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J Am Dent Assoc, Vol 137, No suppl_3, 27S-32S.
© 2006 American Dental Association
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ARTICLES

JADA Continuing Education

Risk assessment and management of periodontal disease



Chester W. Douglass, DMD, PhD


   ABSTRACT
TOP
 ABSTRACT
RISK ASSESSMENT
 PERIODONTAL DISEASE MANAGEMENT
 THE CLINICAL PRACTICE OF...
 SPECIAL POPULATIONS
 MEDICAL COMORBIDITIES
 SUMMARY
 REFERENCES
 
Background. As our understanding of periodontal diseases has increased, it has become clear that certain risk factors are associated with the diseases’ incidence, severity and progression. This article focuses on the role of risk assessment and disease management in improving patient outcomes, both in the general population and in specific population groups with an increased risk of developing periodontal disease or with associated comorbidities.

Types of Studies Reviewed. The author reviewed literature related to the efficacy of risk assessment and periodontal disease management in improving clinical outcomes. In addition, he examined studies demonstrating a link between periodontal disease and specific patient populations and other comorbidities.

Conclusions. Risk assessment can help predict a patient’s risk of developing periodontal disease and improve clinical decision making. In turn, patient adherence to a self-care oral health regimen is a key component to successful periodontal disease management.

Clinical Implications. The clinical practice of risk assessment may reduce the need for complex periodontal therapy, improve patient outcomes and ultimately reduce oral health care costs. Patients are encouraged to become actively involved in periodontal disease management by following a daily three-step regimen of brushing, flossing and rinsing with an antimicrobial mouthrinse.

Key Words: Risk assessment; disease management; risk factors; self-care; antimicrobial mouthrinses; periodontal disease

As our understanding of periodontal diseases has deepened, it has become clear that certain risk factors are associated with disease development. As dental professionals seek to optimize treatment and improve outcomes for patients, the role of risk assessment and disease management has become increasingly important. This article reviews the application of risk assessment and disease management to the general population and to groups at risk of developing periodontal disease.


   RISK ASSESSMENT
TOP
 ABSTRACT
 RISK ASSESSMENT
PERIODONTAL DISEASE MANAGEMENT
 THE CLINICAL PRACTICE OF...
 SPECIAL POPULATIONS
 MEDICAL COMORBIDITIES
 SUMMARY
 REFERENCES
 
The practice of risk assessment involves dental care providers identifying patients and populations at increased risk of developing periodontal disease. Assessing patients’ risk of developing periodontal disease can have a significant impact on clinical decision making.1,2 However, the recognition and control of risk factors should become a more explicit focus in many dental practices. Rather than concentrating on obvious pathology that requires immediate (and typically surgical) intervention, the risk assessment model invites dental care professionals to take a step back and look at the potential development of dental disease over the long term.

In addition to improving clinical decision making, risk assessment may reduce the need for complex periodontal therapy, improve patient outcomes and ultimately reduce oral health care costs.1,2 Dentists’ awareness of risk factors also could help with the identification and treatment of comorbidities in the general population, as many periodontal disease risk factors are common to other chronic conditions such as heart disease, cancer and stroke.


   PERIODONTAL DISEASE MANAGEMENT
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 ABSTRACT
 RISK ASSESSMENT
 PERIODONTAL DISEASE MANAGEMENT
THE CLINICAL PRACTICE OF...
 SPECIAL POPULATIONS
 MEDICAL COMORBIDITIES
 SUMMARY
 REFERENCES
 
While risk assessment for periodontal disease is largely the domain of the dental care professional, periodontal disease management (including disease prevention) requires the patient’s participation. Indeed, self-care has been a key component of preventive dentistry for years. Axelsson and colleagues3 conducted a long-term study of plaque control in adults that showed administration of frequent, regular education in self-diagnosis and self-care techniques resulted in more healthy tooth surfaces, less periodontal attachment loss and fewer sites requiring periodontal care.

As illustrated in the figureGo, a self-care regimen of brushing, flossing and rinsing with an antimicrobial mouthrinse can help control dental plaque biofilm. For patients without periodontal disease, this three-step approach can help prevent the onset of periodontal disease. For patients with periodontal disease, this approach can play a secondary preventive role in early disease control, as well as be an important component of conservative therapy. In addition, self-care with particular oral rinses can be important for the postsurgical management of plaque-induced tissue inflammation.


Figure 1
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  		Figure. A three-step approach to daily oral health care can be part of the regimen for patients with a healthy periodontium, those with gingivitis and those with periodontitis. In each case, the intent is to reduce the microbial challenge.

 
Clearly, patient motivation regarding disease management is critical if the benefits of self-care are to be realized; this may require individualized patient education to ensure that each patient appreciates the relevance of self-care to the enhancement of his or her own oral health. (For more information on patient adherence to self-care, see the article by Silverman and Wilder4 in this supplement.)


   THE CLINICAL PRACTICE OF RISK ASSESSMENT
TOP
 ABSTRACT
 RISK ASSESSMENT
 PERIODONTAL DISEASE MANAGEMENT
 THE CLINICAL PRACTICE OF...
SPECIAL POPULATIONS
 MEDICAL COMORBIDITIES
 SUMMARY
 REFERENCES
 
Abundant evidence in the literature points to the direct and significant link between several risk factors and periodontal disease.5–7 (For a review of risk factors, see the article by Lamster8 in this supplement.) Use of a formal risk assessment tool can aid dental professionals in the identification of patients at elevated risk of developing periodontal disease9 and may help in the selection of patients who require additional education or targeted interventions to prevent or minimize the impact of periodontal disease.

One such tool, the Periodontal Risk Calculator (PRC) described by Page and colleagues,1,2 has been shown to accurately assess and quantify a patient’s risk of developing periodontal disease. The researchers entered information from baseline dental examinations of 523 men into the PRC (data included age, smoking history, diabetes diagnosis and pocket depth). They then calculated a risk score on a scale of 1 (lowest risk) to 5 (highest risk) for each subject. The risk scores were strong predictors of periodontal status as measured by alveolar bone loss and loss of affected teeth, especially periodontally affected teeth, at three, nine and 15 years. By year 15, 83.7 percent of subjects with a risk score of 5, compared with 20.2 percent of subjects with a risk score of 2, had lost one or more periodontally affected teeth.1,2

Early interventions to maximize oral health, including promotion of the use of antimicrobial rinses to control the plaque biofilm, may provide important health benefits for older patients.

The inclusion of a risk assessment tool in routine practice would add only a small amount of time to patient visits. Signs and symptoms targeted in risk assessment might include pocket depth, bleeding on probing, poor oral hygiene, persistent inflammation, loss of attachment, smoking, increasing pocket depth, pregnancy and diabetes. Among the general public, use of a risk assessment instrument may help identify the 20 percent of patients in need of intervention to prevent or minimize development of more advanced periodontal disease.10,11


   SPECIAL POPULATIONS
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 ABSTRACT
 RISK ASSESSMENT
 PERIODONTAL DISEASE MANAGEMENT
 THE CLINICAL PRACTICE OF...
 SPECIAL POPULATIONS
MEDICAL COMORBIDITIES
 SUMMARY
 REFERENCES
 
Special attention to population groups with identified risk characteristics who may need more aggressive interventions and more frequent recall may have a positive impact on disease progression and oral health outcomes. Some of these patient groups are described below.

Elderly people. As the baby-boom generation ages, the number of people 65 years and older will increase dramatically. According to the 2000 U.S. Census, there are approximately 24.2 million people between the ages of 55 and 64 years, representing 8.6 percent of the population. In 2004, there were 36.3 million people in the United States older than 65 years, representing 12.4 percent of the population.12 By 2030 this number will grow to 71.5 million people, or 20 percent of the population.12

Periodontal disease is more prevalent in older groups than in younger groups,13–15 though this may be the result of cumulative tissue destruction throughout a lifetime rather than an age-related risk of periodontal susceptibility.7 In addition, many of the comorbid conditions associated with periodontal disease occur more frequently and with greater severity in people of advanced age. As a consequence, early interventions to maximize oral health, including promotion of the use of antimicrobial rinses to control the plaque biofilm, may provide important health benefits for older patients.

People at lower socioeconomic levels. Socioeconomic status historically has been found to be related to gingivitis and poor oral hygiene.16,17 Borrell and colleagues18 confirmed that education and income were associated with severe periodontitis; they found that residence in an economically disadvantaged neighborhood increased the likelihood of severe disease. Disparities in access to routine dental professional care may account for differences in the rate of periodontal disease and other dental complications.

For this population, culturally relevant education with regard to enhanced self-care practices may yield significant clinical gains. The most culturally relevant competency that will be required increasingly by dental practices is the ability to communicate with non–English-speaking patients. Use of an integrated risk assessment tool during the patient interaction can be expected to aid in the identification of other potential problems or issues, such as tobacco use, and may provide the basis for meaningful educational discussion of the benefits of a daily oral health regimen.

Pregnancy. Periodontal disease has been shown to be associated with preterm delivery and low birth weight, both of which put infants at risk of experiencing increased medical complications.19–21 A recent study found a significant association between preterm birth and third-molar periodontal disease in pregnant women.22 Analysis of gingival crevicular fluid has demonstrated significantly higher levels of the inflammatory mediator prostaglandin E2 in women who delivered preterm low-birth-weight infants.23 However, other research has failed to demonstrate a link between preterm low-birth-weight babies and periodontal disease.24 Although a causal connection has not been established, it is appropriate to advise expectant mothers about the importance of good oral health, including the use of antimicrobial rinses to mitigate the impact of pathogenic bacteria.

Smokers. A wealth of data has established the relationship between the amount and duration of smoking and severity of periodontal pathology.6,25,26 Both local and systemic mechanisms mediate the negative impact of tobacco use on oral health.25,26 Heat from smoke may enhance attachment loss, and the increased calculus deposits that often result from smoking can enhance plaque retention. Nicotine can diminish collagen synthesis and protein secretion and inhibit bone formation.6,26 These findings result in impaired wound healing, as well as increased susceptibility to periodontal disease, which may limit the success of treatment interventions.26 Smoking also inhibits immunological function and negatively affects immunoglobulin levels, which may increase susceptibility to typical and unusual microbial pathogens.25,26

Inclusion of a risk assessment instrument in patient encounters with smokers provides clinicians with an opportunity to identify patients at risk and deliver critical information about the benefits of smoking cessation and the importance of daily self-care strategies to control the plaque biofilm.


   MEDICAL COMORBIDITIES
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 ABSTRACT
 RISK ASSESSMENT
 PERIODONTAL DISEASE MANAGEMENT
 THE CLINICAL PRACTICE OF...
 SPECIAL POPULATIONS
 MEDICAL COMORBIDITIES
SUMMARY
 REFERENCES
 
Oral pathology frequently is associated with a number of complex systemic medical conditions. For a number of these conditions, identification and management of oral manifestations not only proactively addresses potential periodontal problems but also enhances patients’ awareness of medical issues. Educational initiatives to emphasize self-care and referrals to appropriate medical professionals ultimately may optimize treatment outcomes.

Cardiovascular/cerebrovascular disease. Cardiovascular/cerebrovascular disease (CVD) affects adults, at some level, as their ages increase, and the evidence of the link between periodontitis and CVD—though not entirely consistent—continues to grow.

C-reactive protein is a systemic marker for inflammation; plasma levels of this marker are predictive of future myocardial infarct and stroke. Patients with periodontitis have demonstrated elevated C-reactive protein levels.27 Some investigators have suggested that the chronic inflammatory burden of periodontitis may contribute to the CVD process. In an analysis of 4,561 subgingival plaque samples collected from 657 subjects, Desvarieux and colleagues28 found a direct relationship between periodontal bacterial burden and subclinical atherosclerosis. Other reports have noted associations between cerebrovascular stroke and tooth loss, bone loss and poor dental status, though the precise mechanisms that mediate these multiple pathogenic processes have not been delineated.29

These data suggest an association between periodontal disease and CVD; however, these studies have not proven a causal connection.30 Still, the integration of a risk management tool may help dental professionals convince these patients of the need for proper oral self-care, as well as encourage medical evaluation of potential cardiovascular manifestations.

Diabetes. Diabetes mellitus is a key example of a chronic medical condition with a significant impact on oral health. The underlying defect in diabetes is an inability to maintain normal blood glucose levels; this disturbance leads to deranged metabolism of fats, carbohydrates and protein.31 Taylor32 estimated that 20.8 million people, or 7.0 percent of the U.S. population, have diabetes.

Diabetes has been associated with a number of oral complications, including periodontitis and gingivitis, dental caries, salivary gland dysfunction and xerostomia, burning mouth syndrome and increased susceptibility to oral infections.33–35 Of particular concern are patients with diabetes, who are at an increased risk of developing periodontitis.34 In these patients, host responses may be impaired, wound healing is delayed, and collagenolytic activity may be enhanced.36 In addition, since wound healing may be impaired in this group, surgical intervention may need to be avoided.34 As a result, periodontitis may be a particular problem in patients with diabetes, especially those with uncontrolled disease.

Diabetes also may 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.31 Furthermore, active inflammation characteristic of periodontitis generates compounds that may increase insulin resistance.37 Therefore, control of periodontal disease may help patients improve metabolic control.

Immunosuppression. Immunocompromised people are another special patient population for whom aggressive disease management could modify outcomes. Increased susceptibility to oral infection, especially with unusual pathogens, can occur in these patients and may necessitate prompt intervention, often in concert with medical professionals. The underlying cause of the immunosuppression may affect the types of pathogens seen, as well as management options; patients who have lupus, have leukemia, are undergoing high-dose chemotherapy, have received transplants or have HIV infection all may display different clinical manifestations.38 In particular, it should be noted that the oral manifestations of HIV infection have been reduced significantly since the introduction of highly active antiretroviral therapy.39 Nevertheless, vigilance in disease management and communication and cooperation with medical professionals can enhance care for these patients.

Cancer. Patients who have cancer and who undergo chemotherapy and radiation therapy may experience significant deleterious oral complications, including oral mucositis, xerostomia, radiation-induced dental caries and even osteo-radionecrosis.40,41 Opportunistic infections such as Candida albicans have been shown to increase in frequency with mucositis and immunosuppression, and infection may occur months or years after treatment.40 The antibiotics and steroids used to treat these infections can result in secondary infections by the normal oral flora.40 Oral hygiene in these patients must be maintained because of their lowered biological potential for healing in response to physical irritation, chemical agents and microbial organisms.40 Consulting with the patient’s oncologist and developing a targeted daily oral hygiene regimen that includes brushing, flossing and rinsing may help improve outcomes in this population.


   SUMMARY
TOP
 ABSTRACT
 RISK ASSESSMENT
 PERIODONTAL DISEASE MANAGEMENT
 THE CLINICAL PRACTICE OF...
 SPECIAL POPULATIONS
 MEDICAL COMORBIDITIES
 SUMMARY
REFERENCES
 
The practice of risk assessment allows dental care professionals the opportunity to improve dental and medical outcomes in the general population and in specific population groups by focusing on early identification and proactive targeted interventions. Patient self-care is an integral part of disease management and should include a three-step daily oral care regimen of brushing, flossing and rinsing to help control the plaque biofilm.


   FOOTNOTES
 

Dr. Douglass is a professor, Department of Oral Health Policy and Epidemiology, School of Dental Medicine, Harvard University, 188 Longwood Ave., Boston, Mass. 02115, e-mail "chester_douglass{at}hsdm.harvard.edu". Address reprint requests to Dr. Douglass.


   REFERENCES
TOP
 ABSTRACT
 RISK ASSESSMENT
 PERIODONTAL DISEASE MANAGEMENT
 THE CLINICAL PRACTICE OF...
 SPECIAL POPULATIONS
 MEDICAL COMORBIDITIES
 SUMMARY
 REFERENCES
 

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