CHAPTER 2: CLINICAL RISK ASSESSMENT

from book manual only!!

Risk assessment

involves identifying elements that may predispose a patient to developing periodontal disease or influence the progression of existing disease.

risk

the probability that an individual will develop a specific disease in a given period

Risk Factors

modifiable

Environmental behavioral, or biologic characteristics that increase the likelihood of developing a disease

Exposure must occur before disease onset, and these factors are often modifiable through interventions.

examples of risk factors

—modifiable—

Tobacco smoking

Diabetes

Pathogenic bacteria

Microbial tooth deposits

risk determinants

risk factors that cannot be modified

examples of Risk Determinants

— non-modifiable —

Genetic factors

Age

Gender

Socioeconomic status

Stress

risk indicators

probable or putative risk factors identified in cross-sectional studies but not confirmed by longitudinal studies

examples of risk indicators

Osteoporosis

Infrequent dental visits

Human Immunodeficiency Virus (HIV)

Acquired Immunodeficiency Syndrome (AIDS)

Risk Predictors/Markers

Factors associated with increased risk but do not directly cause the disease

examples of risk predictors / markers

bleeding on probing

previous history of periodontal disease

tobacco smoking

risk factor

it negatively impacts the response to therapy

cessation can overcome negative effects on treatment prognosis

a well-established risk factor with a direct relationship to the prevalence of periodontal disease

Diabetes

Risk Factor

Diabetes is a clear risk factor. The prevalence and severity of periodontitis are significantly higher in patients with Type 1 or Type 2 diabetes. The level of diabetic control is an important variable in this relationship.

pathogenic bacteria

risk factor

the composition, or quality, of the complex plaque biofilm is of importance, rather than the quantity of plaque

while plaque accumulation causes gingivitis, establishing a causal relationship between plaque accumulation and periodontitis is more difficult

3 specific bacteria identified as etiologic agents

Tannerella forsythia

Porphyromonas gingivalis

Aggregatibacter actinomycetemcomitans

bacteria of aggressive periodontitis

Aggregatibacter actinomycetemcomitans

bacteria of chronic periodontitis

Porphyromonas gingivalis

genetic factors

risk determinant

Genetic differences may explain why some patients develop periodontal disease and others do not.

Alterations in specific genes encoding inflammatory cytokines (e.g., Interleukin-1) have been associated with severe chronic periodontitis.

Familial aggregation is indicative of genetic involvement, particularly in localized and generalized aggressive periodontitis.

age

risk determinant

prevalence and severity of periodontal disease increase with age.

However, periodontal disease is not an inevitable consequence of aging.

The cumulative effect of prolonged exposure to other risk factors over time is likely responsible for attachment loss seen in older individuals

anatomic factors

furcations, root concavities, developmental grooves

restorative factors

(e.g., subgingival and overhanging margins)

presence of calculus

serves as a reservoir for bacterial plaque

Prognosis

A prediction of the probable course, duration, and outcome of a disease, established after the diagnosis is made and before the treatment plan is set. Prognosis is often confused with risk

prognostic factors

characteristics that predict the outcome, of disease once the disease is present

prognosis determination

a dynamic process that must be reevaluated after initial therapy is completed

good prognosis

Control of etiologic factors and adequate periodontal support ensure easy maintenance.

fair prognosis

25% attachment loss

class I furcation involvement

poor prognosis

50% attachment loss

class II furcation involvement

questionable prognosis

>50% attachment loss

poor crown-to-root ratio

class III furcation involvements

>2+ mobility

hopeless prognosis

Inadequate attachment to maintain health, comfort, and function; tooth must be extracted.

Kwok & Caton

produced the scheme used for treatment decisions based on the probability of obtaining stability of the periodontal supporting apparatus

Favorable prognosis

Questionable prognosis

Unfavorable prognosis

Hopeless prognosis

overall prognosis

concerns the dentition as a whole

determines if treatment should be undertaken and if remaining teeth can support a prosthesis

Individual Tooth Prognosis

Determined after the overall prognosis and is influenced by it

Plaque Control/Patient Compliance influence on prognosis

Critically dependent; effective plaque removal is vital. Without willingness/ability to perform adequate hygiene, treatment cannot succeed

systemic disease influence on prognosis

cessation improves prognosis

negatively affects treatment outcomes and healing potential

prognosis for smokers:

• fair to poor (moderate periodontitis)

• poor to hopeless (severe periodontitis)

patient age influence on prognosis

generally better for the older of two patients with comparable destruction, because rapid destruction in a younger patient may indicate aggressive disease or underlying systemic issues

genetic factors influence on prognosis

currently cannot be altered, but early detection of genetic risk can influence treatment recommendations (like adjunctive antibiotics or increased maintenance frequency) to improve prognosis

Disease Severity influence on prognosis

A history of previous periodontal disease indicates susceptibility for future breakdown.

Level of clinical attachment is more critical than pocket depth alone

Bone Loss and Defects Prognosis is adversely affected if the attachment level is close to the root apex.

Subgingival Restorations influence on prognosis

Margins that are subgingival or have discrepancies (overhangs) contribute to increased plaque and bone loss, resulting in a poorer prognosis.

anatomic constraints influence on prognosis

factors that impede cleaning and instrumentation (by the patient or clinician) negatively affect prognosis

include:

• root concavities

• developmental grooves

• difficult-to-access furcation involvements

• short, tapered roots (poor crown-to-root ratio)

tooth mobility influence on prognosis

mobility caused by inflammation or trauma may be correctable

but mobility resulting from alveolar bone loss is generally not likely to be corrected.

angular bone loss

infrabony pockets

more difficult to manage ; poor prognosis

oblique / uneven bone loss forming vertical defects

better prognosis if osseous walls are favorable for bone regeneration

commonly seen on aggressive periodontitis, advanced chronic cases

prognosis of plaque-induced gingivitis

prognosis is good, provided all irritants are eliminated and good oral hygiene is maintained.

prognosis of chronic periodontitis

slight-to-moderate disease

good prognosis — if inflammation / local factors are controlled

fair to poor — more severe disease or poor compliance

prognosis of localized aggressive periodontitis (LAP)

although rapid destruction occurs in younger patients, early diagnosis and treatment (including systemic antibiotic therapy) can result in an excellent prognosis.

prognosis of generalized aggressive periodontitis (GAP)

fair, poor, or questionable prognosis

may require systemic antibiotics in addition to conventional therapy

patients often have a poor antibody response and significant alterations in host defense

prognosis of necrotizing ulcerative gingivitis (NUG)

Prognosis is good if bacterial plaque and secondary factors (stress, smoking) are controlled.

provisional prognosis

may be established until phase I therapy (initial scaling and root planing) is completed and evaluated. 

The effectiveness of Phase I therapy, particularly the reduction in inflammation, gives a more accurate prognosis.

Enhancing the host response to plaque's microbial challenge significantly and positively influences the periodontal prognosis

For teeth with a questionable outlook, the clinician may consider strategic extraction to improve the prognosis of adjacent teeth or facilitate implant placement.