risk assessment

Seminar on Risk Assessment

For Periodontal Disease

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

Over the last three decades, our understanding 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.

Beck JD. Risk assessment revisited. Community Dent Oral Epidemiol. 1998;26:220–5

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

4

Assessing patients risk of developing periodontal disease can have

a significant impact on clinical decision making.

The role of risk factors and risk assessment in the prediction of

clinical periodontal outcomes has been a subject of much

interest.

5

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.

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

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

6

Risk can be identified in terms of

Risk Factors

Risk Indicators

Risk Predictors

Risk determin

ant

7

A risk factor can be defined as any environmental, behavioral, orbiologic factor that, when present, increases the likelihood that anindividual will develop the disease.

.

Risk indicators are probable or putative risk factors that have beenidentified in cross sectional studies but not confirmed throughlongitudinal disease.

Risk predictors / markers are although associated with increased risk fordisease , but do not cause the disease.

The term risk determinant/background characteristic, which issometimes substituted for the term risk factor, should be reserved forthose risk factors that cannot be modified.

Novak K, Novak M. Risk Assessment. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, editors. Carranza's Clinical Periodontology. 10 ed

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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.

9

Most accepted risk “elements” for

periodontal disease include

Risk Factors Risk determinants Risk indicators Risk predictors

Tobacco smoking Genetic factors HIV/AIDS Previous history of

periodontal disease

Diabetes Age Osteoporosis Bleeding on probing

Pathogenic bacteria Gender Infrequent dental visits

Microbial tooth deposit Socioeconomic status

Stress

10

TOBACCO SMOKING

Tobacco is well established risk factor for periodontitis .American Academy of Periodontology : position paper : epidemiology of periodontal disease , journal of periodontal 67:935,1996

A wealth of data has established the relationship between the amount

and duration of smoking and the severity of periodontal pathology.

Studies comparing the response to periodontal therapy in smokers,

previous smokers and nonsmokers have shown that smoking has a

negative impact on the response to therapy.

11

According to Bolin et al 1993 periodontitis in smokers respond less to

treatment, former smokers get a slower disease progression.

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 MS: Cigarette smoking and periodontal diseases: etiology and management of disease. Ann Periodontol

1998; 3:88.

Both local and systemic mechanisms mediate the negative impact of

tobacco use on oral health.

12

A number of studies indicate that the nicotine found in tobaccoproducts triggers the overproduction of cytokines in the body due tolowered oxygen levels.

Cytokines are signaling chemicals involved in the process ofperiodontal inflammation. When nicotine combines with oral bacteria,such as P. gingivalis, it results in higher levels of cytokines, leading tobreakdown of the supporting tissues of the teeth.

The risk of periodontal disease increases with the number of cigarettessmoked per day.

Johnson GK. Margaret Hill Cigarette smoking and the periodontal patient. J Periodontol. 2004;75:196– 209

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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 ,

American Academy of Periodontology: Position paper. Epi- demiology of periodontal diseases. J Periodontol 1996; 67:935-945.

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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.

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.

Vernillo AT. Dental considerations for the treatment of patients with diabetes mellitus. J Am Dent Assoc. 2003;134(supplement I):245–335

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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.

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.

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Pathogenic Bacteria and 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.

LOE H, Theilade E, Jensen SB: Experimental gingivitis in man. J Periodontol 1965; 36:177-187

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.

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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.

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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.

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Genetic factors

There is evidence that genetic differences between individuals may

explain why some patients develop periodontal disease and others do

not.

Studies conducted in twins have shown that genetic factors influence

clinical measures of gingivitis, probing pocket depth, attachment loss,

and interproximal bone height.Michalowicz BS, Aeppli DP, Kuba RK, et al: A twin study of genetic variation in proportional radiographic alveolar bone height. J Dent Res 1991;

70:1431-1435

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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 S, Wang HY, et al: The interleukin-1 genotype as a severity factor in adult periodontal disease. J Clin Periodontol 1997; 24:72-77

Immunologic alterations, such as neutrophil abnormalities, monocytic

hyper responsiveness to lipopolysaccharide stimulation in patients with

localized aggressive periodontitis.

Hart TC, Shapira L, Van Dyke TE: Neutrophil defects as risk factors for periodontal diseases. J Periodontol 1994; 65: 521-529.

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Research on the Interleukin1 (IL1) polymorphisms has indicated that IL1

genotype positive patients show more advanced periodontitis lesion

that IL1 genotype negative patients of the same age group.

Also there is a trend to higher tooth loss in the IL1 genotype positive

subjects.

In a retrospective analysis of over 300 well maintained periodontal

patients, the IL1 genotype yield higher BOP% during a 1year recall

period than the IL1 genotype negative control patients.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.

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AGE

Both the prevalence and severity of periodontal disease increases with

age .Papapanou PN: Risk assessments in the diagnosis and treatment of periodontal diseases. J Den Edu 1998; 62:822-839

It is possible that degenerative changes related to aging may increase

susceptibility to periodontitis.

However, 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

over a person's life, creating a cumulative effect over time

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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.Khalaf F, AlShammari , Areej K, AlKhabbaz, Jassem M, AlAnsari, et al. Risk indicators for tooth loss due to periodontal disease. J Periodontol.

2005;76:1910–18

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GENDER

Gender plays a role in periodontal disease.

United States national surveys conducted since 1960

demonstrate that males have more loss of attachment than

females.U.S. Public Health Service, National Center for Health Statistics: Periodontal Disease in Adults, United States 1960- 1962.

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In addition, males have poorer oral hygiene than females, as

evidenced by higher levels of plaque and calculus.U.S. Public Health Service, National Institute of Dental Re- search: Oral Health of United States Adults; National Findings

Therefore it appears that gender differences in prevalence and

severity of periodontitis are related to preventive practices rather than

any genetic factor.

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Socioeconomic Status

Gingivitis and poor oral hygiene can be related to lowersocioeconomic status (SES) .

This can most likely be attributed to decreased dental awareness anddecreased frequency of dental visits when compared with moreeducated individuals of higher SES.

After adjusting for other risk factors such as smoking and poor oralhygiene, lower SES alone does not result in increased risk forperiodontitis.

U.S. Public Health Service, National Center for Health Statistics: Basic Data on Dental Examination Findings of Persons 1-74 years; United States 1971-1974.

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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.

Hildebrand HC, Epstein J, Lorjova H. The influence of psychological stress on periodontal disease. J West Soc Periodontol Periodontal Abstr.

2000;48:69–77.

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The incidence of necrotizing ulcerative gingivitis increases during

periods of emotional and physiologic stress, suggesting a link between

the two.Shields WD: Acute necrotizing ulcerative gingivitis. A study of some of the contributing factors and their validity in an Army population. J Periodontol

1977; 48:346-349.

Emotional stress may interfere with normal immune function and may

result in increased levels of circulating hormones that can have an

impact on the periodontium.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.

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Stress diminishes saliva flow and increases dental plaque formation.

Emotional stress modifies the saliva pH and its chemical

composition like the IgA secretion .Reners M, Breex M. Stress and periodontal disease. Int J Dent Hygiene 2007; 5: 199–204.

A series of studies made by Deinzer et al., examine the impact of

academic stress by students at university during their examination

period on periodontal health. Academic stress was shown to be

a risk factor for gingival inflammation with increasing crevicular

interleukin-1b levels and a diminution of the quality of the oral hygiene .

Deinzer R, Ru ttermen S, Mo bes O, Herforth A. Increase in gingi val inflammation under academic stress. J Clin Periodontol 1998; 25:431–433.

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Human Immunodeficiency

Virus/Acquired Immunodeficiency

Syndrome

It has been hypothesized that the immune dysfunction associated with

human immunodeficiency virus (HIV) infection and acquired

immunodeficiency syndrome (AIDS) increases susceptibility to

periodontal disease.

Early reports on the periodontal status of patients with AIDS or

individuals who are HIV seropositive revealed that these patients often

had severe periodontal destruction characteristic of necrotizing

ulcerative periodontitis.Winkler JR, Herrera C, Westenhouse J, et al: Periodontal disease in HIV-infected and uninfected homosexual and bisexual men [letter]. AIDS 1992;

6:1041-1043

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In a 20-month study of 114 homosexual and bisexual men, the relative

risk of longitudinal attachment loss >3 mm was 4.8 when CD4 counts

were less than 400/mm3 and increased to 6.16 when CD4 counts were

less than 200/mm 3, suggesting a correlation between the severity of

periodontal disease and the level of immunosuppression.

Barr C, Lopez MR, Rua-Dobles A: Periodontal changes by HIV serostatus in a cohort of homosexual and bisexual men. J ClinPeriodontol 1992; 19:794-801

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OSTEOPOROSIS

Osteoporosis has been suggested as another risk factor for periodontitis.

Although studies in animal models indicate that osteoporosis does not

initiate periodontitis, there is evidence that the reduced bone mass

seen in osteoporosis may aggravate periodontal disease progression.

Krook L, Whalen JP, Lesser GV, et al: Experimental studies on osteoporosis. Methods Achiev Exp Pathol 1975; 7:72-108

However, reports in humans are conflicting. In a study of 12 women with

osteoporosis and 14 healthy women, Von Wowern et al reported that

the women with osteoporosis had greater loss of attachment than the

control subjects.

Van Wowern J, Klausen B, Kollerup G: Osteoporosis: a risk factor in periodontal disease. J Periodontol 1994; 65: 134.

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Infrequent Dental Visits

Identifying 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 seek dental care

when compared with those that did over a 6-year period.

Page RC, Beck JD: Risk assessment for periodontal diseases. Int Den J 1997; 47:61-87

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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.

Conversely, patients currently free of periodontitis have decreased risk

for developing loss of attachment than those who currently have

periodontitis.Page RC, Beck JD: Risk assessment for periodontal diseases. Int Den J 1997; 47:61-87

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Bleeding on Probing

Bleeding on probing is the best clinical indicator of gingivalinflammation.

Although bleeding on probing alone does not serve as a predictor forloss of attachment, bleeding on probing coupled with increasingpocket depth may serve as an excellent predictor for future loss ofattachment.

Lack of bleeding on probing does appear to serve as an excellentindicator of periodontal health.


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In assessing the patient's risk for disease progression, BOP percentages

reflect a summary of the patient's ability to perform proper plaque

control, the patient's host response to the bacterial challenge and the

patient's compliance, especially when only few residual pockets remain

after active periodontal therapy.

The percentage of BOP, therefore, is used as the first risk factor in the

functional diagram of risk assessment .

Lang & Tonetti Periodontal Risk Assessment (PRA) for Patients in Supportive Periodontal Therapy (SPT) : Oral Health & Preventive Dentisty 2003, S. 7-16

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CLINICAL RISK ASSESSMENT

FOR PERIODONTAL

DISEASE

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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:

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The patient level Perform at initial

examination

The whole 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

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 adetailed 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 smokerHabits like bruxism

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Patientlevel risk assessment Patientlevel risk assessment can be determined at the initial consultation by performing the following:

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 plaqueretentive factors

• Presence of removable prosthesis

• Levels of recession

• Gingival inflammation and depth of pockets

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.

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

• 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

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.

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.

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Current Methods For Periodontal Risk

Assessment :

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In periodontology, current methods to assess

periodontal risk factors include:

Periodontalrisk calculator(PRC),

Healthinformationsuite (OHIS),the Previserrisk calculatorTM

Thehexagonalrisk diagramforperiodontalriskassessment(PRA),

Theperiodontalriskassessmentmodeldevelopedby Chandra

The simplifiedmethod(UniFe) (Unionof Europeanrailwayindustries) forperiodontalriskassessment.

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Douglass CW. Risk assessment and management of periodontal disease. J Am Dent Assoc. 2006;137:275–315

The Periodontal Risk Calculator (PRC)

Page et al. developed a computer-based risk assessment tool, the

PRC, for objective, quantitative assessment of risk.

The PRC is a web based tool that can be accessed through a dental

office computer.Page RC, Krall EA, Martin J, Mancl L, Garcia RI. Validity and accuracy of a risk calculator in predicting periodontal disease. J Am Dent Assoc.

2002;133: 569-576.

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The calculation of risk using this model is based on

mathematically derived algorithms that assign relative

weights to nine 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 and vertical bone

lesions

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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).

An algorithm was developed to quantify disease severity from pocket

depth and bone height values.

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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 sub-

gingival restorations or calculus increase risk when the risk score is

otherwise less than four.

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Health information suite (OHIS),

Previser risk calculator TM

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, for the first time, 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

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The Periodontal Assessment Tool (PAT) is an integral part of the Oral

Health Information Suite (OHIS)TM (PreViser, Inc., Mount Vernon, WA;

www.previser. com) 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 linguistic and 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.

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The hexagonal risk diagram for

Periodontal Risk Assessment (PRA)

Lang and Tonetti described a functional diagram based on six

parameters for use in estimating an individuals’ risk for progression of

periodontitis.Lang NP, Tonetti MS. Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral Health Prev Dent. 2003;1:7-16.

The PRA model consists of an assessment of :

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Percentage of bleeding on probing,

Prevalence of residual

pockets greater

than 4 mm (³ 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.

CALCULATING THE PATIENT'S

INDIVIDUAL PERIODONTAL RISK

ASSESSMENT (PRA)

Based on the six parameters

specified above, a multi-

functional diagram is

constructed for the PRA.

In this diagram, the vectors

have been formed on the

basis of the scientific

evidence available.

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A low PRA patient has all parameters within the low-risk categories or at the most one parameter in the moderate-

risk category

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A moderate PRA patient has at least two parameters in the moderate category, but at most one parameter in the high-

risk category

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A high PRA patient has at least two parameters in the high-risk category

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In a high-risk patient who yields high BOP percentages and high numbers

of residual pockets, the patient's risk for disease progression may be

reduced into the moderate category if further periodontal therapy is

provided.

These two parameters (BOP and residual pockets) are easily affected by

therapy, while other parameters, such as numbers of missing teeth or

systemic and genetic factors are either irreversible and cannot be

reduced or may only be affected with great additional efforts (smoking

cessation).

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The periodontal risk assessment model

developed by Chandra

In 2007, Chandra evaluated a novel periodontal risk assessment model in patients presenting for dental care.

This new model based on the periodontal risk assessment model by Lang and Tonetti where the following parameters are recorded:

Chandra RV. Evaluation of a novel periodontal risk assessment model in patients presenting for dental care. Oral Health Prev Dent. 2007;5:39-48

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other risk determin

ants.

dental status,

smoking status,

diabetic

attachment

loss/age ratio,

number of teeth

lost,

number of sites

with pocket

depths ≥ 5mm,

percentage of

sites with bleeding

on probing,

It is a continuous multilevel risk

assessment model that

incorporates subjective tooth

and site risk assessments and

generates a functional

diagram, and depending on

the area of the polygon

categorizes the patient into

low-, medium- and high-risk

categories.

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The simplified method(UniFe) for

periodontal risk assessment

In 2009, Trombelli and co-workers proposed a new objective method

(UniFe) (Union of European Railway Industries) in order to simplify the risk

assessment procedures.

Risk assessment according to UniFe method is based on five

parameters, derived from the patient medical history and clinical

recordings.

Trombelli L, Farina R, Ferrari S, Pasetti P, Calura G. Comparison between two methods for periodontal risk assessment. Minerva Stomatol. 2009;58:277-287

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Smoking status,

Diabetic status (both type 1 and

type 2),

Number of sites with probing

depth ≥ 5mm,

Bleeding on probing score,

Bone loss/age records

Various models for risk assessment

Author(country) study type Risk assessment tool description Objective

Fors & Sandberg (2001)

(Sweden)

Health Improvement in Dental

Practice Model(HIDEP)

To create and evaluate a

computerized tool capable of

creating overviews of the oral

health situation as well as

identifying risk factors and at-

risk patients.

Page et al. (2003)

(USA)

Periodontal Risk Calculator

(PRC)

To provide a risk score of a

patients susceptibility for

periodontal progression on a

scale of 1(lowest risk) to

5(highest risk).

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Lang & Tonetti (2003)

(Switzerland)

Periodontal Risk Assessment

Model (PRA)

To classify patients a slow,

medium or high risk for

periodontal disease progression

Chandra(2007) (India) Modified Periodontal Risk

Assessment Model (Modified

PRA)

To classify individuals a slow,



Trombelli et al. (2009) (Italy) University of Ferrara (UniFe) To provide a risk score of a

patients’ susceptibility for

periodontal progression on a

scale of 1(lowest risk) to 5

(highest risk)

Lindskog et al. (2010) (Sweden) DRS a patient risk score(DRS

dentition) or tooth risk

score(DRS tooth).

To provide a dentition (patient

level) risk score based upon

systemic and local predictors .

65


Teich (2013) (USA) Risk Assessment-Based

Individualized Treatment(RABIT)

To classify patients as low,



or caries risk with

accompanying

recommendation for

maintenance visit interval

L€uetal.(2013) (China) PRA(as proposed by Lang &

Tonetti 2003):

To classify patients as low,


periodontal disease

progression.

Busby et al. (2014) (UK) Oral Health Status(OHS) as part

of Den Plan Excel/ Previsor

Patient Assessment(DEPPA)

To provide patient-level risk

scores for periodontal disease,

caries and oral cancer.

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Conclusion

Risk assessment is an important part of modern day periodontal practice. It isrecommended 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 toimprove dental and medical outcomes in the general population and in specificpopulation groups by focusing on early identification and prevention of dentaldiseases, especially periodontal disease.

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References Carranza. Clinical periodontology 9th , 10th and 11th 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 PrevDent. 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


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