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## Complete Summary

#### GUIDELINE TITLE

HealthPartners Dental Group and Clinics periodontal risk assessment
guideline.

#### BIBLIOGRAPHIC SOURCE(S)

HealthPartners Dental Group and Clinics periodontal risk assessment
guideline. Minneapolis (MN): HealthPartners; 2006 Mar 15. 23 p.

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Periodontal disease

#### GUIDELINE CATEGORY

Prevention\
Risk Assessment

#### CLINICAL SPECIALTY

Dentistry

#### INTENDED USERS

Dentists

#### GUIDELINE OBJECTIVE(S)

-   To provide a means of identifying patients at risk for developing
    periodontal disease and providing education and other interventions
    to the patient that can reduce this risk

-   To better standardize the care according to the most current
    research, which, in turn, will allow dentists to tailor care and
    resources to better meet the individual\'s needs

#### TARGET POPULATION

HealthPartners Dental Group patients over the age of 18 years

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Medical and dental history update

2.  Periodontal charting

    -   Full-mouth probing

    -   Bleeding on probing

    -   Plaque control record or index

    -   Tooth mobility

    -   Furcations

    -   Gingival status

    -   Determining diagnostic code

    -   Completing risk assessment

3.  Periodontal risk assessment

    -   Consideration of four primary risk factors (smoking, diabetes,
        immunodeficiency, history of periodontal disease) and five
        modifying risk factors (family history of periodontal disease,
        ethnicity, age, plaque and calculus, professional dental
        frequency)

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

An online search using Medline, PubMed, and current journal articles was
conducted.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Articles were reviewed and discussed by a committee of dentists,
including a periodontist.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A draft of the guideline document was sent to expert reviewers for
comment.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Measurements of Periodontal Disease**

Each of these aspects of the appointment should be addressed at every
recall.

1.  **Medical and Dental History Update**

    A.  Medical History

        1.  HealthPartners Medical/Dental History screen is updated.

        2.  Be aware of questions relevant to periodontal disease; i.e.,
            diabetes, acquired immune deficiency syndrome (AIDS),
            certain medications, etc.

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    B.  Dental History

        1.  Record date of last professional visit at the initial exam.
            Does the patient comply with recommended recall intervals?

        2.  Tobacco used:

            -   Record in the medical history

            -   Type and amount of tobacco used

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        3.  Ask patient if there is a history of periodontal disease in
            the family.

        4.  Assess patient\'s dental knowledge regarding periodontal
            disease.

        5.  Oral hygiene habits: record patient\'s current oral hygiene
            habits and frequency

            -   Frequency of brushing and flossing

            -   Use of other adjuncts

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        6.  Radiographs are essential for proper periodontal diagnosis.
            A panographic film and bitewing radiographs do not provide
            the appropriate level of detail to meet this need. Posterior
            vertical bitewing radiographs can be used for both diagnosis
            of caries and monitoring the bone level.

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2.  **Periodontal Charting**

    A.  Full-Mouth Probing (FMP)

        1.  Each adult patient receives a FMP at their initial
            examination. Patients of record that have not had a full
            mouth probing recorded in their chart or electronic dental
            record (EDR) should have a baseline probing completed and
            recorded. All pockets, regardless of depth, are charted.
            Pockets that bleed on probing are circled in red. Bleeding
            points are noted in red in EDR. At subsequent visits, only
            pockets \>3 mm or that bleed on probing are charted.

        2.  Walking the probe, regulated (standardized) pressure

        3.  Working end of probe is parallel to tooth surface.

        4.  Record the deepest measurement in each of 6 areas per tooth
            (3 facial, 3 lingual).

        5.  Periodontal Screening and Recording (PSR) may be considered
            an adequate probing alternative for healthy individuals.

        6.  Attachment Level: measured in millimeters, recession is the
            distance between the exposed cementoenamel junction (CEJ)
            and the (more apically placed) gingival margin. Record most
            advanced area on the facial and lingual of each tooth.

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    B.  Bleeding on Probing (BOP)

        1.  Probing should be done before the prophylaxis.

        2.  Generally is recorded directly after probing procedure,
            before rinsing, and before allowing patient to wipe tongue
            over teeth/gingival margin.

        3.  BOP records 6 potential areas per tooth.

        4.  Quantity of bleeding is not recorded in the BOP index, only
            whether blood was elicited or not elicited. A statement
            regarding quantity, spontaneity, general, or localized may
            be recorded in the progress notes.

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    C.  Plaque Control Record or Index (PCR or PCI)

        1.  Defined: a method of quantifying the number of tooth
            surfaces in a patient\'s mouth that have plaque on them. By
            identifying where the plaque is found, the care provider can
            focus on the positive aspects of the patient\'s current home
            care (plaque removal), and offer suggestions to improve home
            care in other areas of high plaque. PCR records 4 surfaces
            per tooth: mesial, distal, buccal, and lingual (M, D, B, L).

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    D.  Mobility

        1.  Use two, blunt-ended instruments to visually detect
            buccal-lingual movement accurately (not fingers).

        2.  Check mobility of all teeth.

        3.  Record class of mobility according to the total amount of
            movement:

            -   \<1.0 mm = 1

            -   1.0 mm--2.0 mm = 2

            -   \>2.0 mm or depressable = 3

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    E.  Furcations

        1.  Can usually be detected accurately during the FMP procedures
            unless the pocket is deep in the furcation area. In this
            case, a Michigan probe may be useful.

        2.  Classifying:

            -   Class I = detectable concavity on root trunk only,
                slight bone loss.

            -   Class II = detectable roof in any furcation area on root
                trunk, partial bone loss between roots.

            -   Class III = detectable through-and-through passage of
                the probe, no bone within the arch of the furcation.

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    F.  Gingival Status

        1.  Describes in general/localized detail the appearance of
            attached and free gingival margin.

        2.  Categories could include:

            -   Color (pink, red, cyanotic)

            -   Shape and form of: gingival margin (rolled, knife-edged,
                clefts, recession, etc.)

            -   Consistency and tone (edematous, friable, firm, etc.)

            -   Bleeding, the best diagnostic sign of inflammation
                (generalized, localized, spontaneous)

            -   Texture, least reliable (stippled, loss of stippling,
                etc.)

            -   Exudate

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    G.  Diagnosis Codes

        1.  Determine which diagnostic code best describes patient\'s
            periodontal status and record under the Perio tab in the
            EDR.

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    H.  Risk Assessment

        1.  Complete the periodontal risk assessment under the Risk tab.

**Periodontal Risk Assessment**

In the current research, predictors for risk of developing periodontal
disease have been discovered. The goal of this section is for guidance
in using these factors to assess each individual patient\'s risk of
developing periodontal disease.

The factors should be considered collectively to determine one\'s risk.
This is not a cookbook or an absolute diagnosis of the patients\' risk
of future pathology, but rather a tool that helps predict the patient\'s
periodontal future. This should be made clear to the patient when
discussing the final risk assessment.

Clinical judgment, when used in concert with this tool, will
dramatically increase the accuracy of the assessment.

**Four Primary Risk Factors**

*Smoker*

[Positive]{.underline}

Current research suggests that the degree of risk of periodontal disease
is dose dependent. Patients who smoke 10 cigarettes per day or more are
considered heavy smokers and should be placed at the high risk level for
this category. Those who smoke fewer than 10 cigarettes per day are
considered light smokers and would be placed at the moderate risk level
for this category.

Many of these patients may not clinically exhibit signs or symptoms of
the disease due to the systemic changes that have occurred to the
periodontal supportive tissues and their immune system.

This risk category specifically addresses cigarette smoking; however,
pipe, cigar and smokeless forms of tobacco also increase the risk of
various oral diseases.

[Negative]{.underline}

Nonsmokers may be placed at the low risk level for this category.

*Diabetic*

[Positive]{.underline}

The level of periodontal risk depends on whether the patient\'s diabetes
is controlled or uncontrolled.

[Uncontrolled]{.underline}

These patients may be placed at the high risk level for any infectious
disease including periodontal disease.

[Controlled]{.underline}

Because their diabetes is controlled, these patients have fewer systemic
complications and therefore may be placed at the moderate risk level for
this category. If the clinical signs and symptoms are not consistent
with an expected controlled status, then a medical consult would be in
order to verify the disease status.

[Negative]{.underline}

These patients may be placed at the low risk level for this category.

*Immunodeficient*

[Positive]{.underline}

Immunodeficient patients have a difficult time fending off bacterial
diseases, and periodontal disease is no exception. Patients who are
human immunodeficiency virus (HIV)(+) or receiving immunosuppressive
medications are to be placed at a high risk level for this category.

[Negative]{.underline}

These patients may be placed at the low risk level for this category.

*History of Periodontal Disease*

[Positive]{.underline}

As periodontal disease is chronic, a determination of whether the
disease is stabilized or active must be made.

[Active]{.underline}

If active, continuing with this assessment is unnecessary: Follow the
treatment plan for the active disease category.

[Stabilized]{.underline}

This patient may be at risk to redevelop active periodontal disease.
Most of these patients will appropriately fall into the high-risk group.
However, some patients who have established a controlled state for a
significantly long period of time may be better placed in the moderate
group. Check to see if the lamina dura has been re-established. Clinical
judgment is the final determinant.

[Negative]{.underline}

Only those patients with no history of periodontal disease would be
placed in the low risk group for this category. A negative history\'s
predictive value is relative to age. Younger patients may be at risk
without exhibited signs or symptoms of the disease.

**Five Modifying Risk Factors**

These factors should be used to help determine if a patient is at
moderate or high risk. The patient would also have at least one of the
four primary risk factors.

*Family History of Periodontal Disease*

[Positive]{.underline}

This could indicate two associations:

1.  The patient could have inherited traits that place them at risk.

> OR

2.  The patient may have become infected with the bacteria responsible
    for periodontal disease from family members.

Both of these would place the patient at the moderate risk level in most
cases. However, if periodontal disease is prevalent in the patient\'s
immediate family, it may be more appropriate to place the patient at the
high-risk level for this category.

[Negative]{.underline}

These patients may be placed at the low risk level for this category.

*Ethnicity*

Certain ethnic groups appear to be at higher risk for certain
periodontal diseases. (i.e., Afro-American, Asian, American Indian.)

*Age*

The prevalence and severity of periodontal disease increases with age.

*Plaque and Calculus*

This category is more indicative of the patient\'s motivation, knowledge
or compliance. The PCR (Plaque Control Record) will measure the quantity
of plaque. Of greater importance is the bacterial composition of the
plaque. Calculus will contribute to the chronicity of gingivitis or
periodontitis.

*Professional Dental Frequency*

Patient who do not regularly visit the dentist have statistically more
pocketing and are at a higher risk for experiencing attachment loss than
patients who regularly visit the dentist.

**Overall Risk Assessment**

Once all nine risk factors have been examined, look at them collectively
in order to give the patient an overall risk prediction of developing
periodontal disease.

*Low Risk*

If none of the four primary risk factors is positive, the patient should
be at a low risk level for developing periodontal disease.

*Moderate Risk*

The moderate risk level requires the most clinical judgment since the
determination between moderate and low risk in the various categories is
of great importance for proper risk assessment. Other considerations in
determining periodontal risk include occusal trauma and medications
impacting the gingival tissues (e.g., Dilantin, calcium channel
blockers, and antineoplastic medications).

*High Risk*

The first four categories have the most influence on predicting a high
risk level:

1.  Patient history of periodontal disease

2.  Smoking (10 or more cigarettes per day)

3.  Immunodeficiency

4.  Diabetes (uncontrolled)

5.  Systemic diseases impacting the periodontitis

If any one of these is positive, the patient may be considered at high
risk for periodontal disease.

#### CLINICAL ALGORITHM(S)

Algorithms are provided in the original guideline document for
\"Periodontal Risk Assessment.\"

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Decreased prevalence of periodontal disease in HealthPartners Dental
    Group patients through early diagnosis and identification of risk
    factors

-   Appropriate utilization of available resources to tailor care to
    meet the individual patient\'s needs

-   Appropriate monitoring of patient outcome data in order to improve
    patient care delivery

-   Increased use of preventive treatment options

-   Education of patients and providers

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators\
Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

HealthPartners Dental Group and Clinics periodontal risk assessment
guideline. Minneapolis (MN): HealthPartners; 2006 Mar 15. 23 p.

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Mar

#### GUIDELINE DEVELOPER(S)

HealthPartners Dental Group - Professional Association

#### SOURCE(S) OF FUNDING

HealthPartners Dental Group

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Not stated

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: None available

Print copies: Available from HealthPartners, 8170 33^rd^ Avenue South,
P.O. Box 1309, Minneapolis, MN 55440-1309; Phone: (952) 883-5151; Web
site: [http://www.healthpartners.com](http://www.healthpartners.com/)

#### AVAILABILITY OF COMPANION DOCUMENTS

A list of potential measures is available in the original guideline
document.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on August 8, 2007. The
information was verified by the guideline developer on August 28, 2007.

#### COPYRIGHT STATEMENT

No restrictions regarding downloading and use.

### DISCLAIMER

#### NGC DISCLAIMER

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<http://www.guideline.gov/about/inclusion.aspx> .

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Date Modified: 11/3/2008