5.3 Prevention & Health Promotion

SDCEP OHAR & Caries Risk Stratification

The Scottish Dental Clinical Effectiveness Programme (SDCEP) Oral Health Assessment and Review (OHAR) guidance provides a structured framework for the recall interval and the oral health assessment, integrating the NICE CG19 Dental Recall risk-based intervals. Rather than a blanket six-month recall, the clinician assigns a caries risk category (conventionally HIGH, MODERATE or LOW) and sets the recall interval accordingly.

Caries Risk Categories and Intervals

NICE CG19 specifies that the shortest recall interval is 3 months for all patients, the longest for under-18s is 12 months, and the longest for adults is 24 months. The guideline was reviewed in March 2020 following the INTERVAL trial and the recommendations were not updated, so they remain current.

The OHAR Assessment

The OHAR assessment goes beyond a simple 'check-up': it includes a medical and social history, a caries risk assessment, a periodontal assessment (BPE), a soft-tissue screen, an occlusal review, and a tailored preventive plan. It is designed to be delivered by the dental team (dentist, therapist, hygienist) and underpins the personalised recall interval.

Fluoride: Toothpaste, Varnish and the DBOH Toolkit

The Public Health England (PHE) Delivering Better Oral Health (DBOH) evidence-based toolkit is the principal UK reference for prevention in dental practice. Its recommendations are graded by strength and certainty of evidence.

Fluoride Toothpaste by Age and Risk

High-strength fluoride toothpaste (HSFT) should be prescribed only when risk cannot be modified by other means and there is active disease, on a short-term basis with regular review. The 2,800 ppm preparation is the usual first choice for patients aged 10 and over; 5,000 ppm is reserved for those 16 and over with very high clinical need. Patients should be advised to brush for one minute, spit and not rinse, and avoid eating or drinking for 30 minutes afterwards. Total fluoride intake should not exceed 10 mg daily for adults and children over 9.

Fluoride Varnish

• Concentration: 2.26% sodium fluoride (22,600 ppm fluoride) — the formulation with the strongest evidence base.
• Frequency: at least twice a year for children and adults at higher caries risk; the manufacturer's maximum is every three months (around four times a year).
• Evidence: moderate-certainty evidence (Cochrane, Marinho et al.) shows an average caries reduction of 37% in the primary dentition and 43% in the permanent dentition with twice-yearly application.
• Precautions: delay for ulcers or significant mucosal inflammation; the patient should not eat or drink for 30 minutes and avoid hard or sticky food until the next day.

Other Topical Fluorides

Fluoride tablets, drops and gels are no longer routinely recommended in the UK. An alcohol-free 0.05% sodium fluoride (225 ppm) daily mouth rinse can be considered for adults and children over 8 at increased risk, used at a different time from toothbrushing.

Diet, Smoking, Alcohol & Oral Cancer Prevention

Diet Advice

The DBOH toolkit and SDCEP guidance agree that the frequency of sugar intake is more important than the total amount. Practical advice for patients includes:

• Keep sugar to mealtimes only (up to four sugar occasions per day for adults, including meals).
• Snack on sugar-free alternatives (cheese, nuts, raw vegetables).
• Choose sugar-free medicines where available, especially for children.
• Be aware of hidden sugars in sauces, yoghurts, dried fruit and 'low-fat' products.

Smoking Cessation: The 5As Brief Intervention

Smoking is a major risk factor for periodontal disease, oral cancer, delayed wound healing and dry socket. Dental teams are well placed to deliver brief intervention using the 5As framework:

Very Brief Advice (VBA) is a 30-second version (Ask, Advise, Act) for time-pressured settings.

Alcohol: The CAGE Screen

The CAGE questionnaire is a brief alcohol misuse screen suitable for dental practice:

• C — Have you ever felt you should Cut down?
• A — Have you been Annoyed by criticism of your drinking?
• G — Have you ever felt Guilty about your drinking?
• E — Have you ever had an Eye-opener (a drink first thing in the morning)?

Two or more positive answers suggest alcohol misuse and warrant further assessment or referral. UK Chief Medical Officers' guidance is that men and women should drink no more than 14 units per week, spread across three or more days.

Oral Cancer Prevention

Oral cancer risk is multiplicative when smoking and alcohol coexist. The dental team should:

• Deliver smoking cessation and alcohol brief intervention to all at-risk patients.
• Perform a systematic soft-tissue examination at every recall, including the lateral border of tongue, floor of mouth, oropharynx and buccal mucosa.
• Refer any persistent (more than three weeks) ulcer, red or white patch, or lump via the local two-week wait suspected cancer pathway.
• Counsel patients on areca nut / paan / gutka chewing, sun exposure to the lip, and HPV-related oropharyngeal cancer.

Antimicrobial Stewardship & Oral Hygiene Instruction

Antimicrobial Stewardship in Dentistry

Dentists prescribe around 10% of all antibiotics in primary care in the UK, and antimicrobial resistance is a major public health threat. The SDCEP Drug Prescribing for Dentistry and the FGDP/RCS Antimicrobial Prescribing in Dentistry (3rd edition, 2020) set the UK standard. Key principles:

• Prescribe only when clinically indicated — not for pain of inflammatory origin alone.
• Use local measures first — drainage, irrigation, local analgesia.
• Narrow-spectrum first-line — amoxicillin 500 mg three times daily or metronidazole 400 mg three times daily for spreading odontogenic infection. Co-amoxiclav must never be used in penicillin allergy — it contains amoxicillin; the penicillin-allergic alternatives are metronidazole or clarithromycin.
• Shortest effective course — typically 5 days; review at 3 days and stop if resolved.
• Document the indication, drug, dose, course length and review plan.

Conditions where antibiotics are not routinely indicated include irreversible pulpitis, dry socket (alveolar osteitis), localised periapical abscess without systemic involvement (drainage is the treatment), and pericoronitis (local irrigation is first-line).

Oral Hygiene Instruction

Effective oral hygiene instruction (OHI) is personalised, demonstrated and reinforced at every recall:

• Toothbrushing — twice daily with a fluoride toothpaste, last thing at night and at one other time; spit, do not rinse, to retain fluoride.
• Technique — a small-headed soft-bristled manual or electric brush; the modified Bass technique (45 degrees to the gingival margin, short vibratory strokes) is widely taught.
• Interdental cleaning — daily floss or interdental brushes sized to each contact; bleeding is normal in the first week and should reduce with persistence.
• Disclosure — disclosing tablets or solution help patients visualise plaque and monitor improvement.
• Tailoring — for patients with limited dexterity (arthritis, tremor), recommend an electric toothbrush with a thick handle or a specialised grip; for fixed orthodontic appliances, add interdental brushes and a single-tufted brush around brackets.

Delivering Better Oral Health: Summary Evidence

The DBOH toolkit grades its recommendations by strength and certainty. The strongest evidence supports fluoride toothpaste (strong, high certainty), fluoride varnish (strong, moderate certainty), sugar reduction (strong, moderate certainty) and smoking cessation brief intervention (strong, high certainty). Dental teams should use these evidence-based interventions consistently and document them as part of the prevention plan.