Risk factors and risk assessment of periodontal disease.

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Risk factors and risk assessment of periodontal disease.

  1. 1. Presented by Dr. Guru Ram Tej. K Post Graduate Mamata Dental College
  2. 2. CONTENTS..  INTRODUCTION  TERMINOLOGIES  CLASSIFICATION OF RISK FACTORS  RISK ELEMENTS FOR PERIODONTAL DISEASE  RISK ASSESSMENT
  3. 3. TOOLS TO MEASURE RISK Periodontal Screening And Recording (P S R) Interactive Patient Questionnaire Patient Assessment Tool Of OHIS Patient Risk Calculator (Previeser) Uni Fe Hexagonal Risk Diagram For Periodontal Risk Assessment Periodontal Risk Assessment By Vishwa Chandra H I D E P Model Continuous Multilevel Risk Assessment By Lang And Bragger Cronin/ Stassen Beds Chasm Scale Continuous Multilevel Risk Assessment In 2011 Periodontal Risk Using Two Artificial Neural Networks CONCLUSION REFERENCES
  4. 4. INTRODUCTION  Risk  According to American Academy Of Periodontology utilizing risk assessment helps dental professionals predict the potential for developing periodontal diseases and allows them to focus on early identification and to provide proactive, targeted treatment for patients who are at risk for progressive/ aggressive diseases
  5. 5. TERMINOLOGIES  RISK  Risk factors  Risk determinants  Risk indicators  Risk predictors
  6. 6. CLASSIFICATION  Based on the evidence  Primary risk factor  Secondary risk factor  Tertiary risk factor
  7. 7. Pathogenesis of periodontitis Cytokines and prostaglandins Neutrophils Antibodies Complement Bacterial load Antigen LPS Other virulence factors Host response MMP Turn over Serine proteases Oxygen radicals Tissue degradation Clinical changes
  8. 8. RISK FACTORS  GENETIC  ENVIRONMENTAL  BEHAVIOURAL  LIFE STYLE  METABOLIC  HEMATOLOGICAL  GENDER  AGE
  9. 9. RISK FACTORS  HIV  PREVIOUS HISTORY  SOCIOECONOMIC STATUS  BLEEDING ON PROBING  OSTEO POROSIS  NUTRITION  BACTERIA
  10. 10. GENETIC  Polymorphisms
  11. 11.  During periodontal inflammation cytokines activate the catabolic enzymes such as matrix metalloproteinases leading to breakdown of connective tissue, any gene polymorphism of such proteins alters the susceptibility of host.  Michalowicz et al in 2000, demonstrated the hereditary aggregation in a twin study for chronic periodontitis
  12. 12. Pathogenesis of periodontitis Cytokines and prostaglandins Neutrophils Antibodies Complement Bacterial load Antigen LPS Other virulens factors Host response MMP Turn over Tissue degradation Clinical changes Serine proteases Oxygen radicals Interleukin +
  13. 13. BEHAVIOURAL RISK FACTORS  Stress “I tell you, if you don’t get my home soon and help me with these children, I will get gum disease”
  14. 14. STRESS  Stress manifests in periodontium through behavioural changes, like increased smoking and poorer oral hygiene Genco et al in 1998
  15. 15. LIFE STYLE RISK FACTORS  Smoking “What do you mean, smoking is bad for my gums”
  16. 16. Pathogenesis of periodontitis Cytokines and prostaglandins Neutrophils Antibodies Complement Bacterial load Antigen LPS Other virulens factors Smoking Host response MMP Turn over Tissue degradation Clinical changes Serine proteases Oxygen radicals Smoking +
  17. 17. SMOKING With increased use of tobacco, patients show higher periodontal probing depths, increased clinical attachment loss, more alveolar bone resorption, a higher prevalence of gingival recessions, and a higher risk for tooth loss Tonetti in 1998
  18. 18. SMOKING…  Tobacco use shifts the physiological balance between anabolic and catabolic mechanisms in a more destructive direction, due to an alteration of protective immune and tissue mechanisms Palmer 2005 johnson and guthmiller in 2007 Ryder in 2007
  19. 19. SMOKING…  There is a robust evidence from a systematic review, on basis of 70 cross sectional studies , 14 case-control, and 21 cohort studies , it is concluded that smoking negatively interferes with a healthy periodontal condition Bergstrom in 2006  Periodontitis in smokers respond less to treatment, former smokers get a slower disease progression Bolin et al. 1993
  20. 20. METABOLIC RISK FACTORS The reduced function of PMNs increases the risk of periodontal disease in diabetes  Formation of AGEs leads to impaired collagen production and metabolism Schmidt et al in 1996   Infections observed in periodontitis can lead to insulin resistance and poor diabetic control Atkinson and Mclaren in 1990
  21. 21. METABOLIC RISK FACTORS
  22. 22. HEMATOLOGICAL RISK FACTORS Chronic myeloid leukamia  Myelodysplasia syndrome  Agranulocytosis  Neutropenia  Defects in the lymphocyte function 
  23. 23. GENDER  Disease susceptibility may increased due to hormone related alterations in women in the gingival blood flow(Kovar et al in 1985) in the composition of saliva(Laine on 2002) or the bone metabolism( Lerner in 2006)  Men are found with worse periodontal health(Albandar in 2002: Meisel et al in 2007)
  24. 24. AGE The aging process itself is suggested to be an independent risk factor for periodontal diseases Papapanou in 1989  The extent of severity of periodontal diseases are shown to increase with age Albandar in 2002 
  25. 25. HUMAN IMMUNO DEFICIENCY VIRUS  Chapple et al in 2000 stated that highly active anti retroviral therapy has limited periodontal disease progression in HIV patients  Treatment with HAART has indicated that seropositivity with HIV doesn’t in itself constitute a serious risk of periodontal disease
  26. 26. SOCIOECONOMIC STATUS  Indices for assessing SES have been used ranging from income level to education level  SES may represent a measure of personal drive and motivation, and may impact the quality of oral hygiene habits
  27. 27. BACTERIA  Specific bacteria in subgingival plaque 1. Tanerella forsythus 2. Porphyromonas gingivalis 3. Aggregatibacter actinomycetemcomitans
  28. 28. ASSESSMENT OF RISK  Patient level risk assessment  Whole mouth risk assessment  The tooth level risk assessment  The site level assessment
  29. 29. PATIENT LEVEL RISK ASSESSMENT  Family history- for hereditary/ inborn/ genetic factors  Medical history- systemic diseases  Present dental history  Social history- smoking  Habits- bruxism/tongue thrusting
  30. 30. MOUTH LEVEL RISK ASSESSMENT Examination of attachment loss relative to age  Occlusal examination in static relationship  Occlusal examination in dynamic relation ship  Examination of levels oral hygiene  Examination of levels of plaque retentive factors  Presence of removable prosthesis  Gingival tissue quality 
  31. 31. TOOTH LEVEL RISK ASSESSMENT Tooth anatomy  Mobility  Tooth support  Furcation lesions  Presence of ledges, anatomy of embrassures  Individual occlusal contacts  Soft tissue contours  Subgingival calculus 
  32. 32. SITE LEVEL RISK ASSESSMENT  BOP  Suppuration  Root grooves and concavities  Probing pocket depths  Attachment levels  Other anatomic factors  Enamel pearls
  33. 33. TOOLS TO MEASURE RISK FACTORS        PSR INTERACTIVE PATIENT ASSESSMENT TOOL P A T OF OHIS PRC UNIFE HEXAGONAL RISK DIAGRAM FOR PERIODONTAL RISK ASSESSMENT(PRA) PERIODONTAL RISK ASSESSMENT MODEL DEVELOPED BY VISHWA CHANDRA
  34. 34. CONT…       SCHUTTE AND DONLEY 1956 PATIENT QUESTIONAIRE H I D E P MODEL CONTINOUS MULTILEVEL RISK ASSESSMENT by LANG AND BRAGGER CRONIN/STASSEN BEDS CHASM SCALE CONTINOUS MULTILEVEL RISK ASSESSMENT MODEL IN 2011 PERIODONTAL RISK ASSESSMENT USING TWO ARTIFICIAL NEURAL NETWORKS
  35. 35. PERIODONTAL SCREENING AND RECORDING(PSR) Periodontal Screening and Recording (PSR) is a rapid and effective way to screen patients for periodontal diseases and summarizes necessary information with minimum documentation.  PSR is an adaptation of the Community Periodontal Index of Treatment Needs (CPITN), which is endorsed by WHO and FDI for periodontal screening. 
  36. 36. BENEFITS  Early detection  Speed.- appointment time  Simplicity  Cost-effectiveness- probe  Recording ease- sextant  Risk management- documentation
  37. 37. PSR CODES
  38. 38. UNIFE  In 2009, Trombelli and co-workers proposed a new objective method(UniFe), Union of European Railway Industries, in order to simplify the risk assessment Which is based on 5 parameters Smoking status, diabetic status, no. of sites with PD ≥ 5mm, BOP score and bone loss/age records 
  39. 39. Risk assessment according to the UniFe method Trombelli L, Farina R, Ferrari S, Pasetti P, Calura G Comparison between two methods for periodontal risk assessment. Minerva Stomatologica 2009;58:277-287
  40. 40. HEXAGONAL RISK DIAGRAM   Lang and Tonetti in 2003 described a functional diagram based on six parameters for use in estimating an individual risk for progression of periodontitis The PRA model consists of an assessment level of infection, the prevalence of residual pockets, tooth loss, an estimation of loss of periodontal support in relation to patients age, an evaluation of systemic and genetic conditions and an evaluation of the environmental/behavioural factor smoking All parameters have their own scale for low, moderate and high risk profiles
  41. 41. HEAGONAL RISK DIAGRAM DEVELOPED BY LANG AND TONETTI
  42. 42. HEXAGONAL RISK DIAGRAM DEVELOPED BY VISHWA CHANDRA In 2007, Chandra evaluated a novel periodontal risk assessment model based on model by Lang and Tonetti 1. Percentage of sites with BOP 2. No. of sites with PD ≥ 5mm 3. No. of teeth lost 4. Bone loss/age ratio 5. Attachment loss/age ratio 6. Diabetes and smoking 7. Dental status 8. Systemic factors and risk determinants are recorded 
  43. 43. Lang and bragger in 1992
  44. 44. CONTINOUS MULTILEVEL RISK ASSESSMENT  The risk assessment models uses retrospective and current data to assess the risk and is based on the simple scale of 0-5  A functional diagram was developed depending on the area of the polygon it categorizes to low, medium, high risk categories Sandhya and Sripriya in 2011
  45. 45. SCHUTTE AND DONLEY 1956 PATIENT QUESTIONAIRE
  46. 46. H I D E P MODEL  Screening and management method called HIDEP (health improvement in dental practice) model which uses predefined risk groups for selecting and managing individual treatment & prevention schemes The HIDEP model--a straightforward dental health care model for prevention based practice management. Sandberg, Hans C. H. Swedish Dental Journal. 2007, Vol. 31 Issue 4, p171-179.
  47. 47. CRONIN/STASSEN BEDS CHASM SCALE B -BMI score 2 Four step risk E - EthinicIty score 1.5 assessment D - Diabetic score 2.5 model S - Stressed score 2  Odds ratio helps score 2.5 to standardize risk C - College assessment, H - Hygiene score 2 allowing factors to A - Age 65+ score 3.5 be easily S - Smoker score 1.5 compared with the M - Male score 1.5 standard The total score of 19 indicates the highest risk numerical index 
  48. 48. PERIODONTAL RISK ASSESSMENT USING TWO ARTIFICIAL NEURAL NETWORKS  Neural Networks are a different paradigm for computing: Von Neumann machines are based on the processing/memory abstraction of human information processing. Neural networks are based on the parallel architecture of animal brains.
  49. 49. PERIODONTAL RISK ASSESSMENT USING TWO ARTIFICIAL NEURAL NETWORKS  Lavenberg Marquardt Algorithm  Scaled Conjugate Gradient Algorithm
  50. 50. CONCLUSION “ Measurement, Assessment, Elimination or reducing as many risks as possible will improve disease prevention and treatment outcomes”
  51. 51. REFERENCES       American Academy of Periodontology statement on risk assessment. Journal of Periodontology 2008; 79: 202. W. M. Thomson, S. J. Edwards, D. P. Dobson-Le, G. R. Tompkins, R. Poulton, D. A. Knight and A. W. Braithwaite: IL-1 genotype and adult periodontitis among young New Zealanders. J Dent Res. 2001 ;80(8):1700-3 Andreas Siebold, Are you at risk for periodontal disease: interactive patient risk assessment tool: south African Society of Periodontology: 2006 Page R, Krall EA, Martin J, Mancl L, Garcia RI. Validity of Periodontal Assessment Tool® (PAT®) in predicting periodontal disease. Journal of the American Dental Association 2002; 133(5): 569-576 Page R, Martin J, Krall EA, Mancl L, Garcia RI. Longitudinal Validation of risk calculator for periodontal disease. J Clin periodontol 2003; 30(9): 819-27 Trombelli L, Farina R, Ferrari S, Pasetti P, Calura G. Comparison between two methods for periodontal risk assessment. Minerva
  52. 52. REFERENCES…        Lang NP, Tonetti MS. Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral Health Prev Dent. 2003;1:7-16 Chandra RV. Evaluation of a novel periodontal risk assessment model in patients presenting for dental care. Oral Health Prev Dent. 2007;5: 39-48. Uno G H Fors, Sandberg Hans C. H. computer aided risk management- a software tool for the Hidep model: Quintessence Int 2001; 32; 309-320. Sandberg Hans C. H. The HIDEP model-a straightforward dental health care model for prevention based practice management. Swedish Dental Journal. 2007, 31(4), 171-179. Cronin AJ, Claffey N, Stassen LF. Who is at risk? Periodontal disease risk analysis made accessible for the general dental practitioner. Br Dent J. 2008 205(3):131-7 Lang NP, Bragger U, Salvi G, Tonetti MS. Supportive periodontal theraphy. In: LIndhe J, Karring T, Lang NP, editors. Clinical Periodontology and implantology. 4th ed. Oxford: Blackwell Munksgarrd; 2003. pp. 781–805 Rajesh S, Lalit Kumar Mathur, Manju A N, Neema Rai, Aditi Mathur. Periodontitis Risk Assessment using two artificial Neural Networks: Int J of Dent clinics 2010; 2(4): 36-40.
  53. 53. THANK YOU

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