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Evaluate Disease Potential

Basic periodontal risk assessment is key to diagnosis, prognosis, and care planning.

Periodontal risk assessment is a key factor in oral health education and patient care. The process involves ­evaluating factors that predispose patients to develop periodontal diseases. The American Academy of Periodontology (AAP) states that patients should receive a comprehensive periodontal evaluation and risk factor identification at least annually.1

Disease development depends on the individual and the number and extent of risk factors. A developed risk assessment tool can estimate the chance of future disease based on research. Commercially available risk assessment tools also are easy to use and provide quantifiable results. Web-based tools typically use data points to score periodontal risk from low to high. The disadvantages of developed risk assessment tools include the time needed to accurately complete the assessment and cost.

A simple checklist or a scoring mechanism can be developed to assess risk. The first step is to determine who will complete the risk assessment: the patient, clinician, or both. This decision will drive the wording of the questions. In addition, an analysis of how the periodontal risk assessment will be implemented is important. For example, will patients complete the risk assessment prior to entering the operatory, or will the practitioner complete the risk assessment after completing the oral assessment, or a combination of both? If a commercially developed risk assessment tool is selected, both the patient’s and clinician’s roles in completing it should be defined. Another option is recommending self-assessment of risk factors. The AAP, National Institutes of Health, and the University of Maryland offer tools for self-assessment of risk factors.2–4 As with most health interventions, a collaborative format between the patient and provider is an effective strategy for success.


Modifiable risk factors include tobacco use, poorly controlled diabetes, microbial tooth deposits, specific pathogenic microorganisms, nutrition/obesity, gingival bleeding, and pocket depths of 6 mm or greater. A direct relationship exists between smoking and periodontal disease that is independent of other factors such as age or self-care.5 Tobacco smoking modifies the host response to the challenge of bacterial plaque biofilms.6 Fortunately, smokers who have quit respond as well as nonsmokers.5 It is crucial to start a dialogue with patients about why smoking is detrimental to oral and systemic health and to assess willingness for cessation strategies. Waterpipe tobacco smoking may also be significantly associated with periodontal diseases, but more research is needed to demonstrate this link.7

Diabetes, especially when poorly controlled, has a direct relationship with the prevalence and severity of periodontal diseases.6 Assessing the level of glycemic control is paramount to establishing periodontal disease risk. Both type 1 and type 2 diabetes increase the risk for periodontal diseases, and progression might be more rapid among those patients with poorly controlled diabetes.5

Concern about microbial deposits involves both plaque biofilm and calculus accumulation. Abundant biofilm quantity does not always translate into the severity of disease, especially in periodontitis. Instead, it is the quality of the plaque biofilm that affects the development and progression of periodontitis. Calculus is the reservoir for plaque biofilm attraction and accumulation, although the amount of calculus does not always correlate with the degree of attachment loss. Increased accumulations of calculus can create greater accumulations of plaque biofilm, sometimes resulting in disease initiation or progression. Anatomic factors such as furcations, root concavities, developmental grooves, enamel projections, and enamel pearls make effective biofilm removal and professional debridement challenging. Overhanging restorations as well as ill-fitting or inaccurately contoured restorations also affect the ability to remove biofilm and should be included in a risk assessment profile.

Research supports the identification of at least three specific bacteria in periodontal risk, including Aggregatibacter actinomycetemcomitans—which is associated with aggressive periodontitis—and Porphyromonas gingivalis and Bacteriodes forsythus, which are related to chronic periodontitis.5,6 Additionally, Provetella intermedia, Peptostreptococcus micros, and fusobacterium nucleatum have strong connections to adult periodontitis.6

Poor nutrition and obesity are potential risk factors for periodontal diseases, but they are controversial. As low levels of calcium and vitamin C have been implicated in higher rates of periodontal diseases, diet also plays a role in risk assessment.

Gingival bleeding is the best indicator of gingivitis.6 Bleeding on probing and increased pocket depth typically, but not always indicate future loss of attachment. Conversely, lack of bleeding on probing is an excellent indicator of periodontal health.5 Pocket depth of 6 mm or greater and bleeding are possibly more of a disease predictor than risk factor; however, these data should be collected in the assessment to be used in a risk profile.


Nonmodifiable risk factors include family history/genetics, female hormonal changes, age, gender, alveolar bone loss, and stress. Genetic factors include the familiar aggregation seen in localized and generalized aggressive periodontitis, alterations in genes that encode inflammatory cytokines, immunologic alterations, and regulation of the titer of the protective immunoglobulin antibody response of Aggregatibacter actinomycetemcomitans in aggressive periodontitis.5 Commercial testing may be valuable in determining genetic predisposition to disease.

Female hormonal changes during puberty, menstrual cycle, pregnancy, and menopause may alter periodontal health.6 Also, hormonal replacement therapy and oral contraception might play a role in periodontal diseases.6 These factors may be included in the risk assessment to emphasize specific care during different phases of women’s lifecycles.

As age increases, so does the prevalence and severity of periodontitis. Age alone is not a risk factor, and it is unclear what role other factors play in aging.5 Older adults often have increased medication use, poor nutrition, and decreased immune function. In contrast, young individuals presenting with attachment loss pose a grave concern because they have a lifetime of exposure to other risk factors. Risk assessment is essential in young patients to minimize the modifiable risks and control nonmodifiable factors.

Men tend to be less vigilant about their oral hygiene than women, and men have a greater amount of attachment loss than women.6 This is not necessarily an inherent genetic factor; rather, it reflects on self-care practices.5 A recent systematic review affirmed that men appear at greater risk for destructive periodontal disease than women, but men do not seem to have a higher risk for more rapid periodontal destruction than women.8 The overall effect of gender, however, was comparatively small.8

Evidence of alveolar bone loss is a predictor of future attachment loss. Data collection factors, such as attachment loss and radiographic examination of bone level, are critical to classifying the degree of bone loss. Emotional stress might interfere with immune function causing increased circulating hormones that, in turn, affect periodontal disease development and progression.5 Situational stress induced by divorce or death is often modifiable; however, depression, financial concerns, or severe risk behaviors may not be modifiable.

Interventions can help reduce or eliminate modifiable risk factors. Providing patient self-care education and counseling on how to control modifiable risk factors (eg, stress, medical status, smoking) with appropriate referral is key to providing appropriate care.1


Recurrent assessment of risk factors also is essential to identify patients who are susceptible to continuous breakdown of periodontal or peri-implant tissues. The goal of continuing risk assessment is to eliminate or mitigate new or persistent risk and etiologic factors with patient-centered therapy reevaluation. This encourages the establishment of an appropriate recare interval that may be adjusted over the lifespan. For instance, one retrospective study showed the reliability of a risk assessment score in evaluating long-term tooth loss.9 This study also showed the positive influence of patient compliance over time on periodontal treatment outcomes.9 Oliveira Costa et al10 concluded that the risk profile influenced the recurrence of periodontitis and tooth loss, and patients who complied with maintenance had less recurrence of periodontitis and tooth loss than those who did not comply.

In another study, smoking, diabetes, and Il-1 genotype were assessed to classify patients into high- and low-risk groups.12 Patients who presented with one of three risk factors were classified as high-risk. To this end, the preventive visit frequency (per year) relationship to event rate (tooth loss) by risk classification was assessed. There were no significant differences in tooth loss over 16 years for patients with low risk who had preventive visits two times per year vs one time. However, there was a difference in tooth loss for the high-risk group: biannual visits were associated with lower tooth loss.11 Also, the cost of risk-based population stratification plus stratified intervention was lower than when the same regimen was applied equally across all populations.11 This study emphasizes the importance of risk assessment in individualizing care and the recare interval to capitalize on reductions in disease development and progression.

In addition, Matthews12 recommended including assessment and explanation of risk factors for periodontal diseases to patients. He also suggested assigning an individual’s risk level based on medical history and oral health status and then scheduling recare appointments accordingly.12

Adverse changes in risk factors is indicative of disease onset or progression.1 After the initial risk assessment is completed, it should be continually updated to evaluate improvements or deterioration. If risks are not improving, consideration of these findings becomes a part of the updated diagnosis, prognosis, and care planning.


The clinical use of periodontal risk assessment will become a component of both comprehensive and periodic dental and periodontal examinations.14 Now is the time to integrate this concept into care by using checklists or quantifiable risk profiles. If risk assessment is performed early in a patient’s life, risk identification will aid in preventing periodontal diseases that, in turn, will decrease overall disease, severity, and future costs.

Risk assessment provides oral health professionals with individualized information to proactively tailor self-care and therapy. Remaining aware of risk factors helps with the identification and treatment of co-morbidities in the general population because many periodontal disease risk factors are common to other chronic diseases, such as diabetes, cardiovascular disease, and stroke.13


  1. Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology. J Periodontol. 2011;82:943–949.
  2. American Academy of Periodontology. Gum Disease Risk Factors. Available at: Accessed May 25, 2015.
  3. National Institute of Dental and Craniofacial Research. Gum (Peirodontal) Diseases. Available at: Accessed May 25, 2015.
  4. University of Maryland. Periodontal Disease. Available at: Accessed May 25, 2015.
  5. Novak KF, Novak MJ. Clinical risk assessment. In: Carranza’s Clinical Periodontology. 11th ed. Philadelphia: Elsevier Saunders; 2012.
  6. AlJehani YA. Risk factors of periodontal disease: review of the literature. Int J Dent. 2014;2014:182513.
  7. Akl EA, Gaddam S, Gunukula SK, et al. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol. 2010;39:834–857.
  8. Shiau HJ, Reynolds MA. Sex differences in destructive periodontal disease: a systematic review. J Periodontol. 2010;81:1379–1389.
  9. Leininger M, Tenenbaum H, Davideau JL. Modified periodontal risk assessment score: long-term predictive value of treatment outcomes. A retrospective study. J Clin Periodontol. 2010;37:427–435.
  10. Oliveira Costa F, Miranda Cota LO, Pereira Lages EJ, et al. Progression of periodontitis in a sample of regular and irregular compliers under maintenance therapy: a 3-year follow-up study. J Periodontol. 2011;82:1279–1287.
  11. Giannobile WV, Braun TM, Caplis AK, Doucette-Stamm L, Duff GW, Kornman KS. Patient stratification for preventive care in dentistry. J Dent Res. 2013;92:694.
  12. Matthews DC. Prevention and treatment of periodontal diseases in primary care. Evid Based Dent. 2014;15:68–69.
  13. Teich ST. Risk Assessment-Based Individualized Treatment (Rabit): a Comprehensive Approach to Dental Patient Recall. J Dental Ed. 2013;77:448–457.
  14. American Academy of Periodontology Statement on Risk Assessment. J Periodontol. 2007;79:202.

From Dimensions of Dental Hygiene. June 2015;13(6):24–26.

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