20.2 Risk Assessment, Recall Intervals and Preventive Planning
Key Takeaways
- NICE Clinical Guideline 19 requires the recall interval to be determined individually from assessed risk, discussed with the patient and recorded.
- Permitted recall intervals are 3 to 24 months for adults aged 18 and over and 3 to 12 months for children and young people under 18.
- Risk is reassessed at every visit and the interval adjusted in either direction as smoking, diabetes control, diet or disease activity change.
- Delivering Better Oral Health advises brushing twice daily with age-appropriate fluoride toothpaste, spitting but not rinsing.
- Reducing the frequency of free sugars matters more than reducing the total amount, because frequency determines time spent below the critical pH.
Recall Is a Clinical Decision, Not a Habit
The idea that everybody should be seen every six months has no evidence base and is contrary to UK guidance. NICE Clinical Guideline 19, Dental recall, requires that the interval between oral health reviews be determined specifically for each patient and set on the basis of assessed risk of and from oral disease. The interval must be discussed with the patient, recorded, and reviewed and adjusted at each visit.
The NICE ranges are:
| Patient group | Permitted interval |
|---|---|
| Adults (18 and over) | 3 to 24 months |
| Children and young people under 18 | 3 to 12 months |
A 24-month interval may be set for an adult who has demonstrated repeated low risk over a sustained period. A 3-month interval is used where disease is active or risk is high. Because children's teeth develop and erupt more rapidly and caries progresses faster through thin primary enamel and dentine, the maximum interval for under-18s is half that for adults.
What "Risk" Means
The recall interval should be informed by the assessed risk across several domains:
| Domain | Indicators of higher risk |
|---|---|
| Caries | Recent new or active lesions, high frequency of free sugars, low fluoride exposure, hyposalivation, poor plaque control, previous restorations, orthodontic appliances, deprivation |
| Periodontal | Smoking, diabetes, BPE codes 3 or 4, previous attachment loss, family history, poor plaque control |
| Tooth surface loss | Reflux, eating disorder, frequent dietary acids, bruxism, occupational or recreational acid exposure |
| Oral cancer | Tobacco in any form, alcohol above guideline, areca nut, previous oral potentially malignant disorder, immunosuppression, age |
| Medical and social | Medication causing dry mouth, immunosuppression, dependency on a carer, dental anxiety, irregular attendance |
Risk is not static. A patient who stops smoking, whose diabetes comes under control or whose diet changes should have their interval re-set, in either direction.
Building the Preventive Plan
Prevention is planned with the same seriousness as operative treatment, following Delivering Better Oral Health:
- Toothbrushing — twice daily with fluoride toothpaste at the concentration appropriate to age and risk, last thing at night and on one other occasion; spit, do not rinse.
- Fluoride — 1,350 to 1,500 ppm fluoride from age 7; prescription 2,800 ppm from age 10 and 5,000 ppm from age 16 where caries risk is high; fluoride varnish at 22,600 ppm fluoride at least twice a year for children at risk.
- Diet — reduce the frequency of free sugars, not only the amount; confine sugars to mealtimes; reduce frequency of dietary acids.
- Interdental cleaning — interdental brushes where the space allows, floss where it does not.
- Smoking and alcohol — Very Brief Advice at every opportunity with referral to cessation services.
- Fissure sealants — resin-based sealants on permanent molars in children at increased risk.
- Behaviour change — one specific achievable goal at a time, using the approaches in the behavioural sciences chapter.
Auditing the Plan
Recall intervals and preventive plans are good audit subjects: the standard is explicit, the data are in the notes and compliance is measurable. An audit asking "in what proportion of adult records is a recall interval recorded with a documented risk justification?" tests exactly what NICE CG19 requires and what a CQC inspection would look for.
Exam link. A stem describing a 19-year-old non-smoker with no caries for five years, excellent plaque control and no periodontal disease is testing whether you will extend the interval. An interval of up to 24 months is permissible for a low-risk adult, and setting six months by default without a recorded risk assessment does not meet NICE CG19.
What NICE CG19 Actually Says
The UK position on recall intervals is set by NICE clinical guideline 19, and candidates should be able to state it precisely because SBAs are built on the exact numbers. The interval between oral health reviews is determined for each patient individually after assessing disease levels and risk of or from dental disease, and should be between 3 and 12 months for patients under 18 and between 3 and 24 months for patients aged 18 and over. The longest interval is available only to patients who have repeatedly demonstrated low risk and disease levels over several consecutive reviews. The interval is recorded, explained to the patient and reviewed at every visit, and it can be shortened as well as lengthened.
The examinable traps are that a fixed six-month recall for everyone is explicitly not supported, that the recall interval is a clinical decision that must be justified in the notes, and that an interval longer than 12 months is not available to a patient under 18 whatever their risk.
The Preventive Package by Risk Level
Prevention in the UK is delivered through Delivering Better Oral Health, which sets out advice for all patients and additional measures for those giving concern. The everyday measures are brushing twice daily with a fluoride toothpaste last thing at night and on one other occasion, spitting out and not rinsing after brushing, reducing the amount and frequency of sugar intake, and interdental cleaning where indicated. Concentration is stratified by age and risk: children under 3 use a smear of toothpaste containing at least 1,000 ppm fluoride, children aged 3 to 6 use a pea-sized amount of at least 1,000 ppm, and those aged 7 and over use a toothpaste containing 1,350 to 1,500 ppm fluoride. Patients giving concern may be prescribed higher-concentration toothpaste, and fluoride varnish at 22,600 ppm fluoride is applied at least twice a year from the age of 3, and from a younger age for children giving concern.
Auditing the plan matters as much as making it: a preventive plan that has been delivered for a year without a fall in new lesions or in bleeding scores needs re-examination of adherence, diet and salivary function, not simply repetition.
A 19-year-old university student attends. She has never had a carious lesion, does not smoke, has a full-mouth plaque score of 8%, BPE codes of 0 in all sextants and no tooth surface loss. Under NICE Clinical Guideline 19, what recall interval may be set and what must be recorded?