risk assessment tool

1. DR.MITALI.V.THAMKE
III MDS
RISK ASSESMENT

2. Contents
Introduction1
Definitions2
Risk elements3
4
5
Risk Assessment
6
Risk Assessment tools
Conclusion

3. Introduction
 Historically, it was believed that all individuals were
uniformly susceptible to developing periodontal disease.
 However during the past four decades it has been
accepted that periodontal disease is caused by specific
bacterial infections and that individuals are not uniformly
susceptible.
 Thus identification of susceptible individuals prior to
them developing periodontitis and identifying risk factors
that might be modified in order to prevent or alter the
course of periodontal disease is necessary.

4. Definitions
 Risk is the probability that an individual will get a specific
disease in a given period.
 Risk factors may be environmental, behavioral, or
biologic factors that, when present, increase the
likelihood that an individual will get the disease.
 Risk determinant / background characteristic are the
risk factors that cannot be modified.

5. Definitions
 Risk indicators are probable risk factors that have been
identified in cross-sectional studies but not confirmed
through longitudinal studies.
 Risk predictors/markers - although associated with
increased risk for disease, do not cause the disease

6. Categories of risk elements
RISK
FACTORS
RISK
DETERMINANTS
RISK
INDICATORS
RISK
MARKERS
1. Tobacco
Smoking
2. Diabetes
3.Pathogenic
bacteria
4.Microbial
tooth deposits
1. Genetic factors
2. Age
3. Gender
4. Socioeconomic
status
5. Stress
1.HIV/AIDS
2.Osteoporosis
3. Infrequent
dental visits
1. Previous
history of
periodontal
disease
2. Bleeding on
probing

7. RISK ASSESSMENT

8. Risk assessment
 Risk assessment is an accepted component of the
American Academy of Periodontology guidelines for
patient management.
 “Risk assessment goes beyond the identification of the
existence of disease and severity, and considers factors
that may influence future disease progression”.
 Goal of risk assessment is to identify individuals who are
likely, or at least more likely than others, to have
periodontitis.

9.  Risk assesment is defined as the process
by which qualitative or quantitative
assesments are made of the likelihood for
adverse event to occur as a result of
exposure to specified health hazards or by
absence of beneficial influences.
American academy of periodontology(2008)

10. RISK ASSESMENT TOOLS
1. The oral health information suite (OHIS)
2. Periodontal Risk Calculator(PRC)
3. Hexagonal risk daigram for periodontal
assesment (PRA)
4. Periodontal risk assesment model
developed by Chandra
5. UniFe(Union of european Railway
Industries) for periodntal risk assesment

11. 6. AAP risk assesment Tool
7. Dentorisk
8. Risk Assesment-Based Individualized
Treatment (RABIT)
9. Cronin/Stassen BEDS CHASM Scale:

13. Risk assessment
 A recent systematic review found that one good self-
report measure was actually the simple question,
Has any dentist ⁄ hygienist told you that you have deep
pockets?
 It had a sensitivity of 55%, a specificity of 90%, a positive
predictive value of 77% and a negative predictive value
of 75%, which were all calculated using actual clinical
pocket depth as measured by clinicians. (Blicher et al
2005)

14. AAP- self-assessment tool
 How old are you?
 Are you female or male?
 Do your gums ever bleed?
 Are your teeth loose?
 Have your gums receded, or do your teeth look longer?
 Do you smoke or use tobacco products?
 Have you seen a dentist in the last two years?
 How often do you floss?

15. AAP- self-assessment tool
 Do you currently have any of the following health
conditions? i.e. heart disease, osteoporosis, osteopenia,
high stress, or diabetes
 Have you ever been told that you have gum problems,
gum infection or gum inflammation?
 Have you had any adult teeth extracted?
 Have any of your family members had gum disease?

16. Health Improvement in Dental
Practice Model (HIDEP)
 Fors & Sandberg (2001),Sweden
Computerized tool that uses predefined risk groups for
selecting and managing individual treatment and prevention
schemes.
Tool designed to assess the risk of other aspects of oral
health in addition to periodontal status

17. OBJECTIVE
 To create and evaluate a computerized tool
capable of creating overviews of the oral health
situation as well as identifying risk factors and at-
risk patients.
 Consists of 5 risk and 4 disease categories for
both caries and periodontal diseases. Scores
assigned according to 14 parameters. Final
result places patients on a health-disease scale
and low or high risk for disease scale for both
caries and periodontal disease

18. Parameters utilized in tool
 Total number of teeth,
 total number of intact teeth (teeth without restorations, caries, or
crowns, number of caries lesions (initial lesions included),
 caries experience,
 fluoride exposure,
 saliva diagnostics (including secretion, buffering capacity, laotobacilli
criteria, and streptococcus mutans),
 sugar intake frequency,
 oral hygiene screening,
 professional risk estimation for caries and periodontitis,
 gingival bleeding,
 probing of periodontal pockets,
 radiographic examination, registration of tartar and/or overhang

19. PreViser RiskCalculator
Page & co-workers (2003),USA
 A component of the Oral Health Information Suite.
 The PRC is a web‐based tool that can be accessed
through a dental office computer.
 The risk calculation is a multi‐step process involving
mathematical algorithms

20. PARAMETER
 nine risk factors which include:
 • Smoking history
• Diagnosis of diabetes
• History of periodontal surgery
• Pocket depth
• Furcation involvements
• Restorations or calculus below the gingival
margin
• Radiographic bone height

21. Objective
 To provide a risk score of a patients’ susceptibility for
periodontal progression on a scale of 1 (lowest risk) to 5
(highest risk).

22. Periodontal RiskAssessment Model (PRA)
 Lang & Tonetti (2003) (Switzerland)
A functional diagram (spider web shape)
formulated based upon the combination of various
parameters that have been proposed in scientific
literature as impacting the patient risk for further
disease progression.
Hexagonal risk daigram

23. Parameters utilized in tool
 Estimation of patient-level risk involves
using six parameters: bone loss/age,
number of pockets ≥ 5 mm, number of
missing teeth, percentage of sites with
BOP, cigarette smoking and systemic
factors (such as diabetes and IL-1 gene
polymorphism)

27. Objective
 To classify patients as low, medium or high
risk for periodontal disease progression.

28. Modified Periodontal Risk Assessment
Model (Modified PRA)
 Chandra (2007) (India)
A new periodontal risk assessment model based
on periodontal risk assessment (PRA) model by
Lang and Tonetti that was targeted to be:
1. easier to generate and use,
2. would assess diabetes on an individual radius
and
3. would incorporate dental factors include “others
factors” such as stress and socio-economic
factors

29. Parameters utilized in tool
 Additional factors are re-defined or
included:
diabetic status,
age,
dental status-systemic factors interplay and
other background characteristics.

30.  Differences from PRA are that
1.environmental factors, systemic and
genetic factors are specifically defined as
diabetes status and interplay of dental-
systemic factors that accounts for dental
factors.

31. Parameters utilized in tool
2. Bone loss/age is replaced with attachment
level/age
3. Other background factors are included to include
estimated socio-economic or stress factors.
4.the scores on each trajectory ranged between 1
and 5 based on a color coding

33. University of Ferrara(UniFe)
 Trombelli et al. (2009)(Italy)
 A proposed simplified method for periodontal risk
assessment based upon five parameters derived
from patient medical history and clinical
recordings.
 Each parameter assessed is allocated a
parameter score according to defined criteria.
The algebraic sum of the parameter scores is
calculated and relates to a risk score between 1
and 5.

34. Parameters utilized in tool
1. Smoking status,
2. diabetic status,
3. number of sites with probing depth ≥5
mm,
4. bleeding on probing score (BoP)
5. bone loss/age

35.  To provide a risk score of a patients’
susceptibility for periodontal progression
on a scale of 1 (lowest risk) to 5 (highest
risk).

36. DRS a patient risk score (DRS dentition) or
tooth risk score (DRS tooth,DentoRisk).
 Lindskog et al. (2010) (Sweden)
A Web-based analytic tool that calculates
chronic periodontitis risk for the dentition
(Level I) and, if an elevated risk is found,
prognosticates disease progression tooth by
tooth (Level II).

37. Parameters utilized in tool
 Systemic predictors:
age, family history of periodontitis, systemic
disease, skin test result (assesses patient’s
inflammatory reactivity), patient compliance
and disease awareness, socioeconomic
status, smoking habits and therapist’s
experience with periodontal care

38.  Local predictors:
plaque, endodontic pathology, furcation
involvement, angular bony destruction,
radiographic marginal bone loss, pocket
depth, bleeding on probing, marginal dental
restorations and tooth mobility

39. Objective
 To provide a dentition (patient level) risk
score based upon systemic and local
predictors. It allows for further risk
assessment at the tooth level if patient-
level risk is found to be elevated

40. Risk Assessment-Based Individualized
Treatment (RABIT)
 Teich (2013) (USA)
Advocates a modified approach that
supports individualized risk-based recall
schedules not only after active therapy is
completed but also during the course of
treatment. Approach assesses risk of other
aspects of oral health in addition to
periodontal status

41. Parameters utilized in tool
 Computer system assigns a risk level
based upon caries risk assessment and
periodontal risk assessment. The specific
parameters used to generate the level of
risk are not reported in the paper (reported
as developed according to existing
evidence)

42. Objective
 To classify patients as low, medium or high
risk for periodontal disease progression or
caries risk with accompanying
recommendation for maintenance visit
interval

43. Modified MPRA
 Lu et al. (2013) (China)
Modified MPRA is an alternate modification
of the PRA that replaces BOP with bleeding
index≥2 and counting sites with PPD ≥6 mm,
calculating full-mouth average bone loss
over age

44. Oral Health Status (OHS) as part of DenPlan
Excel/ Previsor Patient Assessment
(DEPPA)
 Busby et al. (2014) (UK)
On-line assessment tool that incorporates
PreViserTM risk scores for periodontal disease,
caries, non-carious tooth surface loss, oral cancer,
revised versions of DenPlan Excel’s Oral Health
Score, and capitation-fee guidance

45. Parameters utilized in tool
 Pocketing and bleeding based upon BPE
result in patient
 score for healthy periodontium, gingivitis
only, mild periodontal disease, moderate
periodontal disease and severe periodontal
disease

46. OBJECTIVE
 To provide patient-level risk scores for
periodontal disease, caries and oral
cancer.

47. Cronin/Stassen BEDS
CHASM Scale:
 This represents a four step risk
assessment model.
 The calculated Odds ratio helps to
standardize risk assessment, allowing
factors to be easily compared with the
standard numerical index

48. Parameters utilized in tool
 B-BMI
 E-Ethnicity
 D-Diabetic
 S-Stressed
 C-College
 H-Hygiene
 A-Age 65+
 S –Smoker
 M –Male
 Score 2 Score 1.5 Score 2.5 Score 2 Score 2.5 Score 2 Score 3.5
Score 1.5 Score 1.5
 The total score of 19 indicates the highest risk.14

49. Which one the most accepted??
 PRC and PRA seem well suited to satisfy the goals
proposed with patient-based risk assessment (Tonetti
1998).
 It appears, however, particularly important to emphasize
that risk segmentation of recall populations with PRA or
its modifications have been validated in multiple
populations and settings around the world (Brazil, China,
France, Germany, India, Sweden and Switzer- land),
increasing the generalizability and external validity of the
tool and therefore the potential applicability to clinical
practice.
 Lang NP, Suvan JE, Tonetti MS. Risk factor assessment tools for the prevention of
periodontitis progression a systematic review. J Clin Periodontol 2015;42(Suppl. 16):S59-
S70.

50. Limitations
 Beyond their value in patient education, is it clear that
risk calculators can truly aid clinicians in making better
diagnoses and prognoses?
 Is a computer-aided mathematical tool, such as the
PreViser RiskCalculatorTM, better diagnostic aid than the
clinicians approach?

51. Issues in Risk Assessment
 Diagnosis :
 A diagnostic test is either highly specific or highly sensitive.
 Diagnostic tests differentiate whether or not a person has a
specific disease at that time. Risk is the likelihood that people
without disease who are exposed to certain factors (risk factors)
will get the disease within a specified time interval.
 Risk factors:
 Removal of a risk factor does not necessarily cure the disease
 Reducing a risk factor in a condition that has multiple risk factors
only reduces a proportion of the risk.

52. Conclusion
 Identification of periodontal risk factors has contributed
vastly to our understanding of the pathogenesis of
periodontitis.
 This has opened promising new avenues for periodontal
therapy as well as for periodontal disease prevention.
 However, the utility of such risk factors to predict disease
incidence, progression and treatment outcomes at an
individual patient level remains limited.

53. References
 Lang NP, Suvan JE, Tonetti MS. Risk factor assessment
tools for the prevention of periodontitis progression a
systematic review. J Clin Periodontol 2015;42(Suppl.
16):S59-S70
 Albandar J. Global risk factors and risk indicators for
periodontal diseases. Periodontology 2000,2002;
29:177–206.
 Beck J. Issues in assessment of diagnostic tests and risk
for periodontal diseases. Periodontology 2000,1995;7:
100-108.
 Garcia R, Nunn M, Dietrich T. Risk calculation and
periodontal outcomes. Periodontology 2000,2009; 50:
65–77.

54. References
 Genco R, Loe H. The role of systemic conditions and
disorders in periodontal disease. Periodontology 2000,
1993;2:98-1 16.
 Lindhe, Lang, Karring: Clinical Periodontology and
Implant Dentistry. Blackwell Munksgaard, 5th edition.
 Newman, Takei, Klokkevold, Carranza: Carrazanza’s
Clinical Periodontology, Saunders, 10th edition.
 Salvi G, Lawrence H, Offenbacher S, Beck J. Influence of
risk factors on the pathogenesis of periodontitis.
Periodontology 2000,1997;14:173-201