CHAPTER 10

RISK FACTORS FOR PERIODONTAL DISEASE

DHY 313 Periodontology I

Claire Huynh
Learning Objectives
• Define risk factor and provide various examples of risk factors
• Define etiologic factor and distinguish etiologic factors from risk factors
• Define biologic equilibrium and explain how certain factors can disrupt the balance between
health and disease
• Explain the differences between modifiable and nonmodifiable risk factors
• Describe the significance of performing a thorough periodontal risk assessment for each patient
in a clinical setting
• In a clinical setting- for a patient in your care with periodontitis - explain to your clinical
instructor the factors that may have contributed to your patient's disease progression
Risk Factors for Periodontal Disease

Although it is widely accepted that periodontal disease is

a bacterial-induced infection of the periodontium and
that pathogenic bacteria are the primary etiologic factors in
the initiation of periodontal disease, the presence of bacteria
alone does not mean that the onset of disease will happen.
Microorganisms such as P. gingivalis, T. forsythia and A.
actinomycetemcomitans are thought to be risk indicators of
periodontal disease (no causal effect).
A risk factor is any attribute, characteristic, or exposure that is
associated with an increased likelihood of developing a disease
or injury. For example: smoking is a risk factor for periodontal
disease because those who smoke are more likely to develop
the disease.
On the other hand, an etiologic factor is any
attribute, characteristic, or exposure that is known to
cause the disease.
Risk Factors for Periodontal Disease
Risk factors are either modifiable (can be changed) or
nonmodifiable (cannot be changed)
Local Risk Factors – can either be acquired or anatomical
• Acquired: calculus, overhangs, poorly contoured restorations
• Anatomical: malpositioned teeth, root grooves, concavities,
furcations
Systemic Risk Factors – many systemic diseases or conditions
can affect the periodontium including uncontrolled diabetes and
genetic factors.
Tobacco Use – cigarette smoking is the most significant known
risk for periodontitis. Smoking has a profound impact on disease
development as well as treatment response
Medications – certain medications can cause overgrowth of the
gingiva EX: anticonvulsants, immunosuppressants, calcium
channel blockers
Emerging Evidence of Risk Factors

There is also evidence that suggest possible risk factors such as: nutrition, alcohol
consumption, socioeconomic status and stress levels.
• Studies have demonstrated that individuals under stress are more likely to experience bone loss. This may be
due to an increase in production of IL-6, but it could also be due to reduced homecare.

Osteoporosis: Several studies show that alveolar bone density is changed in osteoporotic
individuals. While there is a connection with osteporosis and bone loss, there is not much
evidence that demonstrates a relationship with clinical attachment levels.

Other Systemic Diseases: Defects of neutrophil function have also been related to
susceptability to periodontal disease.
 Balance Between Periodontal Health and
Disease
Biologic Equilibrium – a state of balance in the internal environment of the
body, also known as homeostasis.

Periodontal Health
• In health, there is a state of biologic equilibrium between the biofilm
bacteria and the host.
• To maintain a healthy state, the bacterial challenge must be contained at a
level tolerated by the host.
• The situation is like a balance scale; if the two sides are in balance there will
be no disease progression.

Periodontal Disease
• The presence of certain risk factors can tip the balance, leading to disease

• However, a risk factor in one individual may not be a risk factor in another.
For example: two individuals can have diabetes, but one is uncontrolled. The
individual with uncontrolled diabetes may be at risk for developing periodontal
disease, while the one who is controlled is not at any greater risk.

The Delicate Balance Between Health and Disease – when active periodontal
sites are present, the goal is to return the oral cavity to a state of biologic
equilibrium
 Balance Between Periodontal Health and
Disease
Periodontal Equilibrium and Dental Plaque Biofilm
• If an individual’s immune system can effectively deal with a mouthful of
periodontal pathogens, there will be no destructive periodontal disease. For example:
patients can exhibit signs of gingivitis year after year but there are no clinicals signs of
progression towards periodontal disease.
• In individuals where the gingivitis progresses to periodontitis, it is thought that the body’s
immune response is responsible for the tissue destruction seen in periodontitis. Also, some
individuals possess systemic factors that significantly increase their susceptibility to
periodontitis
• Many patients are unable or unwilling to perform the necessary self-care to control plaque
biofilm, so it is necessary to increase the frequency of professional care, which can aid
in restoring the balance between health and disease.
Local Contributing Factors
• Often, it is possible to eliminate local risk factors –faulty restorations can be repaired,
malpositioned teeth can be repositioned, open contacts can be closed
• It is also possible to compensate for a local risk factor with improved self-care and/or
increasing the frequency of professional care. This situation reflects adding more weight on
the health-side of the scale to equal or exceed the weight on the disease-side of the scale
Systemic or Genetic Contributing Factors
• Certain systemic or acquired risk factors are possible to control or eliminate, if the patient is
willing to do so – individuals can work with their physician to keep their diabetes under
control and smokers can decide to stop smoking
• In the case of contributing risk factor that cannot be controlled, such as genetic risk factors, it
is necessary to add weight to the health-side of the scale by increasing professional care such
as providing antimicrobials.

Pts with low susceptability to periodontitis may
never progress from gingivitis
In pts with high susceptability, the body's
immune system damages tissues, leading to
periodontitis Some risk factor cannot be eliminated or
Smoking cessation and self-care can restore the controlled, so professional care can help slow
balance disease progression
Periodontal Risk Assessment
Risk Assessment – the process of identifying risk factors that increase an
individual’s probability of disease
The American Academy of Periodontology (AAP) describes the risk
assessment process as “increasingly important in periodontal treatment
planning and should be part of every comprehensive dental and periodontal
evaluation”
1) Assessing the Individual
 An Individual’s Risk Factors –it is possible to consider an individual’s risk
factor for periodontal disease to classify into high vs. low. For example:
smokers have a higher risk of periodontitis than nonsmokers
 Disease prevention for the Individual – clinician can use the risk
assessment to prevent disease in those who are susceptible. For example:
identifying smokers without disease and offering cessation
counseling. Information for risk assessment is gathered through a careful
evaluation of the individual’s demographic data, medical history, dental
history and a periodontal clinical exam.
2) Risk Assessment Systems
 Web-Based Tools – there are several Web-based risk calculation tools
 Risk Questionnaires – practical tools that can help identify individuals
who are at risk for periodontal disease. Dental hygienists can use risk
questionnaires to initiate discussion with patients about periodontal risk
factors.
RISK QUESTIONAIRES
Common Conditions in
Clinic
• Tobacco Use
o Type, amount, frequency, intentions to
quit
o Frequent tenacious staining, coated
tongue, halitosis, reduced bleeding,
fast progression
• Diabetes
o Under care of physician?, current A1C
levels
o Note for changes such as delayed
healing (EX: tissue evaluation)
• Heart Disease
o Last surgery/incident, current meds,
vasoconstrictor caution
• Medications
o Antidepressant, ca channel blocker,
immunosuppressant, anticoagulant
o Associated lesions (EX: HIV)
• Pregnancy
o Current trimester, pt attitudes,
symptoms
o Possible pregnancy gingivitis, erosion
Questions
Additional Question: What would be your next steps?
Possible Answers
• In some cases, like Mr. Merkel, we note patients who lack adequate
homecare but do not show signs of progressing to periodontal disease because
their immune system is able to deal with periodontal pathogens and other risk
factors to maintain balance in the oral cavity.
• On the other hand, in Mrs. Merkel's situation, there are instances where the
patient’s immune system cannot adequately handle the presence of periodontal
pathogens and other risk factors, thus worsening the progression of periodontal
disease. This may be due to systemic factors such as genetics, medications, or
more.
• To help Mrs. Merkel slow down her disease progression, it is best to refer her to
the periodontist in to provide her with more extensive treatment. For example:
adminstering antimicrobials
References
Gehrig, J. S., Shin, D. E., & Willmann, D. E. (2023). Chapter 10 Risk Factors for Periodontal
Disease. Foundations of Periodontics for the Dental Hygienist. Jones & Bartlett Learning.
Van Dyke, T. E., & Sheilesh, D. (2005). Risk Factors for Periodontitis. Journal of the International
Academy of Periodontology, 7(1), 3–7. Retrieved
from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1351013/pdf/nihms4855.pdf