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Literature Review
Introduction
Dentistry as a branch of medical science has successfully and uniquely combined the principles of human science and the art of healing. The dental profession in particular has changed during the past years due to the review of scientific evidences that emerged in the health fields and medicine that rely on systematic approach. The findings from several literatures suggest clinical practices and other relevant concepts pointing out the recommended frequency of visits to dental practitioners for various types of patients. This includes patients suffering from oral cancer, periodontal diseases, and caries risk. In addition, these variations will also be examined between patients from different age groups and demographics. With the emerging technologies scientific breakthroughs in the field of dentistry, practitioners are faced with challenges of effectively integrating and implementing treatment modalities for different types of patients. However, exploring the subject of recall times to dental practitioner for a dental examination requires scientific evidence-based findings. This encompasses the need to examine related scientific evidences pertaining to the clinical modalities and best practices in dentistry. The literatures to be reviewed will consist of journals and articles in the field of dentistry discussing the evidences and findings that justifies appropriate recall times for various types of patients to dental practitioners.
Aims
The review of literatures will focus on identifying the evidences that will address the problem question of how often should patients visit their dental practitioner for a dental examination given the differences in patient types. This will include published journals, articles, and other related materials showing similar concept of studies, which will provide pertinent data supporting the defined subject of exploration for this study. The level of dental care for every patient type varies due to the varying level of risks involved in the aforementioned patient types, which requires specific recall times for treatment (Beirne, Clarkson & Worthington 2009; Wang et al. 1992). These recall times are the focus of the study in which the relevant literatures are examined for evidence-based approach in determining the appropriate frequency of visits for different types of patients.
Search History
The literature review will only utilize published materials such as per-reviewed journals, reports, and articles from credible sources. The method of acquiring the materials for this review is through online data base search and library search. In terms of geographical source of materials, the review will be a variation of the materials published in the United States, but the majority of the published materials will come from sources from within the United Kingdom and Ireland. The strategies involved in searching through online database is with the use of specific keywords such as mouth cancer, oral hygiene, Oropharyngeal Cancer, caries, recall times, periodontal, and other related terminologies. The same approach was used in library search for obtaining relevant materials. However, the keywords used to search for literatures to review came back with successful results when searched in databases such as PubMed, NHS, EBSCO Host on Dentistry and Oral Sciences Source, Google Scholar, Springer, and NCBI. In the aforementioned source databases, specific phrases were used to search for literatures such as, recommended recall times, evidence-based study on dental recall, how often should a patient visit the dentist, and recall times per patient type/disease.
Literature Review
A study conducted by Sheiham (1977) presented an argument that questioned the technical foundation of a dental examination done 6 months apart. The empirical study did not find an ounce of evidence to carry the importance of dental check-ups done every 6 months. His research showed a different result as it revealed it is more suitable that children aged 12-16 years old undergo dental examinations every 12 months (Shieham 1977). Moreover, people over 16 years old, have a decrease in caries activity and is recommend undergoing a test every 18 months. People who live in areas where their water is mixed with fluorine are advised to increase their intervals of their visits to their dentists (Bader 2005). Sheiham’s (1977) research was founded on other studies that was pertinent to the ideal objective of a twice a year dental examination. This was practiced for the longest time as it is believed to be able to detect dental infection or lingering tendency in order to facilitate cure, which will have a higher rate of success. The research further ascertains that there is little connection to the frequency of dental check-ups and periodontal diseases (Loe 2000).
Evidence from the research suggests that dental diseases rapidly affects adolescents and children than aduts, which requires definite recall intervals of no longer than 12 months given the need for reinforcing and delivering preventive measures for promoting awareness among children for a life-long dental health (National Institute for Clinical Excellence 2004). A general guideline was developed to emphasize reccomended recall times for caries disease using a checklist. The checklist is consist of modfying factors along with the reasons for inclusion. Factors such as conditions perpetuating oral diseases and promotes development such as caries diseases requires long-term dental medication that contains fructose, glucose, and or glucose. Social history is also considered as a modifying factor for caries dieases where historic trend in the family etiher the mother or the siblings have had caries and is likely to be passed on to individual children (National Institute for Clinical Excellence 2004).
A further research was done by Davenport and Kujan (2005) according to the published dental recall guidelines by the NICE, highlighted the interval between dental examination routines according to patient type. The study and the guideline emphasized the reccomended shortest and longest inteval where the shortest interval for an oral health review for all patient types should be at least three months (Davenport et al. 2003; National Institute for Clinical Excellence 2004). Their study yielded limited results as it showed possible procedural loopholes. The researchers only arrived at the understanding that there was no data to support that either the addition of a screening plan for higher risk patients is required (Kujan 2005; Ramadas 2003). The use of visual tests in the general test subjects, and the supplementary examination intended at the success rate of opportunistic selection did not help either. The researchers concluded that there is a limit to the quality of data that can hold up or disprove the significance of the regularity of dental check-ups (Bailit 1982). However, there is certainly a need to create a justifiable significance to be utilized in the encouragement for a better oral health (Downer 1997). Furthermore, the study is limited to identifying recall intervals per age group, but further research is needed to examine the impact of adjusted intervals for patients with periodontal diseases, caries, gingivitis, oral cancer, and mucosal diseases.
The importance of a dental examination has been overlooked and this has somewhat created the limiting data it has provided for researchers in studying its significance. The comprehensive reasoning for dental check-up will always vary from person to person. People go to their dentist for their check-ups depend on the persons idea on what check-up is and why they need it. It can go from reasons such as maintenance trouble for people with controllable oral illness, dealing with an identified illness or oral condition, premature discovery among people who are most likely to develop severe oral diseases. The varying reasons behind dental screenings should be based on the frequency of their visits (NICE 2004; National Screening Committee 2001).
Varying levels of deterrence, variety of involvement and the goal entailed in the treatment are all connected with an oral examination as suggested by the study conducted by Davenport et al. (2003). The study was a systematic review of evidences pertaining to routine dental checks focusing on the lack of direction when it comes to the effect of oral health outcomes. The study included reviews of related studies with varying intervention approach, population, patient type, and outcome. Most of the examined recall aproach in the study are connected to investigative and precautionary services for a number of dental illnesses and oral conditions. The high rate of recurrence on dental check-ups as also demonstrated in the study by Bader, Shugars & Bonito (2001) suggests that high frequency of dental check-ups influenced by the type of oral issues like dental caries, periodontal illness, malocclusion and dental cancer. Moreover, the precautionary examinations conducted to the participants composed of random patients are grouped together according to oral health conditions in order to determine the recall times for each patient group. As a result, the most commonl patient in need of oral examination are the ones with highe dental health risk such as oral cancer patients. The variations of distinct points are accessible even for a single dental condition. This disparity among the studies made by different researchers lessens the rate of comparison in basing the results on hard data, making the analysis near impractical.
The abstract study made about dental examinations state clear of the slowness of data gathering and result generation. Other research and several studies have been conducted with logically tapered analysis questions. Limiting the questions that the research only involves particular involvement in parallel test subjects in parallel test environment.
These factors on the rationale behind a dental screening provide a warning about the message being developed in the need and significance of dental check-ups (Newsome & Wright 1999). Putting the main issue at the forefront on the significance of dental examination, a more successful and well-organized procedure is the main concern. Several institutions have created strategies in dealing with the cost-efficiency of oral recall tests for their entire patients at a period founded on the threat of dental illness. These issued guiding principles have set out several proposals for dental practitioners and the general public on the gap between dental screenings. The proposals states that the suggested period between the dental examinations should be settled on purposely for each and every patient, and molded to address his or her dental issues, on the source of an examination of the illness levels and the threat of or from the dental illness. The guiding principle suggests that for people under the age of 18, the gap between dental examinations should be between the third and the twelfth month. Adults on the other hand, should have 3 to 24 months of interval before their next dental check-up. This substituted the observed norm of recommending dental patients to return for examination every six months (Editorial 1977; Silverman 2001).
The guiding principle also suggested that throughout the dental examination, the dental panel must make certain that complete dental records are taken, tests are carried out and the preliminary precautionary opinion is given. This particular guiding principle opens the dental practitioner and the patient to discuss the outcome of dental hygiene, food intake, fluoride use, and the intake of tobacco and alcohol on dental well-being (Axelsson, Lindhe 1981). Another point of their discussion is the threat level that may affect the patient’s dental wellbeing, and their repercussions for settling on the necessary schedule of the patient’s next visit. They could also talk about the financial rate of the patient of undergoing the examination and any succeeding dental treatments.
Moreover, The gap between the dental screenings should be decided on, either after the check-up if there are no other succeeding dental treatments is specified, or on the end of a particular dental treatment (British Dental Association 2000), and the dental practitioner should talk about the suggested time for the patient to come back for another dental check-up. The dentist should also note this period, and the patient’s consent or disapproval in their records. The rate of occurrence of dental screenings should be decided on exclusively for each and every person factoring in whether they are on good dental condition, threatened by a dental illness, detected with a dental condition, and whether the goal of the oral examination is to encourage dental wellness, avert any possible dental condition into becoming a serious threat, avoid development or reappearance. The rate of incidence should think about the success of attaining the goals and the well-organization of the conditions of the overall dental practice.
Dental recalls are recommended by the US Department of Health and Human Services. Children that have undergone risk assessment are categorized by age. Infants usually undergo periodic check-up to monitor the growth of the teeth as well as the health of the baby. Parents are usually given tips on how to assist their children in coping with dental recalls. Adolescents that have experienced caries risk and periodontal diseases are required to undergone radiographic examinations. The frequency of radiographic examination is determined through the assessment of caries risk. Patients that belong to other dental risk categories are also required to do an examination for dental imaging (National Collaborating Centre for Acute Care, 2013).
Studies pertaining to recall intervals, quality of dental care, and dental hygiene was conducted on children. Wang and Riordan (1995) examined the aforementioned factors in two districts in Norway by evaluating the clinical records of subjects’ aged 18 years old and below. The purpose of the study is to determine the quality of dental health outcome in relation to recall intervals (Wang & Riordan 1995). Each of the subjects was scored on a scale of one to four based on the examined records for the level of severity. The findings in the study suggest that the quality of health outcome is indicated by treatment decisions. Treatment decision is also accompanied by determined recall intervals per patient type of disease. For instance, decisions for caries are evaluated for the proportion of sound surfaces and depth of lesions in the dentine (Wang & Riordan 1995). However, radiographic quality, hygiene, and improved administrative routines were found to have significant correlation to recall intervals. The study provides relevant insights to determining the recommended recall intervals for patients given the need for the quality of dental care.
Wang et al (1992) conducted a study using randomized-controlled clinical trial to determine the effect of extending recall intervals on resource consumption and dental health. The randomized clinical trial preferred children as the subject of focus with 185 children at the age of 3, 16, and 18 years old. Using a linear regression analysis, the study concluded that dental health services in Norway could save significant resources if the recall intervals are to be extended (Wang et al. 1992). Furthermore, the study analyzed the varying effect to resources consumption by the Dental Health Services if the recall times were to be adjusted to 24 months as opposed to the usual six or 12 months. Productivity increase was found in the process of extending the recall times. However, the effect on resource consumptions was also found to have a significant effect to treatment modalities given that high risk dental conditions require shorter recall intervals (British Dental Association 2000). The study was able to provide significant insight to effects of changing the recommended recall intervals. However, the results only provide recommendations pertaining to resource consumption and less significant to the determination of recall intervals in relation to risks involved in various oral diseases particularly for children.
Mentioning about high risk dental diseases, oral cancer is considered as a deadly disease that greatly concerns dental practitioners. In the UK alone, about four people die from oral cancer every day. It has a 50% survival rate, especially for the cases that are not diagnosed as early as possible (Neville 2002). For this reason, the recommended recall intervals are suggested by the study conducted by Casiglia & Woo (2001). The evidence based study focusing on observing the risks involved in oral cancer patients suggests three to six months interval for dental examinition (Casiglia & Woo, 2001). This is for the reason that any suspicious lesions that appear at lateral or ventral surfaces of the tongue, as well as the floor of the mouth, should be constantly monitored for any apparent spread of infection. The study also emphasized the importance of prior biopsy and return to primary care as factors that determines the gap in recall intervals. Similar intervals were also reccomended to patients with caries and periodontal diseases like plaque, which requires at least six months recall intervals for dental examination (Casiglia & Woo, 2001; Neville, 2002). However, patients with active periodontal disease may also be required by the dentist for a recall examination one every three months(Hulka 1978; Hindle, Downer & Speight 1996). The study presents significant evidence regarding the reccomended recall intervals for oral cancer. In addition, providing insights and compartive analysis to other diseases determines the variation in terms of frequency of visit for dental examination.
However, in the recent years, the risk has increased gradually for younger age groups with recorded cases of 35-year-old patients (Teich 2012). Material deprivation is also a contributing factor in the occurrence of oral cancer (Greenwood 2003). There has been an observed regional pattern of increased mortality, especially in the Northern regions of England and Wales (Hawkins, Wang &Leake1999: O'Hanlon S, Forster DP, Lowry 1997). Despite the advancement in the technology that is used for curing the disease, there has been no significant improvement in the survival rates for oral cancer patients.
An empirical study conducted by Lissowska et al. (2003) and similar exploration by Jones, Kressin& Spiro (2001) identified the risk factors in determining recall intervals for dental related diseases. The primary cause of oral cancer along with other periodontal diseases such as plaque is excessive tobacco use. This is not limited to smoking tobacco. Chewing tobacco and using smokeless tobacco can bring great risks for the development of high-risk diseases (Jones, Kressin& Spiro 2001: Lissowska et al. 2003; Horowitz 2001). The study composed of randomly selected participants were grouped according to oral disease type was surveyed to determine factors relating to the occurrence of oral diseases (Llewellyn, Johnson &Warnakulasuriya 2001). Caries disease for instance with risk factors occurring from defective restoration recommends recall times of at least six months. The same interval was recommended for periodontal patients particularly children and adolescents that acquired new periodontal disease (Jones, Kressin& Spiro 2001: Lissowska et al. 2003; Llewellyn, Johnson &Warnakulasuriya 2003). Most of the risk factors determined by the study that causes the aforementioned diseases and henceforth the recommended recall intervals were associated to lifestyle and lack of early preventive measures (Jones, Kressin& Spiro 2001: Lissowska et al. 2003). The studies were able to provide relevant insights to the associated risks involved in the aforementioned dental problems, which determines the variation in recall intervals.
Discussion
There is a noticeable low prevalence of the identified diseases in developed countries. Considering this fact, there are two issues that arise in screening programs, which are low yield in population and high incidences of false positive referrals. In the UK, there is a reported high sensitivity for oral cavity cases, which is within the 71-81% range. Generally, the use of toluidine blue dye in screening for primary care is highly discouraged (Gray et al. 2000) for oral cancer patient. Similar results were found for patients with other oral problems such as periodontal and caries diseases in term of prevalence (Rodrigues, Moss &Tuomainen 1998).
Some cases of oral cancer for example were developed from clinically normal mucosa. Periodontal disease patients on the other hand are associated are found to have acquired the condition from their siblings or mother (Moles, Downer & Speight 2002). However, the variation for recall times differs according to age groups and development stage. Previously stable adult patients for instance who are having recurrences of periodontal diseases are recommended to see their dentist at least once every three months while healthy new patients are advised to go for a dental checkup every six months. (Sankaranarayanan et al. 2000). This encompasses a realization that regardless of the patient’s oral health condition, the recall interval is still somewhat similar. If the general patient should follow a bi-annual dental examination and a child with caries disease should also follow the same recall times, therefore, any patient regardless of oral condition should see their dentist within the same recall interval (Leake 2001). This variation of factors contributing to the occurrence of dental problems is due to the different methodology used in identification (Lissowska et al. 2003; Moss et al. 1997).
Taking to account the variation in patient type and oral disease involved, the recall times remain constant across the majority of patient types. On average, dental patients are supposed to visit their dental practitioner at least twice a year. The severity of the oral condition on the other hand appears to be the differentiating factor when it comes to shortening the gap between intervals due to the needed risk monitoring. Individuals with healthy gums and cavities may come follow a yearly recall interval, but the presence of diseases such as caries and periodontal conditions would have to come to the dentist more often. High risk patients such as smokers, patients with oral cancer, weak immune system, and gum problems might need to come to visit the dental practitioners more often than three months. Based on the evidences found in the studies, the scheduling of recall times changes during a lifetime. For instance, children with periodontal disease such as plaque would need to see a dentist at least every six months. However, once the condition was corrected, the recall time changes to once every 12 months. Unless the patient have acquired high risk diseases such as oral cancer, the patient would have shorter recall times.
Conclusion
The varying approach to dental recall and dental visit intervals are determined by the existing patient conditions and patient type. Evidence from the reviewed studies suggests shorter or longer recall intervals depending on the risks involved on the patient’s condition. For instance, oral cancer patients are found to have the shortest recall intervals due to the severity of the risks that needs to be examined. Patients under the age of 18years old are recommended to see their dentists for at least every six months, but periodontal conditions would require at least three months interval between visits. It is apparent from the reviewed studies that varying frequency of visits to dental practitioners is highly reliant to patient types and prevailing dental health conditions.
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