Referral Policy and Parameters of Care

Referral of patients with periodontal problems, to either specialist practitioners or hospital consultants depends on several factors:-

1. The GDP's knowledge and ability to treat patients which will vary considerably.
2. The patient's desire to see a specialist or undergo specialist treatment.
3. The age and general health status of the patient.
4. The complexity of treatment required.

It is difficult to be absolute in determining referral policy guidelines but if a basic periodontal examination is carried out (outlined below) then based upon its criteria Complexity 1 cases may be treated in general practice, Complexity 2 cases either referred or treated by the GDP and Complexity 3 cases mostly referred. It is worthy of note that sometimes apparently simple periodontal treatment may have to be delivered by Specialists as part of a more complex integrated treatment strategy in order to maintain the integrity of the restored dentition. Equally, patients falling into the Complexity 3 category may not necessarily require care from a specialist.

Parameters of Care

• It is the responsibility of the dentist to monitor/screen patients for the presence of periodontal diseases including the use of relevant radiographs to make a diagnosis and institute a treatment plan with defined therapeutic goals.
• Like many other conditions the treatment of periodontal disease depends to a large extent on patient compliance.
• An assessment should be made of rate of disease progression and related to age in the overall context of oral health management. Consequences of no treatment should be explained.
• For reasons of poor general health, lack of effectiveness of plaque control or non-compliance with good oral hygiene regimes, the patient's own wishes or the operators' decision, appropriate treatment to control disease may be deferred or declined.
• In certain cases, because of the severity and extent of the disease, the age and health of the patient, treatment that is not intended to attain optimal results may be indicated. In these cases initial therapy may become the end point.
• All periodontal assessments should be written in the notes particularly with regard to probing depths, attachment levels, bleeding sites, plaque scores and mobility and outcome assessments must be carried out in relation to the balance of the health/disease axis and the comfort function and aesthetics of the patient.
• If the results of initial treatment resolves the periodontal condition, maintenance therapy should be scheduled at appropriate time intervals.

BPE - Basic Periodontal Examination

The Basic Periodontal Examination requires that the periodontal tissue should be examined with a standardised periodontal probe using light pressure to examine the tissue for bleeding, plaque retentive factors and pocket depth:

Modifying Factors that are relevant to Periodontal treatment

A modifying factor can only increase complexity by one increment. Multiple factors are not cumulative.

• Co-ordinated medical (e.g. renal : cardiac) and / or dental (e.g. oral surgery : orthodontic) multi disciplinary care
• Medical history that significantly affects clinical management (See below)
• Special needs for the acceptance or provision of dental treatment.
• Mandibular dysfunction
• Atypical facial pain
• Undiagnosed facial pain
• Presence of a retching tendency
• Limited operating access
• Concurrent mucogingival disease (e.g. Erosive Lichen Planus)

Medical History that Significantly Affects Clinical Management

• Patients requiring IM or IV medication as a component of clinical management.
• Patients with a history of head / neck radiotherapy.
• Patients who are significantly immuno compromised or immuno suppressed.
• Patients with a significant bleeding dyscrasia / disorder.
• Patients with a potential drug interaction.

Periodontal Treatment Assessment

Based on the Basic Periodontal Examination Code as outlined above

• BPE Score 1 - 3 in any sextant = Complexity 1
• BPE Score of 4 in any sextant = Complexity 2
• Surgery involving the periodontal tissues
• Surgical procedures associated with osseointegrated implants
• Surgical procedures involving periodontal tissue augmentation and / or bone removal (e.g. Crown lengthening surgery).
• BPE score of 4 in any sextant and including one or more of the following factors:
• Patients under the age of 35 = Complexity 3
• Smoking 10+ cigarettes daily
• A concurrent medical factor that is affecting the periodontal tissues
• Root morphology that adversely affects prognosis
• Rapid periodontal breakdown >2mm attachment loss in any one year

The index of treatment needs for periodontal treatment assessment administered through the Clinical Audit Committee of the RCS/Eng is based on the most widely used practitioner oriented Basic Periodontal Examination (BPE). It sets complexity codes in a simplistic manner with the addition of a list of modifying factors that are relevant to periodontal treatment and an outline of medical history that significantly effects clinical management.

It is strictly a complexity assessment and does not address either the motivational aspects of treatment or a prioritisation of treatment.

Nevertheless it is a very useful tool not only for providing guidelines of complexity but also for indicating according to complexity where treatment should be carried out. The only area of possible contention may be the smoking issue with a BPE of 4 in any sextant. Recent work has suggested that the treatment of smokers with periodontal disease should be kept as simple as possible.