This document discusses risk assessment in periodontal disease. It defines risk factors, determinants, indicators, and markers. Major risk factors discussed include smoking, diabetes, pathogenic bacteria, genetic factors, age, gender, and socioeconomic status. It also covers risk indicators like HIV/AIDS, osteoporosis, and infrequent dental visits. Recent advances in risk assessment tools are introduced, including the Oral Health Information Suite, Periodontal Risk Calculator, and the Hexagonal Risk Diagram for Periodontal Risk Assessment. Risk is assessed at the patient, mouth, tooth, and site levels.

1. Risk assessment
T.Hudson Jonathan
II nd yr MDS

2. Contents
 Introduction
 Risk factor for periodontal disease
 Risk determinants
 Risk indicators
 Risk markers
 Medical consideration and consultation
 Levels of risk assessment for periodontal disease
 Recent advances in Risk Assessment
 Conclusion
 References

3. Introduction
Risk is the probability that an individual will develop a
specific disease in a given period. The risk of
developing the disease will vary from individual to
individual.
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. (AAP 2008)

4. Risk assessment is defined by numerous
components. (Carranza 12th ed)
1. Risk factor
2. Risk determinants
3. Risk indicators
4. Risk markers

5. Risk factors may be environmental, behavioural or
biologic factors that, when present increase the
likelihood that an individual will develop the disease.
The term Risk determinants/background
characteristics which is sometimes substituted for
the term risk factor, should be reserved for those risk
factors that cannot be modified.

6. Risk indicators are probable or putative risk factors
that have been identified in cross-sectional studies
but not confirmed through longitudinal studies.
Risk predictors/markers ,although associated with
increased risk for disease, do not cause the disease.

8. Risk factor for periodontal disease
Tobacco smoking:
A wealth of data has established the relationship
between the amount and duration of smoking and
the severity of periodontal pathology.
Heat from smoke may enhance attachment loss,
and the increased calculus deposits that often
result from smoking can enhance plaque
retention. (koshi et al 2012)

9. Studies suggest that smokers are 11-times more
likely than non-smokers to harbor the bacteria that
cause periodontal disease and four-times more likely
to have advanced periodontitis. (Johnson et al
2004)
Studies comparing the response to periodontal
therapy in smokers, previous smokers and non-
smokers have shown that smoking has a negative
impact on the respone to therapy. However former
smokers respond smilarly to non –smokers.

10. Diabetes:
Diabetes is a clear risk factor for periodontitis.
Severity of periodontitis are said to be significantly
higher in patients with type I and type II dibetes
mellitus than in those without diabetes.(Carranza 12th
ed)
In these patients, host responses may be impaired,
wound healing is delayed and collagenolytic activity
may be enhanced.

11. As a result, periodontitis may be a particular problem
in patients with diabetes, especially in those with
uncontrolled disease.(Vernillo 2003)
Diabetes may also contribute to the pathogenesis of
periodontitis via associated vascular compromise,
deficits in cell-mediated immunity and the presence
of a high glucose content in the blood, which
enhances bacterial growth.

12. Pathogenic bacteria and microbial tooth deposits:
It is well documented that accumulation of bacterial
plaque at the gingival margin results in the
development of gingivitis that demonstrate a causal
relationship between bacterial plaque and gingival
inflammation.
However, a causal relationship between plaque
accumulation and periodontitis has been more
difficult to establish.

13. In terms of quality of plaque, three specific bacteria
have been identified as etiologic agents for
periodontitis: Aggregatibacter
actinomycetemcomitans ,Porphyromonas gingivalis,
and Tannerella forsythia.(Carranza 12th ed)
Cross-sectional and longitudinal studies support the
delineation of these three bacteria as risk factors for
periodontal disease.

14.  Additional evidence that these organisms are causal
agents includes the following:
1. Their elimination or suppression impacts the
success of therapy.
2. There is a host response to these pathogens.
3. Virulence factors are associated with these
pathogens.
4. Inoculation of these bacteria into animal models
induces periodontal disease.

15. Risk Determinants
Genetic Factors:
In recent years, genetic markers have become
available to determine various genotypes of patients
regarding their susceptibility to periodontal diseases.
Research on the Interleukin-1 (IL-1) polymorphisms
has indicated that IL-1 genotype-positive patients
show more advanced periodontitis lesion than IL-1
genotype-negative patients of the same age group.

16. In a retrospective analysis of over 300
well-maintained periodontal patients, the IL-1
genotype yield higher BOP% during a 1-year recall
period than the control group
This supports the theory that specific environmental
factors can be strong risk factors and that they
overhelm any genetically determined susceptibility or
resistance to disease.(Lang et al 2003)

17. AGE:
Both the prevalence and severity of periodontal
disease increase with age. It is possible that
degenerative changes related to aging may increase
susceptibility to periodontitis.
Changes related to the aging process, such as
intake of medications, decreased immune function,
and altered nutritional status, interact with other well-
defined risk factors to increase susceptibility to
periodontitis. (Muzzi et al 2006)

18. Evidence of loss of attachment may have more
consequences in younger patients. The younger the
patient, the longer the patient has for exposure to
causative factors.
In addition, aggressive periodontitis in young
individuals often is associated with an unmodifiable
risk factor such as a genetic predisposition to
disease.

19. Gender:
Gender plays a role in periodontal disease. Surveys
conducted in the United States since 1960
demonstrate that men have more loss of attachment
than women.
In addition, men have poorer oral hygiene than
women, as evidenced by higher levels of plaque and
calculus. Therefore, gender differences in
prevalence and severity of periodontitis appear to be
related to preventive practices rather than any
genetic factor. (Carranza 12th ed)

20. Socioeconomic Status
Gingivitis and poor oral hygiene can be related to
lower socioeconomic status (SES). This can most
likely be attributed to decreased dental awareness
and decreased frequency of dental visits compared
with more educated individuals with higher SES.
After adjusting for other risk factors, such as
smoking and poor oral hygiene, lower SES alone
does not result in increased risk for periodontitis.

21. Stress:
The incidence of necrotizing ulcerative
gingivitis increases during periods of
emotional and physiologic stress,
suggesting a link between the two.
Emotional stress may interfere with
normal immune function and may
result in increased levels of circulating
hormones, which can affect the
periodontium.

22. Adult patients with periodontitis who are resistant to
therapy are more stressed than those who respond
to therapy. (Genco et al 1999)
Although epidemiologic data on the relationship
between stress and periodontal disease are limited,
stress may be a putative risk factor for periodontitis.

23. Risk Indicators
HIV/AIDS:
It has been hypothesized that the immune
dysfunction associated with HIV infection and AIDS
increases susceptibility to periodontal disease.
Early reports on the periodontal status of patients
with HIV/AIDS revealed that these patients often had
severe periodontal destruction characteristic of
necrotizing ulcerative periodontitis.

24. Results of other studies have found
no relationship between periodontal
diseases and HIV/AIDS status.
Evidence also suggests that affected
individuals who practice good oral
health measures, and seeking
appropriate professional therapy, can
maintain periodontal health. So the
results are not conclusive.

25. Osteoporosis:
Osteoporosis has been suggested as another risk
factor for periodontitis. Although studies in animal
models indicate that osteoporosis does not initiate
periodontitis, reports in humans are conflicting.
In a study of 12 women with osteoporosis and 14
healthy women, von Wowern et al reported that the
women with osteoporosis had greater loss of
attachment than the control subjects.

26. In contrast, Kribbs examined pocket depth, bleeding
on probing, and gingival recession in women with
and without osteoporosis. Although the two groups
had significant differences in bone mass, no
differences in periodontal status were noted.
However, it appears that a link may exist between
osteoporosis and periodontitis, and additional
studies may need to be conducted to determine
whether osteoporosis is a true risk factor for
periodontal disease. (Carranza 12th ed)

27. Infrequent Dental Visits:
The lack of oral hygiene encourages bacterial
build-up and biofilm plaque formation, and can also
increase certain species of pathogenic bacteria
associated with more severe forms of periodontal
diseases (Axelsson et al 2004).
One study demonstrated an increased risk for
severe periodontitis in patients who had not visited
the dentist for 3 or more years.

28. whereas another demonstrated that there was no
more loss of attachment or bone loss in individuals
who did not seek dental care compared with those
who did over a 6-year period.
Additional longitudinal and intervention studies are
necessary to determine whether infrequency of
dental visits is a risk factor for periodontal disease

29. Risk Markers/Predictors
Previous History of Periodontal Disease:
A history of the previous periodontal disease is a good
clinical predictor of risk for future disease. Patients with
the most severe existing loss of attachment are at the
greatest risk for future loss of attachment.
Conversely, patients currently free of periodontitis have
a decreased risk for developing loss of attachment
compared with those who currently have periodontitis.

30. Bleeding on Probing:
Bleeding on probing is the best clinical indicator of
gingival inflammation. Although this indicator alone
does not serve as a predictor for loss of attachment,
bleeding on probing coupled with increasing pocket
depth may serve as an excellent predictor for future
loss of attachment.
Lack of bleeding on probing does appear to serve
as an excellent indicator of periodontal health.

31. Medical considerations and consultation
Medical consultation should be obtained when the
medical history indicates a need for more
information.
When patients give a history of a heart murmur or
joint replacements, Periodontal probing or any
procedure that may induce bleeding should be
excluded in patients with high or moderate risk for
endocarditis unless antibiotic prophylaxis is provided
(Dajani et al 1997).

32. According to other recommendations, patients with
orthopedic pins, plates and screws do not need
antibiotic prophylaxis, nor is it routinely needed for
most dental patients with total joint replacements
(ADA 1997).
However, it is advisable to consider prophylaxis in
some patients and it is important to consult with the
patient’s physician before procedures are
done.(perio 2000)

33. Levels of risk assessment for periodontal disease
One of the problems with risk assessment in periodontal
disease is that the diseases are multifactorial and
assessment should therefore be at multiple levels. In
simple terms, there are four levels to consider:
1. The patient level - Perform at initial examination
2. The whole mouth level - Perform at initial examination
and post-initial therapy
3. The tooth level - Perform post-initial/definitive therapy
and maintenance
4. The site level - Perform post-definitive therapy and
during maintenance

34. Patient-level risk assessment
Patient-level risk assessment can be determined at
the initial consultation by performing the following:
I. Family history - a detailed history of gum disease
or early tooth loss in the family.
II. Medical history for systemic diseases
III. Present dental history – Assess motivation to oral
hygiene.
IV. Social history, which includes smoking – current
or former smoker
V. Habits like bruxism.

35. Mouth-level risk assessment:
Mouth-level risk assessment would be performed at
the initial examination, after a basic periodontal
examination, and would include:
1. Examination of attachment loss relative to age
2. Occlusal examination in static relationship
3. Occlusal examination in dynamic relationship
4. Examination of levels of oral hygiene
5. Examination of levels of plaque-retentive factors
6. Presence of removable prosthesis
7. Levels of recession
8. Gingival inflammation and depth of pockets.

36. Tooth-level risk assessment:
Tooth-level risk assessment may or may not be
carried out at the initial examination. Part of this
assessment includes:
1. Individual tooth mobility (mobility index)
2. Tooth movement or drifting of periodontally
compromised teeth
3. Residual tooth support (radiographically). The
extent of residual radio graphic bone support
helps determine long-term prognosis.

37. 4. Presence, location and extent of furcation lesions
5. Individual tooth anatomy – Presence of “talon
cusps” or bulbous crowns
6. Anatomy of tooth embrasures and contact points
7. Presence of ledges or deficiencies on restorations
8. Individual occlusal contacts – Prematurities
9. Soft tissue contours
10. Subgingival calculus.

38. Site-level risk assessment:
Site-level risk assessment would include:
1. Bleeding on probing
2. Exudation from periodontal pockets
3. Local root grooves or root concavities
4. Individual probing pocket depth
5. Attachment levels
6. Other anatomical factors like enamel pearls, root
grooves.

39. RECENT ADVANCES IN RISK ASSESSMENT
Periodontal risk assessment tools
1. The oral health
information suite (OHIS)
2. Periodontal Risk
Calculator (PRC)
3. Hexagonal risk diagram
for Periodontal Risk
Assessment (PRA)
4. Periodontal risk
assessment model
developed by Chandra
5. UniFe (Union of European
Railway Industries) for
periodontal risk assessment
6. AAP Risk Assessment Tool
7. Dentorisk
8. Cronin/Stassen BEDS
CHASM Scale
9. Risk Assessment-Based
Individualized Treatment
(RABIT)
10. Genetic tests

40. 1. The Oral Health Information Suite (OHIS):
OHIS is an information system protected under the
U.S. Patent #6,484,144. In addition to quantifying the
current periodontal disease state, it also quantifies the
risk for future disease.
A diagnosis is made and a risk score as well as a
disease score are calculated.

41. Based on these scores, it is said to be those of most
likely to be successful, less likely and most unlikely to
be successful.
On re-examination change in the risk and disease
state are automatically analyzed by the system and
are used to update the risk and disease scores as well
as to refine and improve the most appropriate
treatments for any given set of conditions.(Page et al
2005)

42. 2. Periodontal Risk Calculator (PRC):
In 2002, Page et al introduced the Periodontal Risk
Calculator (PreViser), a component of the Oral Health
Information Suite.
The PRC is a web-based tool that can be accessed
through a dental office computer. The risk calculation
is a multi-step process involving mathematical
algorithms that use nine risk factors.

43. • Patient age
• Smoking history
• Diagnosis of diabetes
• History of periodontal surgery
• Pocket depth
• Furcation involvements
• Restorations or calculus below the gingival margin
• Radiographic bone height
• Vertical bone lesions.

44. PRC assigns the individual a level of risk on a
scale ranging from 1 (lowest risk) to 5 (highest
risk).
The risk score is increased if there is a positive
history of periodontal surgery, smokers of more
than 10 cigarettes per day or the poorly controlled
diabetes.

45. 3. The Hexagonal Risk Diagram For Periodontal Risk
Assessment (PRA):
PRA model is a functional diagram, described by Lang
and Tonetti based on six parameters for estimating an
individuals’ risk for progression of periodontitis.
The PRA model consists of an assessment of the level
of infection, the prevalence of residual periodontal
pockets, tooth loss, an estimation of the loss of
periodontal support in relation to the patient’s age, an
evaluation of systemic, genetic conditions and an
evaluation of the environmental/ behavioural factor.

46. If a systemic or genetic factor
is known, the area of high risk
is marked for this parameter.
All other parameters have
their own scale for low-,
moderate and high–risk
profiles. (Lang et al 2003)
Recent advances in periodontal risk assessment-A review, Kiran et al;Journal of
scientific dentitry 6(2);2016
Hexagonal Risk Diagram

47. 4. The Periodontal Risk Assessment Model
developed by Chandra:
In 2007, Chandra evaluated a periodontal risk
assessment model based on Lang and Tonetti’s
model, where the following parameters are recorded:
Sites with bleeding on probing, pocket depths ≥ 5mm,
number of teeth lost, bone loss/age ratio, attachment
loss/age ratio, diabetic and smoking status, dental
status, other systemic factors and risk determinants.

48. In this model, DM is separated from systemic
conditions. It uses a five-point scale for each
factor. The Periodontal Risk Assessment Model

49. In contrast to the PRC, which is calculated at the
onset of treatment, the PRA provides an
assessment of risk for patients during the
supportive, post treatment phase, after active
therapy has been completed.

50. 5. The Simplified Method (UniFe) For Periodontal
Risk Assessment:
In 2009, Trombelli et al proposed a new objective
method (UniFe) (Union of European Railway
Industries) to simplify the risk assessment procedures.
It is based on five parameters, smoking status,
diabetic status (both type 1 and type 2), number of
sites with probing depth ≥ 5mm, bleeding on probing
score, and bone loss/age records.

51. Recent advances in periodontal risk assessment-A review, Kiran et al;Journal of
scientific dentitry 6(2);2016
UniFe method

52. 6. American Academy Of Periodontology Self-
Assessment Tool:
The web based self assessment tool is a brief
13-item questionnaire that include the person’s
age (three response options: <40; 40–65; >65
years) and their flossing behavior (daily, weekly,
seldom).
Other items have simple response choices of:
I. Yes or no,

53. II. Options of don’t know (family history of gum
disease, are your teeth loose, heart disease,
osteoporosis, osteopenia, high stress or diabetes) or
III. Option of don’t remember (seen a dentist in the last
2 years, ever been told that you have gum
problems, gum infection or gum inflammation).
(koshi et al 2012)
By answering the questions, the website inform users
to see if they are at risk for having or developing
periodontal (gum) disease.

54. 7. Dentorisk
Lindskog et al 2010 developed a computerized risk
assessment and prognostication program (DentoRisk)
that is used in conjunction with a skin test for
inflammatory reactivity (Dento test). This model takes
20 factors into consideration including:
Systemic Predictors:
Age in relation to history of chronic periodontitis,
family history, systemic disease, result of skin
provocation test, patient cooperation and disease
awareness, socioeconomic status, smoking, clinician
experience.

55. Local Predictors:
Bacterial plaque,
endodontic pathology,
furcation involvements,
vertical intrabony defects,
radiographic marginal
bone levels, PD, BOP,
marginal dental
restorations, increased
tooth mobility, missing
teeth, abutment teeth,
presence of purulence.
Dentorisk model

56. This model differs in that the assessment is first
calculated from patient’s overall dentition (Level I).
If an elevated risk is detected, a prognosis for
annualized attachment loss for each individual tooth
(Level II) is then computed which is used for
treatment planning.

57. 8. Cronin/Stassen BEDS CHASM Scale:
This represents a four step risk assessment model.
The calculated Odds ratio helps to standardize risk
assessment, allowing factors to be easily compared
with the standard numerical index .
B-BMI Score 2
E-Ethnicity Score 1.5
D-Diabetic Score 2.5
S-Stressed Score 2

58. C-College Score 2.5
H-Hygiene Score 2
A-Age 65+ Score 3.5
S –Smoker Score 1.5
M –Male Score 1.5
The total score of 19 indicates the highest risk.
(Cronin et al 2008)

59. 9. Risk Assessment-Based Individualized Treatment
(RABIT)
In this,First risk assessment is done as part of the initial
diagnosis; recall schedules should be automatically
generated immediately following risk determination.
Second, multiple recall schedules that address different
risk factors need to be implemented; For example, a
patient can be scheduled for quarterly appointments
because of his or her periodontal situation.

60. Third, following periodic reevaluation, the risk for a
particular category may change requiring a new recall
schedule for that category .
Fourth, whenever possible, recall appointments driven
by different risk factors should be combined into single
recall appointments .
Fifth, the electronic recall system should automatically
delete caries risk- and periodontal risk-driven recall
schedules when a patient becomes edentulous. (Sorin
et al 2013)

61. 10. Genetic Tests:
This test determines whether people possess a
combination of alleles in two IL-1 genes. Studies have
reported an increased frequency of a different IL-1
genotype in people with advanced adult periodontitis
compared with those with early or moderate disease.
A recent prospective study reported that this composite
genotype was not associated with progressive clinical
attachment loss during a 2 year period after periodontal
therapy. So more research is needed to evaluate its
utility (Kornman et al 1997)

62. Carranza’s clinical
periodontology 13th edition

63. Conclusion
The aim of risk assessment is to provide the clinician
with the opportunity to develop a risk-based treatment
plan which will incorporate the level of risk as well as
the severity of periodontal disease.
It also highlights the opportunity to develop an acurate
treatment plan that targets the risk factors, such as
periodontal pocket depth, bacteria, tobacco use, and
diabetic control for the purpose of reducing risk .

64. References
Carranza’s clinical periodontology-12th & 13th edition.
Koshi et al, Risk assessment for periodontal disease-
A review; Journal of Indian Society of Periodontology -
Vol 16, Issue 3, Jul-Sep 2012
Kiran et al,Recent Advances In Periodontal Risk
Assessment-A review;Journal of scientific dentistry
6(2);2016.
Bruce et al,Periodontal risk assessment, diagnosis
and treatment planning; Periodontology 2000, Vol.
25, 2001, 37–58

65. Lang NP, Tonetti MS. Periodontal Risk
Assessment (PRA) for patients in supportive
periodontal Therapy (SPT). Oral Health Prev
Dent 2003;1:7-16.
Kornman et al. The interleukin –I genotype as a
severity factor in adult periodontal disease. J Clin
Periodontol 1997;24:72-7.
American Academy of Periodontology statement
on Risk Assessment. J Periodontol 2008;2:202.

66. Thank you