By Richard H. Nagelberg, DDS
There are many risk factors that increase the likelihood of periodontal disease development, as well as increasing the severity and speed at which it may occur. Among the most common are:
• Heredity
• Smoking
• Diabetes
• Stress
• Medication
• Nutrition
• Poor oral hygiene
• Faulty dentistry
• Hormonal variations
• Immunocompromise
• Connective tissue diseases
• Previous history of active perio disease
The individual risk factors have unique mechanisms of action; however, all operate in one of two ways: increasing biofilm levels or impairing the body's ability to respond to the bacterial challenge. In some cases both mechanisms are operating.
Increased biofilm levels are caused by high carbohydrate intake (nutrition), poor oral hygiene, and faulty dentistry. Impairing the body's ability to respond adequately to the level of bacteria is caused by hereditary reduction of immune system function; diabetes; stress; xerostomia from medications; hormonal variations such as those that occur during puberty, pregnancy, menopause, and oral contraceptive use; and in immunocompromised patients. Nutrition can also impair the response to bacteria if the dietary deficiency results in immune system problems. A previous history of active periodontal disease increases the risk of perio disease because of the genetic predisposition which manifests as an immune system incapable of dealing with otherwise acceptable levels of bacteria. This genetic predisposition for perio disease is for life. If sufficient quantities of bacteria are present, the disease will recur.
As dental professionals, we are identifying and modifying risk factors for periodontal disease even if we don't recognize it as such. For example, home-care instructions are an attempt to modify the contribution of poor oral hygiene to the development of perio disease. Smoking cessation and dietary counseling we provide also constitute risk factor modification.
All risk factors are not created equal. Diabetes and smoking are the biggest risk factors for gum disease development, increased severity, and the speed at which it occurs. The number one systemic condition that increases susceptibility to periodontal disease is diabetes. Multiple risk factors do not increase the risk in an additive manner, but rather in an exponential manner. A patient with three risk factors — such as high stress level, poor oral hygiene, and faulty dental work — is not three times more likely to develop gum disease than a patient without these risk factors; he or she is approximately 27 times more likely to develop gum disease or have it worsen rapidly.
When we provide periodontal treatment and behavior modification, however, we reduce the risks for gum disease in an exponential manner as well. Even if we cannot remove or reduce all risk factors, periodontal disease prevention or control is enhanced if we can remove or reduce some of a patient's risk factors. Identifying a patient's risks, counting up the number of factors, and giving added weight to the contribution of diabetes and smoking will help clinicians understand the challenge presented by an individual patient. The treatment plan may be modified by an evaluation of risk factors. Eliminating or reducing as many risks as possible will improve disease prevention and treatment outcomes. In this way we can personalize patient care rather than use a "one size fits all" approach with our perio patients.
Risk factor reduction can take many forms including smoking cessation programs, dietary counseling, home-care instructions, correcting faulty restorations, and encouraging compliance for poorly controlled diabetic individuals. Biofilm control is critical and many recommendations are warranted, such as powerbrush usage, interdental biofilm removal devices, antimicrobial mouthrinses, and more frequent recare appointments.
The primary role of all dental providers is risk reduction. Identifying and modifying risk factors prior to and during perio therapy is critical to successful treatment outcomes, long-term periodontal health and enhanced patient care, and that's what it is all about — the care we provide for all patients, every time they give us the privilege of providing care for them.
© 2009 Richard H. Nagelberg, DDS
