontal therapy improving implant success rate, and preventing
peri‐implantitis in healthy people with one or more implants (18).
Good practice
Advise best methods for
self-care plaque control,
For example, SDCEP 2014 recommends: ‘Patients with an implant-
both toothbrushing and
supported bridge or denture may require training in the use of
interdental cleaning.
interdental brushes and implant floss…’ (3).
Control of specific risks for periodontitis
Tobacco
Strong
Ask, Advise, Act: at every opportunity, ask patients if they
Recommendation: moderate
smoke and record smoking status, advise on the most
certainty evidence that
effective way of quitting and act on patient response, such as
interventions for smoking
refer to local stop smoking support.
cessation improve periodontal
health (13).
Diabetes
Advice

Patients with
diabetes should
try to maintain
good diabetes
control as they
Conditional
are:
• at greater risk of
Recommendation based on low certainty evidence that poorly controlled
developing
diabetes substantially increases the risk or progression of periodontitis (14).
serious
Moderate certainty evidence found that diabetic control improved periodontal
periodontitis and
health (13). Moderate-certainty evidence found that periodontal treatment
• less likely to
improved diabetic control (15).
benefit from
periodontal
treatment if the
diabetes is not
well controlled
Professional
intervention
For patients with

diabetes:
• explain risk
related to
diabetes; ask Good practice
about HbA1c
(glycated For example, Siddiqi 2019 found almost three-quarters of diabetic patients
haemoglobin) were unaware of the link between diabetes and periodontal health (16).
levels
• assess and
discuss clinical
management.
Medications
Advice
Some medications
can affect gingival
health.
Professional
intervention

For patients who

use medications
that cause dry Good practice
mouth or gingival
enlargement: For example, SDCEP 2014 has this advice for doctors: ‘Certain types of
• explain oral medication can lead to gingival enlargement in some patients. These include
health findings the calcium channel blockers, phenytoin and ciclosporin. Good oral hygiene
and risk related to can minimise the risk of gingival enlargement in these patients. However, in
medication severe cases, the patient’s dentist may contact you to discuss modification of
• assess and the drug regimen’ (3).
discuss clinical
management
References
1. Needleman I, Nibali L, Di Iorio A. Professional mechanical plaque removal for prevention of
periodontal diseases in adults – systematic review update (https://pubmed.ncbi.nlm.nih.gov/25495962/).
Journal of Clinical Periodontology 2015; 42(Supplement 16):S12–S35. doi: 10.1111/jcpe.12341.
2. Lamont T, Worthington HV, Clarkson JE, Beirne PV. Routine scale and polish for periodontal health
in adults (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004625.pub5/full). Cochrane
Database of Systematic Reviews 2018; (12). doi: 10.1002/14651858.CD004625.pub5.
3. Scottish Dental Clinical Effectiveness Programme. Prevention and treatment of periodontal

diseases in primary care dental clinical guidance (https://www.sdcep.org.uk/published-
guidance/periodontal-management/). 2014.
4. Zimmerman H, Zimmerman N, Hagenfeld D, Veile A. Is frequency of toothbrushing a risk factor for

periodontitis? A systematic review and meta-analysis (https://pubmed.ncbi.nlm.nih.gov/25255820/).
Community Dentistry and Oral Epidemiology 2014;43(2). doi: 10.1111/cdoe.12126.
5. Wang P, Xu Y, Zhang J, Chen X, Liang W, Liu X, Xian J, Xie H. Comparison of the effectiveness
between power toothbrushes and manual toothbrushes for oral health: a systematic review and
meta-analysis (https://pubmed.ncbi.nlm.nih.gov/32285744/). Acta Odontologica Scandinavica.
2020;78(4):265-274. doi: 10.1080/00016357.2019.1697826.
6. Elkerbout TA, Slot DE, Rosema NAM, Van der Weijden GA. How effective is a powered toothbrush
as compared to a manual toothbrush? A systematic review and meta-analysis of single brushing
exercises (https://pubmed.ncbi.nlm.nih.gov/31050195/). International Journal of Dental Hygiene.
2020;18(1):17-26. doi: 10.1111/idh.12401.
7. West N, Chapple I, Claydon N, D’Aiuto F, Donos N, Ide M and others. British Society of
Periodontology and Implant Dentistry Guideline Group Participants. BSP implementation of European
S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice
(https://pubmed.ncbi.nlm.nih.gov/33573801/). Journal of Dentistry 2021 March;106:103562. doi:
10.1016/j.jdent.2020.103562.
8. Ranzan N, Muniz F, Rosing CK. Are bristle stiffness and bristle end-shape related to adverse
effects on soft tissues during toothbrushing? A systematic review
(https://pubmed.ncbi.nlm.nih.gov/30152076/). International Dental Journal 2019;69(3):171-82.

9. Soldani FA, Lamont T, Jones K, Young L, Walsh T, Lala R, Clarkson JE. One-to-one oral hygiene
advice provided in a dental setting for oral health
10. Newton TJ, Asimakopoulou K. Managing oral hygiene as a risk factor for periodontal disease: a
systematic review of psychological approaches to behaviour change for improved plaque control in
periodontal management (https://pubmed.ncbi.nlm.nih.gov/25639708/). Journal of Clinical Periodontology.
2015;42(Supplement 16):S36–S46. doi: 10.1111/jcpe.12356.
11. Worthington HW, MacDonald L, Poklepovic Pericic T, Sambunjak D, Johnson TM, Imai P and
others. Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and
controlling periodontal diseases and dental caries
Systematic Reviews 2019; (4). doi: 10.1002/14651858.CD012018.pub2.
12. European Federation of Periodontology. Guidelines for Effective Prevention of Periodontal

Diseases (https://www.efp.org/perioworkshop/workshop-2014/guidelines/Prevention-of-periodontal-diseases-
general-guidance.pdf). 2014.
13. Ramseier CA, Woelber JP, Kitzmann J, Detzen L, Carra MC, Bouchard P. Impact of risk factor
control interventions for smoking cessation and promotion of healthy lifestyles in patients with
periodontitis: A systematic review (https://pubmed.ncbi.nlm.nih.gov/31912512/). Journal of Clinical
Periodontology 2020, January 7;47(Suppl 22):90-106. doi: 10.1111/jcpe.13240. Online ahead of print.
14. Nascimento GG, Leite FRM, Vestergaard P, Scheutz F, López R. Does diabetes increase the risk
of periodontitis? A systematic review and meta-regression analysis of longitudinal prospective studies
(https://pubmed.ncbi.nlm.nih.gov/29502214/). Acta Diabetologica Epub 2018 March 3;55(7):653-667.
DOI: 10.1007/s00592-018-1120-4.
15. Baeza M, Morales A, Cisterna C, Cavalla F, Gisela Jara G, Isamitt Y and others. Effect of
periodontal treatment in patients with periodontitis and diabetes: systematic review and meta-
analysis (https://pubmed.ncbi.nlm.nih.gov/31939522/). Journal of Applied Oral Sciences 2020 January
10;28:e20190248. doi: 10.1590/1678-7757-2019-0248.
16. Siddiqi A, Zafar S, Sharma A, Quaranta A. Diabetic patients’ knowledge of the bidirectional link:
are dental health care professionals effectively conveying the message?
(https://onlinelibrary.wiley.com/doi/abs/10.1111/adj.12721) Australian Dental Journal. 2019;64(4);312-326.
doi.org/10.1111/adj.12721.
17. Checchi V, Racca F, Bencivenni D, Lo Bianco L. Role of dental implant homecare in mucositis
and peri-implantitis prevention: a literature overview
(https://www.researchgate.net/publication/338601948_Role_of_Dental_Implant_Homecare_in_Mucositis_and_P
eri-implantitis_Prevention_A_Literature_Overview). Open Dentistry Journal 2019;13:470-477.
doi:10.2174/1874210601913010470.
18. Lin CY, Chen Z, Pan W-L, Wang H-L. The effect of supportive care in preventing peri-implant
diseases and implant loss: a systematic review and meta-analysis
(https://pubmed.ncbi.nlm.nih.gov/31231883/). Clinical Oral Implants Research 2019;30(8):714-724. doi:
10.1111/clr.13496.
Evidence base for Table 3: Oral cancer
Tobacco
Professional intervention - Very

Strong
Brief Advice (VBA)
Recommendation based on moderate certainty evidence

evaluating tobacco cessation in dental settings and the
Ask, advise, act.
effectiveness of brief opportunistic smoking cessation
interventions (1, 2).
Ask
At every opportunity, ask patients if

they smoke and record smoking No specific evidence regarding asking about smoking;
status (smoker, ex-smoker, never however, it is an integral part of the Ask, Advise, Act pathway.
smoker).
For those who smoke
Advise Strong
Moderate certainty evidence from multiple systematic

Explain that a combination of reviews (3 to 8), benefits considered to outweigh harms
behavioural support and varenicline, or (adverse events for these interventions are mild and
short-acting with long-acting Nicotine would not mitigate their use, although concerns been
Replacement Therapy, are likely to be raised that varenicline may slightly increase
most effective. cardiovascular events in people already at increased risk
of those illnesses).
Act Strong
Act on patient response:

• refer people who want to stop smoking
Moderate certainty evidence. NICE guidance supports
to local stop smoking support
this recommendation as ‘evidence and expert opinion
(https://www.nhs.uk/live-well/quit-
showed that support provided by these services is
smoking/nhs-stop-smoking-services-help-
clinically effective and highly cost-effective in helping
you-quit/), preferably where behavioural
people to stop smoking’ (8).
support and prescribed stop smoking
medicines are available.
Conditional
Acknowledge that e-cigarettes may be
helpful for some smokers for quitting or Recommendation based on low certainty evidence from
reducing smoking. one systematic review; insufficient evidence to
demonstrate the long-term effects (9).
Smokeless tobacco
(Predominantly used by those of South Asian origin)
Adults and young people
Ask Strong
Ask patients if they use smokeless tobacco, using the Recommendation: moderate certainty
names that the various products are known by locally. evidence evaluating tobacco cessation in
It may be helpful to show a picture of what the dental settings and the effectiveness of
products look like (Chapter 11 brief opportunistic smoking cessation
(https://gov.uk/government/publications/delivering-better- interventions (1). Guidance on showing
oral-health-an-evidence-based-toolkit-for- pictures of what products look like
prevention/chapter-11-smoking-and-tobacco-use)). presented in NICE guidance (10).
Advise Strong
If someone uses smokeless tobacco, ensure they are Moderate certainty evidence underpinning
aware of the health risks and provide very brief advice. this NICE guidance statement (10).
Act Strong
Based on moderate certainty evidence ‘that

Refer patients who want to quit to specialist support
support provided by these services is
services (https://www.nhs.uk/live-well/quit-smoking/nhs-
clinically effective and highly cost-effective
stop-smoking-services-help-you-quit/).
in helping people to stop smoking’ (8).
Alcohol
Professional intervention - Identification and Brief Advice (IBA)
Ask, advise, act
Ask Strong

Recommendation
based on moderate
certainty evidence
from a systematic
review showed that
Use the AUDIT-C tool brief interventions can
(https://khub.net/documents/135939561/516396401/scratch+card.png/bd822613- reduce alcohol
a8a2-2f79-1d6e-7994a792e8c7) (or similar) to assess a patient’s level of risk consumption in those
of alcohol harm by completing 3 consumption questions. drinking hazardous or
harmful amounts of
alcohol when
compared to minimal
or no interventions
(11).
Advise and Act Strong
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.
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.

Good practice
A well conducted
systematic review
highlights the paucity
of evidence evaluating
For those who are pregnant or think they could become pregnant, the light drinking in
safest approach is not to drink alcohol at all, to remove the risk of alcohol- pregnancy compared
related harm to the baby. with abstinence (12).
Based on this
research, the CMO’s
guidance supports a
‘precautionary’
approach (13).
AUDIT-C score of 11 or above, refer to GP or community specialist alcohol

Good practice
service.
Diet
All patients
Good practice
Promote
increased Most of the evidence underpinning recommendations concerning diet and
consumption of cancer prevention comes from observational studies and laboratory or animal
non-starchy studies and is considered low certainty. The findings regarding increased fruit
vegetables and and vegetable consumption are, however, fairly consistent. A high-quality
fruit. systematic review provides low certainty evidence that increasing fruit and
vegetable intake reduces the risk of cancer and all-cause mortality (17).
Early detection
All patients (with and without teeth)
Evidence
Recommendation
base
Obtain an updated medical, social and dental history and perform an intraoral and
Good
extraoral visual and tactile examination for all patients at each oral health assessment
practice
visit.
Those giving Exams

UK Dental concernMasterclass by Dr Diana McPherson | www.ukdentalexams.com
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 Good practice
lump in the neck
• a lump on the lip or in the oral NICE guidance found no evidence with regard to the positive
cavity consistent with oral predictive values of different symptoms of oral cancer in primary
cancer care (14). The benefits of rapid referrals need balancing against
• a red patch in the oral cavity the harms of over-referral (15).
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
Strong
It’s not recommended to use
vital staining, oral cytology or Recommendation based on moderate certainty evidence from a
light‐based detection and/or well conducted systematic review of diagnostic accuracy of
oral spectroscopy for evaluating index tests for the detection of oral cancer and potentially
lesions for malignancy. malignant disorders of the lip and oral cavity, in patients
presenting with clinically evident lesions (16).
References
1. Holliday R, Hong B, McColl E, Livingstone-Banks J, Preshaw PM. Interventions for tobacco
cessation delivered by dental professionals
2. Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking cessation interventions: a

systematic review and meta-analysis to compare advice to quit and offer of assistance
(https://onlinelibrary.wiley.com/doi/full/10.1111/j.1360-0443.2011.03770.x). Addiction 2012 June;107(6):1066-
73.
3. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural
interventions for smoking cessation

4. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation:

an overview and network meta‐analysis
5. Cahill K, Lindson‐Hawley N, Thomas KH, Fanshawe TR, Lancaster T. Nicotine receptor partial
agonists for smoking cessation
6. Lindson N, Chepkin SC, Ye W, Fanshawe TR, Bullen C, Hartmann‐Boyce J. Different doses,

durations and modes of delivery of nicotine replacement therapy for smoking cessation
(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013308/full). Cochrane Database of
Systematic Reviews 2019; (4). doi: 10.1002/14651858.CD013308.
7. Lindson‐Hawley N, Hartmann‐Boyce J, Fanshawe TR, Begh R, Farley A, Lancaster T.

Interventions to reduce harm from continued tobacco use
8. NICE. Stop smoking services (https://www.nice.org.uk/guidance/ng92). 2008 [updated 2018].
9. Hartmann‐Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for
smoking cessation (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub3/full).
Cochrane Database of Systematic Reviews 2016; (9). doi: 10.1002/14651858.CD010216.pub3.
10. NICE 2012. Smokeless tobacco: South Asian communities (https://www.nice.org.uk/guidance/ph39).

Public Health Guideline [PH39].
11. Kaner EFS, Beyer FR, Muirhead C, Campbell F, Pienaar ED, Bertholet N and others.
Effectiveness of brief alcohol interventions in primary care populations
12. Mamluk L, Edwards HB, Savović J, Leach V, Jones T, Moore THM and others. Low alcohol
consumption and pregnancy and childhood outcomes: time to change guidelines indicating
apparently ‘safe’ levels of alcohol during pregnancy? (https://bmjopen.bmj.com/content/7/7/e015410) A
systematic review and meta-analyses British Medical Journal Open 2017;7:e015410. doi:
10.1136/bmjopen-2016-015410.
13. Department of Health. UK Chief Medical Officers’ low risk drinking guidelines
(https://www.gov.uk/government/publications/alcohol-consumption-advice-on-low-risk-drinking). 2016.
14. NICE. Suspected cancer: recognition and referral (NG12) (https://www.nice.org.uk/guidance/ng12).

2015 [updated July 2017].
15. NHS Scotland. Scottish referral guidelines for suspected cancer

(https://www.cancerreferral.scot.nhs.uk). 2019.
16. Macey R, Walsh T, Brocklehurst P, Kerr AR, Liu JLY, Lingen MW and others. Diagnostic tests for
oral cancer and potentially malignant disorders in patients presenting with clinically evident lesions

17. Aune D, Giovannucci E, Boffetta P, Fadnes LT, Keum N, Norat T and others. Fruit and vegetable
intake and the risk of cardiovascular disease, total cancer and all-cause mortality—a systematic
review and dose-response meta-analysis of prospective studies
(https://pubmed.ncbi.nlm.nih.gov/28338764/). International Journal of Epidemiology June 2017;46
(3);1029–1056.
Evidence base for Table 4: Tooth wear
All patients
Maintain standard oral hygiene practices.

Good practice for preventing
Brush teeth at least twice daily: tooth wear
• last thing at night and on one other occasion Strong recommendation for
• with toothpaste containing fluoride (appropriate to age – see preventing dental caries and
dental caries table) conditional for periodontal
• spitting out after brushing, rather than rinsing with water, to avoid disease.
diluting the fluoride concentration
Maintain good dietary practice in line with the Eatwell Guide

including avoiding or minimising sugar sweetened drinks (especially
Good practice
carbonated) and fruit juice and/or smoothies (limited to 150ml per
day) (1).
Assess tooth wear using a validated tool (for example Basic Erosive
Wear Examination (BEWE)) at the start of any new course of Good practice
treatment.
Patients at higher risk (those with accelerated tooth wear)
Good practice
Identify possible sources of risk:
intrinsic, extrinsic and mechanical. For example, guidance on tooth wear diagnosis by Royal
College of Surgeons (2).
Good practice
Support patient in risk reduction and
management. For example, guidance on tooth wear prevention and
management by Royal College of Surgeons (2).
References
1. Public Health England. Eatwell Guide (https://www.gov.uk/government/publications/the-eatwell-guide).
2016.

2. O’Sullivan E, Barry S, Milosevic A, Brock G. Royal College of Surgeons Faculty of Dental Surgery.
Diagnosis, prevention and management of dental erosion (https://www.rcseng.ac.uk/dental-
faculties/fds/publications-guidelines/clinical-guidelines/). 2013.


11/19/21, 8:34 PM Acknowledgments - GOV.UK
GOV.UK

Department
of Health &
care)
Office for Health
Improvement
and-disparities)
Guidance
Acknowledgments
Contents
Guideline working group

Development oversight group
Guideline development groups
Oral cancer
Dental caries
Tooth wear
Periodontal diseases
Behaviour change
Other
UK contributors
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https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/acknowledgments 1/8

health-an-evidence-based-toolkit-for-prevention/acknowledgments

The development of this edition of Delivering Better Oral Health (DBOHv4) has been led on behalf of
Public Health England (PHE) by:
Dr Jenny Godson MBE, National Lead for Child Oral Health Improvement, PHE
Professor Jenny Gallagher MBE, Newland-Pedley, Professor of Oral Health Strategy and
Honorary Consultant in Dental Public Health, King’s College London, Honorary Consultant in
Dental Public Health, PHE and Academic Lead for DBOHv4
Diane Seymour, Senior Dental Public Health Manager, PHE Secretariat
PHE would like to thank all those who generously gave their time in making the publication of
DBOHv4 possible, this includes the people below.
Guideline working group

The guideline working group led the development process, including planning the project and finding,
appraising, and summarising the evidence on which recommendations were based. This group
included leaders from Cochrane Oral Health and the Scottish Dental Clinical Effectiveness
Programme.
This group comprised:
Dr Jenny Godson MBE, National Lead for Child Oral Health Improvement, PHE (Chair)
Diane Seymour, Senior Dental Public Health Manager, PHE (secretariat)
Professor Jenny Gallagher MBE, Newland-Pedley, Professor of Oral Health Strategy and
Honorary Consultant in Dental Public Health, King’s College London, Honorary Consultant in
Dental Public Health, PHE and Academic Lead for DBOHv4
Professor Jan Clarkson, Professor of Clinical Effectiveness, University of Dundee, Director,
Scottish Dental Clinical Effectiveness Programme, NHS Education for Scotland; Co-ordinating
Editor, Cochrane Oral Health, The University of Manchester
Professor Anne-Marie Glenny, Professor of Health Services Research, Co-ordinating Editor,
Cochrane Oral Health, The University of Manchester
Laura MacDonald, Managing Editor, Cochrane Oral Health, The University of Manchester
Dr Douglas Stirling, Programme Lead (Guidance), Scottish Dental Clinical Effectiveness
Programme, NHS Education for Scotland
Chairs of the Guideline development groups were also members of the working group.
Development oversight group

Dr Sandra White, National Lead Dental Public Health, PHE (Co-chair)

Dr Anna Ireland, National Lead Dental Public Health, PHE (from May 2021)
Dr Jenny Godson MBE, National Lead for Child Oral Health Improvement, PHE (Co-chair)
Diane Seymour, Senior Dental Public Health Manager, PHE (secretariat)

Professor Jenny Gallagher MBE, Newland-Pedley Professor of Oral Health Strategy/Honorary

Consultant in Dental Public Health, King’s College London, Honorary Consultant in Dental
Public Health, PHE and Academic Lead for DBOHv4
Alette Addison, Deputy Director Pharmacy, Dentistry and Eyecare, Department Department of
Health and Social Care (DHSC)
Dr Colette Bridgman MBE, Chief Dental Officer, Wales
Dr Nigel Carter, Chief Executive, Oral Health Foundation
Professor Jan Clarkson, Professor of Clinical Effectiveness, University of Dundee, Director,
Scottish Dental Clinical Effectiveness Programme, NHS Education for Scotland; Co-ordinating
Editor, Cochrane Oral Health, University of Manchester
Professor John Darby, Postgraduate Dental Dean/Dental School Director, Health Education
England
Professor Chris Deery, Dental Schools Council, The University of Sheffield
Michael Donaldson, Acting Chief Dental Officer, Northern Ireland
Professor Michael Escudier, Dean, Faculty Dental Surgery, Royal College of Surgeons
Dr David Felix, Dental Dean, UK Committee of Postgraduate Dental Deans and Directors
Tom Ferris, Chief Dental Officer, Scotland
Matt Garrett, Dean, Faculty Dental Surgery, Royal College of Surgeons
Professor Anne-Marie Glenny, Professor of Health Services Research, Co-ordinating Editor,
Cochrane Oral Health, The University of Manchester
Laura MacDonald, Managing Editor, Cochrane Oral Health, The University of Manchester
Sara Hurley, Chief Dental Officer, England
Dr Ian Mills, Dean, Faculty of General Dental Practice (UK)
Helen Miscampbell, Dental and Eyecare Head, DHSC
Maria Morgan, President, British Association for the Study of Community Dentistry
Carol Reece, Head of Dental and Optical Services Commissioning, NHS England and NHS
Improvement
Guideline development groups

Guideline working group members were members of all Guideline development groups.
Oral cancer
Professor David Conway, Professor of Dental Public Health, Honorary Consultant in Dental
Public Health (Chair), University of Glasgow/Public Health Scotland
Iain Armstrong, Alcohol Programme Manager, PHE
Alan Bateman, Patient Representative
Dr Esther Brewer, Specialty Doctor in Oral and Maxillofacial Surgery
Qasim Chowdary, Tobacco Control Manager, PHE
Dr Julia Csikar, Lecturer in Dental Public Health, University of Leeds
Jane Dalgano, Dental Nurse, Chairman British Association of Dental Nurses

Fiona Ellwood, BEM, National Oral Health Promotion Group and President, Society of British
Dental Nurses
Professor Stefano Fedele, Professor of Oral Medicine/Honorary Consultant, University College
London, Eastman Dental Institute and NIHR UCLH Biomedical Research Centre
Jocelyn Harding, Dental Hygienist, British Society of Dental Hygiene and Therapy
Dr Richard Holliday, Senior Lecturer and Honorary Consultant in Restorative Dentistry,
Newcastle University
Dr Dharmen Patel, General Dental Practitioner, London
Professor Stephen Porter, Professor of Oral Medicine, University College London, Eastman
Dental Institute
Dr Suzanne Scott, Senior Lecturer Health Psychology, King’s College London
Professor Paul Speight, Professor of Oral and Maxillofacial Pathology, The University of
Sheffield
Stephen Taylor, Clinical Dental Technician, President, British Association of Clinical Dental
Technology
Dr Amanda Willis, Clinical Senior Lecturer and Consultant in Oral Medicine, Queen’s University
Belfast
Dental caries
Professor Ivor Chestnutt, Professor and Honorary Consultant in Dental Public Health, Cardiff
University (Chair)
Professor Avijit Banerjee, Professor of Cariology and Operative Dentistry and Honorary
Consultant, Restorative Dentistry, King’s College London
Dr Peter Day, Professor and Consultant in Paediatric Dentistry, University of Leeds
Fiona Ellwood, Dental Nurse, National Oral Health Promotion Group and President, Society of
British Dental Nurses
Heidi Cresswell, British Association of Dental Nurses
Jacqui Elsden, Dental Nurse, President, British Association of Dental Nurses
Joan Hatchard, Dental Nurse, Treasurer, British Association of Dental Nurses
Leigh Hunter, Oral Health Coach, Growing Smiles UK
Emma Jeffcock, Nutrition Advice team, PHE
Dr Gerry McKenna, Clinical Reader/Consultant in Restorative Dentistry, Queen’s University
Belfast
Professor Lorna Macpherson, Professor of Dental Public Health, University of Glasgow
Deirdre McCarthy, Senior Nutrition Scientist in the Nutrition Advice Team, PHE
Rachel Manners, Team Leader of the Nutrition Advice Team, PHE
Professor Paula Moynihan, Director, Food and Health, The University of Adelaide
Dr John Morris, Senior Lecturer in Dental Public Health / Honorary Consultant, University of
Birmingham
Dr Kalajan Nathan, General Dental Practitioner
Dr Thomas O’Connor, Senior Dentist, CLAHRC Fellow
Emma Pacey, British Society of Dental Hygiene and Therapy

Professor Cynthia Pine CBE, Managing Director of Kippax Design Ltd and Emerita Professor of
Dental Public Health, Queen Mary University of London
Professor Iain Pretty, Professor Dental Public Health, The University of Manchester
Dr Mary Tomson, Consultant in Dental Public Health, PHE
Khujeda Rahaman, Patient Representative
Tooth wear
Professor Rebecca Harris, Professor of Dental Public Health/Honorary Consultant, The

University of Liverpool (Chair)
Professor David Bartlett, Head of Centre for Oral, Clinical and Transitional Sciences. Professor
of Prosthodontics, King’s College London
Professor Graham Chadwick, Professor of Operative Dentistry and Dental Material Science,
University of Dundee
Jacqui Elsden, President, British Association of Dental Nurses
Dr James Field, Senior Lecturer in Restorative Dentistry and Honorary Consultant in
Prosthodontics, Cardiff University
Dr Kathryn Harley, Consultant Paediatric Dentistry, Great Ormond Street Hospital
Debora Howe, Chair, National Oral Health Promotion Group
Emma Jeffcock, Nutrition Advice Team, PHE
Professor Rebecca Moazzez, Professor in Oral Clinical Research and Prosthodontics, King’s
College London
Dr Saoirse O’Toole, Clinical Lecturer in Prosthodontics, King’s College London
Dr Elizabeth O’Sullivan, Consultant in Paediatric Dentistry, City Healthcare Partnership CIC
Dr Bhavin Patel, General Dental Practitioner
Simone Ruzario, Dental Therapist/Hygienist, British Society of Dental Hygiene and Therapy
Elaine Tilling, Dental Hygienist, Society of British Dental Nurses
Mr Tom Wallace, Patient Representative
Periodontal diseases
Professor Peter Robinson, Emeritus Professor of Dental Public Health, University of Bristol
(Chair)
Professor Iain Chapple, Professor and Chair of Periodontology and Honorary Consultant in
Restorative Dentistry, The University of Birmingham
Qasim Chowdary, Tobacco Control Manager, PHE
Professor Francesco D’Aiuto, Professor and Chair of Periodontology, Honorary Consultant in
Periodontics, University College London, Eastman Dental Institute

Professor Nikos Donos, Director of Research, Professor and Chair Periodontology and Implant
Dentistry Lead and Honorary Consultant, Centre for Oral Clinical Research, Barts and The
London School of Medicine and Dentistry, Queen Mary University of London
Dr Ana Gambôa, Consultant Senior Lecturer in Periodontology, University of Bristol
Dr Nikolaos Gkranias, Senior Clinical Lecturer and Honorary Consultant in Periodontology,
Queen Mary University of London
Debbie Hemington, Dental Therapist, Chair, British Association Dental Therapists
Professor Mark Ide, Professor of Periodontology/Honorary Consultant Restorative Dentistry,
Specialist Periodontology, Prosthodontics and Restorative Dentistry, King’s College London
Wendy Lodge, Dental Nurse. British Association Dental Nurses
Dr John Milne MBE, Senior National Dental Advisor, Care Quality Commission
Professor Ian Needleman, Professor of Periodontology and Evidence-Informed Healthcare,
University College London, Eastman Dental Institute
Dr Sarah Pollington, Senior Clinical Teacher/Hon Consultant in Restorative Dentistry, The
University of Sheffield
Dr Samantha Rutherford, Specialist Research Lead, Scottish Dental Clinical Effectiveness
Programme, NHS Education for Scotland
Dr Shazad Saleem, General Dental Practitioner, Greater Manchester Local Dental Network
Sally Simpson, Dental Therapist, British Society of Dental Hygiene and Therapy
Fiona Sandom, Dental Therapist, Health Education and Improvement Wales
Brian Stevenson, Consultant/Honorary Senior Teacher in Restorative Dentistry, University of
Dundee
Emma Riley, Chair, Society of British Association Dental Nurses
Janet Goodwin, Dental Nurse, British Association Dental Nurses
Behaviour change
Professor Zoe Marshman, Professor/Honorary Consultant of Dental Public Health, The

University of Sheffield (Chair)
Dr Koula Asimakopoulou, Reader in Health Psychology, King’s College London
Maria Clark, Patient Representative
Dr Rebecca Craven, Senior Lecturer, Academic Consultant in Dental Public Health, The
University of Manchester
Jane Dalgarno, Dental Nurse, Chairman, British Association of Dental Nurses
Dr Bhupinder Dawett, General Dental Practitioner
Dr Eilidh Duncan, Health Psychologist and Research Fellow, University of Aberdeen
Fiona Ellwood BEM, Dental Nurse, National Oral Health Promotion Group and President,
Society of British Dental Nurses
Professor Ruth Freeman, Professor of Dental Public Health Research, University of Dundee
Dr Kara Gray-Burrows, Research Fellow in the design and evaluation of complex interventions,
University of Leeds
Professor Gerry Humphris, Professor in Health Psychology, University of St Andrews
Anup Karki, Consultant in Dental Public Health, Public Health Wales

Dr George Kitsaras, Chartered Psychologist and Research Associate in Behaviour Change, The
University of Manchester
Dr Al Ross, Senior Lecturer in Human Factors in Healthcare, University of Glasgow
Miranda Steeples, Dental Therapist, President Elect British Society of Dental Hygiene and
Therapy
Dr Ben Underwood, General Dental Practitioner
Professor Richard Watt, Professor/Honorary Consultant of Dental Public Health, University
College London
Dr Huda Yusuf, Senior Lecturer/Honorary Consultant in Dental Public Health, Queen Mary
University London
Other contributors
In addition, the following colleagues contributed to DBOHv4:
Dr Aditi Mondkar, Speciality Registrar in Dental Public Health, PHE who undertook the
stakeholder engagement and the PHE Health Equity Audit
Dr Sally Weston-Price, Consultant in Dental Public Health National Team PHE contributed to
editing the final version
Anisha Gupta, Dental Core Trainee King’s College Hospital NHS Trust/Honorary Research
Associate King’s College London
Manveet Alukah, Dental Core Trainee King’s College Hospital NHS Trust/Honorary Research
Associate King’s College London
Dr Sweta Mathur, Former PhD student, University of Glasgow
Dr Naeema Al Bulushi, Former PhD student, University of Glasgow
Jo Weldon, Research Co-ordinator, Cochrane Oral Health, The University of Manchester
Thank you to all stakeholders who contributed to the initial DBOH consultation and the final
stakeholder engagement.
Thank you to all University Dental Schools across the UK for their academic support for DBOHv4.
The original work on the first edition of DBOH was carried out by: Dr Sue Gregory, Mrs J T Duxbury,
Miss M A Catleugh, Professor R M Davies and Dr G M Davies.


11/19/21, 8:34 PM Endorsements - GOV.UK
GOV.UK

Department
of Health &
care)
Office for Health
Improvement
and-disparities)
Guidance
Endorsements

https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/endorsements 1/4

health-an-evidence-based-toolkit-for-prevention/endorsements

Delivering Better Oral Health (DBOH) 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 the 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.
This version of DBOH was developed with the support of Cochrane Oral Health and the Scottish
Dental Clinical Effectiveness Programme (SDCEP). The methodology was based on that of SDCEP
with Cochrane Oral Health appraising the evidence underpinning each recommendation.
DBOH has been endorsed by the following organisations and societies

Association of British Academic Oral and Maxillofacial Surgeons
British Association of Clinical Dental Technology
British Association of Dental Nurses
British Association of Dental Therapists
British Association of Oral Surgery
British Association for the Study of Community Dentistry
British Dental Association
British Orthodontic Society
British Society for Restorative Dentistry
British Society of Dental Hygiene Therapy
British Society of Dental and Maxillofacial Radiology
British Society of Gerodontology
British Society of Oral and Dental Research
British Society of Paediatric Dentistry
British Society of Periodontology and Implant Dentistry
British Society of Prosthodontics
Care Quality Commission
College of General Dentistry
Dental Schools Council

Faculty of Dental Surgery, Royal College of Surgeons England
Health Education England
National Oral Health Promotion Group
Oral Health Foundation
Society for the Advancement of Anaesthesia in Dentistry
Society of British Dental Nurses
UK Committee of Postgraduate Dental Deans and Directors (COPDEND)



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11/19/21, 8:29 PM Chapter 1: Introduction - GOV.

Coronavirus (COVID-19) (/coronavirus)

Who is this guidance for?

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© Crown copyright 2021

This publication is available at https://www.gov.uk/government/publications/delivering-better-oral-

UK Dental Exams Masterclass by Dr Diana McPherson | www.ukdentalexams.com

Who is this guidance for?

Why was it produced?

How was it produced?

What has changed?

Regarding the dental disease chapters:

How can it be used?

Population advice and support on lowering risk

Risk identification and management is essential for prevention

UK Dental Exams Masterclass by Dr Diana McPherson | www.ukdentalexams.com

Assessing risk status

Working in partnership with patients to lower risk

The challenge for dental professionals is to:

Table 1.1 Stages of prevention

Source: Local Government Association (https://www.local.gov.uk/our-support/our-improvement-offer/care-

2. Public Health England. Improving oral health: guideline development manual

3. GRADE Working Group (http://www.gradeworkinggroup.org/#). GRADE 2016.

4. NHS England. Starting Well Core (https://www.england.nhs.uk/primary-care/dentistry/smile4life/) 2015.

6. Public Health England. Inequalities in oral health in England

8. NICE. Dental recall guidelines (https://www.nice.org.uk/Guidance/CG19). London: National Institute for

9. Local Government Association. Prevention London: LGA (https://www.local.gov.uk/our-support/our-

All content is available under the Open Government Licence

UK Dental Exams Masterclass by Dr Diana McPherson | www.ukdentalexams.com

Coronavirus (COVID-19) (/coronavirus)

How to use these tables

UK Dental Exams Masterclass by Dr Diana McPherson | www.ukdentalexams.com

© Crown copyright 2021

This publication is available at https://www.gov.uk/government/publications/delivering-better-oral-

UK Dental Exams Masterclass by Dr Diana McPherson | www.ukdentalexams.com

How to use these tables

children or adults presenting with current or past dental disease

Further details on assessing risk are outlined in Chapter 1

Table 1: Prevention of dental caries

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

All children aged up to 3 years

Support mothers to: Strong

For parents or carers feeding babies by bottle:

UK Dental Exams Masterclass by Dr Diana McPherson | www.ukdentalexams.com

Parents or carers should brush their children’s teeth:

Minimise consumption of sugar-containing foods and drinks Strong

Use sugar-free versions of medicines if possible Good practice

All children aged 3 to 6 years

Minimise amount and frequency of consumption of sugar-containing food and

Use sugar-free versions of medicines if possible Good practice

UK Dental Exams Masterclass by Dr Diana McPherson | www.ukdentalexams.com

Apply ﬂuoride varnish (2.26% NaF) to teeth 2 times a year Strong

Children aged 0 to 6 years giving concern because of dental caries risk

All the above, plus:

Use toothpaste containing 1,350 to 1,500 ppm ﬂuoride Strong

For children taking medication frequently or long term, choose or request

Assign a shortened recall interval based on dental caries risk Conditional

All children from 7 years and young people up to 18 years

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Minimise amount and frequency of consumption of sugar-containing food

Avoid sugar-containing foods and drinks at bedtime when saliva ﬂow is

Apply ﬂuoride varnish to teeth 2 times a year (2.26% NaF) Strong

Assign a recall interval within the range of 3 to 12 months based on oral

All the above, plus: