periodontal risk assessment

1. CONTINUOUS
MULTI-LEVEL
RISK
ASSESSMENT
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2. INTRODUCTION
• Periodontal conditions reflects a dynamic equilibrium between
bacterial challenge and effective host response.
• Whenever the changes occur in either of these aspects, the
homeostasis is disturbed.
• Hence, diagnostic process must be based on continuous
monitoring of the multilevel risk profile.
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3. RATIONALE:
• Time interval between the diagnostic assessments should be
chosen based on the overall risk profile and the expected
benefit for the patient.
• Purpose of PRA:
1. Determine the content and frequency of preventive service
2. Cost-effectiveness : prevent both undertreatment and excessive
overtreatment
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4. 4
RISK ASSESSEMENT
TOOLS
DenPlan
Excel/Previsor® Patient
Assessment (DEPPA)
HIDEP model (Fors &
Sandberg 2001)
Risk Assessment-
Based Individualized
Treatment (RABIT)
(Teich 2013)
Dentition Risk System
(DRS) by Lindskog et
al. 2010
Periodontal Risk
Assessment (PRA) by
Lang & Tonetti 2003
Lang et al, 2015
Periodontal Risk
Calculator by Page et
al, 2013

5. Which parameters serve as early
indicators for a new onset or recurrence
of periodontal disease?
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6. Risk Factors and Risk Indicators
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1.
Patient-level
percentage of bleeding
on probing (BoP).
2.
Number of residual
pockets ≥4 mm
following active
periodontal therapy.
3.
Loss of teeth from a
total of 28 teeth.
4.
Loss of periodontal
support in relation to
the patient’s age
5.
Systemic and genetic
conditions
6.
Environmental factors
such as cigarette
smoking

7. SUBJECT
RISK
ASSESSMENT
Lang & Tonetti 2003
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8. Aims:
1. To identify characteristics of currently published patient-based tools
used to assess levels of risk for periodontitis progression.
2. Are results from current patient-based risk assessment tools
predictive of periodontitis progression in adults treated for this
disease?
Methods:
Prospective and retrospective cohort studies were included as no
randomized controlled clinical trials were available.
Results:
The search identified 5 different risk assessment tools. Results of 9 of
10 cohort studies reporting outcomes of 2110 patients indicate that risk
assessment tools are able to identify subjects with different probability of
periodontitis progression and/or tooth loss. Subjects with higher risk
scores showed more progression of periodontitis and tooth loss.
Conclusion:
In treated populations, results of patient based risk assessments e.g.
Periodontal Risk Calculator (PRC) and Periodontal Risk
Assessment (PRA) predicted periodontitis progression and tooth
loss in various populations. Additional research on the utility of risk
assessment results in improving patient management are needed.
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9. ORAL HYGIENE
• Full mouth assessment of bacterial load must have a pivotal impact
in the determination of the risk for disease recurrence.
• It has been clearly established that biofilm-infected dentitions will
yield recurrence of periodontal disease in multiple locations, while
dentitions under biofilm control and regular SPT maintain periodontal
stability for many years (Rosling et al.1976; Axelsson & Lindhe
1981a, b).
• In a clinical set-up, a biofilm control record of at most 20% will be
tolerated in most patients
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10. 1. Percentage of sites with bleeding on
probing (BOP)
• Risk factor for disease progression because it reflect:
1. Patient’s ability to perform proper biofilm control
2. Host response to the bacterial challenge
3. Patients’ compliance
• No established acceptable level of prevalence of bleeding on
probing in the dentition above which a higher risk for disease
recurrence has been established.
• 25% BOP has been the cut-off point (Joss et al, 1994)
• 20 – 30% determining the high risk for disease progression (Claffey et al,
1990 and Badersten et al, 1990) 10

11. • Scale : 4,9,16,25,36 and >49%
• Low risk : BOP <10% of the
surfaces (Lang et al,1990)
• High risk : BOP >25%
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12. 2. Prevalence of Residual Pocket ≥5mm
• The enumeration of the residual pockets with a PPD of ≥5 mm represents, to a certain extent, the degree of
success of the periodontal treatment rendered.
• Although this depth per se does not make much sense when considered as a sole parameter, the evaluation in
conjunction with other parameters, such as BoP and/or suppuration, will reflect existing ecologic niches from
and in which re-infection might occur.
• The presence of deep residual pockets after initial periodontal therapy and deepening of pockets during SPT
has been associated with high risk for disease progression (Badersten et al. 1990; Claffey et al. 1990).
In contrast with:
• Increased number of residual pockets does not necessarily imply an increased risk for re-infection or disease
progression, because a number of longitudinal studies have established that, depending on the individual SPT
provided, even deeper pockets may be stable without further disease progression for years (Lindhe & Nyman
1984)
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13. • Scale : 2, 4, 6, 8, 10 and ≥12%.
• Low risk : individual with up to 4
residual pockets.
• High risk: more than 8 residual
pockets.
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14. 2. Loss of Teeth From a Total of 28 teeth
• Oral function is usually impaired if more than 2 teeth from a total
of 28 teeth are lost (Kayser, 1981, 1994, 1996).
• The number of teeth lost from the dentition without the third
molars (28 teeth) is counted, irrespective of their replacement
being pontics or implants.
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15. • Scale: 2, 4, 6, 8, 10, and ≥12%
• Low risk : ≤ 4 teeth loss
• High risk : > 8 teeth loss
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16. 4. Loss of Periodontal Support in Relation
to the Patient’s Age
• The estimation of the loss of alveolar bone is performed in the
posterior region.
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1. Periapical radiograph:
- worst affected site is grossly
estimated in per cent of the
root length
2. Bitewing radiograph:
- Worst site affected is
estimated in millimeters.
- One millimeter is considered
to be equal to 10% bone loss.
= Percentage of bone loss
Patient’s age

17. • Scale: 0.25, 0.5, 0.75, 1.0, 1.25
• Low risk: <0.5
• High risk : >1.0
• Risk of underestimation and overestimation of
rate of periodontal destruction when only the
worst affected site is considered.
• In patients successfully treated for
periodontitis, it has recently been
demonstrated that the worst site with bone
loss is posterior segment may, indeed,
represent the past history of destruction of the
entire dentition (Persson et al, 2003)
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18. 5. Systemic and Genetic aspects
• Systemic factors:
1. Diabetes
2. Stress
3. Hormonal changes
• Genetic aspects:
1. Interleukin-1 (IL-1) polymorphisms
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19. • If it is known: Area of high risk.
• If not known or absent, systemic factors
are not taken into account for the
evaluation of the risk.
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20. 6. Cigarette Smoking
• Smoking is the risk factor for periodontal disease.
• The association between smoking has been shown to be dose-
dependent (Haber at al,1993).
• Smoking displayed less favourable healing response both at
reevaluation and during 6-year period of SPT (Baumert-Ah et
al,1994)
• Heavy smokers (≥20 cigarettes/day) – higher risk group during
maintenance.
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21. • Low risk:
• Non-smoker
• Former smoker : more than 5 years
since cessation
• Moderate risk:
• Occasional smokers: <10
cigarettes/day
• Moderate smoker : 10-20
cigarettes/day
• High risk:
• Heavy smoker: smoking more than
one pack per day
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22. CALCULATING THE PATIENT’S PRA
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23. Low PRA
• All parameters within the low-risk
categories
or- at the most-
• One parameter in the moderate-risk
category
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24. Moderate PRA
• At least two parameters within the
low-risk categories.
• But at most one parameter in the
high-risk category.
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25. High PRA
• At least two parameters in the high-
risk category.
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26. REFEREN
CES
• Lindhe's Clinical Periodontology and Implant Dentistry, 7th
Edition.
• Lang, Niklaus P., and Maurizio S. Tonetti. "Periodontal risk
assessment (PRA) for patients in supportive periodontal
therapy (SPT)." Oral Health Prev Dent1.1 (2003): 7-16.
• Persson, R. E., Tzannetou, S., Feloutzis, A. G., Brägger, U.,
Persson, G. R., & Lang, N. P. (2003). Comparison between
panoramic and intra-oral radiographs for the assessment of
alveolar bone levels in a periodontal maintenance
population. Journal of clinical periodontology, 30(9), 833–
839.
• Joss, A., Adler, R., & Lang, N. P. (1994). Bleeding on
probing. A parameter for monitoring periodontal conditions in
clinical practice. Journal of clinical periodontology, 21(6),
402–408.
• Lang, N. P., Suvan, J. E., & Tonetti, M. S. (2015). Risk factor
assessment tools for the prevention of periodontitis
progression a systematic review. Journal of clinical
periodontology, 42 Suppl 16, S59–S70.
• Lang, N. P., Adler, R., Joss, A., & Nyman, S. (1990).
Absence of bleeding on probing. An indicator of periodontal
stability. Journal of clinical periodontology, 17(10), 714–721.
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