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Oral and dental health

About

What is covered

This interactive flowchart covers how members of general dental practice teams can effectively convey the 'advice for patients' set out in Delivering better oral health: an evidence-based toolkit for prevention (Public Health England). This includes how to deliver those messages so that people leave the dentist satisfied about their visit and motivated to follow the advice.
The aim of this advice is to encourage people to:
  • improve their oral hygiene and use of fluoride
  • reduce their consumption of sugary food and drinks, alcohol and tobacco and so improve their general, as well as their oral health.
These recommendations also cover recall intervals between routine dental examinations.

Who is it for?

  • Dentists.
  • Dental care professionals – this includes dental hygienists, dental nurses, dental therapists, dental technicians and orthodontic therapists.
  • Dental practice owners and managers.
  • Dental practice administrative staff, including receptionists.
  • Directors of public health, dental public health consultants and strategic leads who plan local dental services.
  • People responsible for educating dental professionals.
  • Members of the public.

Updates

Updates to this interactive flowchart

14 December 2016 Oral health promotion in the community (NICE quality standard 139) added.
14 December 2015 Restructured to include recommendations from oral health promotion: general dental practice (NG30) and dental recall (CG19).

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on oral and dental health in an interactive flowchart

What is covered

This interactive flowchart covers how members of general dental practice teams can effectively convey the 'advice for patients' set out in Delivering better oral health: an evidence-based toolkit for prevention (Public Health England). This includes how to deliver those messages so that people leave the dentist satisfied about their visit and motivated to follow the advice.
The aim of this advice is to encourage people to:
  • improve their oral hygiene and use of fluoride
  • reduce their consumption of sugary food and drinks, alcohol and tobacco and so improve their general, as well as their oral health.
These recommendations also cover recall intervals between routine dental examinations.

Who is it for?

  • Dentists.
  • Dental care professionals – this includes dental hygienists, dental nurses, dental therapists, dental technicians and orthodontic therapists.
  • Dental practice owners and managers.
  • Dental practice administrative staff, including receptionists.
  • Directors of public health, dental public health consultants and strategic leads who plan local dental services.
  • People responsible for educating dental professionals.
  • Members of the public.

Updates

Updates to this interactive flowchart

14 December 2016 Oral health promotion in the community (NICE quality standard 139) added.
14 December 2015 Restructured to include recommendations from oral health promotion: general dental practice (NG30) and dental recall (CG19).

Sources

NICE guidance and other sources used to create this interactive flowchart.
Guidance on the extraction of wisdom teeth (2000) NICE technology appraisal guidance 1
Mini/micro screw implantation for orthodontic anchorage (2007) NICE interventional procedures guidance 238
Oral health promotion in the community (2016) NICE quality standard 139

Quality standards

Oral health promotion in the community

These quality statements are taken from the oral health promotion in the community quality standard. The quality standard defines clinical best practice in oral health promotion in the community and should be read in full.

Quality statements

Oral health needs assessments

This quality statement is taken from the oral health promotion in the community quality standard. The quality standard defines clinical best practice in oral health promotion in the community and should be read in full.

Quality statement

Local authorities carry out oral health needs assessments to identify groups at high risk of poor oral health as part of joint strategic needs assessments.

Rationale

An oral health needs assessment can identify local groups of people who are at high risk of poor oral health, and determine their likely needs. This can be used as the basis for developing interventions for oral health improvement tailored to the local population. Including oral health in joint strategic needs assessments ensures it is a key health and wellbeing priority.

Quality measures

Structure
Evidence that oral health needs assessments are part of joint strategic needs assessments.
Data source: Local data collection.
Outcome
a) Identification of local groups of people at high risk of poor oral health.
Data source: Local data collection.
b) Development of an oral health strategy.
Data source: Local data collection.

What the quality statement means for public health practitioners and commissioners

Public health practitioners (working in local authorities) ensure that they include oral health needs data from a range of data sources (for example the Public Health England dental epidemiological programme, questionnaire survey data, feedback from community groups) when undertaking joint strategic needs assessments to identify groups at high risk of poor oral health.
Commissioners (working in local authorities and on health and wellbeing boards) ensure that oral health needs data are collected from a range of data sources (for example the Public Health England epidemiological programme, questionnaire survey data) so that oral health needs assessments to identify groups at high risk of poor oral health are included in joint strategic needs assessments. This should be as part of a cyclical planning process.

Source guidance

Oral health: local authorities and partners (2014) NICE guideline PH55, recommendation 2

Definitions of terms used in this quality statement

Groups at high risk of poor oral health
People living in areas that are described as socially and economically disadvantaged are often at high risk of poor oral health. Local authorities (and other agencies) define disadvantaged areas in a variety of ways. An example is the government's Index of Multiple Deprivation. This combines economic, social and housing indicators to produce a single deprivation score.
Based on the oral health needs assessment, local authorities may prioritise other population groups at high risk of poor oral health, such as looked-after children, people who misuse drugs, people with severe mental illness, frail elderly people, some ethnic groups, and people with physical, mental or medical disabilities.
[Adapted from NICE’s guideline on oral health: local authorities and partners, glossary and expert opinion]

Early years settings and schools

This quality statement is taken from the oral health promotion in the community quality standard. The quality standard defines clinical best practice in oral health promotion in the community and should be read in full.

Quality statement

Local authorities provide oral health improvement programmes in early years services and schools in areas where children and young people are at high risk of poor oral health.

Rationale

The risk of dental caries and periodontal disease is reduced by good oral health behaviour, such as reducing sugar consumption and brushing teeth with fluoride toothpaste twice a day. Giving clear advice about good oral health and providing services such as supervised tooth brushing schemes and fluoride varnish programmes encourages this behaviour and reduces the risk of dental decay.
To help support this statement, local authorities should also ensure that healthy food and drink options are displayed prominently in local authority and NHS venues, including early years services and schools (see quality statement 3 in the quality standard on obesity in children and young people: prevention and lifestyle weight management programmes).

Quality measures

Structure
Evidence of local arrangements to ensure that oral health improvement programmes are provided in early years services and schools in areas where children and young people are at high risk of poor oral health.
Data source: Local data collection.
Process
a) Proportion of early years services in areas where children are at high risk of poor oral health where oral health improvement programmes are provided.
Numerator – number in the denominator where oral health improvement programmes are provided.
Denominator – number of early years services in areas where children are at high risk of poor oral health.
Data source: Local data collection.
b) Proportion of schools in areas where children and young people are at high risk of poor oral health where oral health improvement programmes are provided.
Numerator – number in the denominator where oral health improvement programmes are provided.
Denominator – number of schools in areas where children and young people are at high risk of poor oral health.
Data source: Local data collection.
Outcome
a) Plaque on teeth of children.
Data source: Data on the presence or absence of plaque on the teeth of 5 year old children is recorded as part of the oral health survey of five-year-old children.
b) Tooth decay in children and young people.
Data source: Data on the prevalence and severity of dental decay in 5 year old children is recorded as part of the oral health survey of five-year-old children.
c) Tooth extractions in secondary care for children and young people.
Data source: Data on tooth extractions for children aged 10 and under admitted to hospital is included in the NHS Outcomes Framework 2016–17.

What the quality statement means for service providers, healthcare, education and social care practitioners, and commissioners

Service providers (such as school nursing services) ensure that oral health improvement programmes are provided in early years settings and schools in areas where children and young people are at high risk of poor oral health.
Healthcare, education and social care practitioners (such as school nurses, health visitors, social workers and family link workers) ensure that they provide oral health improvement programmes in early years settings and schools in areas where children and young people are at high risk of poor oral health.
Commissioners (local authorities and health and wellbeing commissioning partners) ensure that they commission oral health improvement programmes in early years settings and schools in areas where children and young people are at high risk of poor oral health.

What the quality statement means for children and young people

Children and young people in areas at high risk of poor oral health are told about the importance of looking after their teeth and are helped to do this. For example, they take part in a programme at school or nursery where teachers, teaching assistants or school nurses supervise them brushing their teeth or they are encouraged to reduce the amount of sugar they eat.

Source guidance

Oral health: local authorities and partners (2014) NICE guideline PH55, recommendations 14, 15, 16, 18 and 21

Definitions of terms used in this quality statement

Oral health improvement programmes
These include providing supervised tooth brushing schemes, fluoride varnish programmes or programmes providing advice to encourage brushing with fluoride toothpaste and reducing the amount and frequency of sugar consumption. Advice should be based on the information provided in Public Health England’s (Delivering better oral health 6).
[Adapted from NICE’s guideline on oral health: local authorities and partners, recommendations 14, 15, 16, 18, 19, 20 and 21]
Areas where children and young people are at high risk of poor oral health
Schools and early years settings in areas where children and young people are at high risk of poor oral health can be identified using information from the oral health needs assessment.
Children and young people living in areas that are described as socially and economically disadvantaged are often at high risk of poor oral health. Local authorities (and other agencies) define disadvantaged areas in a variety of ways. An example is the government's Index of Multiple Deprivation. This combines economic, social and housing indicators to produce a single deprivation score.
Based on the oral health needs assessment, local authorities may prioritise other population groups at high risk of poor oral health, such as looked-after children, some ethnic groups, and children and young people with physical, mental or medical disabilities.
[Adapted from NICE’s guideline on oral health: local authorities and partners, glossary, recommendations 3 and 4 and expert opinion]

Oral health in care plans

This quality statement is taken from the oral health promotion in the community quality standard. The quality standard defines clinical best practice in oral health promotion in the community and should be read in full.

Quality statement

Health and social care services include oral health in care plans of people who are receiving health or social care support and at high risk of poor oral health.

Rationale

Oral health is a key part of a person’s overall health and wellbeing. Including oral health in care plans for people receiving health or social care support and at high risk of poor oral health helps ensure that relevant needs are addressed. This may include day-to-day support to help people maintain good oral hygiene and referring to dental services if needed.

Quality measures

Structure
Evidence of local arrangements to include oral health in the care plans of people receiving health or social care support and at high risk of poor oral health.
Data source: Local data collection.
Process
Proportion of care plans that include oral health for people receiving health or social care support and at high risk of poor oral health.
Numerator – number in the denominator that include oral health.
Denominator – number of care plans for people receiving health or social care support and at high risk of poor oral health.
Data source: Local data collection.
Outcome
Tooth decay in people who are receiving health and social care support.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (health and social care providers) ensure that systems are in place so that oral health is included in care plans of people who are receiving health or social care support and at high risk of poor oral health.
Health and social care practitioners (such as GPs, nurses, care workers and social workers) ensure that they include oral health when developing care plans for people at high risk of poor oral health.
Commissioners (clinical commissioning groups and local authorities) ensure that service specifications need oral health to be included in care plans for people who are receiving health or social care support and at high risk of poor oral health.

What the quality statement means for patients and service users

People receiving health or social care support who are at high risk of poor oral health have oral health considerations included in the written plan of the care they agree with professionals.

Source guidance

Oral health: local authorities and partners (2014) NICE guideline PH55, recommendation 8

Definitions of terms used in this quality statement

High risk of poor oral health
Groups of people at high risk of poor oral health should be identified using information from the oral health needs assessment.
People living in areas that are described as socially and economically disadvantaged are often at high risk of poor oral health. Local authorities (and other agencies) define disadvantaged areas in a variety of ways. An example is the government's Index of Multiple Deprivation. This combines economic, social and housing indicators to produce a single deprivation score.
Health and social care services may prioritise other population groups at high risk of poor oral health, such as looked-after children, people who misuse drugs, people with severe mental illness, frail elderly people, some ethnic groups, and people with physical, mental or medical disabilities.
[Adapted from NICE’s guideline on oral health: local authorities and partners, glossary, recommendations 3 and 4 and expert opinion]

Routine attendance after emergency care

This quality statement is taken from the oral health promotion in the community quality standard. The quality standard defines clinical best practice in oral health promotion in the community and should be read in full.

Quality statement

Dental practices providing emergency care to people who do not have a regular dentist give information about the benefits of attending for routine care and how a local dentist can be found.

Rationale

People should be encouraged to attend a general dental practice routinely to help them maintain good oral health. This can reduce problems and the associated costs in the long term. For people who do not have a regular dentist, this contact provides an opportunity for the dental practice team to establish a positive relationship with them and to help them to find a local dentist to attend regularly. For example, dental practice teams can point people to information about local services on the NHS Choices website.

Quality measures

Structure
Evidence of local arrangements to ensure that dental practices providing emergency care give information to people who do not have a regular dentist about the benefits of attending for routine care and how they can find a local dentist.
Data source: Local data collection.
Process
Proportion of emergency attendances at dental practices of people who do not have a regular dentist where information about the benefits of attending for routine care and how to find a local dentist was given.
Numerator – number in the denominator where people were given information about the benefits of attending for routine care and how they can find a local dentist.
Denominator – number of emergency attendances at general dental practices of people who do not have a regular dentist.
Data source: Local data collection.
Outcome
a) Adults who were seen by an NHS dentist in the previous 24 months.
Data source: Local data collection. NHS Dental Statistics for England.
b) Children who were seen by an NHS dentist in the previous 12 months.
Data source: Local data collection. NHS Dental Statistics for England.

What the quality statement means for service providers, dental care professionals and commissioners

Service providers (general dental practices that provide emergency care) ensure information is available about the benefits of attending for routine care and how to find a local dentist.
Dental care professionals (such as dentists and dental nurses) ensure that they establish positive relationships with people not registered with a dentist and give information about the benefits of attending for routine care and how to find a local dentist.
Commissioners (NHS England) ensure that they commission services in which dental practices providing emergency care give information to people who do not have a regular dentist about the benefits of attending for routine care and how to find a local dentist.

What the quality statement means for patients and carers

People who visit a dentist as an emergency and do not have a regular dentist are given information about the benefits of going back for routine check ups and how they can find a local dentist.

Source guidance

Oral health promotion: general dental practice (2015) NICE guideline NG30, recommendations 1.2.2 and 1.2.3

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Checklist of modifying factors

Patient name:
Date of birth:
Oral health review date:
Date:
Medical history
Yes/No
Conditions where dental disease could put the patient's general health at increased risk (such as cardiovascular disease, bleeding disorders, immunosuppression)
Conditions that increase a patient's risk of developing dental disease (such as diabetes, xerostomia)
Conditions that may complicate dental treatment or the patient's ability to maintain their oral health (such as special needs, anxious/nervous/phobic conditions)
Social history
High caries in mother and siblings
Tobacco use
Excessive alcohol use
Family history of chronic or aggressive (early onset/juvenile) periodontitis
Dietary habits
High and/or frequent sugar intake
High and/or frequent dietary acid intake
Exposure to fluoride
Use of fluoride toothpaste
Other sources of fluoride (for example, lives in a water-fluoridated area)
Clinical evidence and dental history
Recent and previous caries experience
New lesions since last check-up
Anterior caries or restorations
Premature extractions because of caries
Past root caries or large number of exposed roots
Heavily restored dentition
Recent and previous periodontal disease experience
Previous history of periodontal disease
Evidence of gingivitis
Presence of periodontal pockets (BPE code 3 or 4) and/or bleeding on probing
Presence of furcation involvements or advanced attachment loss (BPE code: attachment loss is at least 7mm and/or furcation involvements are present)
Mucosal lesions
Mucosal lesion present
Plaque
Poor level of oral hygiene
Plaque-retaining factors (such as orthodontic appliances)
Saliva
Low saliva flow rate
Erosion and tooth surface loss
Clinical evidence of tooth wear
Recommended recall interval for next oral health review:
months
Does patient agree with recommended interval? (If 'No', record reason for disagreement in notes)
Yes/No

Glossary

general dental practices are commonly known as 'high street dentists' and provide primary care dental services; wherever we refer to dentists, dental care professionals and dental practice teams, we mean those working in general dental practices

Paths in this pathway

Pathway created: March 2014 Last updated: June 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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