Risk assessment

Risk assessment in Periodontics

Dr. Monali ShahProfessor, Dept of Periodontics,

KMSDCH, Sumandeep Vidyapeeth

@smonali2011

Sameeksha_2015_Udaipur_Risk Assessment

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Content Introduction Terminologies and importance of study design Risk assessment process Risk assessment tools Conclusion References


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INTRODUCTION Periodontal disease –a multifactorial disease. Manifestation and progression influenced by

various factors. A susceptible host is also essential for disease

to occur. Susceptibility and risk for disease vary greatly from one individual to another, and major factors that place individuals at risk have been identified


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INTRODUCTION All patients are not susceptible to inflammatory

periodontal disease and further, the extent and severity of its clinical manifestation varies as a function of individual risk.

Risk assessment models are needed to target treatment effectively.

Contemporary risk assessment as applied to periodontal disease represents an innovative approach to manage periodontitis.

Kye W, Davidson R, Martin J, Engebretson S Current status of periodontal risk assessment J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):2-11.


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Important Terminologies

1. RISK FACTORS

2. RISK DETERMINANT/ BACKGROUND

FACTORS

3. RISK INDICATORS

4. RISK MARKERS


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Important Terminology Risk is defined as the probability of an

individual's developing a given disease or experiencing a health status change over a specified period.

Risk factor Environmental or individual characteristic which directly increases (when present) or decreases (when absent) the probability of a subject to be affected by a disease.

Beck JD. Risk assessment revisited. Community Dent Oral Epidemiol 1998;26:220‑5

RISK FACTORSTobacco smokingDiabetesPathogenic bacteria.


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Important Terminology Risk determinants/background characteristics:

Those risk factors that cannot be modified . May be strongly predictive of disease but at

present is not changeable.

RISK DETERMINANTSGenetic factorsAgeGenderSocioeconomic factors Stress


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Important Terminology Risk indicators are biologically plausible

causative agent or probable risk factors that have been identified in cross-sectional studies but not confirmed through longitudinal studies.

RISK INDICATORSHIV/AIDSOsteoporosis Infrequent dental visits AllergyAnemia


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Important Terminology Risk predictors / markers A risk predictor is a factor that has no current

biological plausibility as a causative agent but has been associated with disease on a cross-sectional or longitudinal basis.

Risk predictors may be either markers of disease or other historical measures of diseaseRISK MARKERSPrevious history of periodontal diseaseBOP


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Study designs for risk association


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Study designs for risk association For a risk factor to be causal for a disease. It should

satisfy two criteria: 1. It is biologically plausible as a causal agent for disease.2. It has been shown to precede the development of disease

in prospective clinical studies. Risk factor should have been verified to be associated

with disease through longitudinal studies. Interventional trial should also support its association.

(criteria laid down by Beck et al and Offenbacher)


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Risk Assessment Process According to the American Academy of Periodontology,

risk assessment has been defined as the process by which qualitative or quantitative assessments are made of the likelihood for adverse events to occur as a result of exposure to specified health hazards or by the absence of beneficial influences

American Academy of Periodontology statement on Risk Assessment. J Periodontol 2008;2:202.


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Continuous Multilevel Risk Assessment The subject level-- Perform at initial examination

The tooth level – Perform post‑initial/ definitive therapy and maintenance

The site level -- Perform post‑definitive therapy and during maintenance

Clinical periodontology and implant dentistry, Fourth edition, Jan Lindhe


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Subject risk assessment1. Percentage of bleeding on probing2. Prevalence of residual pockets greater than 4mm3. Loss of teeth from total of 284. Loss of periodontal support in relation to patient’s age5. Systemic and genetic condition6. Environmental factors such as smoking

Lang NP, Tonetti MS. Periodontal Risk Assessment (PRA) for patients in supportive periodontal Therapy (SPT). Oral Health Prev Dent 2003;1:7‑16.


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Proportion of sites with bleeding on probingRisk: LR: 0-9%, MR: 10-25% HR: >25%

Prevalence of residual Periodontal pockets RISK: LR: 0-4mm MR: 5-8mm HR: >8mm

Loss of teeth from a total of 28 teeth.RISK: LR: 0-4 MR: 5-8 HR: >8

Systemic and genetic factors RISK: LR: Negative HR: Positive


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Estimation of loss of periodontal support in relation to the patient's age. Proportional relationship between root length and radiographic bone loss at the worst site in the posterior regionRISK: LR: 0-0.5mm MR: 0.5-1mm HR: >1.0mm

Environmental/ Behavioural factors such as cigarette smoking.Risk: LR: non-smoker or former smokerMR: 10-19 cig./day HR: >19cig./day


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Calculating the patient's individual periodontal riskassessment (PRA) A low PR patient has all parameters within the low risk

categories or at the most one parameter in the moderate risk category .

A moderate PR patient has at least two parameters in the moderate category, but at most one parameter in the high risk category .

A high PR patient has at least two parameters in the high risk category.


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Additional factors as suggested by some valid evidences1. Compliance with recall system: Axelsson &

Lindhe(1981), Becker et al (1984), Cortellini et al 1(996) and many others suggested that treated periodontal patients who comply with regular maintanace have better prognosis than patients who do not comply.

2. Oral hygiene: Rosling et al (1976), Axelsson & Lindhe(1981) and others suggested that dentition under plaque control and regular supportive therapy maintain periodontal stability for many years.


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Tooth risk assessment1. Tooth position within the dental arch2. Furcation involvement3. Iatrogenic factors4. Residual periodontal support5. Mobility


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Site risk assessment

1. Bleeding on probing2. Probing pocket depth3. Attachment loss4. Suppuration


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Risk Assessment Models

The relevant risk factors put together into a multivariate model that identifies the combination of factors that will most efficiently distinguish between those who are at high or low risk of developing the disease.

Model is then verified using data sets from other populations before being tested on new populations to determine its utility and efficiency.


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Periodontal risk calculator (PRC)by Page et al. 2002

Page et al. developed a computer-based risk assessment tool, the PRC for objective, quantitative assessment of risk.

The calculation of risk using this model is based on mathematically derived algorithms that assign relative weights to nine factors.


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Nine factors included are:

1. Patient age2. Smoking history3. Diagnosis of diabetes4. History of periodontal surgery 5. Pocket depth6. Furcation involvements 7. Restorations or calculus below the gingival margin 8. Radiographic bone height9. Vertical bone lesions.


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Commercially available: PREVISER

SCALE1

LOWEST RISK

SCALE 5HIGHEST RISK


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In a subsequent study, a comparison of clinician’s subjective assessment versus the PRC was made (Persson et al.2003).

RISK SCORES ASSIGNED BY THE EXPERT CLINICIANS < RISK SCORES

GENERATED BY THE PRC


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Periodontal Risk Assessment(PRA)Hexagonal Risk Diagram Model by Lang &Tonetti 2003

Lang &Tonetti 2003 described a functional diagram based on six parameters :

Lang NP, Tonetti MS. Periodontal Risk Assessment (PRA) for patients in supportive periodontal Therapy (SPT). Oral Health Prev Dent 2003;1:7‑16.


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PRA/multifactorial risk diagram by Renvert & Persson 2004

A modification of the PRA model. 1. The vector bone loss index (bone loss in relation to subject

age) is substituted by the proportion of sites with a distance ≥ 4mm of the cementoenamel junction to bone level.

2. The surface area outlined between the various risk parameters is calculated to provide a numerical score of risk with the aid of a computer program.


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Modification by R Vishwa Chandra (2007):The proposed model, which considers the cumulative periodontal status, risk factors and risk determinants under eight parameters and with clearly demarcated low-, medium- and high-risk zones.1. Percentage of sites with

BOP2. Number of sites with probing depth (PD) ≥ 5 mm3. Number of teeth lost4. Attachment loss (AL)/age ratio5. Diabetic status6. Smoking7. Dental status – systemic factors interplay8. Other background characteristics

Chandra RV. Evaluation of a novel periodontal risk assessment model in patients presenting for dental care.Oral Health Prev Dent. 2007;5(1):39-48.


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Functional Periodontal Pentagon Risk Diagram

Renvert S, Persson GR Patient-based assessments of clinical periodontal conditions in relation to alveolar bone loss. J Clin Periodontol. 2004 Mar;31(3):208-13.


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Risk assessment for Implant Presence of a Biofilm Presence of BOP Presence of suppuration Increased peri-implant probing depth Evidence and extent of radiographic alveolar bone

loss


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Risk assessment for ImplantWho and When

Rocchietta I, Nisand D. in 2012

Why Risk association: The outcome was implant loss, and the risk factors assessed were smoking, diabetes and periodontitis.

What Systematic review (followed STROBE guidelines)Outcome Comprised of 3 cohort study, 101 case seriesImplementation

Risk factor research in implant dentistry is mostly comprised of case series studies. These are used to generate hypotheses, but are the wrong tool to test these hypotheses. In the near future, well-designed observational studies are needed and should be reported according to the proposed checklist.

Rocchietta I, Nisand D. A review assessing the quality of reporting of risk factor research in implant dentistry using smoking, diabetes and periodontitis and implant loss as an outcome: Critical aspects in design and outcome assessment. J Clin Periodontol 2012; 39: 114–121.


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Conclusion

Risk assessment involves identifying elements that either may predispose to occurrence of periodontal disease or may influence the progression of disease that already exists.

Understanding and evaluation of these factors and determinants demands that the evidence for each association be weighed according to study designs, outcome measures and the strength of association.

In addition to evaluation of these risk factors, patients should be educated concerning their risk and when appropriate, suitable intervention strategies implemented.


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Periodontal risk assessment may help clinicians to identify subjects with an impaired periodontal prognosis as well as determine the impact of treatment on periodontal prognosis.

Longitudinal studies where patients with different periodontal status are long-term evaluated are needed to validate the current methods for periodontal risk assessment.

Utilizing risk assessment helps dental professionals predict the potential of 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.


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Further reading Newman et al. Carranza’s clinical periodontology, 10th edition, New Delhi. Elsevier publisher;

2007 Jan Lindhe, Thorkild Karring, Niklaus P Lang clinical periodontology and implant dentistry,

4th edition, New Delhi, Jaypee Brothers medical publishers; 2003 Walter B Hall Decision making in periodontology, 3rd edition, Missouri, Mosby; 1997 Bruce L. Pihlstrom Periodontal risk assessment, diagnosis and treatment planning

Periodontology 2000, Vol. 25, 2001, 37–58 Koshi E, Rajesh S, Koshi P, Arunima PR. Risk assessment for periodontal disease. J Indian Soc

Periodontol 2012;16:324-8 Kye W, Davidson R, Martin J, Engebretson S Current status of periodontal risk assessment J

Evid Based Dent Pract. 2012 Sep;12(3 Suppl):2-11. Renvert S, Persson GR Patient-based assessments of clinical periodontal conditions in relation

to alveolar bone loss. J Clin Periodontol. 2004 Mar;31(3):208-13. Rocchietta I, Nisand D. A review assessing the quality of reporting of risk factor research in

implant dentistry using smoking, diabetes and periodontitis and implant loss as an outcome: Critical aspects in design and outcome assessment. J Clin Periodontol 2012; 39:114–121.


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