RISK ASSESSMENT

definitions

Risk is the probability that an individual will get a specific disease in a given period. Risk factor : An action or event that is related statistically in some way to an outcome and is truly causal Risk determinant: An attribute or event that increases the probability of occurrence of disease Risk indicator : An event that is associated with an outcome only in crosssectional studies Risk marker : An attribute or event that is associated with increased probability of disease but is not necessarily a causal factor

Components for risk assessment

Risk markers Risk factors Risk determinants Risk indicators

RISK FACTORS FOR PERIODONTAL DISEASE

Tobacco Smoking. Diabetes. Pathogenic Bacteria and Microbial Tooth Deposits.

RISK DETERMINANTS FOR PERIODONTAL DISEASE

Genetic Factors Age Gender Socioeconomic Status Stress

RISK INDICATORS FOR PERIODONTAL DISEASE

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Osteoporosis Infrequent Dental Visits

RISK MARKERS/PREDICTORS FOR PERIODONTAL DISEASE

Previous History of Periodontal Disease Bleeding on Probing

RISK FACTORS

Tobacco Smoking

A direct relationship exists between smoking and the prevalence of periodontal disease.

prevelance & severity of periodontal destruction.

rate of periodontal destruction

Smoking has a negative effect on the response to therapy.

Former smokers respond similarly to non-smokers.

diabetes

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 and that the level of diabetic control is an important variable in this relationship. Associated with increased gingival inflammation in response to bacterial plaque Lowered tissue resistance to infection leading to granulomatous subgingival proliferations, periodontitis and multiple lateral periodontal abscess.

Pathogenic bacteria and microbial tooth deposits

Evidence suggests that composition or quality of the complex biofilm is of more importance than the quantity. In terms of quality of plaque, three specific bacteria have been identified as etiologic agents for periodontitis: A. actinomycetemcomitans, Porphyromonas gingivalis, Bacteroides forsythus. P. gingivalis and B. forsythus are often found in chronic periodontitis, whereas A. actinomycetemcomitans is often associated with

Additional evidence that they are causal agents include:

Their elimination or suppression impacts the success of therapy

There is a host response to these pathogens

Virulence factors are associated with these pathogens

Inoculation of these bacteria into animal models induces periodontal disease

Anatomic factors may predispose the periodontium to disease as a result of their potential to harbor bacterial plaque and present a challenge to the clinician during instrumentation.
furcations, root concavities, developmental grooves, cervical enamel projections, enamel pearls, bifurcation ridges.

The presence of calculus, which serves as a reservoir for bacterial plaque, has been suggested as a risk factor for periodontitis.

RISK DETERMINANTS

GENETIC FACTORS
Studies conducted in twins have shown that genetic factors influence clinical measures of gingivitis, probing pocket depth, attachment loss, and interproximal bone height. A specific interleukin 1 (IL-1) genotype has been associated with severe chronic periodontitis. (Kornman et al 1997) Immunologic alterations, such as neutrophil abnormalities, monocytic hyper responsiveness to lipopolysaccharide stimulation in patients with localized aggressive periodontitis, alterations in the monocyte/macrophage FcyRII receptor for IgG2 also appear to be under genetic control

In addition, genetics plays a role in regulating the titer of the protective IgG2 antibody response to A. actinomycetemcomitans in patients with aggressive periodontitis.

AGE AND GENDER

Both the prevalence and severity of periodontal disease increases with age. Attachment loss and bone loss seen in older individuals is a result of prolonged exposure to other risk factors over a person's life, creating a cumulative effect over time. The younger the patient, the longer exposure to causative factors Therefore young individuals with periodontal disease may be at greater risk for continued disease as they age.

Various surveys conducted demonstrate that men have more loss of attachment then women, as they have poorer oral hygiene than women.

Socioeconomic Status & Stress

Gingivitis and poor oral hygiene can be related to lower socioeconomic status but alone does not result in increased risk for periodontitis. (decreased dental awareness and decreased frequency of dental visits in lower SES) Emotional stress may interfere with normal immune function and may result in increased levels of circulating hormones that can have an impact on the periodontium. Patients having stress are more resistant to therapy,

RISK INDICATORS

RISK INDICATORS

HIV infection and AIDS Osteoporosis Infrequent Dental Visits

All the above risk indicators increase susceptibility to periodontal disease

RISK MARKERS

Previous History of Periodontal Disease

A history of previous periodontal disease is a good clinical predictor of risk for future disease

BLEEDING ON PROBING
Bleeding on probing is the best clinical indicator of gingival inflammation. Lack of bleeding on probing does appear to serve as an excellent indicator of periodontal health.

Risk assessment for periodontitis

The risk factors should be assessed because they can affect:

the onset rate of progression severity of periodontal disease response to therapy.

CLINICAL RISK ASSESSMENT FOR PERIODONTAL DISEASE

Periodontal Risk Calculator(PRC)

The PRC incorporates mathematic algorithms that are based on nine known risk factors: age, smoking history, diabetes diagnosis, history of periodontal surgery, pocket depth, furcation involvements, restorations or calculus below the gingival margin, radiographic bone height, and vertical bone lesions

In addition to providing a quick and objective risk assessment, the PRC provides a periodontal diagnosis, quantitative disease score from 1 to 100, and treatment options. The PRC would provide a useful tool for individual patient assessment and may help sort out cost effective treatments and even suggest rational measures

Funtional Diagram to evaluate the patients risk for recurrence of periodontitis

BOPbleeding on probing PD probing depth BL bone loss Syst./Gen systemic/Gen eral

Envir. enviornment
FS- frequent smoker NS nonsmoker

low-risk maintenance patient

medium-risk maintenance patient

high-risk maintenance patient.

Risk modification

Risk modification

Some of these risk factors can be modified to reduce a patients susceptibility to periodontitis. Perioceutics includes antimicrobial therapies can be used to address changes in the microflora. Host modulatory therapy that used to address a host response consisting of excessive levels of enzymes, cytokines, and prostanoids and excessive osteoclast function that may be related to certain risk factors.

Risk assessment as an aid in prevention

Risk assessment as an aid in prevention

Recently, a few clinical risk assessment approaches or tools have been promoted in the literature. One tool is a relatively simple questionnaire that provides a vague but individual risk profile for the clinician and an educational tool for communication with the patient. A more sophisticated instrument employs a continuous multilevel risk assessment that incorporates the consideration of subject, tooth, and site risk evaluations.

Site- and patient-level criteria

to be considered in assessing the stability of periodontal maintenance patients

Inflammation as measured by bleeding on probing (BOP)

Full mouth BOP > 15% - unstable

Sites with consistent BOP over time - unstable Sites with no BOP - stable

Probing depth (PD) measurements

Sites with PD increase of 2 mm from baseline or previous visit - unstable. Number of significant periodontal pocket depths (10 or more sites with 4 mm probing depth are considered unstable) PD 6 mm at any site - unstable Progressive gingival recession from baseline or previous charting

Radiographic considerations

Loss of crestal bone height based on vertical bite wings unstable Consistent presence of crestal lamina dura - stable

Patient-level considerations
Poor hygiene in the presence of attachment loss plaque index >30% - unstable Smoking > 1/2 pack /day - unstable Diabetes mellitus with HBA1c 9% - unstable High-stress events, divorce, loss of a loved one and unemployment - unstable

CONCLUSION

Once an at-risk patient is identified and a diagnosis is made, their treatment plan may be modified accordingly. Previously identified risk elements also may need to be reassessed at the reevaluation stage of treatment. In addition to an evaluation of the factors contributing to their risk, these patients should be educate concerning their risk and, when appropriate, suitable intervention strategies implemented.

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