How often should we go to the dentist?BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7204.204 (Published 24 July 1999) Cite this as: BMJ 1999;319:204
About once a year—but rates of disease progression vary greatly
- Elizabeth J Kay, professor of dental health services research
The 1993 United Kingdom Child Dental Health Survey showed that children who only attended dentists when having problems had more decayed and filled teeth than children who attended when asymptomatic.1 The so called “regular” attenders tended to have fewer teeth extracted. A similar survey of adults also showed that those who had check ups had almost half as many teeth missing as those who visited the dentist only when they had a problem.2 At first glance therefore the evidence suggests that individuals who go the dentist to seek treatment before symptoms arise actually do suffer fewer sequelae from the progression of dental disease. The picture is not, however, that simple.
Oral ill health shows a social class gradient just as every other chronic lifestyle related disease does.1–3 The most affluent and socially advantaged individuals suffer low levels of dental disease, and those in the poorest and most disadvantaged groups have the highest disease rates. Similarly, those in higher socioeconomic groups are more likely to register with a dentist and are more likely to attend for check ups when they do not have symptoms.4 Thus the ubiquitous observation that going to the dentist lowers the risk of disease may in fact simply be yet another social class phenomenon. It might reflect differences in lifestyle, attitudes, behaviour, and access to health-providing products, foods, and services5 rather than being due to the effectiveness of preventive dentistry.
Nevertheless, given that attendance is associated with improved health and makes people less likely to suffer acute symptoms and emergency treatment,6 what is the optimal interval between each attendance. In Britain six months is customary, but why not twice weekly, annually, or even once a decade? To decide whether people should be advised to attend six-monthly for dental examinations the rates of disease progression and the ability of dentists to identify and arrest or treat the disease have to be explored. A review in 1995 examined eight longitudinal datasets and concluded that 38% of early carious lesions would progress into the dentine of a tooth (the point at which the decay is irreversible) within three years, while 46% of lesions which had already reached the inner enamel of a tooth would progress to the dentine within three years.7
Based on these and other data Moles et al in 1999 ran a computer simulation to identify optimal recall intervals.8 They concluded that patients would benefit most by attending dentists at intervals ranging from 13 months to 120 months A more definitive answer was not obtainable because of two factors—some dentists are better than others at recognising the presence of early disease and, more importantly, rates of disease progression vary immensely between individuals.
There has been an intense search for risk indicators for dental disease so that individuals' disease progression rates can be more accurately judged, but, ultimately, the use of a dentist's clinical judgment to identify people at risk of caries has been shown to be as good as, or better than, any other selection method or test.9 10 The only conclusion which can be drawn from the available evidence thus seems to be that judgment about appropriate intervals for treatment of dental caries can only be made on an individual basis Blanket recommendations will result in some diseased teeth being left unexamined, many non-diseased teeth being unnecessarily and frequently investigated, and resources expended to no purpose.
Finally, it must not be forgotten that, although it is dental decay that most often gives rise to acute symptoms, it is not the only oral disease The other, almost ubiquitous, oral problems are gingivitis and periodontitis (reversible and irreversible gum disease). The single most important cause of these conditions is plaque, which can be removed by the patient via thorough cleaning with a toothbrush. A recent systematic review showed that one of the most effective ways of ensuring that this pattern of behaviour was undertaken was for people to receive simple but individualised advice from dental staff on a regular and repetitive basis.11 Thus, regular attendance appears to be important for the delivery of health messages.
So, should everyone attend the dentist twice a year? The evidence for this recommendation is sparse, to say the least. Doing so may encourage healthy behaviours, but the evidence for this link is weak. There is, however, relatively strong evidence that a yearly dental examination will often be beneficial to the patient's health. The strongest evidence, however, suggests that because disease risk varies so widely between individuals, it is only the dentist who can adequately assess the most appropriate interval between dental examinations.
Thus if general medical practitioners encourage their patients to register with a dentist and attend regularly they are less likely to be called on in the night to deal with dental emergencies. Choices about the optimal recall interval, however, like most clinical decisions, can be made only when all the relevant information is available. The only person who will have this information is the dentist. It is thus essential that, if patients' best interests are to be served, medical and dental practitioners act in harmony and individualise the advice they give to patients. The concept of “oral health” is only a historical accident. Oral cavities cannot be healthy or unhealthy, only people can. The new primary care groups offer a mechanism whereby doctor and dentist can support this holistic view in a way which will benefit both professions and, of course, their patients.