Risk Factors And Risk Assessment

Of Periodontal Disease

Presented byDr. Guru Ram Tej. KPost GraduateMamata Dental College

CONTENTS..

INTRODUCTION TERMINOLOGIES CLASSIFICATION OF RISK FACTORS RISK ELEMENTS FOR PERIODONTAL

DISEASE RISK ASSESSMENT

TOOLS TO MEASURE RISKPeriodontal Screening And Recording (P S R)Interactive Patient QuestionnairePatient Assessment Tool Of OHISPatient Risk Calculator (Previeser)Uni FeHexagonal Risk Diagram For Periodontal Risk AssessmentPeriodontal Risk Assessment By Vishwa ChandraH I D E P ModelContinuous Multilevel Risk Assessment By Lang And

BraggerCronin/ Stassen Beds Chasm ScaleContinuous Multilevel Risk Assessment In 2011Periodontal Risk Using Two Artificial Neural Networks

CONCLUSIONREFERENCES

INTRODUCTION Risk

According to American Academy Of Periodontology utilizing risk assessment helps dental professionals predict the potential for developing periodontal diseases and allows them to focus on early identification and to provide proactive, targeted treatment for patients who are at risk for progressive/ aggressive diseases

TERMINOLOGIES

RISK Risk factors Risk determinants Risk indicators Risk predictors

CLASSIFICATION Based on the evidence

Primary risk factor Secondary risk factor Tertiary risk factor

Host response

Cytokines andprostaglandins

MMP

Serine proteases

Oxygen radicals

NeutrophilsAntibodiesComplement

Antigen

LPS

Other virulencefactors

Tissuedegradation

ClinicalchangesBacterial

load Turn over

Pathogenesis of periodontitis

RISK FACTORS GENETIC ENVIRONMENTAL BEHAVIOURAL LIFE STYLE METABOLIC HEMATOLOGICAL GENDER AGE

RISK FACTORS

H I V PREVIOUS HISTORY SOCIOECONOMIC STATUS BLEEDING ON PROBING OSTEO POROSIS NUTRITION BACTERIA

GENETIC Polymorphisms

During periodontal inflammation cytokines activate the catabolic enzymes such as matrix metalloproteinases leading to breakdown of connective tissue, any gene polymorphism of such proteins alters the susceptibility of host.

Michalowicz et al in 2000, demonstrated the hereditary aggregation in a twin study for chronic periodontitis

Pathogenesis of periodontitis

Host response

Cytokines andprostaglandins

MMP

Serine proteases

Oxygen radicals

NeutrophilsAntibodiesComplement

Antigen

LPS

Other virulensfactors

Tissuedegradation

ClinicalchangesBacterial

load Turn over

Interleukin+

BEHAVIOURAL RISK FACTORS Stress

“I tell you, if you don’t get my home soon and help me with these children, I will get gum disease”

STRESS Stress manifests in periodontium

through behavioural changes, like increased smoking and poorer oral hygiene

Genco et al in 1998

LIFE STYLE RISK FACTORS Smoking

“What do you mean, smoking is bad for my gums”

Host response

Cytokines andprostaglandins

MMP

Serine proteases

Oxygen radicals

NeutrophilsAntibodiesComplement

Antigen

LPS

Other virulensfactors

Tissuedegradation

ClinicalchangesBacterial

load Turn over

SmokingSmoking +

Pathogenesis of periodontitis

SMOKING With increased use of tobacco, patients

show higher periodontal probing depths, increased clinical attachment loss, more alveolar bone resorption, a higher prevalence of gingival recessions, and a higher risk for tooth loss

Tonetti in 1998

SMOKING… Tobacco use shifts the physiological

balance between anabolic and catabolic mechanisms in a more destructive direction, due to an alteration of protective immune and tissue mechanisms

Palmer 2005johnson and guthmiller in

2007Ryder in 2007

SMOKING… There is a robust evidence from a systematic

review, on basis of 70 cross sectional studies , 14 case-control, and 21 cohort studies , it is concluded that smoking negatively interferes with a healthy periodontal condition

Bergstrom in 2006

Periodontitis in smokers respond less to treatment, former smokers get a slower disease progression

Bolin et al. 1993

METABOLIC RISK FACTORS The reduced function of PMNs increases the risk

of periodontal disease in diabetes Formation of AGEs leads to impaired collagen

production and metabolismSchmidt et al in 1996

Infections observed in periodontitis can lead to insulin resistance and poor diabetic control

Atkinson and Mclaren in 1990

METABOLIC RISK FACTORS

HEMATOLOGICAL RISK FACTORS Chronic myeloid leukamia Myelodysplasia syndrome Agranulocytosis Neutropenia Defects in the lymphocyte function

GENDER Disease susceptibility may increased due to

hormone related alterations in women in the gingival blood flow(Kovar et al in

1985) in the composition of saliva(Laine on 2002) or the bone metabolism( Lerner in 2006)

Men are found with worse periodontal health(Albandar in 2002: Meisel et al in 2007)

AGE The aging process itself is suggested to

be an independent risk factor for periodontal diseases

Papapanou in 1989

The extent of severity of periodontal diseases are shown to increase with age

Albandar in 2002

HUMAN IMMUNO DEFICIENCY VIRUS Chapple et al in 2000 stated that highly

active anti retroviral therapy has limited periodontal disease progression in HIV patients

Treatment with HAART has indicated that seropositivity with HIV doesn’t in itself constitute a serious risk of periodontal disease

SOCIOECONOMIC STATUS Indices for assessing SES have been

used ranging from income level to education level

SES may represent a measure of personal drive and motivation, and may impact the quality of oral hygiene habits

BACTERIA Specific bacteria in subgingival plaque

1. Tanerella forsythus

2. Porphyromonas gingivalis

3. Aggregatibacter

actinomycetemcomitans

ASSESSMENT OF RISK Patient level risk assessment

Whole mouth risk assessment

The tooth level risk assessment

The site level assessment

PATIENT LEVEL RISK ASSESSMENT

Family history- for hereditary/ inborn/ genetic factors

Medical history- systemic diseases Present dental history Social history- smoking Habits- bruxism/tongue thrusting

MOUTH LEVEL RISK ASSESSMENT Examination of attachment loss relative to

age Occlusal examination in static relationship Occlusal examination in dynamic relation ship Examination of levels oral hygiene Examination of levels of plaque retentive

factors Presence of removable prosthesis Gingival tissue quality

TOOTH LEVEL RISK ASSESSMENT Tooth anatomy Mobility Tooth support Furcation lesions Presence of ledges, anatomy of embrassures Individual occlusal contacts Soft tissue contours Subgingival calculus

SITE LEVEL RISK ASSESSMENT BOP Suppuration Root grooves and concavities Probing pocket depths Attachment levels Other anatomic factors

Enamel pearls

TOOLS TO MEASURE RISK FACTORS PSR INTERACTIVE PATIENT ASSESSMENT

TOOL P A T OF OHIS P R C UNIFE HEXAGONAL RISK DIAGRAM FOR

PERIODONTAL RISK ASSESSMENT(PRA) PERIODONTAL RISK ASSESSMENT

MODEL DEVELOPED BY VISHWA CHANDRA

CONT… SCHUTTE AND DONLEY 1956 PATIENT

QUESTIONAIRE H I D E P MODEL CONTINOUS MULTILEVEL RISK

ASSESSMENT by LANG AND BRAGGER CRONIN/STASSEN BEDS CHASM SCALE CONTINOUS MULTILEVEL RISK

ASSESSMENT MODEL IN 2011 PERIODONTAL RISK ASSESSMENT USING

TWO ARTIFICIAL NEURAL NETWORKS

PERIODONTAL SCREENING AND RECORDING(PSR)

Periodontal Screening and Recording (PSR) is a rapid and effective way to screen patients for periodontal diseases and summarizes necessary information with minimum documentation.

PSR is an adaptation of the Community Periodontal Index of Treatment Needs (CPITN), which is endorsed by WHO and FDI for periodontal screening.

BENEFITS

Early detection Speed.- appointment time Simplicity Cost-effectiveness- probe Recording ease- sextant Risk management- documentation

PSR CODES

UNIFE In 2009, Trombelli and co-workers

proposed a new objective method(UniFe), Union of European Railway Industries, in order to simplify the risk assessment

Which is based on 5 parametersSmoking status, diabetic status, no. of sites

with PD ≥ 5mm, BOP score and bone loss/age records

Trombelli L, Farina R, Ferrari S, Pasetti P, Calura GComparison between two methods for periodontal risk assessment.Minerva Stomatologica 2009;58:277-287

Risk assessment according to the UniFe method

HEXAGONAL RISK DIAGRAM Lang and Tonetti in 2003 described a functional

diagram based on six parameters for use in estimating an individual risk for progression of periodontitis

The PRA model consists of an assessment level of infection, the prevalence of residual pockets, tooth loss, an estimation of loss of periodontal support in relation to patients age, an evaluation of systemic and genetic conditions and an evaluation of the environmental/behavioural factor smoking

All parameters have their own scale for low, moderate and high risk profiles

HEAGONAL RISK DIAGRAM DEVELOPED BY LANG AND TONETTI

HEXAGONAL RISK DIAGRAM DEVELOPED BY VISHWA CHANDRA In 2007, Chandra evaluated a novel periodontal risk

assessment model based on model by Lang and Tonetti

1. Percentage of sites with BOP2. No. of sites with PD ≥ 5mm3. No. of teeth lost4. Bone loss/age ratio5. Attachment loss/age ratio6. Diabetes and smoking7. Dental status8. Systemic factors and risk determinants are

recorded

Lang and bragger in 1992

CONTINOUS MULTILEVEL RISK ASSESSMENT

The risk assessment models uses retrospective and current data to assess the risk and is based on the simple scale of 0-5

A functional diagram was developed depending on the area of the polygon it categorizes to low, medium, high risk categoriesSandhya and Sripriya in 2011

SCHUTTE AND DONLEY 1956 PATIENT QUESTIONAIRE

H I D E P MODEL Screening and management method

called HIDEP (health improvement in dental practice) model which uses predefined risk groups for selecting and managing individual treatment & prevention schemes

The HIDEP model--a straightforward dental health care model for prevention based practice management. Sandberg, Hans C. H. Swedish Dental Journal. 2007, Vol. 31 Issue 4, p171-179.

CRONIN/STASSEN BEDS CHASM SCALE

Four step risk assessment model

Odds ratio helps to standardize risk assessment, allowing factors to be easily compared with the standard numerical index

B -BMI score 2

E - EthinicIty 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 1.5The total score of 19 indicates the highest risk

PERIODONTAL RISK ASSESSMENT USING TWO ARTIFICIAL NEURAL NETWORKS Neural Networks are a different

paradigm for computing: Von Neumann machines

are based on the processing/memory abstraction of human information processing.

Neural networks are based on the parallel architecture of animal brains.

PERIODONTAL RISK ASSESSMENT USING TWO ARTIFICIAL NEURAL NETWORKS

Lavenberg Marquardt Algorithm

Scaled Conjugate Gradient Algorithm

CONCLUSION

“ Measurement, Assessment, Elimination or reducing as many risks as possible will improve disease prevention and treatment outcomes”

REFERENCES American Academy of Periodontology statement on risk assessment.

Journal of Periodontology 2008; 79: 202. W. M. Thomson, S. J. Edwards, D. P. Dobson-Le, G. R. Tompkins, R.

Poulton, D. A. Knight and A. W. Braithwaite: IL-1 genotype and adult periodontitis among young New Zealanders. J Dent Res. 2001 ;80(8):1700-3

Andreas Siebold, Are you at risk for periodontal disease: interactive patient risk assessment tool: south African Society of Periodontology: 2006

Page R, Krall EA, Martin J, Mancl L, Garcia RI. Validity of Periodontal Assessment Tool® (PAT®) in predicting periodontal disease. Journal of the American Dental Association 2002; 133(5): 569-576

Page R, Martin J, Krall EA, Mancl L, Garcia RI. Longitudinal Validation of risk calculator for periodontal disease. J Clin periodontol 2003; 30(9): 819-27

Trombelli L, Farina R, Ferrari S, Pasetti P, Calura G. Comparison between two methods for periodontal risk assessment. Minerva Stomotol. 2009; 58; 277-287.

REFERENCES… Lang NP, Tonetti MS. Periodontal risk assessment (PRA) for patients in

supportive periodontal therapy (SPT). Oral Health Prev Dent. 2003;1:7-16 Chandra RV. Evaluation of a novel periodontal risk assessment model in

patients presenting for dental care. Oral Health Prev Dent. 2007;5: 39-48. Uno G H Fors, Sandberg Hans C. H. computer aided risk management- a

software tool for the Hidep model: Quintessence Int 2001; 32; 309-320. Sandberg Hans C. H. The HIDEP model-a straightforward dental health

care model for prevention based practice management. Swedish Dental Journal. 2007, 31(4), 171-179.

Cronin AJ, Claffey N, Stassen LF. Who is at risk? Periodontal disease risk analysis made accessible for the general dental practitioner. Br Dent J. 2008 205(3):131-7

Lang NP, Bragger U, Salvi G, Tonetti MS. Supportive periodontal theraphy. In: LIndhe J, Karring T, Lang NP, editors. Clinical Periodontology and implantology. 4th ed. Oxford: Blackwell Munksgarrd; 2003. pp. 781–805

Rajesh S, Lalit Kumar Mathur, Manju A N, Neema Rai, Aditi Mathur. Periodontitis Risk Assessment using two artificial Neural Networks: Int J of Dent clinics 2010; 2(4): 36-40.

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