Risk Assessment for General and Oral Conditions

Healthcare topics have been front-page news over the past year. With emphasis on healthcare reform and emerging science linking systemic diseases with oral diseases, opportunities exist to enhance patient assessment and treatment. Many individuals are not aware that they present with risk factors for diseases or conditions that could compromise their general health. Likewise, they are often unaware that their oral health condition may be related to their systemic health. Risk assessment provides a means for evaluating patients in order to prevent disease or to provide early intervention for conditions to minimize their systemic impact.

Two major diseases that are of concern are cardiovascular disease (CVD) and diabetes mellitus. Both have been associated with the potential for changes in oral health status.^1-3

Heart disease is responsible for 26 percent of deaths in the United States, that’s one in four Americans; in fact, it is the leading cause of death for both men and women, as the maleto- female ratio for heart disease is now 1:1.⁴ Coronary heart disease is the most common type of cardiovascular disease. A recent report from the American Heart Association revealed that each year approximately 785,000 Americans have a first heart attack, and 470,000 will have another heart attack. The cost of providing care for those with CVD in 2010 is estimated at $316.4 billion.⁵

REDUCE THE RISK

It has long been established that controlling risk factors for heart disease, such as lowering cholesterol and blood pressure levels, reduces the risk of dying from heart disease, having a nonfatal myocardial infarction, and needing surgical procedures such as bypass surgery or angioplasty. Further, for those without CVD, maintaining low cholesterol and blood pressure levels can reduce the risk of developing heart disease.

Risk factors for CVD are classified as modifiable and nonmodifiable. Table 1 highlights these risk factors. The more risk factors a person has, the greater the chance of developing coronary heart disease.

Diabetes mellitus (DM) is another serious medical condition with long-term health implications. It is estimated that 23.6 million Americans have diabetes and 57 million have prediabetes. Approximately 25 percent of those with DM do not know they have the disease.⁷ According to the Centers for Disease Control and Prevention, those with DM represent an increase of more than 3 million in almost two years. Almost 8 percent of the US population has diabetes. The cost of diabetes totals $174 billion representing an increase of 32 percent since 2002.⁷

Diabetes can contribute to serious health complications and premature death. Systemic complications associated with DM include CVD, end stage renal disease, lower extremity amputation, neurologic conditions, and blindness. A relative perspective on a daily basis indicates that 4,100 people are diagnosed with diabetes, 230 amputations occur in people with diabetes, 120 people will enter end stage renal disease programs, 55 people will go blind, and 810 will die.⁸

As noted in Table 1, there are multiple risk factors for Type 2 DM. Some individuals do not recognize the signs and symptoms, and may not be aware of their risk for this disease. Assessing them for risk factors may be one of the ways that encourages patients to be tested and diagnosed. The impact of early intervention for DM cannot be overstated when it comes to preventing or limiting the devastating effects of this disease.

ORAL HEALTH RISKS

Patients who present for dental hygiene examinations and treatment may demonstrate signs of oral conditions, many of which can lead to detrimental effects with respect to both oral health and general health. Oral cancer, periodontal disease, caries and xerostomia are examples of oral disease that have risk factors requiring assessment. Opportunities exist to identify risks that may be prevented or reversed, or that have consequences that can be limited by early intervention.
Oral cancer remains a serious condition with statistics that have not improved substantially in more than 50 years. Approximately 35,000 people will be diagnosed with oral cancer each year and 7,600 will die from this disease.⁹ Early detection is critical to improving prognosis, however, the survival rate for oral cancer remains dismal. In general, only about 53 percent of people who are diagnosed with oral cancer will survive longer than five years. When this cancer has spread to distant sites, the survival rate drops to 28 percent.⁹ This rate is influenced by late diagnosis. Studies have demonstrated that oral healthcare providers do not routinely perform a comprehensive oral examination (COE) contributing to this late diagnosis and poor outcome.^10,11

There are multiple risk factors for oral cancer as highlighted in Table 2. It is important to note that a growing number of individuals do not present with these risk factors.¹² Evaluating risk factors and providing routine COE, supplemented by other diagnostic devices, may be the key to improving diagnosis and survival rates.

Like oral cancer, caries is a devastating disease that affects children, adults and the elderly. A recent study from the Pew Charitable Trusts revealed that two-thirds of states are doing a poor job ensuring proper dental health and access to care for children most in need. Within this report it was noted that the proportion of children between the ages of 2 and 5 with caries actually increased 15 percent within the past decade. Further, over 29 percent of 6- to 8-year-old children have untreated decay in their permanent or primary teeth.¹³ Many oral healthcare providers and clients fail to perceive caries as an infection thereby limiting the opportunities to prevent this disease. Steinberg¹⁴ refers to the need to diagnose caries as a condition of the entire mouth, not just a tooth or several teeth. He proposed using a comprehensive approach to caries diagnosis in order to use a more generalized chemotherapeutic approach to treatment with surgical treatment as a secondary consideration.

Risk factors for caries, including root caries, appear in Table 2. In this past decade, caries management by risk assessment (CAMBRA) has become accepted as the most current concept in caries assessment and management.¹⁵ CAMBRA incorporates both new and existing disease into the risk analysis. As well, it provides recommendations for treatment and predicts the likelihood of recovery or that further disease may develop. This risk assessment and proposed interventions are based on the concept of altering the caries balance between pathologic factors and protective factors.¹⁶ Five treatment categories are established for this protocol including:

• Caries-balanced low-risk
• Caries-balanced moderate-risk
• Caries-active moderate-risk
• Caries-active high-risk
• Caries-active extreme-risk

Treatment recommendations include behavioral, chemical and minimally invasive procedures. Evidence has shown that with the use of CAMBRA early damage to teeth from dental caries may be reversed and some manifestations of this disease prevented.¹⁷

PERIODONTAL RISK FACTORS

Periodontal diseases are another oral health challenge with systemic implications. Mild to moderate forms of periodontitis affect 30 to 50 percent of adults. The severe generalized form affects between 5 to 15 percent of all adults in the U.S.¹⁸ The American Academy of Periodontology (AAP) estimates that approximately 75 percent of Americans have some form of periodontal disease, from mild cases of gingivitis to severe forms of periodontitis.¹⁹ Risk factors for periodontal disease are summarized in Table 2. The AAP has an online risk assessment test for periodontal disease that can be accessed at www.perio.org.¹⁹

Previously, technology for standardized objective measurement of risk for periodontal conditions was not available. Consequently, there has been considerable variation between general dentists and periodontists, and between periodontists themselves affecting clinical decision making. It has been suggested that clinicians may not be providing the necessary preventive and reparative interventions for those clients who are at risk but do not yet manifest signs of periodontal disease, or for those who have early stages of the disease.²⁰ In 2003, Lang and Tonetti proposed use of a periodontal risk assessment (PRA) categorizing individuals into low, medium, or high-risk categories.²¹ Limitations of this model were described by Chandra in 2007.²² Page, et al, developed use of a Previser Risk Calculator designed to assign relative weights to known risks for periodontitis as well as provide a periodontal diagnosis. Possible treatment recommendations and interventions are color coded and ranked as most effective, possibly effective, and probably not effective. A recommendation for number of visits per year to maintain health is provided.²⁰ Chandra conducted a study comparing a new periodontal risk assessment model based on improvements to the Lang and Tonetti model that incorporates both local and systemic risk factors. Findings revealed that both models were adept at detecting potential risk groups.²²

DNA testing of periodontal pathogens measures the specific bacteria associated with periodontal diseases. Understanding the host susceptibility to periodontitis and knowing the bacteria involved can be useful in not only assessing risk, but also in treatment planning.

Xerostomia is a perception of oral dryness associated with multiple diseases, medications and lifestyle choices. Xerostomia is a common problem affecting approximately 25 percent of individuals, with elderly individuals having higher rates.^23,24 It is estimated that more than 60 percent of xerostomic symptoms can be attributed to the use of multiple medications.^25,26 It is important to note that xerostomia is a risk factor for other oral conditions, as well, including fungal infections and cervical caries.

Examples of risk factors for xerostomia appear in Table 2. The American Dental Hygienists’ Association recently published a screening tool for hyposalivation that can be accessed through www.adha.org. This tool summarizes conditions associated with hyposalivation and xerostomia, provides a mathematical basis for identifying risk, and proposes treatment options for low, moderate, and highrisk categories.²⁷

CLINICAL IMPLICATIONS

Conducting risk assessment procedures in dental and dental hygiene practice settings requires perceptual shifts. First, there is the issue of time. Most dental hygiene appointments do not allow time for significant review of medical and dental histories, medication risk assessment, and risk assessment for systemic and oral diseases. Performing these processes may take up to 30 minutes. One approach is to build time for these functions into the appointment schedule (although this additional time will need to be accounted for financially). Not all clients have dental insurance, and even those with coverage may question this additional time commitment. It is incumbent upon the practice to adopt a philosophy that places value on risk assessment, and communicates that value to its patients.

Another implication is the shift to preventive education and interventions. Too many times, practitioners are attempting to provide some oral hygiene education while performing scaling or debridement procedures being under the impression that two things can be accomplished at once. As can be seen from the multiple risk factors for the diseases described above, extensive preventive education may be warranted. This education should be tied directly to a diagnosis and treatment plan, provide the patient the opportunity to ask questions, and for procedures to be identified that incorporate follow-up.

Further, as captured by his presentation of caries risk assessment, Steinberg¹⁴ discussed the need for comprehensive care that evaluates the person as a whole. When we think in terms of a diseased tooth or gingival complex, we demonstrate tunnel vision that prevents us from considering the entire scope of treatment that can be utilized to prevent disease or provide early intervention to reverse disease processes. Opportunities are present to incorporate minimally invasive treatments, different types of fluoride vehicles, use of xylitol products, and various plaque preventive agents/ products. Collaborations with other healthcare specialists to maximize preventive approaches for total health are warranted.

Ultimately, as healthcare professionals, dental hygienists are responsible for the decisions made in terms of what is established for client care. The statistics noted for each general and oral disease were described as an impetus to inspire the oral health team to improve them. Performing risk assessment procedures may provide the means to achieve that goal.

REFERENCES

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From Dimensions of Dental Hygiene. May 2010; 8(5): 68-71.