Patrick Fee is a Clinical Research Fellow and Specialty Registrar in Restorative Dentistry and leading author of an updated Cochrane Review on dental check-up frequency. In this blog for anyone wondering how often they should have a dental check-up, and primary care dentists, Patrick discusses the latest evidence and what it means in practice.
How often to recall our patients for a check-up is perhaps the most common decision dentists make. Traditionally most adult patients are used to having a routine check-up every 6 months, regardless of an individual’s risk of oral disease (e.g. tooth decay or gum disease). The most recent UK Survey reported that 61% of adults with teeth said the usual reason they attend the dentist is for a check-up (Hill 2013).
Dental check-ups allow early detection of oral disease, in particular dental decay and gum disease, as well as checking the health of the rest of the mouth (British Dental Association 2000, Conway 2002). This allows dentists to treat problems early, before decay or gum disease progress and potentially need more complex treatment. Integrating the information collected as part of the check-up allows the dentist to use their clinical judgement to predict the individual’s likely risk of developing future dental disease and provide tailored advice to address specific risk factors. Preventive advice may include oral hygiene and dietary advice, and smoking cessation or alcohol-related health advice (National Institute for Health and Care Excellence 2015, Public Health England 2017).
The risk of developing dental disease varies between individuals. The National Institute for Health and Care Excellence (NICE) has therefore recommended a personalised risk-based check-up frequency since 2004. Time between check-ups would depend on an individual’s likely risk of developing dental disease, varying between three and 24 months. This recommendation is however based on low quality evidence, and despite this recommendation, encouraging patients to attend for check-ups every six months continues to be widespread.
New Cochrane evidence on how often people should visit their dentist for a checkup
The latest Cochrane Review on Recall intervals for oral health in primary care patients (published October 2020) is an update of a review last published in 2013 which found very low-certainty evidence from one study and a lack of evidence to support or refute the practice of six-monthly check-ups (Riley 2013).
Our updated Cochrane Review includes results from one additional UK-based study (Clarkson 2020) which provides high-certainty evidence to the review question. We included a total of 1736 people from two studies who had regular dental check-ups. One study was conducted in a public dental clinic in Norway in children and adults aged under 20 years. It compared 12-monthly and 24-monthly check-ups, and measured results after two years. The other study was in adults at 51 dental practices in the UK. It compared six-monthly, 24‑monthly and personalised risk-based check-ups and measured results after four years.
The studies looked at how different intervals between check-ups affected: the number of people with tooth decay; the number of tooth surfaces affected by decay; gum disease (percentage of bleeding sites in the gums); and quality of life (well-being) related to having healthy teeth and gums.
This review found high-certainty evidence that in adults, there was little to no difference between six-monthly and personalised risk-based check-ups in:
- the number of tooth surfaces affected by decay
- gum disease
- well-being after four years
There was also probably little to no difference in the number of people with moderate-to-extensive decay affecting at least one tooth (moderate-certainty evidence).
For adults receiving dental check-ups in primary care settings, there is high-certainty evidence that, overall, there is no difference in oral health when comparing 6-monthly and risk-based check-up frequency. In addition, there is moderate- to high-certainty evidence that there is little to no difference in oral health when comparing a 24-monthly check-up with either 6-month or risk-based check-ups over a four-year period. We concluded that further studies comparing check-up frequency for adults in primary care seem unnecessary, given the certainty of the evidence.
We did not find enough reliable evidence about the effects of 12-monthly and 24-monthly check-ups in children and adolescents after two years and recommend robust studies in this area.
What does this mean for adults having routine check-ups?
This Cochrane Review shows that traditional practice of scheduling a universal, one-size-fits-all six-monthly check-up for all adults having routine check-ups is unlikely to improve oral health compared to a personalised risk-based check-up approach or compared to check-ups every two years when patients are at low risk of dental disease.
These results indicate that a risk-based check-up frequency can be supported, as it does not seem to be detrimental to oral health and is acceptable to patients. But it is important to understand this evidence relates to adults having routine check-ups, not those who need to seek emergency treatment or children.
Are there other risks if people have infrequent check-ups?
One of the persistent arguments in favour of maintaining six-monthly dental check-ups is that dentists may miss the opportunity to diagnose oral cancer lesions at an early stage in patients who attend less frequently. No studies in this review reported the effect of different check-up frequencies on detecting oral cancer. The incidence of oral cancer in the UK is highest in Scotland, at 10.0 per 100,000 males (Conway 2018). However, it has been reported that 53.7% of patients diagnosed with oral cancer had not attended a dental check-up at all in the two years before diagnosis (Purkayastha 2018). It is estimated that dentists in Scotland will see a case of oral cancer once every 10-20 years – depending on the geographical location (Purkayastha 2018).
In addition, adults at higher risk of oral cancer are also at higher risk of dental decay and gum disease – people with higher alcohol intake, those who smoke, and individuals from lower socioeconomic status are at increased risk of all three diseases. A personalised risk-based check-up frequency would allow those individuals at greater risk to be seen more frequently, while healthy patients can be seen less frequently. Checking the health of the mouth is still recommended at every check-up, as is the recall of patients at high risk of dental disease and oral cancer more frequently than patients at low risk of these diseases.
The COVID-19 pandemic and dental care
This research is also valuable when considering the significant impact of the COVID-19 global pandemic and its effect on dental services worldwide, limiting patient access to dental treatment. Patient access to dental care may remain limited for some time, however the results of this review provide reassurance that intervals between check-ups can be extended beyond six months without detriment to oral health.
What is my risk of dental disease?
When weighing up an individual’s risk of developing future dental disease, a dentist will assess factors such as:
- self-performed oral hygiene habits and timing (e.g. brushing teeth, flossing)
- dietary habits – including amount and frequency of sugar intake
- fluoride use
- tobacco use
- alcohol intake
- signs of active disease
- plaque control
- quantity and quality of saliva (which helps to protect teeth against disease)
- past disease experience (which can be assessed through the number of teeth with fillings or teeth that have been previously extracted)
- medical history, including factors that may impact on oral health
Bringing this collected information together allows the dentist to use their clinical judgement to predict the individual’s likely future disease experience and recommend an appropriate tailored recall interval based on this risk assessment. This is a joint decision between dentist and patient and involves discussing the recommended interval, exploring patient preferences and expectations, and discussing any relevant financial implications.
In circumstances where there is uncertainty about an individual’s disease risk, an initial conservative recall can be extended if good oral health is maintained over time. On the other hand, previously longer recall intervals can be adjusted to account for changes in likely future disease experience (for example, if a new risk factor is identified at check-up).
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Patrick Fee has nothing to disclose.