Risk Factors, Assessment, Management

Question 1

What is periodontitis

Answer 1

Microbially associated, host mediated inflammation which is modified by the several risk factors resulting in loss of periodontal attachment

Question 2

What is risk and risk assessment

Answer 2

Risk is the probability that an individual will develop a specific disease in a given period of time. It can be identified in terms of:
Risk factors
Risk indications
Risk predictors

Risk assessment is a way of examining risk so that they may be avoided, reduced or managed.

Question 3

What are risk elements

Answer 3

Risk markers
Risk indications
Risk determinant or background characteristics
Risk factors

Question 4

Risk factors

Answer 4

They are:
Behavioral
Lifestyle -associated
Attributed to environmental exposure

Examples- tabacco smoking, medications, uncontrolled diabetes, stress, microbial deposits, poor OH

Risk factors when present, increase the likelihood that an individual will develop the disease

Question 5

Systemic medications that affect the periodontium

Answer 5

Anticonvulsant (phenytoin, ethotoin, valproic acid)

Immunosuppressant (cyclosporin)

Calcium channel blockers (nifedipine, verapamil, diltiazem)

Question 6

Two types of gingival elargement

Answer 6

1. Inflammatory gingival enlargement - occurs due to plaque accumulation and often it is localised. Gingiva is tender, soft, red, bleeds easily
2. Drug-induced gingival enlargement - often generalized, the gingival tissues are firm, non-tender, pale pink in colour, and do not bleed easily

Question 7

Risk determinants

Answer 7

Usually non modifiable

It is an inborn or inherited characteristic of an individuals

Examples- age, gender, genetic factors, socioeconomic status

Question 8

Risk indications

Answer 8

These are probable or putative risk factors, which have been identified in the cross-sectional studies but not confirmed through the longitudinal studies

Examples- HIV/AIDS, osteoporosis, presence of Epstein-Barr virus type 1 and human cytomegalo virus

Question 9

Risk predictors/markers

Answer 9

They are associated with increased risk for the disease but they do not cause the disease

Risk predictors may be either markers of disease or other historical measures of disease; aids the predictive course of disease progression.

Examples-BOP, irregular dental visits, CAL, number of kissing teeth

Question 10

Risk assessment

Answer 10

It is qualitative or quantitative process, where assessment is made of the likelihood of adverse events to occur as a result of:
Exposure to specific health hazards
By the absence of the beneficial influence.

Periodontitis is multifactorial disease and therefore assessment should be done at multiple levels:

1. Patient level-performed at the initial examination
2. Whole mouth level- at initial examination and post-treatment
3. Tooth level- at post-initial/definitive therapy and maintenance
4. The site level- post-definitive therapy and maintenance

Question 11

Patient level risk assessment

Answer 11

Factors to consider:
Positive family history of periodontal disease (genetic risk) (ask about gum disease and early tooth loss)
Medical history of systemic disease (diabetes, CVD, osteoporosis)
Present dental history (OH motivation)
Social/behaviour history (smoking-previous or present, stress)
Habits (bruxism…)

Question 12

Mouth-level risk assessment

Answer 12

Factors to consider:

Examination of the attachment loss relative to the age
Occlusal examination in both static and dynamic relationship
Examination.of levels of oral hygiene
Examination of the levels of plaque-retentive factors
Presence of removable prosthesis
Levels of recession
Gingival inflammation and pocket depths

Question 13

Tooth level risk assessment

Answer 13

Factors to consider:

Individual tooth mobility/mobility index
Pathological migration or drifting of periodontally compromised teeth
Residual tooth support ( helps determining long term prognosis)
Presence, location and extent of furcation
Individual tooth anatomy/anomaly
Anatomy of tooth embrasures and contact points
Presence of ledges or deficiencies on restorations
Individual occlusal contacts (premature contact)
Soft tissue contours
Presence of subgingival calculus

Question 14

Site-level risk assessment

Answer 14

Factors to consider:

BOP
Exudation from periodontal pocket
Local root grooves or root concavities
Individual PPD
Attachement levels
Other anatomical factors-enamel pearls, root grooves…

Question 15

Risk assessment process

Answer 15

1. Medical, dental history, periodontal examination
2. Risk factors/determinants identification
3. Nonsurgical and surgical periodontal therapy
4. If positive response- appropriate periodontal maintenance
5. If negative- reassess risk factors/determinants

Question 16

Periodontal risk assessment tools can help in-

Answer 16

Screening and monitoring of periodontal disease
Disease surveillance

Question 17

Periodontal risk factor analysis

Answer 17

1. Local risk factors- poor OH, BOP, PPD, CAL, furcation involvement, subgingival calculus
2. Environmental factors- tabacco, alcohol, stress, nutrition, medications
3. Systemic factors- diabetes, pre-diabetes, obesity, genetics

Question 18

Pathways of periodontitis -systemic disease link

Answer 18

Untreated periodontitis leads to-
1. Systemic microbial dissemination
2. Systemic dissemination of pro-inflammatory cytokines

Question 19

Subgingival environment

Answer 19

Provides reservoir of bacteria

Subgingival microorganisms in patients with periodontitis provides significant persistent gram negative bacterial challenge to host:

• bacteria and by-products like lipopolysaccharides gain access to circulation through an ulcerated sulcular epithelium

Total surface area epithelium of a patient with generalized chronic periodontitis is of a size of a palm
Bacteremia is common after mechanical periodontal therapy as due to mastication and oral hygiene procedures

Question 20

Systems and conditions influenced :

Answer 20

CVS ( atherosclerosis, MI, coronary artery disease)
Reproductive system ( pre-term birth, low birth weight)
Cerebrovascular system ( stroke)
Endocrine system (diabetes)
Respiratory system ( acute bacterial pneumonia, COPD)

Question 21

Effects of periodontal infections:

Answer 21

Ischaemic heart disease - increased viscosity of blood may promote ischaemia; pts with periodontitis show elevated levels of fibrinogen, WBC, coagulation factor VIII; bacteremia can be caused by daily activities like mastication, oral hygiene procedures

Question 22

Most current evidence between perio and CVS

Answer 22

Patients with moderate or severe periodontitis , poor OH status and fewer teeth are 2.5 more likely to suffer from MI than periodontally- healthy individuals

Question 23

Periodontitis and stroke

Answer 23

Evidence shows that there is a strong association between severity of periodontitis and risk of developing stroke

Question 24

Periodontitis and Diabetes

Answer 24

It is a two way relationship

Perio affects on diabetes:
Periodontitis is the 6 th complication of diabetes. Diabetics with severe periodontitis had worsening of glycemic control. Periodontal treatment results in reduced insulin demand. Antibiotics given in uncontrolled diabetic pt induce positive change in glycemic control (eliminated residual bacteria, decreases activity of tissue degrading enzymes like matrix metalloproteinases

Diabetes effects on perio
Diabetes is a risk factor for gingivitis and periodontitis. Levels of glycemic control is the most important determinant in this relationship. Diabetic patients are 2.8-3.4 times likely to have perio compared to non-diabetics. Increased instance of increased attachment and bone loss,BOP, recurrent periodontal abscesses.

Polymorphonuclear leukocytes (PMNs) are known to be impaired so their function is impaired (chemotaxis, adherence, phagocytosis) which means that the host response resistance is impaired- leading to increased risk of perio
Also compromised wound healing

Question 25

Periodontal treatment and glycemic control

Answer 25

Periodontitis results in insulin resistance due to gram negative bacterial

So treatment of perio leads to decreased bacterial challenge, reduces inflammation and leads to better glycemic control.

Well-connected diabetics should be treated similar to non-diabetic patients- aim of treatment is to control acute infections, avoiding long stressful appointments (early morning is preferred)

Question 26

Periodontal disease and pregnancy outcome

Answer 26

Low birth weight
Various studies show that perio increases LBW by 7folds

Question 27

Periodontal infections and acute respiratory infections

Answer 27

Upper respiratory passage can become contaminated with bacteria from oral, nasal and pharyngeal regions.
Dental plaque contains gram negative bacilli,S. gordonii that can be aspirated. All that enhances the ability or pathogens like H. influenzae to adhere to respiratory epithelial cells and lead to release of cytokines, attracts neutrophils, damages the epithelium and leads to infection

Question 28

Periodontal infections and COPD

Answer 28

Both have similar pathogenic mechanisms
Host inflammatory response happens as a result of chronic challange- leading to connective tissue destruction

Question 29

Perio and other systemic conditions

Answer 29

Obesity- studies show that obese people are 1.5 times more likely to develop periodontitis

Cancer- Porphyromonas gingivalis was found in 61% of cancerous tissues of oesophageal cancer compared to 0% in non cancerous.