Centre of Studies in PeriodontologyUniversiti Teknologi MARATutorial Year 5 (2014/15)

Tutorial 14TITLE: Periodontal Risk Assessment (PRA)DATE: 24 February 2015

1. Define risk factors and risk assessment in periodontal disease and give one example.RISK FACTORS

Definition: any attribute, characteristic or exposure of an individual that increases the likelihood of developing periodontal disease

Example: Diabetes Mellitus

RISK ASSESSMENT

Definition: a systematic process of evaluating the potential risks that may be involved in developing periodontal diseases.

Example: Periodontal Risk Assessment (PRA)

2. List the factors/parameters with reference to PRA web (diagram – Lang & Tonetti 2003).

1. Percentage of bleeding on probing (BOP)2. Prevalence of residual pockets greater than 4mm (PD≥5mm)3. Loss of teeth from total of 28 teeth (Tooth Loss)4. Loss of periodontal support in relation to patient’s age (BL/Age)5. Systemic and genetic conditions (Syst./Gen.)6. Environmental factors, such as cigarette smoking (Envir.)

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3. Explain in detail your interpretation of the 6 parameters. a) Percentage of BOP-between 20-30% : higher risk of disease progression (Claffey et al 1990, Badersten et al 1990)- reflect summary of patient ability to perform proper plaque control, host response to bacteria, and compliance esp. when only few residual pocket remain after active periodontal therapy- Lang et al 1990 :

1. low means BOP less than 10% of surfaces-low risk for recurrent disease. 2. mean BOP, more than 25%-high risk for periodontal breakdown

b) prevalence of pocket more or equal to 5mm- Claffey et al 1990, Badersten et al 1990:

-minimal residual pocket indicate periodontal stability- high frequency of residual pocket and deepening during SPT associated with high risk of disease progression

-Lang et al:- up to 4 residual pocket – relatively low risk- more than 8 residual pocket –high risk for recurrent disease

c) Loss of teeth out of 28- number of teeth in a dentition reflect functionality of dentition- individual of to 4 teeth loss – low risk category- more than 8 – high risk

d) Bone loss/ age- estimation of bone loss perform on posterior region either by PA or bitewing radiograph-PA – the worst side affected is grossly estimated in percent of root length- BW – worst side affected is estimated in mm, 1mm is considered to be equal 2-10% of bone loss percentage divided by age of patient- 0.25 ( low risk ) 0.5 ( between low and moderate risk ) 1.0 ( moderate to high risk )

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e) Systemic and genetic aspect- Gusberty et al 1983, Emrich et al 1991, Genco and Loe et al 1993 :> modification of disease susceptibility and progression of perio disease arise from studies of type I and type II DM- assumption that influence systemic condition may affect recurrent of disease- genetic markers have become available to determine various genotype of patient regarding their susceptibility to perio disease (eg IL-1)- if not known or absent systemic factors are not taking into account for overall evaluation

f) Smoking- tobacco smoking affect the susceptibility and treatment outcome of chronic perio- Smoking per se not only a risk marker but a true risk factor for periodontitis ( Ismail et al 1983, Bergstrom et al 1991 )- smoking will affect the treatment outcome after scaling & root planning ( Praber and Bergstrom et al 1985 )- heavy smoker, 20 cigarettes and more per day considered in higher risk group in maintenance- non-smoker and former smoker (more than 5 years since cessation) – relatively low risk for recurrent periodontitis- occasional smoker ( less than 10 cigarette per day ) – moderate risk- moderate smoker ( 10-19 cigarette per day ) – moderate risk

4. How do you interpret the web below?

BOP: Moderate risk – 25% of surfaces

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PD≥5mm : High risk – 10% of residual pockets with probing depth of ≥5mmTooth loss: Moderate risk – total loss of 5 teeth without the involvement of third molarsBL/Age: Moderate risk – 1.0 (percentage of alveolar bone loss, divided by patient’s age)Systemic and genetic aspects : Low risk – has no systemic/ genetic diseases that modifies periodontal disease progression and susceptibilityEnvironmental factors : High risk – particularly for cigarette smoking, that smokes > 19 cigarettes/day

Calculating patient’s periodontal risk assessment: Patient has at least 2 parameters in the high risk categories, which are the

periodontal pocket depth and cigarette smoking. These 2 parameters can be affected by further periodontal therapy (PPD),

smoking cessation (environmental) So, patient is in high risk for periodontal disease, but can be reduced to

moderate risk if one of the high risk parameters are reduce to moderate risk.

5. Why do you think that PRA can provide valuable information in the management of your periodontal patients..

1. May estimate the risk for susceptibility for progression of periodontal disease

2. Patient's risk assessment for recurrence of periodontitis may be evaluated

3. It consists of an assessment of the level of infection, prevalence of residual periodontal pockets, tooth loss, an estimation of the loss of periodontal support in relation to the patient's age, an evaluation of the systemic conditions of the patient, an evaluation of environmental and behavioral factors such as smoking

4. The entire spectrum of risk factors and risk indicators evaluated simultaneously

5. A functional diagram may help in determining the risk for disease progression on the subject level

6. It useful in customizing the frequency and content of SPT visit

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6. How would you apply PRA into managing this case? 35 years old male factory worker with no known medical problem came to your clinic complaining of spacing between 11 and 21.

i) Clinical pictures

ii) Periapical radigraphs

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iii) PRA web

iv) Perio charting

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