Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 3.2 – Dental Care: Scope of Services

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3.3.2.4 Periodontal Disease Program

  • Policy

    • All California Department of Corrections and Rehabilitation (CDCR) dental facilities shall maintain a periodontal disease program for the diagnosis and treatment of periodontal disease that incorporates consideration of the most current version (MCV) of the Adult Correctional Dental Care (ACDC), Periodontal Treatment Guidelines (PTG).  Periodontal treatment shall be available to all patients based on completion of a comprehensive dental examination, the presence of a treatment plan, prior completion of Dental Priority Classification (DPC) 1 dental treatment and time remaining on their sentence. (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.5.3, Appendix 1, Dental Priority Classification).

  • Purpose

    • To establish guidelines and procedures for the treatment and management of periodontal disease in the patient population.

  • Procedure

    • Diagnosis of Periodontal Disease

      • Mainline Facility Dental Clinics:

        • Comprehensive Periodontal Examination and Charting

          • Patients transferring to a Mainline Facility shall be eligible for a comprehensive periodontal examination.

          • The comprehensive periodontal examination shall be performed in conjunction with the comprehensive dental examination within the parameters outlined in the HCDOM, Section 3.3.2.3(c)(1)(B)4.

          • The comprehensive periodontal examination and charting shall be documented on and include conditions contained in the Electronic Dental Record System (EDRS) Perio Chart, in accordance with EDRS Workflow 1-3 as well as 1-4 and associated Back Office Job Aids.

        • Classification of Periodontal Disease

          • Periodontal Disease shall be classified according to the following categories from the American Academy of Periodontology (AAP) Position Paper “Diagnosis of Periodontal Disease” (J Periodontol. 74: 1237-1247).

            • Gingivitis

            • Chronic Periodontitis

            • Aggressive Periodontitis

            • Periodontitis as a manifestation of systemic disease

            • Necrotizing periodontal disease

            • Abscess of the periodontium

            • Periodontitis associated with an endodontic lesion

          • Descriptive modifiers shall be used to distinguish the extent and severity of the periodontal disease including, but not limited to:

            • Localized (<30% of sites involved)

            • Generalized (>30% of sites involved)

            • Slight

            • Moderate

            • Advanced

            • Case Type IndicatorsType II Slight PeriodontitisType III Moderate PeriodontitisType IV Advanced   Periodontitis
              Bleeding on probingYesYesYes
              Probing depth< 4 mm4 to 6 mm> 6 mm
              Bone loss≤ 10%≤ 33%> 33%
              Mobility≤ 1≤ 2≤ 3
              Furcation grade≤ 1≤ 2≤ 3
              Clinical attachment loss< 2 mm2 to 4 mm> 4 mm
              Localized – < 30% of sites involvedGeneralized – ≥ 30% of sites involved

          • The classification type and descriptive modifiers shall be documented in the EDRS Perio Chart, and in a clinical note in accordance with EDRS Workflow 1-4 and associated Back Office Job Aid.

      • RC Dental Clinics

        • Each parole violator or new commitment arriving at a Reception Center (RC) shall undergo a dental screening as outlined in the HCDOM, Section 3.3.2.2, Dental Care – Reception Center.

    • Patient Education and Treatment of Periodontal Disease

      • The treatment of periodontal disease is a major part of dental practice and requires a coordinated effort between the patient and the dental team. The ultimate responsibility for controlling periodontal disease is that of the patient. 

      • Gross debridement may be performed for Mainline Facility or RC patients regardless of the Plaque Index (PI) score at the treating dentist’s discretion.

      • Mainline Facility Dental Clinic

        • Education

          • Methods and procedures to control periodontal disease shall be taught and demonstrated to patients by dental staff. These measures shall consist of individual instructions and training in oral hygiene and plaque control, which may include, but not be limited to:

            • The documenting of the PI score in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, as well as in the EDRS Periodontal Chart, in accordance with EDRS Workflow 1-4 and associated Back Office Job Aid.

            • Education on oral hygiene which is included in the Patient Orientation to Health Care Services Handbook.

            • Education on the signs and symptoms of periodontal disease.

            • Education on the effect of periodontal disease on oral and systemic health.

            • Education on the importance of controlling oral disease for female patients during and after pregnancy to reduce the potential for transmitting oral bacteria from mother to child.

            • Demonstration and training on the methods of preventing periodontal disease.

            • Education and training on proper oral hygiene techniques.

            • Availability of appropriate treatment modalities at the assigned facility.

          • The PI score is used to determine the percentage of teeth stained with plaque and is calculated as outlined in the HCDOM, Section 3.3.2.13(c)(2)(B). (Reference the HCDOM, Section 3.3.2.13(c)(2)(G) and (H) regarding documentation of the PI score).

        • Clinical Treatment

          • The treatment of moderate or advanced periodontitis shall be classified as DPC 2 care. Patients with aggressive periodontitis, periodontitis as a manifestation of systemic diseases, and necrotizing periodontal diseases may require consultation and coordinated case management with their primary care provider (PCP).

          • The treatment of gingivitis or slight periodontitis shall be classified as DPC 3 care. (Reference the HCDOM, Section 3.3.2.13(c)(2)(A) for treatment eligibility requirements).

          • The predominant mode of periodontal therapy within CDCR shall consist of periodontal scaling and root planing (SRP).  CDCR clinicians shall not provide periodontal therapy other than SRP without prior approval of the Dental Authorization Review (DAR) Committee and the Dental Program Health Care Review Committee (DPHCRC).  (Reference the HCDOM, Section 3.3.4.5(c)(3) and (4)).

            • Prior to SRP procedures, the attending dentist shall document a baseline charting of the periodontal status which shall include, but is not limited to, review of a radiographic survey.

            • Clinicians shall initiate treatment in a timely manner and minimize the number of encounters needed to complete SRP.  When this is not done, the treating clinician shall document the reason in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

            • It is recommended that patients who need two quadrants or less of SRP have it completed in a single encounter and those needing more than two quadrants have the treatment completed in two encounters that are at least two weeks apart.

            • Extreme care shall be exercised when providing scaling and/or root planing to patients with implants.  To prevent damage to the implant, the use of metal scalers and probes shall be avoided.

          • Patients shall receive a re-evaluation of their periodontal condition four to eight weeks following completion of treatment procedures associated with active therapy. When this is not done, the treating clinician shall document the reason in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

            • If a patient refuses a perio re-evaluation, the patient shall be advised to submit a CDCR 7362, Health Care Services Request Form, when they are ready to have the procedure performed. (Reference the HCDOM, Section 3.3.5.6, Patient’s Right to Refuse Treatment for requirements concerning a refusal).

            • When a patient submits a CDCR 7362 request for perio re-evaluation and it is determined that the patient previously refused the perio re-evaluation, at the discretion of the treating dentist, the Office Technician (OT) shall create a No Face-to-Face Treatment Request and schedule the patient. The appointment shall take place within 30 calendar days of the clinic’s receipt of the CDCR 7362. At the time of the appointment, the dentist shall treatment plan the perio re-evaluation in the EDRS Progress Note panel with the current date as the diagnosis date.

          • The re-evaluation shall include documenting of pocket depths, mobility, furcation involvement and bleeding on probing. These clinical observations may be performed and documented by a Registered Dental Hygienist (RDH) who shall forward the findings along with treatment recommendations to the treating dentist.

          • Patients who require continuing active therapy shall be assigned a DPC based on their periodontal disease condition at the time of the most recent re-evaluation.

            • For scheduling purposes, the “Date of Diagnosis” is the date that the re-evaluation is completed and the need for continuing active therapy is identified.

            • The patient may continue to receive non-periodontal procedures in accordance with and within the timeframes of their established treatment plan.

          • In order to assist in maintaining periodontal health and facilitate detecting active disease recurrence, CDCR clinicians may recommend periodontal maintenance for patients with a documented susceptibility to periodontal disease.

          • CDCR dentists shall document recommendations for periodontal maintenance on the EDRS odontogram Progress Note panel, in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid.

          • Patients for whom the treating dentist recommends periodontal maintenance shall not be assigned a DPC for the periodontal maintenance when the patient has untreated, diagnosed dental conditions.  The patient’s DPC shall be based on the most urgent diagnosed, untreated condition.

          • When a patient no longer has any active periodontal disease sites; and all active and continuing active therapy has been completed; and the patient has reached a state of periodontal health; and the patient has no untreated, diagnosed dental conditions; and the dentist is recommending that the patient receive periodontal maintenance; or the dentist is not recommending periodontal maintenance, the patient shall be assigned a DPC 4.

          • When a CDCR dentist recommends periodontal maintenance for a patient, dental staff shall either assign a Continuing Care type of Perio in the EDRS Family File or update the Continuing Care as needed, in accordance with EDRS Workflow 1-4 and associated Back Office Job Aid. The patient shall be advised to submit a CDCR 7362 within a specified timeframe (e.g., 3, 4 or 6 months), based on the treating dentist’s professional judgment, to ask for periodontal maintenance.  The treating dentist shall inform the patient of the reason for the periodontal maintenance.

          • When a patient submits a request for periodontal maintenance, the dentist performing the paper review shall review the health record, or instruct a dental staff member to review the health record, to ensure that a CDCR dentist recommended periodontal maintenance and that the patient submitted the CDCR 7362 consistent with the recommended periodicity for the periodontal maintenance encounter.

          • When the health record review reveals that a CDCR dentist recommended periodontal maintenance and that the patient submitted the CDCR 7362 within the appropriate timeframe, the individual who conducted the health record review shall inform the dentist performing the paper review who shall indicate on the CDCR 7362 that the patient needs a periodontal maintenance appointment which the OT, or designated dental staff, shall enter in the EDRS Treatment Request Manager, in accordance with EDRS Workflow 1-2 and associated Front Office Job Aid.

          • When the health record review reveals that a CDCR dentist recommended periodontal maintenance and that the patient submitted the CDCR 7362 greater than 60 calendar days before the date when they are eligible, a CDCR dentist shall send a written response informing the patient when to submit a request.

          • When a patient submits a CDCR 7362 beyond the recommended timeframe, they shall be scheduled for a periodontal maintenance appointment as outlined in Section (c)(2)(C)2.m.

          • If a patient for whom a dentist has recommended periodontal maintenance fails to submit a CDCR 7362 to request the procedure, and the patient subsequently becomes eligible for and receives a periodic comprehensive dental examination, the treating dentist shall reject the unscheduled periodontal maintenance procedure at the time of the examination appointment in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid.

          • Provision of periodontal maintenance shall incorporate consideration of the most recent version of the ACDC, PTG.

      • RC Dental Clinics

        • Education

          • Patients diagnosed with periodontal disease shall be eligible to receive education on how to control the condition as outlined in Section (c)(2)(C)1.a.2) through 7).

        • Clinical Treatment

          • RC patients shall receive dental treatment as outlined in the HCDOM, Section 3.3.2.2, Dental Care – Reception Center.

  • References

    • Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.2.2, Dental Care – Reception Center

    • Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.2.3, Comprehensive Dental Examinations

    • Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.2.13, Facility Level Dental Health Orientation and Self-Care

    • Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.4.5, Dental Authorization Review Committee

    • Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.5.3, Dental Priority Classification

    • Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.5.6, Patient’s Right to Refuse Treatment

    • California Correctional Health Care Services, Patient Orientation to Health Care Services Handbook

  • Revision History

    • Effective: 04/2006
      Revised: 03/2019, 11/2020, 02/2022