Risk

Dental risk assessment

  • Oral health assessment and review (OHAR) involves a comprehensive assessment of the patient’s histories and oral health status that leads to diagnosis and risk assessment

  • The dental risk assessment forms part of the OHAR and follow on from the patient history assessment, i.e. medical, social, past dental history, EO, IO, special investigations, etc

Why?

  • Having undertaken the OHA and RA, the clinician is then able to create a personalised care planning and ongoing review

  • The clinician is assessing an individual’s risk of developing common and less common oral diseases in the future

  • NICE recommended a dental patient’s recall interval between routine examinations is based on the individual’s risk of dental caries, oral cancer and periodontal disease

How?

  • Involves using clinical judgement and knowledge of the patient to assess modifying factors identified in the patient’s histories and integrating this information collated during the clinical examinations

  • A risk level of high, medium or low is then assigned for each of the dental diseases: dental caries, periodontal disease, oral cancer and tooth surface loss/wear

  • Taking into account the risk levels for all of the dental diseases, then an overall risk level is assigned to the patient

Be aware

These risk levels can be influenced by patients:

  • Possible inaccurate self-reporting

  • Risk factors and protective factors can change over time

  • Past disease experience might not always be a reliable predictor of future disease

  • The patient’s attitude to care and ability and willingness to cooperate

They need to ve re-evaluated at every new course of treatment and review appointment/special investigations changed to reflect this

Impact of patient’s risk:

Frequency of

  • Recalls

  • Radiographs

Recall intervals

SCDEP

  • Assign on interval for a focussed oral health review (FOHR) for the patient, if required, that is based on their overall risk level and specific to their needs within the following ranges

    • Adult: 3-24 months

    • Children: 3-12 months

FGDP

Multifactorial - risk assessment should be undertaken and consideration with other risk factors such as diet, OHAR, smoking, diabetes, alcohol, lifestyle, disease experience, etc

Radiographic Investigations

Dental Caries

  • High risk:

    • 6 month bitewings

    • Until no new active lesions are apparent and the individual has entered another risk category

  • Medium risk

    • 12 month bitewings

    • Until no new or active lesions are apparent and the individual has entered another risk category

  • Low risk

    • 24 month bitewings

    • More extended recall intervals may be employed if there is explicit evidence of continuing low risk of caries

Periodontal disease

  • Radiographic imaging is generally advisable for BPE codes 3 or 4 especially where mobility is also present, since it will help the clinician to establish a complete diagnosis and formulate a treatment plan. It is also essential where the clinican suspects that other pathology is present. Following the principle of the lowest dose commensurate with the diagnostic purpose, either periapical views or an OPG may be appropriate

  • Bitewings - crestal bone leve;s must be visibel

  • Frequency - dependent on several factors

RLBUH dental risk assessment performa (Adults)

  • Oral hygiene

  • Caries risk assessment

  • Periodontal risk assessment

  • Oral cancer risk assessment

  • TSL risk assessment

Tailored patient advice all evidence-based:

  • DBOH

  • Scientific bases of OH

  • Eatwell guide

  • BSP guidelines

  • VBA - smoking cessation

  • Alcohol consumption guidelines

Assess current OH regime

  • Frequency

  • Toothpaste

  • Mouthwahses

  • Manual/Electric

  • Interdental

  • Other

Caries risk assessment

Identify risk:

  • Regular attendance at routine dental visits

  • High and/or frequent sugar intake

  • History of extractions due to caries

  • Evidence of previous disease (restoration)

  • Medical risk factors e.g. xerostomia

  • Regular brushing

  • Plaque visible on teeth

  • Evidence of caries

Follow DBOH guidelines, Challacombe scale

Low risk (generic tailored OHI)

High risk:

  • FV 2x a year

  • Daily fluoride rinse

  • Prescribe 2800 or 5000ppm toothpaste

  • Investigate diet and assist to adopt good dietary practice in line with Eatwell guide

Periodontal risk assessment

Identify risk:

  • Regular attendance at routine dental visits

  • History of extractions due to periodontal disease

  • FH

  • Smoking

  • Medical risk factors, e.g. diabetes

  • Regular brushing

  • Plaque visible on teeth

  • Evidence of periodontal disease

Low risk (self care plaque removal, type of toothbrush)

High risk

  • Smoking (VBA)

  • Diabetes (explain risk/link)

  • Interdental/subgingival care (correct size, make of IDB)

  • Set targets for reducing PI and GBI

Oral cancer risk assessment

Identify risk

  • Smoking

  • Smokeless/chewing tobacco

  • Alcohol consumption exceeding recommended maximum levels

  • Daily diet including 5 portions of fruit/veg

  • History of oral cancer or premalignant oral lesions

Advice

  • VBA - smoking and alcohol

  • Increase intake of non-starchy vegetables and fruit

Smoking and alcohol

  • A simple form of advice developed by the National Centre for smoking cessation and training (NCSCT)

  • Designed to be used in less than 30 seconds

  • Three main elements:

    1. Establish and record smoking status (Ask)

    2. Advising on the personal benefits of quitting (Advise)

    3. Offering help (Act)

Signposting to: NHS support services

Quitting smoking

  • E-cigarettes

  • NRT

  • POM:

    • Buproprion

    • Varenicline

Dose Response

  • Relationship found between prevalence of moderate to advanced periodontitis and the number of cigarettes smoked per day, and the number of years they have smoked for

  • Packs years - packs of cigarettes smoked per day multiplied by the number of years the subject has smoked for

  • Used to quantify the effect

  • No cut off as to what is a risk, but more packs and more years, a bigger health impact

  • Social smokers tend to smoke heavily

Reversibility

Former smokers are intermediate between current smokers and non-smokers in their risk for periodontitis

Alcohol misuse advice (AMA)

  • Recommended no more than 14 units per week

  • 1 unit = ½ pint = ½ glass of wine = 1 shot

  • Smoking and drinking increases your risk of oral cancer significantly if heavily used.