Assigning patient risk

The BSP implementation of European S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice (BSP-S3) guideline⁶ recommends risk factor control interventions as part of the first step of periodontitis therapy. To facilitate this, risk factors must be identified and discussed with the patient.

Carrying out this risk assessment combines clinical judgement along with knowledge of the patient’s history and periodontal status to identify risk factors that may affect the development or progression of oral disease. The individual patient’s risk level is part of the information used to determine the level of ongoing care required by the patient and the appropriate recall interval.

While the importance of risk assessment to inform a patient’s care is accepted, it is acknowledged that risk assessment itself is an imperfect science. Approaches to risk assessment may be structured (i.e. using a validated risk assessment tool) or unstructured (i.e. making a subjective judgement based on known risk factors). A structured approach to risk assessment, which incorporates a series of questions or examinations to assess a range of factors associated with periodontal disease, may allow for a more objective judgement of risk.

Key recommendation

When carrying out a risk assessment, use a structured approach to assess the patient’s medical, dental and social history, any relevant risk factors and the outcome of the clinical examination, to inform future treatment and recall.

(Conditional recommendation; low certainty evidence)

Various tools that enable a formal structured approach to risk assessment are available and evidence suggests that they can be effective at predicting periodontitis progression and/or tooth loss.³¹ The evidence is considered low certainty due to the observational nature of the data and substantial heterogeneity. Predictors common to these tools include age, smoking status, systemic disease status (most notably diabetes), pocket depth, furcation involvement and bone loss in relation to age.

Further details on the development of the recommendations in this guidance can be found in Methodology.

A basic risk assessment tool might be helpful when determining the risk of disease initiation/progression in an individual patient and to inform the appropriate recall interval.

Assign a risk level, based on the patient’s medical history, an assessment of risk factors and the outcome of the clinical examination, to inform future treatment and recall interval (see Risk assessment tool).

A structured approach to risk assessment that documents age, smoking status (including whether the patient uses e-cigarettes), oral hygiene status, systemic disease status (e.g. diabetes) and pocket depth may be helpful when assigning a risk level.
Relevant social factors include a family history of early tooth loss or periodontitis, non-attendance and socio-economic status.
Other clinical factors that may be considered are bleeding on probing, furcation involvement, bone loss in relation to age, the presence of periapical bone lesions and marginal restorations.

Risk information

Once a risk level has been assigned to a patient, it is important that the patient is aware of that risk. The BSP-S3 guideline⁶ notes that following a diagnosis of periodontitis and prior to potential therapy, initial discussions with patients should include information on the causes of the condition and risk factors for disease progression.

Key recommendation

For patients who are at increased risk of periodontitis, provide information about their periodontal risk, how it affects them and the ways that they can reduce this risk (e.g. provide oral hygiene instruction or advice on smoking cessation) as part of a strategy to encourage behaviour change.

(Conditional recommendation; low certainty evidence)

While there is limited evidence that informing patients about their periodontal risk results in behaviour changes to reduce their risk,³² there is more evidence that interventions to promote improved oral hygiene, smoking cessation and diabetes control have some success in changing patient behaviour.^33-36

The certainty of the evidence is considered to be low due to risk of bias, heterogeneity and indirectness. However, ensuring patients' understanding of their risk is considered part of ongoing informed consent.

Further details on the development of the recommendations in this guidance can be found in Methodology.

Explain to patients who smoke the effect smoking can have on their oral health and general health. Direct patients who express a desire to stop smoking to smoking cessation services (see Smoking cessation and this supporting tool).

Explain to patients who have diabetes that sub-optimally controlled blood sugar levels increase the risk of developing periodontitis or worsening existing periodontitis (see Control of diabetes). Consider communicating with their GMP if necessary.

Explain to patients with diabetes and periodontitis that periodontal inflammation can interfere with their glycaemic control.

Explain to all patients the benefits of a healthy, balanced diet and regular exercise to their overall health and oral health in particular (see Other modifiable risk factors).

Ensure that patients who are pregnant are aware of their increased risk of developing pregnancy gingivitis or, if they have a diagnosis of periodontitis, worsening existing disease. Highlight the possible need for more frequent visits for professional mechanical plaque removal (PMPR; see Professional mechanical plaque removal) or, if required, periodontal maintenance care during pregnancy (see Pregnancy).