As our understanding of

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1 Risk assessment and management of periodontal disease Chester W. Douglass, DMD, PhD 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 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 profes- ABSTRACT 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. JADA 2006;137(11 supplement):27s-32s. ARTICLE Dr. Douglass is a professor, Department of Oral Health Policy and Epidemiology, School of Dental Medicine, Harvard University, 188 Longwood Ave., Boston, Mass , chester_douglass@ hsdm.harvard.edu. Address reprint requests to Dr. Douglass. C O N T J I N U A I N G D A E D U C A T 4 I O N JADA, Vol November S

2 Daily Oral Health Care Regimen: Brushing, Flossing, Use of Antimicrobial Mouthrinse Patients without periodontitis: To control plaque accumulation and biofilm development Patients with periodontitis: As part of initial disease management If surgery not needed: To manage disease by preventing further tissue destruction If surgery needed: To manage plaque-induced inflammation after surgery 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. sionals 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 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 colleagues 3 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 figure, 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. 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 selfcare, see the article by Silverman and Wilder 4 in this supplement.) THE CLINICAL PRACTICE OF RISK ASSESSMENT Abundant evidence in the literature points to the direct and significant link between several risk 28S JADA, Vol November 2006

3 factors and periodontal disease. 5-7 (For a review of risk factors, see the article by Lamster 8 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 disease 9 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 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 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 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. 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, 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 colleagues 18 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 JADA, Vol November S

4 of experiencing increased medical complications 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 E 2 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 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 colleagues 28 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 Taylor 32 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 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, espe- 30S JADA, Vol November 2006

5 cially 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 osteoradionecrosis. 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 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 threestep daily oral care regimen of brushing, flossing and rinsing to help control the plaque biofilm. 1. Page RC, Krall EA, Martin J, Mancl L, Garcia RI. Validity and accuracy of a risk calculator in predicting periodontal disease. JADA 2002;133(5): Page RC, Martin J, Krall EA, Mancl L, Garcia R. Longitudinal validation of a risk calculator for periodontal disease. J Clin Periodontol 2003;30(9): Axelsson P, Nystrom B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries, and periodontal disease in adults: results after 30 years of maintenance. J Clin Periodontol 2004;31(9): Silverman S Jr, Wilder R. Safety and compliance factors for comprehensive daily oral care that includes an antiseptic mouthrinse. JADA 2006;137(11 supplement):22s-26s. 5. Borrell LN, Papapanou PN. Analytical epidemiology of periodontitis. J Clin Periodontol 2005;32(supplement 6): Axelsson P. Diagnosis and risk prediction of periodontal disease. Vol 3. Chicago: Quintessence; 2002: Timmerman MF, van der Weijden GA. Risk factors for periodontitis. Int J Dent Hyg 2006;4(1): Lamster IB. Antimicrobial mouthrinses and the management of periodontal diseases. JADA 2006;137(11 supplement):6s-9s. 9. Bader JD, Shugars DA, Kennedy JE, Haden WJ Jr, Baker S. A pilot study of risk-based prevention in private practice. JADA 2003; 134(9): Fox CH, Douglass CW. Periodontal destruction assessed by two sites per tooth vs six sites (abstract 699). J Dent Res 1989:68(special issue): Douglass CW, Fox CH. Cross-sectional studies in periodontal disease: current status and implications for dental practice. Adv Dent Res 1993:7(1): U.S. Census Bureau. U.S. Interim projections by age, sex, race, and Hispanic origin. Available at: usinterimproj. Accessed on July 11, Marshall-Day CD, Stephens RG, Quigley LF Jr. Periodontal disease: prevalence and incidence (abstract 77). J Dent Res 1954;33(5): Schei O, Waerhaug J, Lövdal A, Arno A. Alveolar bone loss as related to oral hygiene and age. J Periodontol 1959;30: Abdellatif HM, Burt BA. An epidemiological investigation into the relative importance of age and oral hygiene status as determinants of periodontitis. J Dent Res 1987;66(1): U.S. Public Health Service, National Center for Health Statistics. Periodontal disease in adults: United States, Washington: U.S. Department of Health, Education and Welfare, U.S. Public Health Service, Public Health Service publication (PHS) Vital Health Stat; series 11, no U.S. Public Health Service, National Center for Health Statistics. Basic data on dental health examination findings of persons 1-75 years, United States, Hyattsville, Md.: National Center for Health Statistics, U.S. Department of Health, Education and Welfare publication (PHS) Vital Health Stat; series 11, no Borrell LN, Beck JD, Heiss G. Socioeconomic disadvantage and periodontal disease: the Dental Atherosclerosis Risk in Communities Study. Am J Public Health 2006;96(2): Offenbacher S, Lieff S, Beck JD. Periodontitis-associated pregnancy complications. Prenat Neonat Med 1998;3(1): Offenbacher S, Boggess KA, Murtha AP, et al. Progressive periodontal disease and risk of very preterm delivery. Obstet Gynecol 2006;107(1): Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection and preterm birth: results of a prospective study. JADA 2001;132(7): Moss KL, Mauriello S, Ruvo AT, Offenbacher S, White RP Jr, JADA, Vol November S

6 Beck JD. Reliability of third molar probing measures and the systemic impact of third molar periodontal pathology. J Oral Maxillofac Surg 2006;64(4): Offenbacher S, Jared HL, O Reilly PG, et al. Potential pathogenic mechanisms of periodontitis associated pregnancy complications. Ann Periodontol 1998;3(1): Davenport ES, Williams CE, Sterne AI, Murad S, Sivapathasundram V, Curtis MA. Maternal periodontal disease and preterm low birthweight: case-control study. J Dent Res 2002;81(5): Tomar JL, Asma S. Smoking-attributable periodontitis in the United States: findings from NHANES III. National Health and Nutrition Examination Survey. J Periodontol 2000;71(5): Johnson GK, Hill M. Cigarette smoking and the periodontol patient. J Periodontol 2004;75(2): Deliargyris EN, Madianos PN, Kadoma W, et al. Periodontal disease in patients with acute myocardial infarction: prevalence and contribution to elevated C-reactive protein levels. Am Heart J 2004;147(6): Desvarieux M, Demmer RT, Rundek T, et al. Periodontal microbiota and carotid intima-media thickness: the Oral Infections and Vascular Disease Epidemiology Study (INVEST). Circulation 2005;111(5): Offenbacher S, Beck JD. A perspective on the potential cardioprotective benefits of periodontal therapy. Am Heart J 2005;149(6): Joshipura K, Ritchie C, Douglass C. Strength of evidence linking oral conditions and systemic disease. Compend Contin Educ Dent Suppl 2000;30: Ship JA. Diabetes and oral health: an overview. JADA 2003;134 (supplement 1):4S-10S. 32. Taylor G. Consensus statement on oral and systemic health. Inside Dent 2006;2(special issue 1): Selwitz RH, Pihlstrom BL. How to lower risk of developing diabetes and its complications: recommendations for the patient. JADA 2003;134(supplement 1):54S-58S. 34. Vernillo AT. Dental considerations for the treatment of patients with diabetes mellitus. JADA 2003;134(supplement 1):24S-33S. 35. Moore PA, Zgibor JC, Dasanayake AP. Diabetes: a growing epidemic of all ages. JADA 2003:134(supplement 1):11S-15S. 36. Ryan ME, Carnu O, Kamer A. The influence of diabetes on the periodontal tissues. JADA 2003;134(supplement 1):34S-40S. 37. Taylor GW. The effects of periodontal treatment on diabetes. JADA 2003;134(supplement 1):41S-48S. 38. U.S. Department of Health and Human Services. Oral health in America: A report of the surgeon general. Rockville, Md.: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; Navazesh M. Current oral manifestations of HIV infection. J Calif Dent Assoc 2001;29(2) Weldon JK Jr. Nonsurgical cancer therapies: dental complications and patient management. U.S. Army Med Department J. Available at: Accessed July 11, Rosenbaum EH, Silverman S, Festa B, et al. Mucositis: Oral problems and solutions. Available at: com/oral.html. Accessed July 11, S JADA, Vol November 2006