This document provides information on risk assessment for periodontal disease. It defines risk assessment and identifies various elements of risk, including risk factors, determinants, indicators, and predictors. Major risk factors discussed include tobacco use, diabetes, and specific pathogenic bacteria. Other risk determinants addressed are genetic factors, age, gender, socioeconomic status, and stress. The document also discusses models for clinical risk assessment, including assessing risk at the patient, mouth, tooth, and site levels. Current methods for risk assessment mentioned are the Periodontal Risk Calculator, Health Information Suite, Periodontal Assessment Tool, and Hexagonal Risk Diagram for Periodontal Risk Assessment.

1. RISK ASSESSMENT
FOR PERIODONTAL DISEASE
Presented by:
Dr. Yogita Landge

2. CONTENTS
➢Introduction
➢Definitions
➢Elements for periodontal disease
➢Risk factors
➢Clinical risk assessment for periodontal disease
➢Current models for periodontal risk assessment
➢Conclusion
➢References

3. INTRODUCTION
➢It has demonstrated that the host plays a major role in the pathobiology of
periodontitis and risk varies greatly from one individual to another.
➢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.
➢The role of risk factors and risk assessment in the prediction of clinical periodontal
outcomes has been a subject of much interest.
Beck JD. Risk assessment revisited. Community Dent Oral Epidemiol. 1998;26:220–5

4. DEFINITION
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.
American Academy of Periodontology statement on risk assessment. Journal of Periodontology 2008; 79: 202. 6

5. RISK CAN BE IDENTIFIED IN TERMS OF
Risk Factors
Risk Indicators
Risk Predictors
Risk Determinants
-Novak K, Novak M. Risk Assessment. Carranza's Clinical Periodontology. 10 ed 8

6. ➢A risk factor can be defined as any environmental, behavioral, or biologic factor
that, when present, increases the likelihood that an individual will develop the
disease.
➢The 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 disease.
➢Risk predictors / markers are although associated with increased risk for disease
, but do not cause the disease.

7. ➢Tobacco smoking
➢Diabetes
➢Pathogenic bacteria/ Microbial tooth deposit
➢Genetic factors
➢Age
➢Gender
➢Socioeconomic status
➢Stress
➢HIV/AIDS
➢Osteoporosis
➢Infrequent dental visits
➢Previous history of periodontal disease
➢ Bleeding on probing
Most accepted risk “elements”
for periodontal disease include

8. RISK FACTORS
➢Tobacco smoking
➢Diabetes
➢Pathogenic bacteria and microbial tooth deposits

9. TOBACCO SMOKING
➢Tobacco is well established risk factor for periodontitis.
➢Both local and systemic mechanisms mediate the negative impact of tobacco use on
oral health.
➢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.
American Academy of Periodontology : position paper : epidemiology of periodontal disease , journal of
periodontal 67:935,1996
Tonetti MS: Cigarette smoking and periodontal diseases: etiology and management of disease. Ann
Periodontol 1998; 3:88.

11. ➢When nicotine combines with oral bacteria, such as P. gingivalis, it results in higher
levels of cytokines, leading to breakdown of the supporting tissues.
➢The risk of periodontal disease increases with the no. of cigarettes smoked per day.
➢According to Bolin et al 1993 periodontitis in smokers respond less to treatment.
➢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 tooth loss.
Johnson GK. Margaret Hill Cigarette smoking and the periodontal patient. J Periodontol. 2004;75:196– 209 13

12. DIABETES
➢Diabetes is a clear risk factor for periodontitis.
➢Epidemiologic data demonstrate that the prevalence and severity of periodontitis is
significantly higher in patients with type I and type II diabetes than in those without
diabetes
➢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.
American Academy of Periodontology: Position paper. Epi- demiology of periodontal diseases. J Periodontol 1996;
67:935-945. 14

13. 1. Change in bacterial pathogens
2. Alteration in polymorphonuclear leukocyte function
3. Altered collagen metabolism
Proteins & matrix molecules
Non-enzymatic Glycosylation
Collagen Less soluble
(accumulation of old collagen-susceptible to pathogenic breakdown)
AGEs formation

15. ➢Host responses may be impaired, wound healing is delayed and collagenolytic
activity may be enhanced.
➢Diabetes may also contribute to the pathogenesis of periodontitis via associated
vascular compromise and deficits in cell mediated immunity.
➢Furthermore, active inflammation of periodontitis generates compounds that may
increase insulin resistance.
Mealey B. Diabetes and periodontal diseases. J Periodontol. 1999;70:935–49. Tervonen T, Oliver RC. Long term
control of diabetes mellitus and periodontitis. J Clin Periodontol.1993;20:431–5. 16

16. PATHOGENIC BACTERIA &
MICROBIAL TOOTH DEPOSITS
➢It is well documented that 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
➢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.
➢However, although quantity may not indicate risk, there is evidence that the
composition, or quality, of the complex plaque biofilm is of importance.
➢In terms of quality of plaque, three specific bacteria have been identified as etiologic
agents for periodontitis:
I. A. actinomycetemcomitans,
II. P. gingivalis,
III. Bacteroides forsythus.

17. ➢Cross-sectional and longitudinal studies support the delineation of these three
bacteria as risk factors for periodontal disease.
➢Additional evidence that they are causal agents include:
(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 and
(4) Inoculation of these bacteria into animal models induces periodontal disease.
Haffajee AD, Socransky SS: Microbial etiological agents of destructive periodontal diseases. Periodontol
2000 1994; 5:78-111. 19

18. ➢ Anatomic factors - Furcation, Root concavities, Developmental grooves,
Cervical enamel projections, Enamel pearls, Bifurcation ridges.
➢ Restorative factors
➢ Calculus

19. RISK DETERMINANTS
➢Genetic factors
➢Age
➢Gender
➢Socioeconomic status
➢Stress

20. GENETIC FACTORS
➢Studies conducted in twins have shown that genetic factors influence clinical
measures of gingivitis, probing pocket depth, attachment loss, and interproximal bone
height. The familial aggregation seen in localized and generalized aggressive
periodontitis also is indicative of genetic involvement in these diseases.
➢A specific interleukin 1 (IL-1) genotype has been associated with severe chronic
periodontitis.
Kornman KS, Crane A, Wang HY, Newman MG, Pirk FW, Wilson TG, Jr, et al. The interleukin I genotype as a severity factor in adult
periodontal disease. J Clin Periodontol. 1997;24:72–7. 22

21. ➢Immunologic alterations, such as neutrophil abnormalities, monocytic hyper
responsiveness to lipopolysaccharide, alteration in monocytes or macrophage
receptors are under genetic control.
➢Genetic plays important role in regulating IgG2 antibody response to AA in pts with
aggressive periodontitis
Hart TC, Shapira L, Van Dyke TE: Neutrophil defects as risk factors for periodontal diseases. J Periodontol 1994; 65:
521-529. 21

22. AGE
➢Both the prevalence and severity of periodontal disease increases with age
➢It is possible that degenerative changes related to aging may increase susceptibility to
periodontitis.
➢It also is possible that the attachment loss and bone loss seen in older individuals is a
result of prolonged exposure to other risk factors.

23. GENDER
➢Gender plays a role in periodontal disease.
➢Male > Female
➢In addition, males have poorer oral hygiene than females, as evidenced by higher
levels of plaque and calculus.
➢Therefore it appears that gender differences in prevalence and severity of
periodontitis are related to preventive practices rather than any genetic factor.
U.S. Public Health Service, National Institute of Dental Re- search: Oral Health of United States Adults;
National Findings

24. 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 when compared with more educated individuals of 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.

25. STRESS
➢It has been strongly suggested that stress and related body distress are important risk
determinants for periodontal disease.
➢A recent study shows that people under physical or psychological stress are prone to poor
oral hygiene with increased dental plaque formation and increased gingivitis.
➢Increased clenching and griding of teeth, frequency of smoking
➢Stress diminishes saliva flow and also modifies the saliva pH and its chemical composition
like the IgA secretion.
➢The incidence of necrotizing ulcerative gingivitis increases during periods of emotional and
physiologic stress.
Haffajee AD, Socransky SS: Microbial etiological agents of destructive periodontal diseases. Periodontol 2000 1994; 5:78-111.
Rose RM: Endocrine responses to stressful psychological events. Psychiatr Clin N Am 1980; 3:251-276.

26. Stress induced Immunosuppression

27. RISK INDICATORS
➢Human Immunodeficiency Virus
➢Osteoporosis
➢Infrequent dental visits

28. HUMAN IMMUNODEFICIENCY VIRUS
➢Immune dysfunction associated with HIV infection and AIDS increases susceptibility to
periodontal disease.
➢However, evidence suggests that patients with AIDS or individuals who are HIV
seropositive who practice good oral hygiene and appropriate professional therapy can
maintain the periodontal health.
➢HIV infection and immunosuppression as a risk factor for periodontal disease, the
evidence is not conclusive.
Barr C, Lopez MR, Rua-Dobles A: Periodontal changes by HIV serostatus in a cohort of homosexual and bisexual men. J Clin Periodontol
1992; 19:794-801 32

29. OSTEOPOROSIS
➢Osteoporosis has been suggested as another risk factor for periodontitis.
➢Studies in animal models indicate that osteoporosis does not initiate periodontitis.
➢Von Wowern et al conducted a study of 12 women with osteoporosis & 14 healthy
women, reported that the women with osteoporosis had greater loss of attachment
than the control subjects.
➢In contrast, Kribbs examined PPD, BOP, gingival recession in subjects with and
without osteoporosis, results showed that both group had no difference in periodontal
status. However, a link appear to be exist between osteoporosis and periodontitis
➢Additional studies need to conducted to determine whether osteoporosis is a true
risk factor for periodontitis.

30. INFREQUENT DENTAL VISITS
➢Failure to visit the dentist on a regular basis as a risk factor for periodontitis is
controversial.
➢Study demonstrated an increased risk for severe periodontitis in patients who had not
visited the dentist for three or more years, whereas another demonstrated that there
was no more loss of attachment or bone loss in individuals who did not visited dental
clinic over a 6-year period.
➢Additional longitudinal studies are necessary to determine as a risk factor.

31. RISK MARKERS
➢Previous history of periodontal disease
➢Bleeding on probing

32. PREVIOUS HISTORY OF
PERIODONTAL DISEASE
➢A history of 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.
➢Patients currently free of periodontitis have decreased risk for developing loss of
attachment than those who currently have periodontitis.

33. BLEEDING ON PROBING
➢Bleeding on probing is the best clinical indicator of gingival inflammation.
➢BOP 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.
➢Therefore percentage of BOP, is used as the first risk factor in the functional diagram
of risk assessment

34. CLINICAL RISK ASSESSMENT FOR
PERIODONTAL DISEASE
➢The diseases are multifactorial, therefore risk assessment should be performed at
multiple levels.
➢There are four levels :
▪ The patient level (Perform at initial examination)
▪ The mouth level (Perform at initial examination and post initial therapy)
▪ The tooth level (Perform post- initial/definitive therapy and maintenance)
▪ The site level (Perform post definitive therapy and during maintenance)

35. PATIENT LEVEL RISK ASSESSMENT
➢ Family history for hereditary or genetic risk factors.
➢ 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

36. ➢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
MOUTH LEVEL RISK ASSESSMENT

37. TOOTH LEVEL RISK ASSESSMENT
• Individual tooth mobility
• Tooth movement or drifting of periodontally compromised teeth
(A detailed periodontal chart and radiographic assessment should be performed)
• Residual tooth support (radiographically)
• 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
• Subgingival calculus

38. SITE LEVEL RISK ASSESSMENT
➢ 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.

40. CURRENT METHODS FOR
RISK ASSESSMENT
In periodontology, current methods to assess periodontal risk factors include:
• Periodontal risk calculator (PRC),
• Health information suite (OHIS),
• Periodontal assessment tool (PAT)
• The hexagonal risk diagram for periodontal risk assessment (PRA).

41. PERIODONTAL RISK CALCULATOR (PRC)
➢ The PRC is a web based tool that can be accessed through a dental office computer.
➢ A three point scale is used to document pocket depth and radiographic bone height.
➢ The PRC assigns the individual a level of risk on a scale from
1 (lowest risk) to 5 (highest risk).

42. HEALTH INFORMATION SUITE
(OHIS)
➢ The OHIS is an information system that compiles, analyzes and quantifies clinical
information about factors like current oral health status, interventions needed and
treatment outcomes, be they beneficial or detrimental, that are attributable to treatment
and behavioral decisions.
➢ The OHIS satisfies the need for a quantitative way to assess risk for periodontitis, as
well as providing, quantification of periodontal status and changes in status over time.
Page RC, Martin JA, Loeb CF. The Oral Health Information Suite (OHIS): its use in the management of periodontal disease.
J Dent Educ. 2005;69:509– 20 51

43. PERIODONTAL ASSESSMENT TOOL
(PAT)
➢ It is an integral part of the Oral Health Information Suite (OHIS) and is considered as
a modification of the PRC method.
➢ Following the input of only twenty-three items taken from a routine periodontal
examination, the system generates numeric periodontal diagnoses and a risk score for
future disease, and prepares a report in two versions; one for the dentist’s clinical
documentation and another for the patient.

44. HEXAGONAL RISK DIAGRAM FOR
PERIODONTAL RISK ASSESSMENT (PRA)
➢Lang and Tonetti described a functional diagram for use in estimating an individuals’
risk for progression of periodontitis.
➢Based on the six parameters, a multi- functional diagram is constructed for the PRA.
Lang NP, Tonetti MS. Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral
Health Prev Dent. 2003;1:7-16.

45. The PRA model consists of :
• Percentage of bleeding on probing,
• Prevalence of residual pockets > 5 mm,
• Loss of teeth from a total of 28 teeth,
• Loss of periodontal support in relation to the
patient's age,
• Systemic and genetic conditions, and
• Environmental factors, such as cigarette
smoking

46. 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 and in specific population by
focusing on early identification and prevention of dental diseases, especially
periodontal disease.

47. REFERENCES
• Carranza. Clinical periodontology 10th and 13th edition
• Periodontal risk assessment, diagnosis and treatment planning Periodontology 2000, Vol. 25, 2001, 37–58
• 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
• Beck JD. Risk assessment revisited. Community Dent Oral Epidemiol. 1998;26:220–5 American Academy of
Periodontology statement on risk assessment. Journal of Periodontology 2008; 79: 202.
• Haffajee AD, Socransky SS: Microbial etiological agents of destructive periodontal diseases. Periodontol 2000 1994;
5:78-111.
• Elizabeth Koshi, S. Rajesh, Philip Koshi,and P. R. ArunimaRisk assessment for periodontal disease J Indian Soc
Periodontol. 2012 JulSep; 16(3): 324–328
• Aous Dannan PERIODONTAL RISK ASSESSMENT; ARE WE ON THE RIGHT TRACK? Archives of Oral Sciences
& Research 2011;1(3):162-167
• Kornman KS, Crane A, Wang HY, Newman MG, Pirk FW, Wilson TG, Jr, et al. The interleukin I genotype as a severity
factor in adult periodontal disease. J Clin Periodontol. 1997;24:72–7
• Papapanou PN: Risk assessments in the diagnosis and treatment of periodontal diseases. J Den Edu 1998; 62:822-839
Page RC, Beck JD: Risk assessment for periodontal diseases. Int Den J 1997; 47:61-87 68.