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A Clinical Example of Risk Assessment by Rachel Wall, RDH, BS with Stacy McCauley, RDH, MS and Kim Miller, RDH, BS

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Risk assessment has been a buzzword in dentistry for many years. While many teams look for a cookie-cutter approach to their treatment protocols, the time has come to set clear guidelines and standards for treatment planning, taking into consideration clinical findings, the patient’s medical and dental history, and personal concerns.

Risk assessment requires high-level critical thinking. Even with all the risk assessment forms, programs and testing products available, these tools can’t do all the thinking for you and might be overwhelming for both the clinician and the patient when we attempt to implement them all in a short period of time.

The goal of this article is to provide a real-life risk assessment example with strategies for helping strengthen critical thinking skills to improve provider-to-patient communication and enrollment success.

Moving Toward Assessment
Have you ever experienced this? A patient sits in your chair and you’re immediately overwhelmed by the need to introduce the latest in oral cancer detection, caries prevention, complete periodontal charting and don’t forget photos to present his restorative needs.

It can feel overwhelming not only to you but to your patient. He can feel he’s being “sold” every new gadget and product you have. Risk assessment is the key to overcoming the feeling of being overwhelmed and using critical thinking to identify the most critical need the patient presents today. If the patient presents with significant decay on many teeth and has one 4mm bleeding pocket, this patient has a higher risk for tooth loss from the progression of the decay than he does for tooth loss due to periodontal disease. Perhaps you review daily oral hygiene and plant the seed to re-evaluate the inflamed area soon, but speaking to repairing the decay to save the teeth and then recommending an anti-cavity homecare regime is the top priority at this time.

First and foremost, ask your patient this question “What is your primary concern today?” The patient’s concerns and questions are always the starting point for setting priorities for the current visit as well as future treatment appointments. The daily schedule is only a guide for what might occur with each patient. Being flexible and focusing on the patient’s current need rather than what he was scheduled for is a key building block in developing higher-level risk assessment skills. The time commitment and relative complexity of some risk assessment tools can be overwhelming. And while they are valuable, they can’t do the thinking for you.

Clinical Example: Nick*
Nick is a 40-year-old white male with arthritis, high blood pressure and attention deficit disorder (ADD). He is taking Crestor for high cholesterol, Vyvanse for ADD. Six months ago he presented as a new patient with generalized, moderate periodontal disease, moderate alveolar bone loss, moderate to heavy bleeding, red, swollen tissue and moderate to heavy subgingival calculus and plaque biofilm. It had been several years since the patient visited the dentist. As a motivated, health-conscious patient, he moved forward with non-surgical periodontal treatment right away. Arestin was used at the time of therapy in sites measuring 5mm or deeper with bleeding. The patient began using dental floss regularly, a power toothbrush, as well as mouthrinse to elevate the pH.

Tooth #16 is present and creating a bacterial reservoir contributing to infection in adjacent teeth. Orthodontics, removal of #16 and restoration of deteriorating, old restorations were all recommended, however, treatment of periodontal infection was set as the first priority.

Nick returned for re-evaluation two months after active therapy. Pocket depths and bleeding points were reduced yet there still remained 4mm bleeding pockets in the UL adjacent to #16. The area was reinstrumented and oral hygiene was reviewed. Three months later, he returned for a periodotnal maintenance visit. When asked what his primary concern was that day, Nick stated he had noticed an increase in bleeding on brushing and flossing. A periodontal exam revealed an increase in pocket depth and bleeding in localized areas.

Upon reviewing the medical history and positing the openended inquiry: “Tell me more about the arthritis,” he shared a history of rheumatoid arthritis as an immune system response to psoriasis outbreaks. He stated his immune system “overreacts” when he has psoriasis flair up and results in the arthritic symptoms.

Another open-ended question was asked: “Who in your family has a history of periodontal disease?” He then shared that his mother lost half her teeth at a very young age. He also reported a family history of heart disease.

Remember, he’s taking Crestor for high cholesterol and Vyvanse for ADD.

Let’s Review the Facts
  • Vyvanse increases the stress hormone Cortosol. There has been evidence showing the relationship of periodontal disease progression and this hormone.1
  • There is evidence that periodontal disease might independently increase the risk for cardiovascular disease.2 Nick has a family history of PD and CVD.
  • The periodontal disease has quickly gone from remission to active in localized areas.
  • The patient has an exaggerated immune response to psoriasis outbreaks resulting in rheumatoid arthritis (RA).
  • Multiple studies and scientific reviews have shown evidence that periodontal pathogens (especially P. gingivalis) and oral infections seem to be linked to the onset of RA 3&4
The risk assessment conversation sounded like this:

RDH: “Nick, before I check the health of your gums, I see on your medical history you circled arthritis. Tell me more about that.”

Nick: “I have psoriasis that usually flairs up in the winter. My immune system overreacts and then I also have a rheumatoid arthritis flair up with pain and joint stiffness.”

RDH: “I see you’re also taking Crestor for high cholesterol. I’m wondering if you have a family history of heart disease or gum disease. Can you tell me about that?”

Nick: Yes, my mother lost at least half her teeth at a very young age and there is heart disease in the family on my mother’s side.

RDH: I believe the gum infection might have a connection to the RA. I’m going to check your gums again today just like we did before. I will call out a lot of numbers and remember, 1- 3 is normal and healthy gums don’t bleed. I’d like you to remember the lowest and highest numbers and if you feel pain anywhere, please let me know. This should not hurt. [Complete periodontal exam was performed; pocket depths and bleeding points were called out loud.]

RDH: Nick, you heard when I did the gum exam that there are several areas where the pocket depths have increased and there is bleeding. This means the infection is again active. I’m suspicious there might be something going on in your body that is also causing you to have an exaggerated response to the gum infection, just like you have with the psoriasis.

Gum disease and RA have a lot in common. They are both the result of inflammation and some studies have shown that there’s a two-way relationship and that active gum infection might influence the severity of the RA. It’s in your best interest to get this gum infection under control and to determine if you have a genetic reason for your exaggerated response to inflammation.

The good news is we can test for that very easily. Based on your medical history and the fact that the inflammation has returned so quickly, I recommend both a bacterial test to see what bacteria are present and whether oral antibiotics will be helpful and a genetic test to see if you are positive for the gene that causes this overreaction to inflammation (Fig. 1 & 2). The cost of these two tests together is about $300. The sample collection is very simple and we can do that today.

The other thing that concerns me is that you have high cholesterol and a family history of heart disease. Studies have also shown that untreated gum disease might be a risk factor for heart attacks and strokes. Keeping the infection in remission might help reduce your already high risk.

I also recommend you shorten the time between visits to see us. This way I am able to help you in disrupting the bacteria at the base of the gums. These are areas you cannot reach with your brush and floss. How does this plan sound to you?

Nick: Let’s do it. I really want to know more about the immune system issue and I’m determined to get this gum disease under control.

Nick was scheduled for periodontal maintenance but because of the importance (and his motivation) to stop the progression of his PD we took a different treatment route. It’s important to not only treat periodontal disease clinically, but also recognize the risk factors involved.


Treatment Provided and Planned for the Future
  • Homecare instructions were reviewed with the additional recommendation to change powerbrush head frequently, use interproximal brushes and a water-flossing device.
  • To determine if Nick truly has an exaggerated inflammatory response, a saliva sample was collected for genetic testing.
  • The same saliva sample was used to determine if periodontal pathogen levels were high and if a systemic antibiotic would be appropriate adjunct therapy.
  • Education, enrollment and treatment planning used the better part of the 60-minute appointment. Periodontal maintenance treatment was rescheduled two weeks later when test results were ready. At that time it could be determined if systemic antibiotics were appropriate.
  • Due to the identified risk factors, Nick’s maintenance interval was shortened to eight weeks.
  • Restorative treatment plan was developed and referrals to appropriate orthodontic and surgical specialists were made.
  • Future treatment would include re-evaluation to determine if repeating the non-surgical therapy, referral to periodontist and/or medical doctor are appropriate next steps.
Putting It into Practice
This example demonstrates how the hygienist used highlevel processing of information to discuss risk with the patient. This approach requires knowledge, preparation and time. With practice, it becomes easier and faster to process risk information and make a treatment recommendation. A few things to consider:
  • Review charts ahead of time. Being prepared by reading the patient’s chart notes ahead of time will help you begin to put his history and your knowledge of oral-systemic health together in your mind. Figure 3 provides a checklist for chart review.
  • Regularly update the medical history. If patients balk at completing a detailed history it might be because they don’t know why you need it. Connect the dots for them. Share that the most common side effect of prescription medication is dry mouth and that puts them at increased risk for gum disease and cavities. Also share that you will use medical history to see if there’s anything they can do medically to help prevent future dental problems and vice versa.
  • Use open-ended questions. When asking about medications, rather than saying “Do you have any changes?” ask “What medications are you taking?”
  • Study. In order to use risk assessment in your daily practice, you must study the connections between dental disease and systemic health. Several continuing education courses on this topic are available online on both Dentaltown.com and Hygienetown.com. Each issue of Dentaltown Magazine and Hygienetown (digital) includes Perio Reports research summaries. A new organization focuses on this topic exclusively, the American Academy of Oral Systemic Health (www.aaosh.org). PubMed.com allows you to easily search and view abstracts of research articles on just about any medical/dental topic. Want to learn more about RA and PD? Just type in rheumatoid arthritis and periodontal disease in the search field.
  • Review the case. Regularly spend time as a team reviewing cases. Nick’s case would be perfect for review and discussion. This calibrates your team and ensures everyone understands and supports the recommended treatment and can reinforce its importance with the patient.
  • Make recommendations personal. Always remember to find something specific to the patient that supports your treatment recommendation and speak to that. Is it the patient’s history of stroke and desire to prevent recurrence? Is it his diabetes that he has a hard time managing?


Conclusion
This process of treatment planning using risk assessment requires moving to a new level of patient care. It’s an incredible opportunity to leave the rote, day-in day-out routine of dental practice and dive into an exciting world as part of the patient’s health-care team focused on risk assessment. So often, dental professionals find themselves going through the motions of prophy after prophy or crown after crown to “fix” the existing problem without looking at the big picture – the cause of the disease and associated risks.

Diagnostic data collection takes time. Processing the data takes time. Communication takes time. Give yourself permission to take the time to incorporate risk assessment into your patient care and see your patients achieve a higher level of health.

* Name has been changed.
  1. Rosania AE, Low KG, McCormick CM, Rosania DA. Stress, depression, cortisol, and periodontal disease. J Periodontol. 2009 Feb;80(2):260-6.
  2. Friedewald, Cornman, Beck, et al. The American Journal of Cardiology and Journal of Periodontology Editors’ Consensus: Periodontitis and Atherosclerotic Cardiovascular Disease. J Perio July 2009
  3. Straka M, Trapezanlidis M, Dzupa P, Pijak R. Associations between marginal periodontitis and rheumatoid arthritis. Neuro Endocrinol Lett. 2012;33(1):16-20.
  4. Detert J, Pischon N, Burmester GR, Buttgereit F. The association between rheumatoid arthritis and periodontal disease. Arthritis Res Ther. 2010;12(5):218. Epub 2010 Oct 22.
Author's Bio
As owner of Inspired Hygiene, Rachel Wall, RDH, BS, partners with dentists, hygienists and office managers to elevate their hygiene services, systems and profits. In addition to coaching, Rachel draws from her 20 years of experience as a hygienist and practice administrator to deliver to-the-point articles and speaking programs. She has spoken across the country including the Townie Meeting, RDH Under One Roof, the AACD annual session. Inspired Hygiene’s programs include in-office coaching, a free weekly e-zine, the Hygiene Profits Mastermind group and the new Profitable Perio Online Workshop. To contact Rachel, e-mail her at Rachel@InspiredHygiene.com or call 877-237-7230.
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