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this ppt emphasizes on risk and risk factors and the risk assessment and management based on risk factors
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Risk Factors And Risk Assessment
Of Periodontal Disease
Presented byDr. Guru Ram Tej. KPost GraduateMamata Dental College
CONTENTS..
INTRODUCTION TERMINOLOGIES CLASSIFICATION OF RISK FACTORS RISK ELEMENTS FOR PERIODONTAL
DISEASE RISK ASSESSMENT
TOOLS TO MEASURE RISKPeriodontal Screening And Recording (P S R)Interactive Patient QuestionnairePatient Assessment Tool Of OHISPatient Risk Calculator (Previeser)Uni FeHexagonal Risk Diagram For Periodontal Risk AssessmentPeriodontal Risk Assessment By Vishwa ChandraH I D E P ModelContinuous Multilevel Risk Assessment By Lang And
BraggerCronin/ Stassen Beds Chasm ScaleContinuous Multilevel Risk Assessment In 2011Periodontal Risk Using Two Artificial Neural Networks
CONCLUSIONREFERENCES
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
TERMINOLOGIES
RISK Risk factors Risk determinants Risk indicators Risk predictors
CLASSIFICATION Based on the evidence
Primary risk factor Secondary risk factor Tertiary risk factor
Host response
Cytokines andprostaglandins
MMP
Serine proteases
Oxygen radicals
NeutrophilsAntibodiesComplement
Antigen
LPS
Other virulencefactors
Tissuedegradation
ClinicalchangesBacterial
load Turn over
Pathogenesis of periodontitis
RISK FACTORS GENETIC ENVIRONMENTAL BEHAVIOURAL LIFE STYLE METABOLIC HEMATOLOGICAL GENDER AGE
RISK FACTORS
H I V PREVIOUS HISTORY SOCIOECONOMIC STATUS BLEEDING ON PROBING OSTEO POROSIS NUTRITION BACTERIA
GENETIC Polymorphisms
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
Pathogenesis of periodontitis
Host response
Cytokines andprostaglandins
MMP
Serine proteases
Oxygen radicals
NeutrophilsAntibodiesComplement
Antigen
LPS
Other virulensfactors
Tissuedegradation
ClinicalchangesBacterial
load Turn over
Interleukin+
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”
STRESS Stress manifests in periodontium
through behavioural changes, like increased smoking and poorer oral hygiene
Genco et al in 1998
LIFE STYLE RISK FACTORS Smoking
“What do you mean, smoking is bad for my gums”
Host response
Cytokines andprostaglandins
MMP
Serine proteases
Oxygen radicals
NeutrophilsAntibodiesComplement
Antigen
LPS
Other virulensfactors
Tissuedegradation
ClinicalchangesBacterial
load Turn over
SmokingSmoking +
Pathogenesis of periodontitis
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
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 2005johnson and guthmiller in
2007Ryder in 2007
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
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 metabolismSchmidt et al in 1996
Infections observed in periodontitis can lead to insulin resistance and poor diabetic control
Atkinson and Mclaren in 1990
METABOLIC RISK FACTORS
HEMATOLOGICAL RISK FACTORS Chronic myeloid leukamia Myelodysplasia syndrome Agranulocytosis Neutropenia Defects in the lymphocyte function
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)
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
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
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
BACTERIA Specific bacteria in subgingival plaque
1. Tanerella forsythus
2. Porphyromonas gingivalis
3. Aggregatibacter
actinomycetemcomitans
ASSESSMENT OF RISK Patient level risk assessment
Whole mouth risk assessment
The tooth level risk assessment
The site level assessment
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
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
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
SITE LEVEL RISK ASSESSMENT BOP Suppuration Root grooves and concavities Probing pocket depths Attachment levels Other anatomic factors
Enamel pearls
TOOLS TO MEASURE RISK FACTORS PSR INTERACTIVE PATIENT ASSESSMENT
TOOL P A T OF OHIS P R C UNIFE HEXAGONAL RISK DIAGRAM FOR
PERIODONTAL RISK ASSESSMENT(PRA) PERIODONTAL RISK ASSESSMENT
MODEL DEVELOPED BY VISHWA CHANDRA
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
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.
BENEFITS
Early detection Speed.- appointment time Simplicity Cost-effectiveness- probe Recording ease- sextant Risk management- documentation
PSR CODES
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 parametersSmoking status, diabetic status, no. of sites
with PD ≥ 5mm, BOP score and bone loss/age records
Trombelli L, Farina R, Ferrari S, Pasetti P, Calura GComparison between two methods for periodontal risk assessment.Minerva Stomatologica 2009;58:277-287
Risk assessment according to the UniFe method
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
HEAGONAL RISK DIAGRAM DEVELOPED BY LANG AND TONETTI
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 BOP2. No. of sites with PD ≥ 5mm3. No. of teeth lost4. Bone loss/age ratio5. Attachment loss/age ratio6. Diabetes and smoking7. Dental status8. Systemic factors and risk determinants are
recorded
Lang and bragger in 1992
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 categoriesSandhya and Sripriya in 2011
SCHUTTE AND DONLEY 1956 PATIENT QUESTIONAIRE
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.
CRONIN/STASSEN BEDS CHASM SCALE
Four step risk assessment model
Odds ratio helps to standardize risk assessment, allowing factors to be easily compared with the standard numerical index
B -BMI score 2
E - EthinicIty score 1.5
D - Diabetic score 2.5
S - Stressed score 2
C - College score 2.5
H - Hygiene score 2
A - Age 65+ score 3.5
S - Smoker score 1.5
M - Male score 1.5The total score of 19 indicates the highest risk
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.
PERIODONTAL RISK ASSESSMENT USING TWO ARTIFICIAL NEURAL NETWORKS
Lavenberg Marquardt Algorithm
Scaled Conjugate Gradient Algorithm
CONCLUSION
“ Measurement, Assessment, Elimination or reducing as many risks as possible will improve disease prevention and treatment outcomes”
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 Stomotol. 2009; 58; 277-287.
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.
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