Assessing Risk

Our understanding of periodontal diseases has grown, making certain risk factors associated with disease development more apparent. The use of periodontal risk assessment allows for comprehensive and proactive management of the patient’s oral health. As dental hygienists continue to pursue optimal treatment and improved outcomes for patients, the application of risk assessment has become increasingly important.

The management of periodontal diseases has traditionally been conducted with the repair model of care. Problems are diagnosed and resolved with treatments that were empirical and fundamentally the same for all patients.¹ As studies began to show that periodontitis is a preventable disease, transition to the wellness or needs-based model began.^1-5 This form of patient care is based on risk reduction and disease prevention.

THE RISK

Risk is the probability that an individual will develop a specific disease in a given period.⁶ Identifying risk factors is essential to the wellness model, which results in improved health care, a lessening of the need for complex therapy, and a significant reduction in health care costs.^1,7

The presence of bacteria alone is insufficient for periodontal diseases to occur.⁸ Susceptibility and risk for the disease are necessary for its development and can vary greatly from one individual to another. See Table 1 for host-related risk factors that determine the onset and progression of periodontal diseases.^8-11

Risk indicators are probable factors that have been identified in cross-sectional studies but not confirmed through longitudinal studies. Additional longitudinal studies on individual risk factors are still necessary and they are currently underway to validate each relative predictive value.^8,9

Table 1. Host-related risk factors that determine the onset and progression of periodontal diseases include but are not limited to:^8-11

• advancing age
• compromised host defense (HIV infection, immunosuppressive drugs, etc)
• poorly controlled diabetes
• positive family history
• previous disease experience
• race/ethnicity (African-American)
• male gender
• tobacco smoking
• poor oral hygiene
• inadequate margins on dental restorations
• gingival bleeding
• probing depths > 6 mm
• extent and severity of bone loss
• number of missing teeth
• presence of certain etiologic microorganisms (actinobacillus actinomycetemecomitans, bacteroides forsythus, porphyromonas gingivalis, treponema denticola)

DETERMINING THE RISK

Risk assessment is defined by the American Academy of Periodontology (AAP) 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.”⁹ Rather than focusing on apparent pathology that requires immediate treatment, such as surgery, risk assessment allows the clinician to have a broader view that focuses on the potential development and progression of periodontal disease over a long period of time. This method has been incorporated into the AAP’s guidelines for the management of patients with periodontal diseases.

The AAP has made a web-based selfassessment tool available to help patients analyze their individual risk for periodontal diseases. The link can be accessed from www.perio.org/consumer/4a.html. Once a short questionnaire is submitted, the patient’s risk is determined as low, medium, or high for developing periodontal diseases. The patient is shown a personalized profile report and referral recommendations.

The calculations used in the AAP’s assessment tool are based on the periodontal risk calculator (PRC) or periodontal assessment tool (PAT) of the Oral Health Information Suite (OHIS)*.^12,13 The PRC or PAT is a computer web-based tool that uses information gathered during a routine oral examination to calculate a patient’s risk of developing periodontal diseases.

The following patient information is required:

• patient age
• smoking history
• diabetes
• history of periodontal surgery
• pocket depths
• bleeding on probing
• restoration or calculus below gingival margin
• radiographic bone height
• furcation involvement
• vertical bone lesions

The risk scores range from 1 to 5, with 1 representing the lowest risk and 5 the highest. The scores are based on the risk factors and history of the individual patient. The disease state score ranges from 1 to 100 reflecting the sequence from periodontal health to most severe periodontitis—healthy: 0-1; gingivitis: 2-3; mild gum disease: 4-10; moderate gum disease: 11-36; and severe gum disease: 37-100.

A patient can present with a high risk, but show no current symptoms of disease. Treatment and interventions are ranked and colorcoded as the most likely to be successful, to those less likely, and those unlikely to be successful. A patient report can be printed in two versions: one for the patient and the other for the clinician. When treatment is completed, the post-treatment risk and disease assessment is done. The scores and recommended treatment at that time are automatically updated.

The high validity and accuracy of risk scores calculated using OHIS were determined in a longitudinal study of 523 subjects over a period of 15 years.¹³ The results of a study examining the risk assessment done by a clinician versus a computerized tool suggests that manually summarizing and analyzing the risk factors are more complex. The variation in data among the expert clinicians was unexpectedly large.¹⁴

CONCLUSION

Although additional research is needed to determine the specific effectiveness of periodontal risk assessment, the preliminary studies suggest that proactive targeting interventions may reduce disease progression and, ultimately, health care costs. The registered dental hygienist is in the position to effectively manage periodontal diseases and improve clinical outcomes by using a risk assessment tool as part of the treatment planning process. The use of technology provides useful visual aids for patient education. It also allows for objective rather than subjective evaluation of the patient assessment and course of treatment. This may result in a more uniform clinical decision making process between the dentist and hygienist.

* PreViser Corp, Mount Vernon, Wash

REFERENCES

1. Page RC, Martin JA, Loeb CF. The Oral Health Information Suite (OHIS): its use in the management of periodontal disease. J Dent Ed. 2005;69:509-520.
2. Axelsson P, Lindhe J, Nystrom B. On the prevention of caries and periodontal disease: results of a 15-year longitudinal study in adults. J Clin Periodontol. 1991; 18:182-189.
3. Axelsson P, Paulander J, Svardstrom G, Kaiser H. Effects of population based preventive programs on oral health conditions. J Parodontol d’Implantol Orale. 2000;19:255-269.
4. Axelsson P, Lindhe J. Effect of controlled oral hygiene procedures on caries and periodontal disease in adults: results after six years. J Clin Periodontol. 1981;8:239- 248.
5. Axelsson P, Nystrom B, Lindhe J. The long-term effect of plaque control program on tooth mortatlity, caries and periodontal disease in adults: results after 30 years of maintenance. J Clin Periodontol. 2004;31:749-757.
6. Novak K, Novak J. Risk Assessment. Caranza’s Clinical Periodontology. 10th ed. Philadelphia: WB Saunders Co;2006:602-608.
7. Douglass CW. Risk assessment and management of periodontal disease. J Am Dent Assoc. 2006;137:27S-32S.
8. Page RC, Beck JD. Risk assessment for periodontal diseases. Int Dent J. 1997;47:61-87.
9. American Academy of Periodontology. American Academy of Periodontology Statement on Risk Assessment. J Periodontol. 2008;79:202.
10. Lamster IB. Antimicrobial mouthrinses and the management of periodontal diseases. J Am Dent Assoc. 2006;137:5S-9S.
11. Drisko CH. Trends in surgical and nonsurgical periodontal treatment. J Am Dent Assoc. 2000; 131:31S-38S.
12. Page RC, Krall EA, Martin J, Mancl L, Garcia RI. Validity and accuracy of a risk calculator in predicting periodontal disease. J Am Dent Assoc. 2002; 133:569-576.
13. Page RC, Martin J, Krall EA, Garcia R. Longitudinal validation of a risk calculator for periodontal disease. J Clin Periodontol. 2003; 30: 819-927.
14. Persson GR, Mancl LA, Marin J, Page RC. Assessing periodontal disease risk: a comparison of clinicians’ assessment versus a computerized tool. J Am Dent Assoc. 2003;134:575-582.

From Dimensions of Dental Hygiene. March 2009; 7(3): 36, 38.