Letter to BDJ from Aubrey Sheiham (sans tables)

Sir, — The BDA Press Release (17 April 2000) in response to my Jean Todd Lecture at the Dental Practice Board Conference in April says that ‘the public are now advised by their dentists to go for check-ups less often than in the past — that is, at least once a year — unless they need to go more often.’ They also state that the recent Adult Dental Health Survey found that around three quarters of the public has visible plaque. Regarding X-rays, they quote the RCS report which says that routine radiographs for low-risk people need not be taken more often than once every two years.  

In my lecture I said: ‘If NICE recommends that unless a person can be defined as high-risk, the intervals between dental examinations should be 18 months for under 18-year-olds and 2–3 years for adults, the numbers of dental examinations on adults would be reduced by about half, assuming that approximately half the adults currently attending are regular annual attenders. There would be about six to 10 million fewer dental visits a year and a saving of between £50 to £120m considering that fewer radiographs would be taken.’

On scaling and polishing teeth, I said: ‘Over 13 million scaling and polishings are done annually on adults in England and Wales. Yet there is no evidence that there is any health gain from such procedures. In a state-of-the-science review of mechanical oral hygiene practices, Frandsen (1986) concluded that the optimal frequency and starting age for scaling and polishing has not been determined. Scaling, polishing, root planing, and surgical treatment of shallow periodontal pockets results in permanent loss of attachment. A recent systematic review of 144 studies on the effectiveness of scale and polish carried out more frequently than once a year compared to once a year, concluded that there was very little gain in periodontal health from more frequent scalings. Add to these conclusions the findings in the systematic review that chairside dental health education was ineffective in reducing periodontal disease or caries, then there is little scientific justification for prophylaxis and chairside dental health education. Once a year or so, cleaning has questionable health benefit. Yet, that item costs about as much as all NHS inlays and crowns in England and Wales in 1997/98 (DPB 1998), £113.3m compared to £120.2m. That is 13.2 per cent of total GDS annual expenditure for adults.’

I did not state that people should not go to the dentist; merely that the intervals between recalls should be increased and that scale and polishes should be done less frequently. Longer recall intervals would logically mean taking fewer X-rays. Therefore, if we want to assess whether there is any detriment to dental health by increasing the recall intervals, we should compare Regular Attenders (RA) with Occasional Attenders (OA). An analysis of the results from the recent Adult Dental Health Survey — Oral Health in the United Kingdom 1998(3) indicates that there is very little difference in dental health between adults who go regularly or occasionally. Fifty-eight per cent had made no dental visit in the past five years, 34 per cent had made 3–4 visits and six per cent made 5–9 visits in the past five years.

What is most interesting is that OA’s had three or more sound teeth (no fillings) than RA’s. OA’s also had more teeth present and fewer missing teeth.

OA’s had less periodontal disease than RA’s (39 per cent of OAs versus 43 per cent RAs with loss of attachment of 4mm or greater and the differences in plaque (68 per cent in RA’s versus 72 per cent in OAs) and calculus (68 per cent in RA’s versus 75 per cent in OAs) are small and can be explained by the fact that because OA’s had more teeth, there were more surfaces to get plaque and calculus.

In summary, there is no evidence that increasing the interval for dental check-ups to one year or longer had any significant adverse effect on dental status. On the contrary, OA’s had more sound unattacked teeth and fewer teeth with deep periodontal pockets. The BDA state that people are now being advised by their dentists to go for check-ups less often than in the past. Fifty-nine per cent of dentate adults go for regular check ups and 82 per cent of regular attenders have visited a dentist in the last six months - a further 15 per cent have made visits between six months and up to one year. This suggests that either the dentists are not advising their adult patients to go for check ups less often, the 6–month recall was the previous recall interval, or that large percentages of patients, who are now much more dentally healthy than before, are deciding to go for the outdated 6–monthly recall. So, contrary to what the BDA stated, there is some dental health gain in extending recall intervals to 2–3 years for adults, as argued in the Jean Todd Lecture.

 A. Sheiham Professor of Dental Public Health, University College London Medical School