Clinical risk assessment for periodontal disease

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2. Contents
Introduction
Definitions
Categories of Risk Elements for periodontal disease
Clinical risk assessment for periodontal disease.
Conclusion
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3. Introduction
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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

4. Risk can be identified in terms of
Risk Factors Risk Indicators Risk Predictors Risk determinant
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5.  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.

6. 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 .
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7. 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 Factors
1. Tobacco smoking
2. Diabetes
3. Pathogenic bacteria & Microbial tooth deposit

9. 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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10.  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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11.  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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12. 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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13.  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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14.  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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15. 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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16.  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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17.  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.
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18. Risk Determinants
1. Genetic factors
2. Age
3. Gender
4. Socioeconomic status
5. Stress

19. 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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20.  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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21. 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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22.  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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23. 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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24. 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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25. 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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26.  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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27.  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 .
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28. Risk Indicators
1. HIV / AIDS
2. Osteoporosis
3. Infrequent dental visits

29. 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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30. 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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31. 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.
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32. Risk Predictors
1.Previous history of periodontal disease
2.Bleeding on probing

33. 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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34. 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
Once the social, demographic, medical history, dental history,
and clinical presentation data are collected, they must be analyzed
to identify patients at risk for developing periodontal disease.
This use of a computer-based risk assessment tool.
E.g. Periodontal Assessment Tool
component 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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39. 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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