Risk factors revisited
Risk factors are the primary determinants of the course periodontal disease takes by the variety of mechanisms ...
By Richard H. Nagelberg, DDS
Risk factors are the primary determinants of the course periodontal disease takes by the variety of mechanisms in which they influence the development, progression, resolution, and recurrence of the disease.
Risk factors are actually only one category of a wider group of risk elements. There are risk determinants such as genetics, age, gender, socioeconomic status, and stress; risk markers such as previous history of periodontal disease and bleeding upon probing; and risk indicators including HIV/AIDS, osteoporosis, and infrequent dental visits (Carranza’s Clinical Periodontology 11th edition). Consideration of risk elements during the treatment-planning phase of periodontal therapy is essential to maximize the patient’s prognosis. When a favorable outcome is not achieved, the impact of risk elements is the reason in the vast majority of cases.
The most important risk element of all, bar none, is the specific bacterial species causing each patient’s disease. This also holds true for the patient’s health beyond the oral cavity. Research continues to reveal the effect of periodontal pathogens on cardiovascular health, independently from the presence of periodontal disease. Some bacterial species such as Aggregatibacter actinomycetemcomitans (Aa) and Porphyromonas gingivalis (Pg) are highly pathogenic in low levels, tissue invasive, transmittable, and associated with aggressive forms of periodontal disease.
Contrast these with other weaker periodontal pathogens such as the Capnocytophaga species, which are much less pathogenic and contribute to tissue damage when found in combination with other bacteria. It is easy to see the major influence of the specific causative bacteria on the course of the disease. Causative bacteria will directly affect the treatment plan and prognosis. Failure to identify the bacteria responsible for a patient’s disease is like putting a blindfold on the clinician. Proceeding this way necessarily involves a complete absence of knowledge regarding which bacteria are being reduced or eradicated, and the proper adjunctive antibiotics to use. This may affect the patient’s ability to achieve disease resolution as quickly as possible.
Another primary risk element is genetic susceptibility to periodontal disease. This is easily determined by salivary testing (www.OralDNAlabs.com). Patients who test positive have an exaggerated inflammatory response to a bacterial challenge, accompanied by the release of higher levels of inflammatory mediators. These include tissue-destructive enzymes and cytokines, which amplify inflammation. Individuals who test positive are three to seven times more likely to have severe periodontal disease compared to negative testers. More aggressive treatment is commonly necessary for these patients.
When the causative bacteria and genetic susceptibility are combined with other risk elements in the treatment plan, the likelihood of a successful outcome is enhanced. Furthermore, the therapeutic endpoint, which includes clinical improvement and bacterial reduction, is measurable by salivary bacterial testing approximately six weeks after the adjunctive antibiotic course is complete. Clinical resolution without significant bacterial reduction may require further rounds of treatment, a change in the antibiotic regimen, and additional biofilm control tools. Reexamining the risk elements, however, is the first place to start.
Risk elements are the best indicators of both the overall prognosis and the prognosis for each individual tooth. The first determination is the overall prognosis, followed by the likelihood of successfully resolving the disease around individual teeth. The prognostic value of the patient’s risk elements is among the most important criteria when developing a treatment plan. The patient’s ability to eliminate and disrupt the biofilm is the most significant factor for a favorable treatment outcome. This makes perfect sense since the most impactful risk element is the bacterial species responsible for the disease being treated.
Using all of the information at our disposal — including the patient’s dental history, health and family histories, risk elements, bacterial species identification, genetic susceptibility determination, and all the parameters revealed by their clinical presentation — may seem like a daunting task. But this information is vitally important to maximize favorable treatment outcomes.
The dental profession has moved past the one-size-fits-all approach to periodontal disease. Keeping risk elements in mind — especially the most important one — will enhance the level of care we provide for every patient. This is, after all, the reason we went into the dental profession in the first place — to provide the best care for every patient, every time, with any level of periodontal disease.
DR. RICHARD NAGELBERG has practiced general dentistry in suburban Philadelphia for more than 29 years. He is a speaker, advisory board member, consultant, key opinion leader for several dental companies and organizations, and lecturer on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at email@example.com