Risk Factors for Periodontal Disease: A Review

324 Journal of Indian Society of Periodontology - Vol 16, Issue 3, Jul-Sep 2012
Review Article
Address for
correspondence:
Dr. Elizabeth Koshi,
Professor and Head of
Department, Department
of Periodontics, Sree
Mookambika Institute
of Dental Sciences,
Kulasekharam,
Kanyakumari,
Tamil Nadu, India.
E‑mail: elizabethkoshi_dr@
yahoo.com
Submission: 01‑10‑2010
Accepted: 12‑12‑2011
Departments of
Periodontics and
1
Conservative
Dentistry, Sree
Mookambika Institute
of Dental Sciences,
Kulashekharam,
Kanyakumari,
Tamil Nadu,
2
Department of
Orthodontics, GDC,
Kottayam, Kerala, India
Risk assessment for periodontal disease
Elizabeth Koshi, S. Rajesh1
, Philip Koshi2
, P. R. Arunima1
Abstract:
The prevention and treatment of periodontal disease is based on accurate diagnosis, reduction or elimination
of causative agents, risk management and correction of the harmful effects of the disease. The practice of risk
assessment involves dental care providers identifying patients and populations at increased risk of developing
periodontal disease. This can have a significant impact on clinical decision making. Risk assessment reduces
the need for complex periodontal therapy, improve patient outcome and, ultimately, reduce oral health care cost.
The awareness of risk factors also helps with the identification and treatment of co‑morbidities in the general
population as many periodontal disease risk factors are common to other chronic diseases such as diabetes,
cardiovascular diseases and stroke.
Key words:
Periodontal disease, risk assessment, risk assessment tools, risk factors
INTRODUCTION
Overthelastthreedecades,ourunderstanding
on the pathogenesis and etiology
of periodontal diseases has grown greatly.
Numerous studies have demonstrated that the
host plays a major role in the pathobiology of
periodontitis and that risk varies greatly from one
individual to another.[1]
Identifying risk factors
and indicators, as well as undertaking measures
that can reduce the risk, can help in maintaining
oral health and prevent the onset of any form of
periodontal disease. Risk management involves
dental care providers to identify patients and
populations at increased risk of developing
periodontal disease. Assessing patients risk
of developing periodontal disease can have a
significant impact on clinical decision making.
Some risk factors can be modified to reduce
one’s risk of initiation or progression of disease,
such as smoking or improved oral hygiene,
while other factors cannot be modified, such as
genetic factors.[2]
Risk factors for periodontal disease
Risk can be identified in terms of risk factors,
risk indicators or risk predictors. A risk factor
is thought to be a cause for a disease. It should
satisfy two criteria: (1) it is biologically plausible
as a casual agent for disease and (2) it has been
shown to precede the development of disease
in prospective clinical studies. Risk factors
are biologically related to the occurrence of the
disease, but they do not necessarily imply cause
and effect, i.e. just because a patient possesses a
risk factor does not mean that they will definitely
develop the disease. Equally, absence of a risk
factor does not mean that the disease will not
develop. Evidence in the literature points to the
direct and significant link between several risk
factors and periodontal disease.[3]
Risk factors may be broadly categorized as:
1. Systemic risk factors – factors that affect the
host response to the plaque biofilm, upsetting
the host–microbial balance.
2. Localriskfactors – factorslocaltotheoralcavity,
which may influence plaque accumulation or
occlusal forces.[4]
Age
As people age, their risk for developing
periodontal disease increases. Over half of the
adult population has gingivitis, a less severe form
of periodontal disease surrounding three to four
teeth,andnearly30%havesignificantperiodontal
disease. In a study of people over 70 years old,
86% had at least moderate periodontitis or a
severe form of periodontal disease, and over
one‑fourth of this 86% had lost their teeth. The
study also showed that the disease accounted for
a majority of tooth extractions in patients older
than 35 years of age.[5,6]
Use of tobacco
A wealth of data has established the relationship
between the amount and duration of smoking
and the severity of periodontal pathology. Both
local and systemic mechanisms mediate the
negative impact of tobacco use on oral health.
Heat from smoke may enhance attachment
loss, and the increased calculus deposits that
often result from smoking can enhance plaque
retention. Nicotine can diminish collagen
synthesis and protein secretion and inhibit bone
formation. These findings result in impaired
wound healing as well as increased susceptibility
to periodontal disease, which may limit the
success of treatment interventions. Smoking
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Journal of Indian Society of Periodontology - Vol 16, Issue 3, Jul-Sep 2012 325
Koshi, et al.: Risk assessment
also inhibits immunological function and negatively affects
immunoglobulin levels, which may increase susceptibility to
typical and unusual microbial pathogens.[7]
A number of studies indicate that the nicotine found in
tobacco products triggers the overproduction of cytokines
in the body due to lowered oxygen levels. Cytokines are
signaling chemicals involved in the process of periodontal
inflammation. When nicotine combines with oral bacteria,
such as P. gingivalis, it results in higher levels of cytokines,
leading to breakdown of the supporting tissues of the teeth.
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. In one study, over 40% of smokers had lost their
teeth by the end of their lives. The risk of periodontal disease
increases with the number of cigarettes smoked per day. It is
important to note that smoking cigars and pipes carries the
same risk as smoking cigarettes.[8,9]
Diabetes mellitus
There is much evidence showing a link between type 1 and
2 diabetes mellitus and periodontitis. Diabetes has been
associated with a number of oral complications, including
gingivitis and periodontitis, dental caries, salivary gland
dysfunction and xerostomia, burning mouth syndrome and
increased susceptibility to oral infections. Of particular concern
are patients with diabetes who are at an increased risk of
developing periodontitis. In these patients, host responses
may be impaired, wound healing is delayed and collagenolytic
activity may be enhanced. As a result, periodontitis may be a
particular problem in patients with diabetes, especially in those
with uncontrolled disease.[10]
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. Furthermore, active inflammation characteristics of
periodontitis generates compounds that may increase insulin
resistance. Therefore, control of periodontal disease may
help patients improve metabolic control. Obesity, which is
common in type 2 diabetes, may also predispose a person to
periodontal diseases.[11,12]
Stress
It has been strongly suggested that stress and related
body distress are important risk indicators for periodontal
disease. A recent study shows that people under physical
or psychological stress are prone to elevated biofilm plaque
levels and increased gingivitis.[13]
It also seems likely that high
levels of financial stress and poor coping abilities increase
the likelihood of developing periodontal disease two‑fold.
Furthermore, it is likely that systemic disease associated with
periodontal disease such as diabetes, cardiovascular diseases,
pre‑term delivery and osteoporosis may share psychosocial
stress as a common risk factor. However, a direct association
between periodontal disease and stress remains unproven.[14]
Genetic risk 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 periodintitis
lesion that IL‑1 genotype‑negative patients of the same age
group. Also there is a trend to higher tooth loss in the IL‑1
genotype‑positive subjects. 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
IL‑1 genotype‑negative control patients. This supports the
theory that specific environmental factors can be strong risk
factors and that they overwhelm any genetically determined
susceptibility or resistance to disease.[15,16]
Pregnancy
Periodontal disease has been shown to be associated with
pre‑term delivery and low birth weight, both of which put
infants at risk of experiencing increased medical complications.
Analysis of gingival crevicular fluid has demonstrated
significantly higher levels of the inflammatory mediator
prostaglandin E2 in women who delivered pre‑term low
birth weight infants. However, other research has failed to
demonstrate a link between pre‑term low birth weight babies
and periodontal disease.[17,18]
Cardiovascular diseases
Cardiovascular diseases affect adults, and there is evidence
that links periodontitis and cardiovascular diseases. C‑reactive
proteinisasystemicmarkerforinflammation.Theplasmalevels
of this marker are predictive of future myocardial infarct and
stroke. Patients with periodontitis have demonstrated elevated
C‑reactive protein levels. Some investigators have suggested
that the chronic inflammatory burden of periodontitis may
contribute to cardiovascular diseases.[19]
In an analysis of
4561 subgingival plaque samples collected from 657 subjects,
Desvarieux and colleagues found a direct relationship between
periodontal bacterial burden and subclinical atherosclerosis.
Other reports have noted associations between cerebrovascular
stroke and tooth loss, bone loss and poor dental status, although
the precise mechanisms that mediate these multiple pathogenic
processes have not been delineated.[20]
Poor oral hygiene as a risk factor
Many studies have demonstrated significant reductions in
probing pocket depths, attachment gains and, of course, in
gingival inflammation, with improvements in oral hygiene
alone. 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.[21]
Risk indicators
A risk indicator is a factor that is biologically plausible as a
causative agent for a disease but has only been shown to be
associated with disease in cross‑sectional studies. An example
of a risk indicator of periodontal disease is the presence of
herpes viruses in subgingival plaque. A risk predictor is a
factor that has no current biological plausibility as a causative
agent but has been associated with disease on a cross‑sectional
or longitudinal basis. Example, the number of missing teeth is
a risk predictor for disease, but has little or no plausibility as a
causative agent for periodontitis.[3]

Risk assessment
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.[22]
One of the problems with risk assessment in periodontal disease
is that the diseases are multifactorial and assessment should
therefore be at multiple levels. The presence of pathogenic
bacteria alone is not sufficient to cause the disease. In simple
terms, there are four levels to consider:
1. The patient level Perform at initial examination
2. The whole mouth level Performatinitialexaminationand
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
This approach also allows the clinician to separate risk factors
that may initiate periodontal disease from those responsible for
its progression or for the failure of initial therapy.[23,24]
Patient‑level risk assessment
Patient‑level risk assessment can be determined at the initial
consultation by performing the following:
• Family history for hereditary, inborn or genetic risk factors.
Take a detailed history of gum disease or early tooth loss
in the family.
• Medical history for systemic diseases, e.g. diabetes mellitus,
cardiovascular diseases, osteoporosis
• Present dental history – Assess motivation to oral hygiene.
• Social history, which includes smoking – current or former
smoker
• Habits like bruxism.
Mouth‑level risk assessment
Mouth‑level risk assessment would be performed at the initial
examination, after a basic periodontal examination, and would
include:
• Examination of attachment loss relative to age
• Occlusal examination in static relationship
• Occlusal examination in dynamic relationship
• Examination of levels of oral hygiene
• Examination of levels of plaque‑retentive factors
• Presence of removable prosthesis
• Levels of recession
• Gingival inflammation and depth of pockets.
Tooth‑level risk assessment
Tooth‑level risk assessment may or may not be carried out
at the initial examination. A detailed periodontal chart and
radiographic assessment should be performed. Part of this
assessment includes:
• Individual tooth mobility (mobility index)
• Tooth movement or drifting of periodontally compromised
teeth
• Residual tooth support (radiographically). The extent
of residual radio graphic bone support helps determine
long‑term prognosis.
• Presence, location and extent of furcation lesions
• Individual tooth anatomy – Presence of “talon cusps” or
bulbous crowns
• Anatomy of tooth embrasures and contact points
• Presence of ledges or deficiencies on restorations
• Individual occlusal contacts – Prematurities
• Soft tissue contours
• Subgingival calculus.
Site‑level risk assessment
Site‑level risk assessment would include:
• Bleeding on probing
• Exudation from periodontal pockets
• Local root grooves or root concavities
• Individual probing pocket depth
• Attachment levels
• Other anatomical factors like enamel pearls, root grooves.
The clinical practice of risk assessment
Most dentists and periodontists are not trained or experienced
in risk assessment nor in using interventions aimed at risk
reduction in the prevention and management of periodontal
diseases. Manually summarizing and analyzing the risk factors
could be a complex process. Hence, a computer‑generated risk
assessment model can aid in the identification of patients at
elevated risk of developing periodontal disease, and may help
in the selection of patients who require additional education
or targeted interventions to prevent or minimize the impact
of periodontal disease. Several models like the Oral Health
Information Suite (OHIS), Periodontal Risk Calculator (PRC)
and American Academy of Periodontology self‑assessment
tool have been used to assess risk.[25]
The oral health information suite
OHISä is an information system protected under the U.S.
Patent #6,484,144. The system is comprised of a suite of
related tools for major oral health conditions including caries,
periodontal disease and oral cancer. OHIS is unique for
clinical dentistry by virtue of quantifying the risk for future
disease in addition to quantifying the current periodontal
disease state. Both clinical and radiographic examinations
are conducted including medical and dental histories,
with specific questions concerning risk factors for oral
disease. Diagnostic and demographic data and the patient
and provider objectives are entered into the assessment
tool appropriate for the disease state under consideration.
A diagnosis is made and a risk score and a disease score are
calculated. Based on these scores, treatment and interventions
are ranked and color coded as those most likely to be
successful, those less likely and those most unlikely to be
successful. The recommended treatment plan is evaluated
and modified by the dentist and patient to their satisfaction,
and the treatments and interventions are performed. On
re‑examination following treatment, post‑treatment risk
and disease assessment are performed. Change in 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.[26]
Periodontal risk calculator
The PRC is a web‑based tool that can be accessed through a

Journal of Indian Society of Periodontology - Vol 16, Issue 3, Jul-Sep 2012 327
dental office computer. PRC was developed using the six design
parameters on a desktop computer using Microsoft Excel.
1. PRC calculated risk is for future periodontal disease for
those patients who do not yet have it and risk for future
progression of periodontal disease for those who already
have it.
2. A risk factor is defined as a factor that is part of the causal
chain of disease or exposes the patient to the casual chain,
which, if present, directly increases the probability of
disease occurring and, if absent, reduces the probability.
3. A risk factor must have a scientific basis that is supported
by publication in refereed scientific journals.
4. The application of risk assessment information through the
development of treatment recommendations to reduce risk
must occur.
5. All requisite information must be obtained during a
traditional periodontal examination as performed by
dentists in the United States; the time required for data
collection and input must fit within the usual time these
dentists use for diagnosis.
6. A five‑point risk scale is to be used to balance the sensitivity
of risk assessment with the time and cost required to obtain
the necessary information.
The calculation of risk is a multi‑step process involving
mathematical algorithms that use nine risk factors, including:
• 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.
A three‑point scale is used to document pocket depth and
radiographic bone height. An algorithm was developed to
quantify disease severity from pocket depth and bone height
values. The base risk score is calculated using an algorithm that
correlates disease severity with age. The risk score is increased
if there is a positive history of periodontal surgery and if the
patient smokes more than 10 cigarettes per day, or the patient
has diabetes that is poorly controlled. The existence of furcation
involvements, vertical bone lesions or subgingival restorations
or calculus increase risk when the risk score is otherwise less
than four.[27]
American academy of periodontology self‑assessment tool
The web‑based self‑assessment tool available on the American
Academy of Periodontology website is a good example
of the value and limitations of how knowledge about the
role of individual periodontal risk factors may be used in
combination to educate patients, raise awareness and assist
in decision‑making. The tool’s web interface is a brief 13‑item
questionnaire that asks straightforward questions that most
persons would be able to answer easily. The items 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 yes or no, whereas several
items in addition to the yes/no option also include the option
of don’t know (any of your family members had gum disease,
are your teeth loose, do you currently have any of the following
health conditions, i.e. heart disease, osteoporosis, osteopenia,
high stress or diabetes) or the 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). The answers
to the questions are combined using a proprietary algorithm
to yield one of three risk categories: low risk, medium risk or
high risk. The website informs users that by using the answers
to the questions, the self‑assessment tool will help them to see
if they are at risk for having or developing periodontal (gum)
disease.[28]
Genetic tests
Recently, a genetic test was available to test patients for
periodontal disease risk. This test determines whether
people possess a combination of alleles in two IL‑1 genes.[16]
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. There is
also retrospective evidence that genetic testing for the specific
IL‑1 genotype may give indication of increased susceptibility to
tooth loss in periodontal maintenance patients. A more recent
prospective study reported that this composite genotype was
not associated with progressive clinical attachment loss during
a 2‑year period after periodontal therapy. However, it may be
concluded that genetic testing has potential for the future, but
more research is needed to evaluate its utility.[3]
CONCLUSION
Risk assessment is an important part of modern day periodontal
practice. It is recommended that systemic and local risk factors
are documented alongside the diagnosis in patients’ case
records. The practice of risk assessment allows dental care
professionals the opportunity to improve dental and medical
outcomes in the general population and in specific population
groups by focusing on early identification and prevention of
dental diseases, especially periodontal disease.
The inclusion of a risk assessment tool in routine practice would
add only a small amount of time to patient visits. Signs and
symptoms targeted in risk assessment might include pocket
depth, bleeding on probing, poor oral hygiene, persistent
inflammation, loss of attachment, smoking, increasing pocket
depth, pregnancy and diabetes. Among the general public,
use of a risk assessment instrument may help identify the
20% of patients in need of intervention to prevent or minimize
development of more advanced periodontal disease.
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How to cite this article: Koshi E, Rajesh S, Koshi P, Arunima PR.
Risk assessment for periodontal disease. J Indian Soc Periodontol
2012;16:324-8.
Source of Support: Nil, Conflict of Interest: None declared.

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