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of your patients are most “AT-RISK” for periodontal disease? Here’s a little test that may help you fit the treatment to the level of overall risk By Larry Burnett, DDS If you’ve read any of my earlier articles about conservative perio therapy, you know that I firmly believe that an appropriate recall level can preserve teeth that many consider “hopeless.” Not always, I admit. And sometimes not forever. But unless a person is in discomfort from mobility, the longer you can help him keep his natural teeth, the better. |
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my friend John for example ... Eleven years ago I wrote my first article about ultrasonic irrigation for Parkell Today. In it, I described John. He’d been told by his periodontist that he should have all his lower anteriors extracted. When I looked at the radiographs I had to admit that things looked pretty bleak. But John is a professional clarinetist, and you can’t play a wind instrument without anteriors. Since John had nothing to lose, we began an intense regimen of ultrasonic debridement using povidone iodine as an irrigant. Thirteen years later he still has his anteriors. The endo- treated central fractured a few years ago, presumably due to brittleness plus the unfavorable crown/root ratio ... and #26 really IS hopeless now because of a vertical root fracture. But his periodontal condition hasn’t changed appreciably in 13 years. When you adjust the maintenance to the proper level of need, you may be astonished at what you can accomplish. Obviously John required extensive monitoring and professional intervention. But what about patients where the periodontal condition isn’t so clear? How much professional monitoring does a specific patient require? In my lectures, I often describe perio health as a see-saw teetering in precarious balance. The forces of darkness, the perio disease factors (pathogens, smoking, etc.), sit on one side and the forces of good (home care, professional intervention) sit on the other. The patient’s immune system provides the fulcrum. If the patient has a strong immune system, the fulcrum slides way over toward the dark side of the see-saw. This means that the forces of health exert a lot of leverage. These patients may show little sign of attachment loss even in the face of bad habits, poor home care, and infrequent visits to the dentist. Conversely, if the immune system is weak, the fulcrum slides toward the other side. Here the forces of darkness exert disproportionate leverage. These patients may spiral downhill despite impeccable habits and meticulous home care. They require careful monitoring and immediate intervention at the earliest signs of infection. I offer this questionnaire as an aid for determining the level of attention a patient may require. It helps individualize treatment and recall schedule to fit the needs of the specific patient rather than simply grab a one-size-fits-all perio program off the rack. Notice that this form isn’t something the patient fills out. Scoring requires considerable professional judgement, so you must complete the form yourself after careful examination and discussion with the patient. By the way, if you’re filling out the forms for existing patients, most of the information should be available in your current records. In this scoring system “low risk” is represented by a low number. A low-risk patient (5 or below) will probably do just fine on a standard 6-month recall schedule. High-risk patients (11 or above) generally require closer scrutiny, and more frequent recall. I make a copy of the completed form for the patient. The definitions and comments on the back of the form are for the patient. Showing high-risk patients their score may motivate them to improve their home care. A few comments concerning the risk factors in the questionnaire: 1.) Attachment and bone loss Nothing short of X-rays taken over several appointments and probing records will tell you whether the patient is undergoing active attachment loss. In fact, I wrote an entire article on the importance of comparing sequential radiographs a few years ago. But a current snapshot of the bone and connective tissue can tell you a couple of things. For one, it tells you if the patient is prone to tissue destruction. If so, it’s logical that under the right circumstances (I guess I actually mean the “wrong” circumstances) tissue destruction may resume. And it tells you how important hygiene will be for this particular individual. A few definitions - Class 1 furcation - probe will barely enter furcation Class 2 furcation - probe will pass halfway in to furcation Class 3 furcation - probe will pass completely through furcation. Deep pockets and class 2 or 3 furca are harder to clean. If the patient isn’t motivated, you may need much more frequent recalls. And absent a strong recall program, perhaps surgery. 2) Genetic pre-disposition Genetic vulnerability to perio disease is an extremely powerful risk factor, because it determines where the fulcrum of that teeter-totter will be located. A weak immune system means all the other risk factors will exert excessive leverage on the patient’s health. Ask the patient when and if a parent had gum disease or lost teeth because of loosening. Was it one parent? Or both parents? What about siblings? And at what age did they lose teeth? Evaluating this genetic risk involves considerable professional judgement. Suppose, for example, you discover that your patient is descended from a long line of denture-wearers. Is it because of a weak immune system (genetics)? Or because of poor training in home care? 3) Home care - I don’t need to elaborate on the nature or importance of oral hygiene. But I should say a few words about my scoring system. “Home care” is the only risk factor that permits negative scores. That’s because truly extraordinary hygiene can offset less-than-great scores in the other criteria. For example, a xerostomia patient with super habits may be no more at risk than a normal patient. So I give good oral hygiene a “0” score. I give extraordinary hygiene a “-1” . And those rare patients that routinely brush, floss, and if necessary irrigate till they’re virtually plaque-free receive a “-2.” 4) Smoking - The more they smoke, the higher the number. By the way, there’s a lot of research showing that smoking dramatically increases the risk of perio disease but reduces the BOP! 5) Unresolved stress - Increasingly, research is suggesting that high stress can dampen the effectiveness of the immune system. Depending on the patient, a new job, a divorce, a serious illness in the family can affect oral health. 6) Diabetes - A well-controlled diabetic who does not exhibit periodontal disease would be a #1. 7.) Xerostomia - This powerful risk factor is often missed. Dryness may be caused by medication, medical treatment such as surgery or radiation, or systemic or rheumatological disease. Regardless of the cause, xerostomia will deprive the mouth of the natural antibacterial activity of saliva. 8) Bleeding - Light bleeding during examination is not an established risk factor. However, if the degree of bleeding increases or continues (particularly in deep pockets) despite a year of maintenance, it becomes a risk factor. Of course hemorrhagic bleeding requires immediate attention. I also include a fudge-factor. It is permissible to add or subtract one or two points to reflect your overall impression of the patient. Now, don’t misunderstand. I’m not pretending that this is a super-scientific screening process. As I was putting it together I back-tested the questionnaire by scoring my existing patients using their early records and then comparing the form’s predictions with the actual outcomes. I added and deleted risk factors till there was a good correlation between the patient-score and the actual history. I could have added more risk factors, but I wanted to keep it simple and easy to use. Over the years I’ve found this form surprisingly helpful in predicting which patients require special attention. |
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Evaluation Form The form pictured below is modeled after one I use in my office. You can create your own or use this as a model.
Attachment and
bone loss - Periodontal disease is an episodic bacterial
infection that attacks the connective tissue holding teeth in
the socket and destroys the supporting bone. Even if the disease
is not currently active, a history of attachment- and bone-loss
suggests that it is likely to recur.
Genetic-Predisposition - Some patients have inherited a weak immune system that makes them more vulnerable to periodontal disease and tooth loss. For these patients home hygiene and frequent check-ups are particularly important. Home-care - Patients determine much of their personal risk. The goal of periodontal home care is to reduce the level of pathogens below the critical mass that will trigger disease.Smoking - There is a strong correlation between smoking and periodontal disease. Smokers are more likely to suffer bone and attachment loss. Furthermore, the disease is likely to progress faster and be more severe. Stress - Personal stress seems to lower the efficiency of the immune system. Diabetes mellitus - Patients with long-duration, poorly controlled diabetes show higher rates of periodontal bone destruction. Diabetics under good control are far less vulnerable.Xerostomia (Dry Mouth) - Saliva is a delivery mechanism for the immune system, so patients with low saliva flow may be less likely to resist periodontal disease. Xerostomia may be caused by medication (particularly anti-depressants), medical treatment, and systemic or rheumatologic diseases. Bleeding upon mechanical stimulation - Occasional light bleeding upon stimulation is not a risk factor. Heavy bleeding, or an increase in bleeding (particularly from deep pockets) should be considered a risk factor. |
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