Oral health professionals need to have an in-depth understanding of oral disease risk factors and include a proper risk assessment into their oral health-care model. The likelihood of an individual developing a disease or injury increases if he or she presents with certain risk factors.1 Risk factors are described as any attribute, characteristic, or exposures that affect the onset and progression of disease; therefore, risk factors may significantly alter treatment results.1,2 More specifically, periodontal risk factors are environmental, behavioral, or biological factors that raise the probability of treatment failures.3 Over the past 10 years, the American Academy of Periodontology (AAP) has offered guidelines that incorporate risk assessment in patient management, noting that without risk assessment, comprehensive dental and periodontal evaluations are incomplete.4 In June 2018, the AAP released the new periodontal classification scheme, which includes grading levels relating to the risk of periodontitis progression and general health status.5 This grading system further signifies the evidence-based relationship of risk assessment and periodontitis treatment recommendations.
DATA COLLECTION TOOLS
Data collection of clinical findings is essential to proper treatment planning, yet only after identifying a patient’s individual risk factors through risk assessment can an appropriate treatment plan be created.6 Comprehensive data collection occurs through medical and dental history, patient interviewing, and oral assessment information.6,7
Risk assessment can be time-consuming, but tools are available to increase efficiency. Easy-to-use risk assessment forms or more advanced scientific methods that use mathematic algorithms—also knowns as risk calculators—can predict risk. Software products, online programs, and application programs may aid in predication of prognosis and facilitate proper treatment planning.8 Several electronic risk calculation programs are available. Some are inexpensive or free and can be found easily online, while others are more expensive and require software updates and user training. It remains unclear whether these options offer better accuracy over proper clinical judgment.8
Via either a risk assessment tool or clinical data assessment alone, thorough risk assessment data include medical and dental history, intraoral/extraoral exam, probing depths, bleeding/exudate on probing, recession, mucogingival involvement, furcation involvement, radiographic bone levels, and periodontitis etiology (biofilm/calculus or other).6
Once the patient assessment data have been gathered, clinicians must categorize the identified risk factors into two categories: modifiable risk factors and nonmodifiable risks factors (Table 1).2,6,7,9–13 Modifiable risk factors are improvable or changeable factors, while nonmodifiable factors cannot be changed or modified. The purpose of categorizing risk factors is to determine which factors should be targeted by the clinician in the treatment plan. Nonmodifiable risk factors are also called risk determinants. Neither the clinician nor the patient have control over these risk factors; however, the patient must be informed that they may affect treatment outcomes and disease progression.8
Some risk factors, such as smoking, diabetes, age, systemic diseases, and genetics, are more significant indicators of periodontal disease progression.6,10 Smoking alone can inhibit a patient’s immune response to harmful pathogens found subgingivally in biofilm. Evidence shows that smoking is a catalyst in the extent and severity of periodontal diseases.10,13–15
Diabetes and periodontal disease have been linked as a proportional relationship; periodontal inflammation has a negative effect on glycemic control and diabetes increases the risk of periodontitis.16,17 A systematic review of the literature found that the prevalence and severity of periodontal disease escalates with age.10 Older adults are vulnerable to diseases, may struggle to complete adequate self-care, and experience diminished access to care.10 Genetics and familial patterns, including a history of chronic and aggressive periodontitis, may predispose a patient to periodontitis.18,19
If two or more of these high-risk factors are identified in a patient, he or she is seven times more likely to experience tooth loss due to periodontitis than an individual without these risk factors.6 Patients who smoke heavily and have one other risk factor are at the highest risk for periodontal destruction.6,20 One study found that a population of male smokers, who had one parent with periodontitis, had more severe periodontitis.20 Patients with periodontitis who possess more significant risk factors, such as smoking, diabetes, genetic markers, or systemic diseases, must stay on an aggressive periodontal therapy program. Once these major risk factors have been identified, the AAP offers numerous resources to assist clinicians with determining how to classify patients based on their risk indicators/factors and overall health status according to the newly established levels of periodontitis grading.21
TREATMENT PLANNING FOR PATIENTS WITH PERIODONTAL RISK FACTORS
Extensive treatment planning is required to treat and maintain patients who have risk factors for periodontitis. Patients who do not have periodontal diseases but possess risk factors must make frequent preventive care visits, receive proper education, and eliminate modifiable risk factors to prevent the onset of periodontal diseases.6 Patients who already have periodontitis, in addition to one or more of the discussed risk factors, must be encouraged to comply with aggressive treatment plans. Interventions to consider for an individualized-aggressive treatment plan for high-risk periodontitis patients are:
- Nonsurgical periodontal therapy as soon as possible
- Immediate smoking cessation and adjunctive support
- Physician consult(s) or referral to appropriate health care professionals
- Rigorous self-care
- Education on oral-systemic health connections
- Education on susceptibility
- Use of antimicrobial mouthrinse, oral irrigation, systemic antibiotics, local chemotherapeutic agents, and/or extended low dose doxycycline to control collagenase activity
- Elimination or reduction of modifiable risk factors
- Supportive periodontal maintenance every 2 months to 3 months, based on patient response to care
- Referral to periodontist for surgery
VALUE OF RISK ASSESSMENT
Caring for patients’ total health is not solely the oral health professional’s job, however, there is undeniable educational value in providing patients with risk assessment information. Presenting risk assessment findings increases the patient’s knowledge, possibly leading to better compliance with treatment recommendations.8 Demonstrating patient-centered communication, compassion, and genuine interest in the promotion of the patient’s overall health establishes patient rapport and builds trust.22 Patients’ self-care practices and motivation are positively influenced through the education and communication that risk assessment presentation facilitates.8,9,23
The literature supports risk assessment as a critical component of comprehensive oral care, and the inclusion of risk assessment into the oral health professional’s model is considered the standard of quality care.
THE BOTTOM LINE
- Risk factors are any attribute, characteristic, or exposures that affects the onset and progression of disease.
- The American Academy of Periodontology released a new periodontal classification scheme, which includes grading levels relating to the risk of periodontitis progression and general health status.
- Thorough risk assessment data include medical and dental history, intraoral/extraoral exam, probing depths, bleeding/exudate on probing, recession, mucogingival involvement, furcation involvement, radiographic bone levels, and periodontitis etiology (biofilm/calculus or other).
- Modifiable risk factors are improvable or changeable factors, while nonmodifiable factors cannot be changed or modified.
- Extensive treatment planning is required to treat and maintain patients who have risk factors for periodontitis.
- World Health Organization. Risk Factors. Available at: who.int/topics/risk_factors/en/. Accessed February 24, 2019.
- American Academy of Periodontology. Statement on risk assessment. J Periodontol. 2008;79:202.
- Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontol 2000. 2013;62:59–94.
- American Academy of Periodontology. Guidelines for the management of patients with periodontal diseases. J Periodontol. 2006;77:1607–1611.
- Caton JG, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and periimplant diseases and conditions- Introduction and key changes from the 1999 classification. J Periodontol. 2018;89(Suppl 1):S1–S8.
- Tolle SL. Periodontal risk assessment. In: Darby ML, Walsh MM, eds. Dental Hygiene: Theory and Practice. 4th ed. St. Louis: Saunders Elsevier; 2015:313–353.
- Otomo-Corgel J, Pucher J, Rethman M, et al. State of the science: chronic periodontitis and systemic health. J Evid Base Dent Prac. 2012;12(Suppl 3):20–28.
- Garcia RI, Compton R, Dietrich T. Risk assessment and periodontal prevention in primary care. Periodontol 2000. 2016;71:10–21.
- Kye W, Davison R, Martin J, et al. Current status of periodontal risk assessment. J Evid Base Dent Prac. 2012;12(Suppl 3):2–11.
- Yousef AA. Risk factors of periodontal disease: a review of the literature. International Journal of Dentistry. Available at: http:/ / dx.doi.org/ 10.1155/ 2014/ 182513. Accessed February 25, 2019.
- Hujoel PP, Lingstom P. Nutrition, dental and periodontal disease: a narrative review. J Clin Periodontol. 2017;44(Suppl 18):S79-S84.
- Moynihan P, Petersen PE. Diet, nutrition and the prevention of dental diseases. Pub Health Nutr. 2004;7:201–226.
- Borojevic T. Smoking and periodontal disease. Mater Sociomed. 2012;24:274-276.
- Ozcaka O, Bicakici N, Pussinen P, et al. Smoking and matrix metalloproteinases, neutrophil elastase and myeloperoxidase in chronic periodontitis. Oral Dis. 2011;17:68–76.
- Shchipkova AY, Nagaraja HN, Jumar PS. Subgingival microbial profiles of smokers with periodontitis. J Dent Res. 2010;89:1247–1253.
- Preshaw PM, Alba AL, Herrara D, et al. Periodontitis and diabetes: a two-way relationship. Diabetology. 2012;55:21–31.
- Bascones-Martinez A, Matesanz-Perez P, Escribano-Barmejo M, et al. Periodontal disease and diabetes- review of the literature. Med Oral Patol Oral Cir Bucal. 2011;16:e722–729.
- Benjamin SD, Baer PN. Familial patterns of advanced alveolar bone loss in adolescence (periodontosis). Periodontics. 1967;5:82–88.
- Marazita ML, Burmeister JA, Gunsolley TE, et al. Evidence for autosomal dominant inheritance and race-specific heterogeneity in early-onset periodontitis. J Periodontol. 1994;65:623–630.
- Zuikaite L, Slot DE, Loos BG, et al. Family history of periodontal disease and prevalence of smoking status among adult periodontitis patients: a cross-sectional study. Int J Dent Hyg. 2017;15:e28–e34.
- Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Periodontol. 2018;89:59–72.
- Zarkowski P. Legal and ethical decision making. In: Darby ML, Walsh MM, eds. Dental Hygiene: Theory and Practice. 4th ed. St. Louis: Saunders Elsevier; 2015:1123–1146.
- Drisko CL. Periodontal self-care: evidence-based support. Periodontol 2000. 2013;62:243–255.
From Dimensions of Dental Hygiene. March 2019;17(3):48–50.