Step 6: Periodontal Risk Assessment: Examples of Available Programs Trisha E. O’Hehir, RDH, MS

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            Creating and maintaining an effective perio program is important to general dental practices. Despite the importance, it's not an easy task to undertake. Realizing that, clinicians and RDH consultants have shared their experiences and expertise to help readers create their own perio program to provide individualized periodontal care for their patients. Since April, this series has covered: assessing the periodontal health of your practice, getting the conversation going between dentists and hygienists on their philosophies of periodontal treatment and prevention, creating the plan for your perio program, implementation to gain patient acceptance and full participation, and reflections on the implementation and acceptance of the perio program.
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            Our clinical and consulting experts provided the steps to follow in creating or re-inventing your perio program. The focus is on individualizing the treatment and maintenance for each person. They also provided helpful suggestions for measuring success and identifying areas needing improvement during this process.
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            Now that you have developed a periodontal treatment and prevention philosophy and created your plan, it's time to put it into action. The first step with your patient is gathering the general health and periodontal examination data. With this information you can determine the diagnosis and treatment plan. It sounds easy, but if you haven't been doing this on a regular basis, it can be intimidating. To streamline your perio program there are established risk assessment programs available to you, some with a fee, others free of charge. Four approaches to risk assessment are profiled here. They can all be accessed online. You enter the data, which takes only minutes and the program will analyze the data and provide you with the risk profile for that patient. This information can be printed for sharing with the patient.
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            PreViser and the University of Bern Perio Risk Assessment (PRA) were both introduced in early 2000 and both have been validated through scientific clinical studies. The American Academy of Periodontology's online tool and the Sonicare CARE program are also available, but without scientific validation. All provide clinicians with a program to assess the risk of periodontal disease and some provide guidance on potential treatment options to follow.
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            <span style="font-weight: bold; color: #753742;">PreViser</span><br />
            <a href="http://www.PreViser.com" target="_blank">PreViser.com</a> was the first interactive, online tool for perio risk assessment, introduced in 2002. A few scientific studies have been conducted validating the PreViser suite of assessments. An individual record is created online for each patient and then information you have gathered during your examination and charting can be entered into the interactive record. The first assessment may take three minutes, but subsequent data entry takes only seconds. Data entered includes:
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                <li>History of smoking</li>
                <li>Diabetes status including HbA1C score</li>
                <li>Prior periodontal treatment</li>
                <li>The deepest probing depth in each quadrant and bleeding</li>
                <li>Eyeball measure of bone loss, less than 2mm, 2-4mm or more than 4mm</li>
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            With this data, three Gum Disease Risk and Health Assessment scores are provided. The Gum Disease Risk Score ranges from 1 (very low risk) to 5 (very high risk). This score predicts the probability the periodontal condition will deteriorate without professional care. The Gum Disease Score ranges from 1 to 100. A score of 1 indicates health with no bleeding, no pocketing and no bone loss. Scores of 2 to 3 indicate inflammation without bone loss or pocketing. Scores of 4 to 100 indicates current disease or past disease. The Gum Health Stability Score indicates duration of time the patient has been periodontally stable.
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            Treatment interventions are provided as an option. Treatments are listed as most likely, likely or least likely to be effective, based on the data provided. For maintenance visits, the previous data can be preloaded so the clinician simply inputs any changes.  PreViser offers a 30-day free trial after which there is a practice charge and a per-patient charge.
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            <span style="font-weight: bold; color: #753742;">Periodontal Risk Assessment</span>
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            In 2003, periodontists Niklaus P. Lang and Maurizio S. Tonetti introduced the Periodontal Risk Assessment (PRA). This perio tool uses six parameters weighted equally to determine a person's risk for progression of periodontal disease. This data comes directly from your patient examination. Visit <a href="http://www.Perio-Tools.com" target="_blank">Perio-Tools.com</a> for more. <br />
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            The six parameters assessed are:
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                <li>Percentage of bleeding on probing</li>
                <li>Prevalence of pockets greater than 4mm</li>
                <li>Loss of teeth from a total of 28 teeth</li>
                <li>Loss of periodontal support related to the patient's age</li>
                <li>Systemic and genetic conditions </li>
                <li>Environmental factors such as smoking </li>
            </ul>
            Evaluating all these factors together creates a polygon or spider web diagram to help the clinician determine the risk for disease progression. This visual image enhances discussion with the patient about their own periodontal condition. The diagram for a periodontally healthy person with low to no risk will focus on the first and second center rings of the polygon. As specific areas of risk increase, the shape of the web changes, with outward dips depicting high risk. Patients with risk factors in all six areas will have a balanced, but very full polygon or web indicating high risk. Most patients will have one or more risk factors, but are not likely to have all, thus the interesting shapes of the webs based on risk factors. This PRA has been validated by several clinical research studies.
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            Here are a few examples of the how the PSA diagram depicts low, moderate and high risk.
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            <img alt="" width="100%" src="https://www.dentaltown.com/images/Dentaltown/magimages/1114/PS03.jpg" style="margin-left: 10px; margin-right: 10px; margin-bottom: 10px; float: right;" />
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            <strong>Fig.1: Polygon diagram with six vectors</strong><br />
            Functional diagram to evaluate the patient's risk for recurrence of periodontitis. Each vector represents one risk factor or indicator with an area of relatively low risk, an area of moderate risk and an area of high risk for disease progression. All factors have to be evaluated together and hence, the area of relatively low risk is found within the center circle of the polygon, while the area of high risk is found outside the periphery of the second ring in bold. Between the two rings in bold, there is the area of moderate risk.
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            <img alt="" width="100%" src="https://www.dentaltown.com/images/Dentaltown/magimages/1114/PS02.jpg" style="margin-left: 10px; margin-right: 10px; margin-bottom: 10px; float: left;" />
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            Fig.2: Low Risk</strong><br />
            Functional diagram of a low-risk maintenance patient. BOP is 15%, 4 residual pockets &ge;5mm are diagnosed, 2 teeth had been lost, the bone factor in relation to the age is 0.25, no systemic factor is known and the patient is a nonsmoker.
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            <strong>Fig. 3: Moderate Risk</strong><br />
            Functional diagram of a medium-risk maintenance patient. BOP is 9%, 6 residual pockets 5mm are diagnosed, 4 teeth had been lost, the bone factor in relation to the age is 0.75,the patient is a Type I diabetic, but a non-smoker
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            <img alt="" width="100%" src="https://www.dentaltown.com/images/Dentaltown/magimages/1114/PS05.jpg" style="margin-left: 10px; margin-right: 10px; margin-bottom: 10px; float: left;" /><br />
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            <strong>Fig. 4: High Risk</strong><br />
            Functional diagram of a high-risk maintenance patient. BOP is 32%, 10 residual pockets 5mm are diagnosed, 10 teeth had been lost, the bone factor in relation to the age is 1.25, no systemic factor is known and the patient is an occasional smoker.
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            <span style="font-weight: bold; color: #753742;">Sonicare CARE tools (<a href="http://www.PhilipsOralHealthCare.com" target="_blank">PhilipsOralHealthCare.com</a>)</span><br />
            Sonicare recently introduced online CARE tools: customized assessment and risk evaluator. A team of dentists and hygienists worked to develop this tool, based on scientific evidence and best practices. It consists of several yes or no questions asked about the patient with answers entered into the record.
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            Here are the questions:
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                <li> Does the patient have a current or past diagnosis of periodontal disease?</li>
                <li>Has the patient lost teeth (excluding third molars or teeth removed for orthodontic purposes)?</li>
                <li>Does the patient have radiographic bone loss? Choices are none, less than 20 percent, 20-40 percent, 40 percent
                or more.</li>
                <li>Does the patient have clinical and/or radiographic evidence of furcation involvement on any teeth?</li>
                <li>Does the patient have any tooth mobility?</li>
                Choices are none, one to two teeth only, three to five teeth only, or more than six teeth.
                <li>Does the patient have any pathological migration of teeth?</li>
                <li>How many periodontal pockets with depths greater than five millimeters does the patient have? Choices are none, one to three, or four or more.</li>
                <li>Does the patient have gingival inflammation with bleeding upon probing on four or more teeth?</li>
                <li>Does the patient have generalized gingivitis (more than 50% of gingival tissue involved)?</li>
                <li>Does the patient have gingival recession (more than two millimeters) on any teeth?</li>
                <li>Does the patient have any unprompted gingival pain?</li>
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            Press the calculate button and your assessment is calculated resulting in a four-level scoring system: low, medium, high and extremely high risk. There is an option to view deciding factors for the assessment and print a copy for the patient if desired. Next, you can review and consider the recommended clinical guidelines for your patient's assessed risk level. With that in mind, you can customize your suggested care protocol by selecting the treatment options, oral hygiene recommendations and suggested products. With your practice details added, the form is customized and ready for printing or saving for your records.
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            <span style="font-weight: bold; color: #753742;">Periodontal Disease Risk Assessment Test (<a href="http://www.Perio.org" target="_blank">Perio.org</a>)</span><br />
            The American Academy of Periodontology (AAP) offers an online, periodontal disease risk assessment test for consumers consisting of 12 questions covering age, sex, bleeding gums, loose teeth, recession, smoking, dental visits, flossing, health conditions (heart disease, osteoporosis, osteopenia, high stress or diabetes), history of gum infection, tooth extractions and family members with gum disease. After answering the questions, the consumer or clinician, if being used in the practice, clicks the Get Report button. The report indicates low, medium or high risk. The report also describes gum disease risks and symptoms, and what can be done about the disease. This risk assessment tool is a guide for consumers to educate them about gum disease and suggest they see a dentist or periodontist for a complete examination.
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            <span style="font-weight: bold; color: #753742;">Conclusion</span><br />
            With these risk assessment tools, you are ready to move ahead with your newly designed or revamped perio program. The visuals provided by each of these programs help patients understand their level of disease and risk for further disease progression. These risk assessment tools are also helpful after therapy to measure the success of treatment and effectiveness of patient participation in self-care. Good luck with your perio risk assessment, treatment and follow-up care. Your patients will benefit significantly from your care.
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