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By : Hamed Bakri

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Contents

Introduction

Definitions

Categories of Risk Elements for periodontal disease

Clinical risk assessment for periodontal disease.

Conclusion

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Introduction Risk: Probability of an individual to get a disease in a given period.

Numbers of studies have demonstrated that the host is play a major role in the of periodontitis and that risk varies greatly from one individual to another.

Identifying risk factors and indicators help us in : •Can reduce the risk, •Can help in maintaining oral health•Prevent the onset of any form of periodontal disease

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Risk can be identified in terms of

Risk Factors Risk Indicators Risk Predictors Risk determinant

Risk factor can be defined as any environmental, behavioral, or biologic factor that, when present, increases the chance for individual to develop the disease.

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Risk indicators are possibility risk factors that have been identified in cross sectional studies but not confirmed through longitudinal .

Risk predictors / markers associated with factor can increased risk for disease but do not cause the disease.

risk determinant/background characteristic, risk factors that cannot be modified.

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Risk assessment :A process by which qualitative or quantitative assessments are made

of the likelihood for adverse events to occur as a result of exposure to health hazards or by the absence of beneficial effect .

Risk Factors

Tobacco smoking

Diabetes

Pathogenic bacteria Microbial tooth deposit

Risk determinants

Genetic factors

Age

Gender

Socioeconomic status

Stress

Risk indicators

HIV/AIDS

Osteoporosis

Infrequent dental visits

Risk predictors

Previous history of periodontal disease

Bleeding on probing

Categories of Risk Elements for Periodontal Disease

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Risk Factors1. Tobacco smoking 2. Diabetes3. Pathogenic bacteria & Microbial tooth deposit

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1- TOBACCO SMOKING

A wealth of data has established the relationship between the amount and duration of smoking and the severity of periodontal pathology.

Studies comparing the response to periodontal therapy in smokers, previous smokers and nonsmokers have shown that smoking has a negative impact on the response to therapy.

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According to Bolin et al 1993 periodontitis in smokers respond less to treatment, former smokers get a slower disease progression.

With increased use of tobacco, patients show higher periodontal probing depths, increased clinical attachment loss, and alveolar bone resorption, a higher

prevalence of gingival recessions a higher risk for tooth loss

Both local and systemic mechanisms mediate the negative impact of tobacco use on oral health.

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A number of studies indicate that the nicotine found in tobacco products cause the over production of cytokines in the body due to decrease of oxygen levels.

Cytokines are chemical signaling involved in the process of periodontal inflammation. When nicotine combines with oral bacteria, such as P. gingivalis,

it results in higher levels of cytokines, leading to breakdown of the supporting tissues of the teeth.

Johnson GK. Margaret Hill Cigarette smoking and the periodontal patient. J Periodontol. 2004;75:196– 209

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2- DIABETES

Diabetes is a clear risk factor for periodontitis.

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 ,

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Diabetes has been associated with a number of oral complications, including gingivitis and periodontitis, dental caries, salivary gland dysfunction, xerostomia, and increased susceptibility to oral infections.

In diabetic patients, host responses may be impaired, healing is delayed and collagenolytic activity may be enhanced. As a result, periodontitis may be a

particular problem in patients with diabetes, especially in uncontrolled Vernillo AT. Dental considerations for the treatment of patients with diabetes mellitus. J Am Dent Assoc. 2003;134(supplement I):245–335

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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.

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3 -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 good oral hygiene.

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In terms of quality of plaque, three specific bacteria have been identified as etiologic agents for periodontitis:

I. A. actinomycetemcomitans,II. P. gingivalis,III. Bacteroides forsythus.

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Additional evidence that they are causal agents include:(1) Their elimination or suppression impacts the success of therapy, (2) There is a host response to these pathogens, (3) Virulence factors are associated with these pathogens(4) Inoculation of these bacteria into animal induces periodontal disease.

Risk Determinants1. Genetic factors2. Age3. Gender4. Socioeconomic status 5. Stress

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1 -Genetic factors

The evidence that genetic differences between individuals may explain why some patients develop periodontal disease and others do not.

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The familial aggregation seen in localized and generalized aggressive periodontitis also is indicate for genetic involvement in these diseases.

A specific interleukin 1 (IL-1) genotype has been associated with severe chronic

periodontitis.

Immunologic alterations, such as neutrophil abnormalities, monocytic hyper responsiveness to lipopolysaccharide stimulation in patients with localized aggressive periodontitis.

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2 -AGE

Both the prevalence and severity of periodontal disease increases with age .

It is possible that degenerative changes related to aging may increase susceptibility to periodontitis.

However, it also is possible that the attachment loss and bone loss seen in older individuals is a result of prolonged exposure to other risk factors over a person's life over time

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In a study of people over 70 years old, 86% had at least moderate periodontitis or a severe form of periodontal disease, and over one fourth of this 86% had lost their teeth.

The study also showed that the disease accounted for a majority of tooth extractions in patients older than 35 years of age.

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3 -GENDER

US surveys conducted since 1960 demonstrate that males have more loss of attachment than females.

Therefore it appears that gender differences in prevalence and severity of periodontitis are related to preventive practices rather than any genetic factor.

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4 -Socioeconomic Status

Gingivitis and poor oral hygiene can be related to lower socioeconomic status .

This can most likely be to decreased dental awareness and decreased frequency of dental visits when compared with more educated individuals of higher SES.

After adjusting for other risk factors such as smoking and poor oral hygiene, lower SES alone does not result in increased risk for periodontitis.

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5 -STRESS

It has been strongly suggested that stress and related body distress are important risk indicators for periodontal disease.

A recent study shows that people under physical or psychological stress are prone to elevated biofilm plaque levels and increased gingivitis.

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The incidence of necrotizing ulcerative gingivitis increases during periods of emotional and physiologic stress.

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.

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Stress decrease saliva flow and increases dental plaque formation. Emotional stress modifies the saliva pH and its chemical composition like the IgA secretion .

A studies made by Deinzer et al., examine 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 decrease of the quality of the oral hygiene .

Risk Indicators

1. HIV / AIDS 2. Osteoporosis3. Infrequent dental visits

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1 -Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

It has been hypothesized that the immune dysfunction associated with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) increases susceptibility to periodontal disease.

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2 -OSTEOPOROSIS

Osteoporosis has been suggested as another risk factor for periodontitis.

reduced bone mass seen in osteoporosis may aggravate periodontal disease progression.

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3 -Infrequent Dental Visits

Study demonstrated an increased risk for severe periodontitis in patients who had not visited the dentist for three or more years, whereas another demonstrated that 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.

Risk Predictors 1.Previous history of periodontal disease2.Bleeding on probing

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1 -Previous History of Periodontal Disease

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

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2 -Bleeding on Probing

Bleeding on probing is the best clinical indicator of gingival inflammation.

Although bleeding on probing alone does not serve as a predictor for loss of attachment,

bleeding on probing coupled with increasing pocket depth may serve as an excellent predictor for future loss of attachment.

Lack of bleeding on probing does appear to serve as an excellent indicator of periodontal health.

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CLINICAL RISK ASSESSMENT

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CLINICAL RISK ASSESSMENT

Once the social, demographic, medical history, dental history,and clinical presentation data are collected, they must be analyzedto identify patients at risk for developing periodontal disease. This use of a computer-based risk assessment tool.

E.g. Periodontal Assessment Toolcomponent of the PreViser Oral Health Information Suite (OHIS).

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Following the input of only twenty-three items taken from a routine periodontal examination, the system generates diagnosis and numeric periodontal diagnoses and a risk score for future disease, from 1-5 ranks 1- lowest risk 5-highest risk

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Conclusion Risk assessment is an important part of modern day

periodontal practice.

The practice of risk assessment allows dental care professionals 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.

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assessment tools can help reduce disease progression & ultimately treatment costs.Risk assessment tools should be used to diagnose & manage periodontal disease.

Selection of patients requiring additional education , interventions & preventions. And better treatment planning decisions…

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