It seems such a simple question: how often should you see a dentist?

But there are no simple answers, according to an evidence-based analysis recently undertaken for the Deeble Institute for Health Policy Research.

The researchers found that there is no high quality evidence to either support or refute the common recommendation of six-monthly dental check ups.

And they suggest that policymakers grappling with the implementation of national dental health reforms may be well advised to move towards a risk-based recall system rather than a fixed six-monthly recall.

The evidence brief notes that:

“A large minority of the Australian population cannot access dental care in a timely way, and those that can, may not require dental care at the frequency at which they are receiving it.”

In many ways, the findings are illustrative of much wider concerns with health care – that some people get more than they need, while those who are in most need are also more likely to miss out.

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Weighing up the evidence on dental check-ups

Anne-marie Boxall, Mark Gussy and Stacey Bracksley write:

Most commonly, people are advised to visit the dentist, or have dental visits, every six months.

But is it really necessary for most people to go this often, or is this recall period based on tradition rather than scientific evidence?

This recently published Evidence Brief examines what the peer-reviewed literature says about how often people should have dental visits.

It reveals that there is little supporting evidence for a standard 6-monthly recall period.

Several systematic reviews, which are considered the highest quality evidence in healthcare, have been conducted in an attempt to resolve the debate about how often people should have dental visits.

The first systematic review was commissioned in 2003 by the UK’s National Institute of Clinical Excellence to inform the development of clinical guidelines on dental recall in the NHS.

The review included twenty-eight studies that compared outcomes such as caries (also known as tooth decay or a cavity), tooth loss, periodontal conditions, oral cancer and quality of life.

All the studies in the review compared two groups of patients: one group that had 6-monthy visits and another that had a different frequency of visits (it differed from study to study). Only three of the studies were controlled trials, and all had several minor threats to their validity.

The review concluded that there was no high quality evidence to support or refute six-monthly dental visits.

The clinical guideline that was subsequently developed recommended that recall periods be determined by individual patient need, with no patient waiting more than two years between visits.

The guidelines also stipulated that the level of evidence underpinning these recommendations was considered low. Ultimately, it was the clinical experience of the Guideline Development Group that informed them.

The guidelines were subsequently reviewed in 2008 and 2012, and no new evidence was found that changed the original guideline recommendations.

The Cochrane Collaboration (an international and independent non-profit organisation dedicated to evidence-based health care) has also conducted a systematic review on this topic.

The review, which was published in 2008, focused specifically on the relationship between the frequency of dental visits and health outcomes such as dental caries, periodontal diseases and oral mucosal lesions.

Only one study satisfied the Cochrane’s inclusion criteria: a randomised controlled trial conducted in a public dental facility in a fluoridated region of Norway. In this study, children in three age groups were randomised to be recalled at either 12 or 24 months, after they had had an initial dental examination.

The results showed that although there was a trend towards more dental caries in the group that was recalled every 24 months, this difference was not statistically significant.

The only significant findings in the study was that over the course of the study, the total time spent examining children who were recalled every 24 months was less than that for children who were recalled every 12 months (this is not surprising given they were recalled less often).

The time spent providing the required treatment to the children was the same regardless of recall period. From these results the researchers concluded that extending the recall interval from 12 to 24 months had no significant impact on the incidence of disease.

The most recent systematic review in this field was published in 2010, and looked at the association between recall intervals and a single health outcome: dental caries.

Using less stringent inclusion criteria than the Cochrane review, these researchers included seven studies, but only one randomised controlled trial, the same Norwegian study that was included in the Cochrane review. This shows that in the intervening period no new good quality research was conducted.

It is no surprise then that this review also concluded that the evidence to support a one-recall-fits-all protocol was weak, and that recall intervals should instead be customised to fit a patient’s individual needs, based on a risk-assessment.

With a relatively weak evidence-base to draw on, and a growing consensus for risk-based recall periods, some are likely to conclude that the frequency of dental visits is something people should decide for themselves, in consultation with their oral health care professional.

While this is true at an individual level, there are important policy implications around the frequency of dental visits.

Dental diseases are a costly public health issue that disproportionately affect disadvantaged people.

In recent years, there has been growing concern about inequities in access to care in Australia, with a particular focus on the length of time people are waiting to access state and territory-funded public dental services.

In response to these concerns, the Gillard Government established a National Advisory Council on Dental Health, and in 2012 it announced a new dental reform package.

The new reform package provides more funding to state and territory governments so that they can reduce public dental waiting lists and establish more effective and efficient dental care for low income families and children.

To implement the new reform package, policymakers will need to make important decisions about access to publicly-funded dental care: who should be eligible, how often should they be able to access services, and what services should be covered.

The decisions made about access, in particular how often it is recommended that people have dental visits, will have a major bearing on the cost of these news programs and how effective they are in reducing inequity.

 • Dr Anne-marie Boxall is director of the Deeble Institute for Health Policy Research; Associate Professor Mark Gussy and Stacey Bracksley are from the Department of Dentistry and Oral Health at La Trobe Rural Health School

 

 

 

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