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BSP Guidelines for Periodontal Patient Referral This document sets out referral guidelines for periodontal treatment and maintenance. It describes levels of complexity linked to the appropriate referral of patients in need of periodontal treatment in a secondary care setting. As with all treatment involving a team approach, the long-term success of a care pathway depends on good communication between clinicians and the patient. This is to ensure consistency of treatment objectives and appropriate follow up. This care policy describes 3 levels of complexity together with a list of relevant modifying factors. The policy lists medical conditions that significantly affect the clinical management of patients with periodontal diseases and is intended as a guide for clinical practice. Referral of patients with periodontal diseases to specialists in Periodontology or other appropriately qualified oral healthcare professionals depends on several factors including- • The stage and grade of the disease and complexity of treatment required. It is also linked to the patient's desire to see a specialist or undergo specialist treatment. • The knowledge, experience and training of oral healthcare professionals to manage patients with a range of periodontal conditions. • The presence of genetic and lifestyle/behavioural risk factors. The BSP guidelines for referral are aligned to the the BSP implementation of the 2017 Classification of Periodontal Diseases and Conditions and the Commissioning Standard for Restorative Dentistry. Further background information is available, including detail of BPE- based periodontal screening and related periodontal assessments, in the associated BSP policy document – 'Basic Periodontal Examination (BPE) . Periodontal Treatment Comprehensive interpretation of medical, social, Assessment behavioural factors relevant to periodontal health Level 1 Complexity Diagnosis and management of patients with uncomplicated periodontal diseases including but not limited to: − All Patients − Evaluation of periodontal risk, diagnosis of periodontal − Treatment should condition and design of initial care plan within the ideally be performed context of overall oral health needs. in general dental − Measurement and accurate recording of periodontal indices. practice − Communication of nature of condition, clinical findings, risks and outcomes − Designing care plan and providing treatment − Assessment of patient understanding, willingness and capacity to adhere to advice and care plan − Evaluation of outcome of periodontal care and provision of supportive periodontal care program − On-going motivation and risk factor management including plaque biofilm control − Avoidance of antibiotic use except in specific conditions (necrotizing periodontal diseases or acute abscess with systemic complications) unless recommended by specialist as part of comprehensive care plan − Preventive and supportive care for patients with implants − Palliative periodontal care and periodontal maintenance Level 2 Complexity Management of Patients: - Treatment may be − Who following primary care periodontal therapy have provided by oral stage II, III or IV periodontitis (>30% bone loss) periodontitis healthcare and residual true pocketing of 6mm and above? professionals in − With Grade C periodontitis as determined by a specialist general dental at referral. practice or referred. − With furcation defects and other complex root - There may be morphologies when strategically important and, realistic instances where and delegated by a specialist. periodontal/peri- − With gingival enlargement non-surgically, in collaboration implant treatment with medical colleagues. may need to be − Who require pocket reduction surgery when delegated delivered by a by a specialist? specialist as part of a − With certain non-plaque-induced periodontal diseases more complex e.g. virally induced diseases, auto-immune diseases, integrated treatment abnormal pigmentation, vesiculo-bullous disease, strategy. periodontal manifestations of gastrointestinal & other systemic diseases and syndromes, under specialist guidance. − With peri-implant mucositis. Level 3 Complexity Triage and Management of patients: - Patients are usually − With Grade C or Stage IV periodontitis (bone loss > 2/3 referred once the root length) & true pocketing of 6mm or more. lifestyle or behavioural − Requiring periodontal surgery. risk factors have been − Furcation defects and other complex root morphologies addressed and not suitable for delegation. appropriate non- − With non-plaque induced periodontal diseases not surgical treatment suitable for delegation to a practitioner with enhanced undertaken in general skills. practice. − Patients who require multi-disciplinary specialist care (Level 3). − Where patients of level 2 complexity do not respond to treatment. − Non-plaque induced periodontal diseases including periodontal manifestations of systemic diseases, to establish a differential diagnosis, joint care pathways with relevant medical colleagues & where necessary, manage conditions collaboratively with practitioners with enhanced skills if appropriate & provide advice and treatment planning to colleagues. − With peri-implantitis. All cases of periodontitis should have initial care (including treatment) and if unsuccessful, referral may then be indicated. Patients with modifying factors may require movement to the next level of care, including those where behaviour change is challenging. Evidence for the latter will be required to accompany referral letters. Patients with Grade C Periodontitis should be referred after initial preventive advice on risk factor management and oral hygiene instruction. Modifying Factors that are Relevant to Periodontal Treatment • Co-ordinated medical or dental multi-disciplinary care • Regular tobacco smoking and tobacco substitute products that deliver nicotine e.g. vaping • Dental special care for the acceptance or provision of treatment • Concurrent mucogingival disease e.g. erosive lichen planus • Medical history that significantly affects clinical management: - Patients with a history of head/neck radiotherapy or intravenous bisphosphonate therapy - Patients who are significantly immunocompromised or immunosuppressed - Patients with a significant bleeding dyscrasia/disorder - Patients with a potential drug interaction © The British Society of Periodontology and Implant Dentistry 2020 www.bsperio.org Registered Charity Number. 265815