RISK ASSESSMENT

Questions

• Risk assessment in Periodontal Diseases

• Risk factors in Periodontal Diseases
• Risk assessment models
• Smoking as a risk factor
• Diabetes mellitus as a risk factor
• Role of genetics
• Role of microbes
 CONTENTS
• Introduction
• Definitions/ Basic Terminologies
• Risk elements
– Risk factors
– Risk indicators
– Risk predictors
– Risk determinants
• Lilienfeld’s criteria
• Clinical Risk assessment for Periodontal Diseases
– Patient level
– Mouth level
– Tooth level
– Site level
• Models for Periodontal Risk assessment
• Summary
• Conclusion
• References
Introduction

Page and Kornman , 1997

Basic Terminologies

• Risk – is the probability that an individual will

develop a specific disease in a given period.
Risk assessment

According to the American Academy of Periodontology, risk

assessment has been defined as the process by which qualitative or
quantitative assessments are made of the likelihood for adverse events
to occur as a result of exposure to specified health hazards or by the
absence of beneficial influences.
Risk can be identified in terms of
• Risk factors- may be environmental, behavioral, or
biologic factors, that, when present, increase the
likelihood that an individual will develop the disease.

• Risk determinant/background characteristics – which

is sometimes substituted for the term risk factor,
should be reserved for those factors that cannot be
modified.
• Risk indicators – are probable or putative risk
factors that have been identified in cross sectional
studies but not confirmed through longitudinal
disease.

• Risk predictors/markers – are although associated

with increased risk for disease, but do not cause the
disease. These factors are identified in cross
sectional and longitudinal studies.
LILIENFELD’S CRITERIAS
1. Strength of the association
2. Specificity of the association
3. Degree of exposure
4. Consistency of association
5. Temporal consistency/ correct time sequence
6. Biological plausibility
BECK ET AL 1994, OFFENBACHER 1996 have added one
more criteria to LILIENFELD’S CRITERIAS

• Support from experimental evidence: Experimental

reproduction of the disease should occur frequently in
animals exposed to risk factor.

• RCT which test the effect of intervention to prevent disease

occurrence are also strong evidence of a causal relationship.
 Randomized
Control Trials
Cohort Studies
Case Control Studies
Cross Sectional Studies
and Case Reports
Ideas, Editorials and Opinions
Animal Research
In vitro (test tube) research
• Putative risk factors- factors that are confirmed by
means of longitudinal studies and meet the criteria
described by Lilienfeld above are properly called,
putative risk factors but often are referred to as risk
factors.
 RISK RISK RISK RISK
FACTORS DETERMINANTS INDICATORS PREDICTORS

Tobacco Genetic factors HIV/AIDS Previous history

smoking of periodontal
disease

Diabetes Age Osteoporosis Bleeding on

Mellitus probing
Pathogenic Gender Infrequent
bacteria dental visits

Microbial Socioeconomic
tooth deposit status

Stress
 Tobacco smoking
• Tobacco is a well established risk factor for periodontitis.(JOP
1996)

 One of the largest studies, by Grossi et al., 1995, conducted at

Erie County, New York,
 1361 subjects, aged 25 to 74.
 Results: Smokers were at greater risk for experiencing severe
bone loss compared to non smokers.
• NHANES III

– 12,000 dentate individuals over 18 years of age

– Results: smokers were four times as likely to have
the disease
<=9 cigarettes/day – 2.70 (OR)
>=31 cigarettes/day – 6x more likely
Effect on microflora

Effect on host response

Effect on immune system

Effect on GCF
Effect on non surgical therapy

Effect on surgical therapy

Effect on Implants

Effect on healing
Conclusion for status of Smoking as a risk factor
• Smokers

– May present with periodontal disease at an early age,

– May be difficult to treat with conventional therapy
and
– May continue to have progressive or recurrent
periodontitis leading to tooth loss
 Diabetes Mellitus
• Epidemiologic data demonstrate that the prevalence and
severity of periodontitis is significantly higher in patients with
type I and type II diabetes than in those without diabetes.
(JOP, 1996)
Periodontal effects
• In these patients,
– host responses may be impaired,
– wound healing is delayed and
– collagenolytic activity may be enhanced.

• Diabetes may also contribute to the pathogenesis of

periodontitis via
– associated vascular compromise,
– deficits in cell-mediated immunity and
– the presence of a high glucose content in the blood, which
enhances bacterial growth.
• Furthermore, active inflammation characteristics of
periodontitis generates compounds that may increase
insulin resistance.

• Therefore, control of periodontal disease may help

patients improve metabolic control.
Pathogenic Bacteria and Microbial
tooth deposits
• It is well documented that accumulation of bacterial
plaque at the gingival margin results in the development
of gingivitis and that the gingivitis can be reversed with
the implementation of oral hygiene measures. (Loe et al,
1965)

• However, often patients with severe loss of attachment

have minimal levels of bacterial plaque on the affected
teeth,
– indicating that the quantity of plaque is not of major
importance in the disease process.
• In terms of quality of plaque, three specific bacteria have
been identified as etiologic agents for periodontitis:
I. A. actinomycetemcomitans,
II. P. gingivalis,
III. Tannerella forsythia (Bacteroides forsythus)

Cross-sectional and longitudinal studies support the

delineation of these three bacteria as risk factors for
periodontal disease.
Haffajee AD, Their elimination or suppression impacts
Socransky SS, the success of therapy,
1994
There is a host response to these
pathogens,

Virulence factors are associated with these

pathogens and

Inoculation of these bacteria into animal

models induces periodontal disease.
 Anatomic factors Restorative factors

• Furcations • Subgingival margins

• Root concavities • Overhanging margins
• Developmental grooves • Overcontoured crowns
• CEPs • Materials
• Enamel pearls • RPD designs
• Bifurcation ridges

Presence of calculus
RISK DETERMINANTS/ BACKGROUND
CHARACTERISTICS
 Genetic factors
• Why some patients develop periodontal disease and others
do not?

• Studies conducted in twins - genetic factors influence

clinical measures of gingivitis, PPD, CAL, and interproximal
bone height. (Michalowicz BS et al.)

• Localized and generalized aggressive periodontitis - familial

aggregation seen
 Kornman et al. demonstrated that alterations in specific
genes encoding the inflammatory cytokines (IL-1α/β) –
associated with severe chronic periodontitis in non-
smokers.

In a retrospective analysis - 300 well maintained periodontal

patients,
- the IL1 genotype yield higher BOP% than the IL1 genotype
negative control patients.
- (Kornman KS et al)
Immunologic alterations
❑ Neutrophil abnormalities,
❑ Monocytic hyper responsiveness to lipopolysaccharide
❑ Alterations in the monocyte/macrophage receptors for
the Fc portion of antibody
Age
• Prevalence and severity of periodontal disease -
increases with age . (Papapanou PN et al.)

• Studies have shown minimal loss of attachment in

aging subjects throughout their lives. (Papapanou PN
et al.)

• Therefore, it is suggested that periodontal disease is

not an inevitable consequence of the aging process.
 Gender
• Gender plays a role in periodontal disease.

• United States national surveys - males have more loss

of attachment than females. (1960-62)

• In addition, males have poorer oral hygiene than

females, as evidenced by higher levels of plaque and
calculus.
Socioeconomic status
• Gingivitis and poor oral hygiene can be related to lower
socioeconomic status (SES) .

• Decreased dental awareness and decreased frequency

of dental visits when compared with more educated
individuals of higher SES.
 Stress

• A recent study- people under physical or psychological

stress are prone to elevated biofilm plaque levels and
increased gingivitis.
Hildebrand HC et al.
• The incidence of necrotizing ulcerative gingivitis increases -
during periods of emotional and physiologic stress
Shields WD
 Emotional stress

Interfere with normal

immune function

Increased levels of
circulating hormones

Affect the
periodontium
• A series of studies made by Deinzer et al., examined the
impact of academic stress by students at university during
their examination period on periodontal health.

• Academic stress was shown to be a risk factor for gingival

inflammation with increasing crevicular interleukin-1b
levels and a diminution of the quality of the oral hygiene .
RISK INDICATORS
HIV/AIDS
• Hypothesis – immune dysfunction associated with HIV
infection and AIDS

Barr C et al.
 Osteoporosis
• Studies in animal models - that osteoporosis does not initiate
periodontitis, it may aggravate periodontal disease
progression. (Krook L et al.)

• Study of 12 women with osteoporosis and 14 healthy women,

– Von Wowern et al reported that the women with
osteoporosis had greater loss of attachment than the
control subjects.
Infrequent Dental visits
• Study - an increased risk in patients who had not visited
the dentist for three or more years, whereas

• Study- there was no more loss of attachment or bone loss

in individuals who did not seek dental care when
compared with those that did over a 6-year period.
Page RC et al., 1997
RISK MARKERS/ PREDICTORS
Previous history of Periodontal Disease

❑ Patients with the most severe existing loss of

attachment are at the greatest risk for future loss of
attachment.

❑ Conversely, patients currently free of periodontitis have

decreased risk for developing loss of attachment than
those who currently have periodontitis.
Page RC, Beck JD
Bleeding on Probing
• BOP + increasing Pocket depth

excellent predictor for future loss of attachment

• BOP percentages reflect
– the patient's ability to perform proper plaque control,
– the patient's host response to the bacterial challenge,
– the patient's compliance

• The percentage of BOP, therefore, is used as the first risk

factor in the functional diagram of risk assessment by Lang
& Tonetti.
Peri-implant disease
GENETIC TRAITS
• No relation b/w IL-1 gentotype & periimplantitis.
Wilson & Nunn 99; Lachmann 2006

DIABETES

• Poor metabolic control & periodontitis…. 64.6% peri

implant mucositis & 8.9% peri implantitis.
Ferreira 2006
SMOKING

• Enhanced risk of biologic complications.

Ataoglu 02; Strietzel 2007,Attard & Zarb 2002

Poor oral hygiene

• Peri implantitis. Lindquist 97; Ferriera 2006

CLINICAL RISK ASSESSMENT FOR
PERIODONTAL DISEASE
• One of the problems with risk assessment in periodontal
disease is that the diseases are multifactorial and
assessment should therefore be at multiple levels.
The patient The whole
level mouth level
• The presence of pathogenic bacteria alone is not sufficient
to cause the disease.

The tooth level The site level

Patient-level risk assessment
• Family history
• Medical history
• Present dental history - Assess motivation to oral hygiene.
• Social history
• Habits like bruxism.
Mouth-level risk assessment
• Examination of attachment loss relative to age
• Occlusal examination in static relationship
• Occlusal examination in dynamic relationship
• Examination of levels of oral hygiene
• Examination of levels of plaque-retentive factors
• Presence of removable prosthesis
• Levels of recession
• Gingival inflammation and depth of pockets.
 Tooth-level risk assessment
• Individual tooth mobility (mobility index)
• Tooth movement or drifting
• Residual tooth support (radiographically).
• Presence, location and extent of furcation lesions
• Individual tooth anatomy
• Anatomy of tooth embrasures and contact points
• Presence of ledges or deficiencies on restorations
• Individual occlusal contacts - Prematurities
• Soft tissue contours
• Subgingival calculus.
Site-level risk assessment
• Bleeding on probing
• Exudation
• Local root grooves or root concavities
• Individual probing pocket depth
• Attachment levels
• Other anatomical factors like enamel pearls, root grooves.
RISK ASSESSMENT PROCESS
• In an attempt to clarify the process of identifying high-risk
individuals, a research group at the University of North
Carolina has delineated a 4-step process.

1. Identification of risk factors.

2. Development of a risk assessment model or models.
3. Assessment.
4. Targeting.

Beck JD, Kohout F, Hunt RJ 1988.

CLINICAL RISK ASSESSMENT FOR
PERIODONTAL DISEASE
PERIODONTAL RISK CALCULATOR (PRC) BY
PAGE ET AL.
 For future periodontal disease and also progression

• The PRC is a web-based tool that can be accessed through

Definition
a dental of a computer.
office risk factor

• PRCScientific basis
was developed using the six design parameters on a
desktop computer using Microsoft Excel.
Application of risk assessment

Time required for data collection

A five-point scale
 Patient age
Vertical
Smoking
bone
history
lesions

Radiographic Diagnosis
bone height of diabetes

Restorations
or calculus History of
below the periodonta
gingival l surgery
margin

Furcation
Pocket depth
involvements
• Information from baseline examinations was entered into
the risk calculator and a risk score, on a scale of 1–5, for
periodontal deterioration was calculated for each subject.

• Reassessment was done at 3, 9 and 15years.

• The risk scores at baseline were found to be strong

predictors of future periodontal status measured as
worsening severity and extent of alveolar bone loss and
loss of periodontally affected teeth.
PERIODONTAL RISK ASSESSMENT (PRA) HEXAGONAL
RISK DIAGRAM MODEL BY LANG & TONETTI (2003)
 Lang and Tonetti described a functional diagram based on six
parameters for use in estimating an individuals’ risk for
progression of periodontitis.

Loss of
Prevalence periodontal
Percentage Loss of teeth Systemic
of residual support in Environment
of bleeding from a total and genetic
pockets >= 5 relation to al factors
on probing of 28 teeth conditions,
mm the patient's
age
 A low PRA patient
has all parameters
within the low-risk
categories or at the
most one
parameter in the
moderate- risk
category.
 A moderate PRA
patient has at least
two parameters in
the moderate
category, but at
most one
parameter in the
high- risk category
A high PRA patient
has at least two
parameters in the
high-risk category
• In a high-risk patient who yields high BOP percentages and
high numbers of residual pockets, the patient's risk for
disease progression may be reduced into the moderate
category if further periodontal therapy is provided.

• These two parameters (BOP and residual pockets) are easily

affected by therapy, while other parameters, such as
numbers of missing teeth or systemic and genetic factors are
either irreversible and cannot be reduced or may only be
affected with great additional efforts (smoking cessation).
PRA/ multifactorial risk diagram by Renvert
& Persson
A modification of the PRA model.
MODIFICATIONS:
1. The vector bone loss index (bone loss in relation to subject
age) is substituted by the proportion of sites with a distance
≥ 4mm of the cementoenamel junction to bone level.

2. The surface area outlined between the various risk

parameters is calculated to provide a numerical score of risk
with the aid of a computer program.
THE PERIODONTAL RISK ASSESSMENT
MODEL DEVELOPED BY CHANDRA
This new model based on the periodontal risk
assessment model by Lang and Tonetti.

% of sites with No of sites with

No of teeth lost
BOP PD>= 5mm

Attachment
Diabetic Smoking status
loss/age ratio

Other risk
Dental status determinants
It is a continuous multilevel risk
assessment model that
incorporates subjective tooth and
site risk assessments and
generates a functional diagram,
and depending on the area of the
polygon categorizes the patient
into low-, medium- and high-risk
categories.
THE SIMPLIFIED METHOD (UNIFE) FOR
PERIODONTAL RISK ASSESSMENT
• In 2009, Trombelli and co-workers proposed a new
Parameters Smoking status,
objective method (UniFe) (Union of European
Railway Industries) in order to simplify the risk
Diabetic
assessment status (both type 1 and type 2),
procedures.

Numberaccording
• Risk assessment of sites with probing
to UniFe depth ≥is5mm,
method
based on five parameters, derived from the patient
medical history and
Bleeding onclinical
probingrecordings.
score,

Bone loss/age records

AMERICAN ACADEMY OF PERIODONTOLOGY SELF-
ASSESSMENT TOOL
• Brief 13-item questionnaire
– person's age (three response options: <40; 40-65; >65
years) and
– their flossing behavior (daily, weekly, seldom)

• Yes/no/don’t know
– any of your family members had gum disease,
– are your teeth loose,
– do you currently have any of the following health
conditions, i.e. heart disease, osteoporosis, osteopenia,
high stress or diabetes
• Yes/no/don’t remember
– seen a dentist in the last 2 years,
– ever been told that you have gum problems,
– gum infection or gum inflammation

The answers to the questions are combined using a proprietary

algorithm to yield one of three risk categories:
low risk, medium risk or high risk.
DENTORISK
Lindskog and coworkers
• A computerized risk assessment and prognostication
program (DentoRisk) that is used in conjunction with a
skin test for inflammatory reactivity (Dento test)
Systemic
Local Predictors
Predictors:
• Age in plaque
bacterial relation
(oraltohygiene),
history of chronic
• periodontitis,
endodontic pathology,
• family history
furcation involvements,
of chronicvertical
periodontitis,
intrabony
• systemicradiographic
defects, disease and related
marginaldiagnoses,
bone levels,
• result
PD, BOP,
of skin provocation test,
• patient cooperation
marginal dental restorations,
and disease awareness,
• socioeconomic
increased toothstatus,
mobility,
• smoking,teeth, abutment teeth, presence of
missing
• clinician experience
purulence
• An assessment is first calculated from patient’s overall
dentition (Level I)

• If an elevated risk is detected, a prognosis for annualized

attachment loss for each individual tooth (Level II) is then
computed.
CRONIN/STASSEN BEDS CHASM SCALE
• A four step risk assessment model.

• The calculated Odds ratio helps to standardize risk

assessment, allowing factors to be easily compared with
the standard numerical index
B-BMI Score 2
E-Ethnicity Score 1.5
D-Diabetic Score 2.5
S-Stressed Score 2
C-College Score 2.5
H-Hygiene Score 2
A-Age 65+ Score 3.5
S –Smoker Score 1.5
M –Male Score 1.5
 RISK ASSESSMENT-BASED
INDIVIDUALIZED TREATMENT (RABIT)
risk assessment is done as part of the initial diagnosis

recall schedules should be automatically generated

multiple recall schedules that address different risk factors

the risk for a particular category may change requiring a new recall schedule for that
category

recall appointments driven by different risk factors should be combined into single recall
appointments

the system should automatically delete caries risk- and periodontal risk-driven recall schedules
when a patient becomes edentulous.
THE ORAL HEALTH INFORMATION
SUITE
 Data +
Examination is Diagnosis is
objectives are
conducted made
entered

Treatment &
Risk & disease
Color coded interventions
score
are ranked

Changes and
Treatment plan Re-
refinement
is performed examination
done
GENETIC TESTS
• This test determines whether people possess a
combination of alleles in two IL-1 genes.

• There is also retrospective evidence that genetic testing

for the specific IL-1 genotype may give indication of
increased susceptibility to tooth loss in periodontal
maintenance patients.

• However, it may be concluded that genetic testing has

potential for the future, but more research is needed to
evaluate its utility.
SUMMARY OF RISK ASSESSMENT TOOLS
Author Risk assessment tool Objective
Fors & Sandberg Health Improvement in To create and evaluate a computerized
(2001) (Sweden) Dental Practice tool capable of creating overviews of the
Model(HIDEP) oral health situation as well as
identifying risk factors and at- risk
patients.

Page et al. (2003) Periodontal Risk To provide a risk score of a patients

(USA) Calculator (PRC) susceptibility for periodontal
progression on a scale of 1(lowest risk)
to 5(highest risk)
Lang & Tonetti Periodontal Risk To classify patients a slow, medium or
(2003) Assessment Model high risk for periodontal disease
(Switzerland) (PRA) progression
Author Risk assessment tool Objective

Chandra(2007) Modified Periodontal To classify individuals a slow, medium or

(India) Risk Assessment Model high risk for periodontal disease
(Modified PRA) progression

Trombelli et al. University of Ferrara To provide a risk score of a patients’

(2009) (Italy) (UniFe) susceptibility for periodontal progression
on a scale of 1(lowest risk) to 5 (highest
risk)
Lindskog et al. DRS a patient risk To provide a dentition (patient level) risk
(2010) (Sweden) score(DRS dentition) or score based upon systemic and local
tooth risk score(DRS predictors
tooth).
Busby et al. Oral Health Status(OHS) To provide patient-level risk scores for
(2014) (UK) periodontal disease, caries and oral
cancer
CONCLUSION
• Risk assessment is an important part of modern day periodontal practice.

• It is recommended that systemic and local risk factors are documented

alongside the diagnosis in patients′ case records.

• It gives an opportunity to improve dental and medical outcomes in the

general population and in specific population groups by focusing on early
identification and prevention of dental diseases, especially periodontal
disease.
REFERENCES
• “Clinical Periodontology” 10th edition by Glickman
• Jan Lindhe, 5th edition.
• ‘Current view of risk factors for periodontal disease’ Genco JP 2007.
• ‘Risk factors for periodontal disease’ Timmerman 2005.
• ‘Risk factors for periodontal disease’ Fehrenbach 2008.
• ‘Peri-implant disease: diagnosis and risk indicators’ Mayfield JCP 2008.
• ‘A systematic review of stress and psychosocial factors as possible risk factors for
periodontal disease.’ JP 2007.
• ‘Tobacco use and periodontal patient: Position paper’ JP 1999.
• ‘Diabetes and periodontal disease: Position paper’ JP 2007.
drchitrajay@gmail.com