this ppt emphasizes on risk and risk factors and the risk assessment and management based on risk factors

1. Presented by
Dr. Guru Ram Tej. K
Post Graduate
Mamata Dental College

2. CONTENTS..

INTRODUCTION

TERMINOLOGIES

CLASSIFICATION OF RISK FACTORS

RISK ELEMENTS FOR PERIODONTAL
DISEASE

RISK ASSESSMENT

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. 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. TERMINOLOGIES

RISK

Risk factors

Risk determinants

Risk indicators

Risk predictors

6. CLASSIFICATION

Based on the evidence
 Primary risk factor
 Secondary risk factor
 Tertiary risk factor

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. RISK FACTORS

GENETIC

ENVIRONMENTAL

BEHAVIOURAL

LIFE STYLE

METABOLIC

HEMATOLOGICAL

GENDER

AGE

9. RISK FACTORS

HIV

PREVIOUS HISTORY

SOCIOECONOMIC STATUS

BLEEDING ON PROBING

OSTEO POROSIS

NUTRITION

BACTERIA

10. GENETIC

Polymorphisms

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. 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. 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. STRESS

Stress manifests in periodontium through
behavioural changes, like increased smoking
and poorer oral hygiene
Genco et al in 1998

15. LIFE STYLE RISK FACTORS

Smoking
“What do you mean, smoking is bad for my gums”

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. 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. 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. 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. 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. METABOLIC RISK FACTORS

23. HEMATOLOGICAL RISK FACTORS
Chronic myeloid leukamia
 Myelodysplasia syndrome
 Agranulocytosis
 Neutropenia
 Defects in the lymphocyte function


24. 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)

25. 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


26. 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

27. 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

28. BACTERIA

Specific bacteria in subgingival plaque
1.
Tanerella forsythus
2.
Porphyromonas gingivalis
3.
Aggregatibacter actinomycetemcomitans

29. ASSESSMENT OF RISK

Patient level risk assessment

Whole mouth risk assessment

The tooth level risk assessment

The site level assessment

30. 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

31. 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


32. 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


33. SITE LEVEL RISK ASSESSMENT
 BOP
 Suppuration
 Root
grooves and concavities
 Probing pocket depths
 Attachment levels
 Other anatomic factors
 Enamel pearls

35. 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

36. 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

37. 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.


38. BENEFITS

Early detection

Speed.- appointment time

Simplicity

Cost-effectiveness- probe

Recording ease- sextant

Risk management- documentation

39. PSR CODES

45. 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


46. 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

48. 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

49. HEAGONAL RISK DIAGRAM DEVELOPED BY
LANG AND TONETTI

50. 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


51. Lang and bragger in 1992

53. 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

54. SCHUTTE AND
DONLEY 1956
PATIENT
QUESTIONAIRE

55. 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.

56. 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


57. 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.

58. PERIODONTAL RISK ASSESSMENT USING TWO
ARTIFICIAL NEURAL NETWORKS

Lavenberg Marquardt Algorithm

Scaled Conjugate Gradient Algorithm

59. CONCLUSION
“ Measurement, Assessment, Elimination or
reducing as many risks as possible will
improve disease prevention and treatment
outcomes”

60. 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

61. 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.

62. THANK YOU