This document discusses risk factors for periodontal disease. It begins by outlining treatment goals such as reducing bleeding, pocket depth, and furcation involvement. It then discusses diagnosing and prognosing periodontal disease at both overall and individual tooth levels. Several categories of risk elements are described, including risk factors like smoking and diabetes; risk determinants like age, gender, and socioeconomic status; risk indicators requiring more research like HIV and osteoporosis; and risk markers like bleeding on probing. Specific periodontal risk factors discussed in depth include pathogenic bacteria, age, gender, socioeconomic status, stress, smoking, and various systemic diseases. The document concludes by describing a periodontal risk assessment model called the "risk hexagon

1. PERIODONTOLOGY II
9. THE RISK FACTORS OF PERIODONTAL DISEASES
PETER VÁLYI DMD, PHD

2. COMPLEX TREATMENT
Diagnostics
Prognosis
Therapy

3. TREATMENT PLANNING
TREATMENT GOALS
• REDUCTION OR RESOLUTION OF GINGIVITIS (BOP) (BOP<10%)
• REDUCTION IN PPD (NO SITES WITH PPD>4 MM)
• ELIMINATION OF OPEN FURCATION IN MULTIROOTED TEETH (ONLY F0 OR F1)
• INDIVIDUAL SATISFACTORY ESTHETICS AND FUNCTION

4. DIAGNOSIS
• OVERALL DIAGNOSIS – AGP
• DIAGNOSIS FOR INDIVIDUAL TEETH OR SURFACES OF INDIVIDUAL TEETH
• PRELIMINARY
• DEFINITIVE

5. PROGNOSIS
• OVERALL PROGNOSIS
• PROGNOSIS FOR INDIVIDUAL TEETH
• GOOD PROGNOSIS
• IRRATIONAL-TO-TREAT – HOPELESS TEETH
• BECAUSE OF PERIODONTAL, ENDODONTAL OR DENTAL REASONS
• QUESTIONABLE

6. PROGNOSIS
• INITIAL PROGNOSIS: BASED UPON THE INITIAL CLINICAL FINDINGS AND
PRELIMINARY DIAGNOSIS
MUST FREQUENTLY BE REVISED DURING AND AFTER TREATMENT:
• DEFINITIVE PROGNOSIS: DETERMINE AFTER CAUSE-RELATED THERAPY OR
DURING/AFTER CORRECTIVE PHASE

7. PROGNOSIS
GENERAL FACTORS
• GENERAL HEALTH, RESISTANCE,
IMMUNE STATUS
• GENETIC, SYSTEMIC AND ACQUIRED
RISKS
• AGE IN RELATION TO AL
• DEMANDS AND POSSIBILITIES FOR
THE PATIENT
• REGULARITY OF PERIODONTAL
RECALL APPOINTMENTS
• MOTIVABILITY AND COMPLIANCE
LOCAL FACTORS
• TOOTH AND ROOT MORPHOLOGY
• TOOTH POSITION ANOMALIES
• AMOUNT AND COMPOSITION OF THE PLAQUE
• RAPIDITY OF PLAQUE FORMATION
• POCKETS (LOCALIZATION, DEPTH, ACTIVITY)
• FURCATION INVOLVEMENT
• AL
• TYPE OF BONE DESTRUCTION
• TOOTH MOBILITY IN RELATION TO BONE LOSS
• TOOTH MOBILITY IN RELATION TO OCCLUSAL
TRAUMA

8. PERIODONTAL RISK ASSESSMENT
• AIM: TO DETERMINE AN INDIVIDUAL RISK PROFILE –
• PERMITS THE CLINICAN TO ESTABLISH A DEFINITIVE DIAGNOSIS, PROGNOSIS AND AN OPTIMUM
TREATMENT PLAN
• ALSO PROVIDES THE PATIENT WITH VALUABLE INFORMATION AND MOTIVATION TOWARD
REMOVING OR ELIMINATING ANY ALTERABLE MAJOR RISK FACTORS
• DETERMINE THE FREQUENCY AND COMPLEXITY OF SPT(SUPPORTIVE PERIODONTAL THERAPY)
VISITS

9. DEFINITIONS
• RISK FACTORS MAY BE ENVIRONMENTAL, BEHAVIORAL, OR BIOLOGIC FACTORS
THAT, WHEN PRESENT, INCREASE THE LIKELIHOOD THAT AN INDIVIDUAL WILL
DEVELOP THE DISEASE. RISK FACTORS ARE IDENTIFIED THROUGH LONGITUDINAL
STUDIES OF PATIENTS WITH THE DISEASE OF INTEREST.
• EXPOSURE TO A RISK FACTOR OR FACTORS MAY OCCUR AT A SINGLE POINT IN
TIME; OVER MULTIPLE, SEPARATE POINTS IN TIME; OR CONTINUOUSLY
• AIM OF THE TREATMENT: IDENTIFYING AND MODIFYING OF RISK FACTORS

10. DEFINITIONS
• RISK DETERMINANT/BACKGROUND CHARACTERISTIC, WHICH IS
SOMETIMES SUBSTITUTED FOR THE TERM RISK FACTOR, SHOULD BE RESERVED FOR
THOSE RISK FACTORS THAT CANNOT BE MODIFIED.
• 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

11. CATEGORIES OF RISK ELEMENTS FOR PERIODONTAL
DISEASE
RISK FACTORS
• TOBACCO SMOKING
• DIABETES
• PATHOGENIC BACTERIA
• MICROBIAL TOOTH DEPOSITS

12. PATHOGENIC BACTERIA – MICROBIAL TOOTH
DEPOSITS
• ACCUMULATION OF BACTERIAL PLAQUE AT THE GINGIVAL MARGIN RESULTS IN THE
DEVELOPMENT OF GINGIVITIS AND THAT THE GINGIVITIS CAN BE REVERSED WITH
THE IMPLEMENTATION OF ORAL HYGIENE MEASURES (LÖE ET AL 1965)
• CAUSAL RELATIONSHIP BETWEEN PLAQUE ACCUMULATION AND PERIODONTITIS
HAS BEEN MORE DIFFICULT TO ESTABLISH. OFTEN, PATIENTS WITH SEVERE LOSS OF
ATTACHMENT HAVE MINIMAL LEVELS OF BACTERIAL PLAQUE ON THE AFFECTED
TEETH, INDICATING THAT THE QUANTITY OF PLAQUE IS NOT OF MAJOR
IMPORTANCE IN THE DISEASE PROCESS ALTHOUGH QUANTITY MAY NOT INDICATE
RISK, THERE IS EVIDENCE THAT THE COMPOSITION, OR QUALITY, OF THE COMPLEX
PLAQUE BIOFILM IS OF IMPORTANCE

13. PERIODONTOPATHOGENIC BACTERIA
• THEIR ELIMINATION OR SUPPRESSION IMPACTS THE SUCCESS OF THERAPY.
• THERE IS A HOST RESPONSE TO THESE PATHOGENS.
• VIRULENCE FACTORS ARE ASSOCIATED WITH THESE PATHOGENS.
• INOCULATION OF THESE BACTERIA INTO ANIMAL MODELS INDUCES PERIODONTAL
DISEASE.

14. PATHOGENIC BACTERIA – MICROBIAL TOOTH
DEPOSITS
• ANATOMIC FACTORS, SUCH AS FURCATIONS, ROOT CONCAVITIES, DEVELOPMENTAL GROOVES, CERVICAL
ENAMEL PROJECTIONS, ENAMEL PEARLS, AND BIFURCATION RIDGES, MAY PREDISPOSE THE
PERIODONTIUM TO DISEASE AS A RESULT OF THEIR POTENTIAL TO HARBOR BACTERIAL PLAQUE AND
PRESENT A CHALLENGE TO THE CLINICIAN DURING INSTRUMENTATION.
• IATROGENIC FACTORS: PRESENCE OF SUBGINGIVAL AND OVERHANGING MARGINS CAN RESULT IN
INCREASED PLAQUE ACCUMULATION, INCREASED INFLAMMATION, AND INCREASED BONE LOSS.
ALTHOUGH NOT CLEARLY DEFINED AS RISK FACTORS FOR PERIODONTITIS, ANATOMIC
FACTORS AND RESTORATIVE FACTORS THAT INFLUENCE PLAQUE ACCUMULATION MAY PLAY A
ROLE IN DISEASE SUSCEPTIBILITY FOR SPECIFIC TEETH (BLIEDEN, 1999).

15. PATHOGENIC BACTERIA – MICROBIAL TOOTH
DEPOSITS
THE PRESENCE OF CALCULUS, WHICH SERVES AS A RESERVOIR FOR BACTERIAL
PLAQUE, HAS BEEN SUGGESTED AS A RISK FACTOR FOR PERIODONTITIS (PAGE &
BECK, 1997).
• ALTHOUGH THE PRESENCE OF SOME CALCULUS IN HEALTHY INDIVIDUALS RECEIVING
ROUTINE DENTAL CARE DOES NOT RESULT IN SIGNIFICANT LOSS OF ATTACHMENT,
• THE PRESENCE OF CALCULUS IN OTHER GROUPS OF PATIENTS, SUCH AS THOSE NOT
RECEIVING REGULAR CARE AND PATIENTS WITH POORLY CONTROLLED DIABETES, CAN
HAVE A NEGATIVE IMPACT ON PERIODONTAL HEALTH

16. CATEGORIES OF RISK ELEMENTS FOR PERIODONTAL
DISEASE
RISK DETERMINANTS/BACKGROUND CHARACTERISTICS
RESERVED FOR THOSE RISK FACTORS THAT CANNOT BE MODIFIED.
• GENETIC FACTORS
• AGE
• GENDER
• SOCIOECONOMIC STATUS
• STRESS

17. AGE
BOTH THE PREVALENCE AND SEVERITY OF PERIODONTAL DISEASE INCREASE WITH
AGE (BURT 1994, PAPAPANOU 1994, 1998)
• POSSIBLE THAT DEGENERATIVE CHANGES RELATED TO AGING MAY INCREASE SUSCEPTIBILITY TO
PERIODONTITIS
• RESULT OF PROLONGED EXPOSURE TO OTHER RISK FACTORS OVER A PERSON’S LIFE, CREATING A
CUMULATIVE EFFECT OVER TIME.
• 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

18. GENDER
• GENDER DIFFERENCES IN PREVALENCE AND SEVERITY OF PERIODONTITIS APPEAR
TO BE RELATED TO PREVENTIVE PRACTICES RATHER THAN ANY GENETIC FACTOR

19. SOCIOECONOMIC STATUS
GINGIVITIS AND POOR ORAL HYGIENE CAN BE RELATED TO LOWER SOCIOECONOMIC
STATUS (SES)
• 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

20. STRESS
ALTHOUGH EPIDEMIOLOGIC DATA ON THE RELATIONSHIP BETWEEN STRESS AND
PERIODONTAL DISEASE ARE LIMITED, STRESS MAY BE A PUTATIVE RISK FACTOR FOR
PERIODONTITIS
• 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
• STRESSFUL LIFE EVENTS, SUCH AS BEREAVEMENT AND DIVORCE, APPEAR TO LEAD TO A GREATER PREVALENCE OF
PERIODONTAL DISEASE
• STRESSFUL LIFEAN APPARENT ASSOCIATION EXISTS BETWEEN PSYCHOSOCIAL FACTORS AND RISK BEHAVIORS
SUCH AS SMOKING, POOR ORAL HYGIENE, AND CHRONIC PERIODONTITIS
• ADULT PATIENTS WITH PERIODONTITIS WHO ARE RESISTANT TO THERAPY ARE MORE STRESSED THAN THOSE
WHO RESPOND TO THERAPY
• INDIVIDUALS WITH FINANCIAL STRAIN, DISTRESS, DEPRESSION, OR INADEQUATE COPING MECHANISMS HAVE
MORE SEVERE LOSS OF ATTACHMENT

21. CATEGORIES OF RISK ELEMENTS FOR PERIODONTAL
DISEASE
RISK INDICATORS
PROBABLE OR PUTATIVE RISK FACTORS NOT CONFIRMED THROUGH LONGITUDINAL
STUDIES.
• HIV/AIDS
• OSTEOPOROSIS
• INFREQUENT DENTAL VISITS

22. HIV
• EVIDENCE ALSO SUGGESTS THAT AIDS-AFFECTED INDIVIDUALS WHO PRACTICE GOOD PREVENTIVE
ORAL HEALTH MEASURES, INCLUDING EFFECTIVE HOME CARE AND SEEKING APPROPRIATE
PROFESSIONAL THERAPY, CAN MAINTAIN PERIODONTAL HEALTH. THEREFORE, ALTHOUGH IT SEEMS
REASONABLE TO HYPOTHESIZE THAT HIV INFECTION AND IMMUNOSUPPRESSION ARE RISK FACTORS
FOR PERIODONTAL DISEASE, THE EVIDENCE IS NOT CONCLUSIVE

23. OSTEOPOROSIS
• OSTEOPOROSIS DOES NOT INITIATE PERIODONTITIS, EVIDENCE INDICATES THAT THE REDUCED BONE
MASS SEEN IN OSTEOPOROSIS MAY AGGRAVATE PERIODONTAL DISEASE PROGRESSION
• HOWEVER, REPORTS IN HUMANS ARE CONFLICTING: ALTHOUGH THE TWO GROUPS HAD
SIGNIFICANT DIFFERENCES IN BONE MASS, NO DIFFERENCES IN PERIODONTAL STATUS WERE NOTED

24. INFREQUENT DENTAL VISIT
• IDENTIFYING FAILURE TO VISIT THE DENTIST REGULARLY AS A RISK FACTOR FOR PERIODONTITIS IS
CONTROVERSIAL. ONE STUDY DEMONSTRATED AN INCREASED RISK FOR SEVERE PERIODONTITIS IN
PATIENTS WHO HAD NOT VISITED THE DENTIST FOR 3 OR MORE YEARS, 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
NOTE: „THE LONG-TERM SUCCESS OF PERIODONTAL THERAPY DEPENDS ON THE MANNER IN WHICH
THE CASE WAS ACTIVELY TREATED THAN ON RIGOROUS FOLLOW-UP OF THE WOUND HEALING
PROCESS IMMEDIATELY AFTER THERAPY AND ON HOW WELL THE CASE IS MAINTAINED IN
SUBSEQUENT RECALL.”
(ROSLING ET AL. 1976, NYMAN ET AL. 1970, KNOWLES ET AL. 1979, RAMFJORD ET AL. 1982,
WILSON 1996, AXELSSON 2002, AAP 2003)

25. CATEGORIES OF RISK ELEMENTS FOR PERIODONTAL
DISEASE
RISK MARKERS/PREDICTORS
ASSOCIATED WITH INCREASED RISK FOR DISEASE, DO NOT CAUSE THE DISEASE
• PREVIOUS HISTORY OF PERIODONTAL DISEASE
• BLEEDING ON PROBING
• HIV, HUMAN IMMUNODEFICIENCY VIRUS; AIDS, ACQUIRED IMMUNODEFICIENCY
SYNDROME

26. RISK MARKERS/PREDICTORS
• A HISTORY OF PREVIOUS PERIODONTAL DISEASE IS A GOOD CLINICAL PREDICTOR
OF RISK FOR FUTURE DISEASE
• 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
• ALTHOUGH IT SEEMS REASONABLE TO HYPOTHESIZE THAT HIV INFECTION AND
IMMUNOSUPPRESSION ARE RISK FACTORS FOR PERIODONTAL DISEASE, THE
EVIDENCE IS NOT CONCLUSIVE

27. PERIODONTAL RISK ASSESSMENT
• THE MODEL WAS CREATED BY LANG AND TONETTI (2003) – AT THE UNIVERSITY
OF BERNE
• „RISK HEXAGON”
• „BERNESE SPIDER WEB”

28. PERIODONTAL RISK ASSESSMENT
ANALYTICAL CRITERIA
• PERCENTAGE OF POCKETS WITH POSITIVE BOP
• NUMBER OF RESIDUAL POCKETS PPD>4 MM
• NUMBER OF MISSING TEETH
• BONE LOSS IN RELATION TO AGE
• SYSTEMIC DISEASE, GENETICS
• SMOKING

29. PERIODONTAL RISK ASSESSMENT
ANALYTICAL CRITERIA
PERCENTAGE OF POCKETS WITH POSITIVE BOP
• BOP REPRESENTS AN OBJECTIVE INFLAMMATORY
PARAMETER
• BOP REFLECTS, AT LEAST IN PART, THE PATIENT’S
COMPLIENCE AND STANDARDS OF OH
PERFORMANCE
• BOP REFLECT A SUMMERY OF THE PATIENT’S
ABILITY TO PERFORM PROPER PLAQUE CONTROL,
THE PATIENT’S HOST RESPONSE TO THE
BACTERIAL CHALLANGE AND THE PATIENT’S
COMPLIENCE.

30. PERIODONTAL RISK ASSESSMENT
ANALYTICAL CRITERIA
NUMBER OF RESIDUAL POCKETS PPD>4 MM
• THE RESIDUAL POCKETS (PPD>4 MM) REPRESENTS THE
DEGREE OF SUCCESS OF PERIODONTAL TREATMENT
RENDERED (CONJUNCTION WITH BOP OR SUPPURATION)
• PRESENCE OF HIGH FREQUENCIES OF DEEP RESIDUAL
POCKETS AND DEEPENING OF POCKETS DURING SPT CARE
HAS BEEN ASSOCIATED WITH HIGH RISK FOR DISEASE
PROGRESSION (CLAFFEY ET AL 1990, BADERSTEN ET AL
1990), BUT IT IS DEPENDING ON THE INDIVIDUAL SPT
PROVIDED, EVEN DEEPER POCKETS MAY BE STABLE WITHOUT
FURTHER DISEASE PROGRESSION FOR YEARS (KNOWLES ET
AL 1979, LINDHE AND NYMAN 1984)

31. PERIODONTAL RISK ASSESSMENT
ANALYTICAL CRITERIA
NUMBER OF MISSING TEETH
• THE NUMBER OF REMAINING TEETH IN A
DENTITION REFLECTS THE FUNCTIONALITY
OF THE DENTITION
• MORE THAN 8 TEETH FROM A TOTAL 28
TEETH ARE LOST, ORAL FUNCTION USUALLY
IMPAIRED (KÄYSER 1981, 1994, 1996)

32. PERIODONTAL RISK ASSESSMENT
ANALYTICAL CRITERIA
BONE LOSS IN RELATION TO AGE
• THE EXTENT AND PREVALENCE OF PERIODONTAL
ATTACHMENT LOSS, AS EVALUATED BY THE HEIGHT OF
THE ALVEOLAR BONE ON RADIOGRAPHS, MAY
REPRESENT THE MOST OBVIOUS INDICATOR OF SUBJECT
RISK WHEN RELATED TO PATIENT’S AGE
• THE ESTIMATION OF THE LOSS OF ALVEOLAR BONE IS
PERFORMED IN THE POSTERIOR REGION AT THE WORST
SITE AFFECTED. FOR EXAMPLE 40 YEAR-OLD-PATIENT
WITH 20% BONE LOSS: BL/AGE=0,5

33. PERIODONTAL RISK ASSESSMENT
ANALYTICAL CRITERIA
SYSTEMIC DISEASE, GENETICS
• THE MOST SUBSTANTIATED EVIDENCE FOR MODIFICATION
OF DISEASE SUSCEPTIBILITY AND/OR PROGRESSION OF
PERIODONTAL DISEASE ARISES FROM STUDIES ON TYPE I
AND TYPE II DM POPULATIONS (GUSBERTI ET AL 1993,
EMRICH ET AL 1991, GENCO AND LÖE 1993)
• IL-1 GENOTYPE POSITIVE PATIENTS SHOW MORE
ADVANCED PERIODONTITIS LESIONS THAN IL-1 GENOTYPE
NEGATIVE PATIENTS OF THE SAME AGE GROUP (KORNMAN
ET AL, 1997). THERE IS A TREND TO HIGHER TOOTH LOSS
IN THE IL-1 GENOTYPE POSITIVE SUBJECTS (MCGUIRE AND
NUNN 1999)

34. PERIODONTAL RISK ASSESSMENT
ANALYTICAL CRITERIA
SMOKING
• CONSUMPTION OF TOBACCO AFFECTS THE
SUSCEPTIBILITY AND THE TREATMENT OUTCOME OF
PATIENTS WITH ADULT PERIODONTITIS.
• SMOKING A TRUE RISK FACTOR FOR PERIODONTITIS
(ISMAIL ET AL 1983, BERGSTRÖM 1989, BERGSTRÖM
ET AL 1991, HABER ET AL 1993)
• THE ASSOCIATION OF SMOKING AND PERIODONTITIS
HAS BEEN SHOWN TO BE DOSE-DEPENDENT (HABER
ET AL 1993)

35. PERIODONTAL RISK ASSESSMENT
CALCULATING THE PATIENT’S INDIVIDUAL PERIODONTAL RISK ASSESSMENT
• A LOW PR PATIENT: HAS ALL PARAMETERS WITHIN THE LOW RISK
CATEGORIES OR AT THE MOST ONE PARAMETER IN THE MODERATE RISK
CATEGORY
• A MODERATE PR PATIENT: HAS AT LEAST TWO PARAMETERS IN THE
MODERATE CATEGORY, BUT AT MOST ONE PARAMETER IN THE HIGH
RISK CATEGORY
• A HIGH RISK PR PATIENT: HAS AT LEAST TWO PARAMETERS IN THE
HIGH RISK CATEGORY

36. TOOTH RISK ASSESSMENT
• MAY BE USEFUL IN EVALUATING THE PROGNOSIS AND
FUNCTION OF AN INDIVIDUAL TOOTH
• MAY INDICATE THE NEED FOR SPECIFIC THERAPEUTIC
MEASURES DURING SPT VISITS
• TOOTH POSITION WITHIN THE DENTAL ARCH
• FURCATION INVOLVEMENT
• IATROGENIC FACTORS
• RESIDUAL PERIODONTAL SUPPORT
• MOBILITY

37. SITE RISK ASSESSMENT
• MAY BE USEFUL IN EVALUATING PERIODONTAL DISEASE ACTIVITY AND
DETERMINING PERIODONTAL STABILITY OR ONGOING INFLAMMATION.
• IT IS ESSENTIAL FOR THE IDENTIFICATION OF THE SITES TO BE INSTRUMENTED
DURING SPT
• BOP
• PPD AND AL
• SUPPURATION

38. THANK YOU FOR YOUR ATTENTION!