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Pathology

Risk factors
1. Systemic risk factors factors that affect

the host response to the plaque biofilm,


upsetting the hostmicrobial balance.
2. Local risk factors factors local to the oral
cavity,
which may influence plaque accumulation or

occlusal forces.[4] (TimmermanMF, 2006)

Causes
Oral microorganisms
Porphyromonas gingivalis
Tannerella forsythensis
Treponema denticola.
Actinobacillus actinomycetemcomitans in

young adults

Pathology
Risk factors
1. Systemic risk factors factors that affect

the host response to the plaque biofilm,


upsetting the hostmicrobial balance.
2. Local risk factors factors local to the oral
cavity,
which may influence plaque accumulation or

occlusal forces.[4] (TimmermanMF, 2006)

Risk factors for periodontal disease


Age
Age -> Periodontal disease

Use of tobacco
Diabetes mellitus
Gingivitis, periodontitis, dental caries,

salivary gland dysfunction, xerostomia,


burning mouth syndrome, oral infections

Use of tobacco
Heat from smoke attachment loss, calculus

from plaque retention


Nicotine - collagen synthesis, bone formation

- Nicotine + P. gingivalis ->


breakdown of
supporting tissue of teeth

11 times harbor bacteria

4 times advanced periodontitis

Stress
biofilm plaque, gingivitis

Genetic risk factor


IL-1 genotype-positive develop more

advanced periodontitis than IL-1


genotype-negative
Pregnancy
?

Cardiovascular diseases
C-reactive protein -> myocardial

infarct, stroke
Poor oral hygiene
Biofilm plaque -> pathogenic bacteria of

periodontal disease

Risk assessment
Four levels
1. Patient level
2. Whole mouth level
3. Tooth level
4. Site level

Patient-level risk assessement


Family history
Medical / dental history
Social history eg. Smoking
Habits

Mouth-level risk assessment


Initial examination
Attachment loss
Oral hygiene
Recession
Gingival inflammation & pockets
Plaque-retentive factors

Tooth-level risk assessment


Tooth mobility
Residual tooth support (radiographically)
Furcation
Tooth anatomy (eg. Talon cusp)
Subgingival calulus

Site-level risk assessment


Bleeding on probing
Pocket depth

Periodontal risk calculator


(PRC)
Using 9 risk factors to calculate risk for periodontal disease by
Microsoft excel
Patient age
Smoking history
Diagnosis of diabetes
History of periodontal surgery
Pocket depth
Furcation involvements
Restorations or calculus below the gingival margin
Radiographic bone height
Vertical bone lesions

American
academy of
periodontolo
gy selfassessment
tool

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.

PSR codes

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
Modified PRA
In 2007, Chandra evaluated a novel periodontal risk

assessment model based on model by Lang and


Tonetti
1. Percentage of sites with BOP
2. No. of sites with PD 5mm
3. No. of teeth lost
4. Bone loss/age ratio
5. Attachment loss/age ratio
6. Diabetes and smoking
7. Dental status
8. Systemic factors and risk determinants are
recorded

Gingival inflammation
GI - Loe and Silness (1967)
Plaque thickness at gingival margin
M/B/D/L

Gingival inflammation
Bleeding on probing index

M/B/D/L

Index :is a numerical value describing the


relative status of population on
graduated scale with definite upper and
lower limit which is designed to permit
and facilitate comparison with other
population classified by the same criteria
and method.

Assessment of inflammation of
the periodontal tissue.
Plaque index:

Gingival index:

Silness & Le(1964)

Le & Silness(1967)

Plaque index: Silness &Le(1964)


Score

Criteria

Absence of plaque deposits

Plaque disclosed after running the


probe along the gingival margin

Visible plaque

Abundant plaque

periodontal

Gingival index: Le(1967)


Score

Criteria

Normal gingiva

Mild inflammation: slight change in

color and

slight edema. No bleeding on probing.


2
Moderate inflammation: redness, edema, and
glazing. running along
soft tissue wall of gingival crevice.
3
Severe inflammation: marked redness and
edema. Ulceration,
Tendency toward spontaneous bleeding.

Assessment of loss of periodontal


tissue support:
Periodontal index: Russell(1956)

Periodontal Disease lndex:

Ramfjord(1959)

COMMUNITY PERIODONTAL INDEX OF TREATMENT NEEDS (CPITN)

Code

CPI

TN

Healthy

Bleeding on probing

Supra and\or Subgingival

I . Oral hygiene instruction

II .

I+ calculus removal

calculus Iatrogenic marginal


irritation

Shallow pockets up to
5 mm

Deeper pockets from

6mm

III. I+II+ root planning

IV. I+II+ complex treatment

Indices Used To Assess Gingival


Inflammation
Papillary-marginal-attachment index (PMA) - (Schour & Massler,
1948).

Gingival index (GI) - (Loe & Silness, 1963).

Modified Gingival Index (MGI)- (Lobene et al., 1986)

Periodontal index (PI)- (Russell, 1956)

Gingivitis component of periodontal disease index (PDI) (Ramfjord SP ,

1959)

Indices used to assess gingival bleeding


Gingival index used by the National Institute of Dental Research (NIDR)

(Miller et al., 1987)


National Institute of Dental & Craniofacial Research (NICDR) (NHANES III,

1997)
Sulcus Bleeding Index (Mhlemann & Major, 1958)
Bleeding Point Index

(Lenox & Kopczyk, 1973)

Ainamos Gingival Bleeding Index (Ainamo & Bay, 1975)


Carters Gingival Bleeding Index (Carter & Barnes, 1974)
Eastman Interdental Bleeding Index (Caton & Polson, 1985)

Indices used to assess plaque & calculus


Plaque Index (PI) (Silness & Loe, 1964)
Plaque component of PDI (Ramfjord, 1959)
Turesky modification of Quigley Hein Index (Quigley & Hein

1962,Turesky 1970)
Shick and Ash Modification of Plaque Criteria ( Shick & Ash 1961)

Oral Hygiene Index-Simplified (OHI -S) (Greene & Vermillion ,

1964)
Calculus component of PDI (Ramfjord, 1959)
Calculus severity index (Ennever &Radike 1961)

Indices to measure degree of


periodontal destruction
Periodontal disease index (Ramfjord SP , 1959)

Extent and Severity Index (ESI) (Carlos et al,1986)

Indices used to assess treatment needs


Gingival plaque index (O'Leary et al., 1963)

Periodontal Treatment Need System (PTNS) (Bellini

& Gjermo, 1973)

CPITN- Community Periodontal Index Of

Treatment Needs (Ainamo et al., 1982)

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