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SARANRAJ JPS PUBLICATION DR. SYED WALi PEERAI

Bl. IAITHIIEYAI IAMAL/lliAM
Essentials of
PERIODONTICS &
ORAL IMPLANTOLOGY

DR. SYED WALi PEERAN

DR. KARTHIKEYAN RAMALINGAM
Essentials Of
PERIODONTICS & ORAL IMPLANTOLOGY
Published by Dr. Syed Wali Peeran and Dr. Karthikeyan Ramalingam @
Saranraj JPS Publication,
Tamil Nadu, India

© Dr. Syed Wali Peeran &

Dr. Karthikeyan Ramalingam
1st Edition 2021
ISBN: 978-81-950475-4-3
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopy, recording or any information storage and retrieval system without the permission in writing from the
publisher.
Note: As new information becomes available, changes become necessary. The editors/author/contributors and the publishers have,
as far as it is possible, taken care to ensure that the information given in this book is accurate and up to date. In veiw of the possibility
of human error or advances in medical science neither the editor nor the publisher nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete. Readers
are strongly advised to conirm. This book is for sale in India only and cannot be exported without the permission of the publisher in
writing. Any disputes and legal matters to be settled under Chennai jurisdiction only.

Published in India
 Dr. Syed Wali Peeran is Professor of Periodontology and Oral lmplantology.
He finished his postgraduation in Periodontology in 2008 and has a doctoral degree.
He has a postgraduate certificate in advanced oral implantology and a
fellowship from international congress of oral implantologists.
He is the Editor in Chief and the founding editor for the journals-
Dentistry & Medical Research and Case Reports in Odontology.
He has over 63 national and international publications to his credit.
He has attended various national and international conferences and workshops.
He has also authored "Perio-Quest- MCQs in Periodontics with Self-Assessment
Picture Test" published by EMMESS publishers. He has been a reviewer for Libyan
Journal of Medicine,Journal of Nature, Biology and Medicine and various other
journals. He is a Life member of Indian Academy of Osseo Integration,
Indian Society of Periodontology, Indian immunological Society,
Indian Society of Oral lmplantologists and Indian Dental association.

Dr. Syed Wali Peeran, B.D.S, M.D.S (Peria), Ph.D. FICO/., PGCOI.
Professor, Department of Periodontics & Oral lmplantology,Faculty of Dentistry, Sebha
University, Sebha, Libya.

Dr. Karthikeyan Ramalingam is a Professor of Oral Pathology and Microbiology.

He finished his graduation and post graduation from Saveetha Dental College,
Chennai. He was the College topper in Part I and Part II postgraduate University
examinations.
He had secured the Gold medal in Pathology & Microbiology and Community
Dentistry in University examinations.He has guided postgraduates in oral pathology for
their seminars, research studies, journal discussions, library dissertations, thesis
preparation and in submitting articles for publication in various national and
international journals. He has also handled lectures and practical demonstrations
for undergraduates in oral histology,dental anatomy, forensic odontology, oral
pathology and microbiology. He has 65 international and national publications to his
credit. He is the Co-author of Textbook of Prosthodontics by Jaypee Brothers Medical
Publishers (P) Ltd. He has also contributed multiple choice questions and clinical
pictures to Perio-Quest- MCQs in Periodontics with Self-Assessment Picture Test by
EMMESS publishers. He is the Editor for Journals - Dentistry and Medical Research &
Case reports in Odontology.He is also the Reviewer for Journal of Oral and
Maxillofacial Pathology and North American Journal of Medical Sciences
(Indexed with PUBMED) and Journal of Cranio-Maxillary diseases.
He is a member of International Association of Oral Pathologists since 2016.
He is a Life member of Tamilnadu Dental Council since 2001, Life member of
Indian Association of Oral and Maxillofacial Pathologists since 2006 and a Life
member of Saveetha Dental College Old Students Association since 2001.
Dr. Karthikeyan Ramalingam, B.D.S, M.D.S
Professor, Department of Oral Pathology & Microbiology,Faculty of Dentistry, Sebha University,
Sebha,Libya
 Dr. ABDULNASIR MAQBOOL AHMED.
MSc, FICOI (U.S.A), Private Practice,
U.A.E.
Dr. Abhilash.
P.R. M.D.S
(Oral Pathology and Microbiology),
Reader, Department of Oral Pathology
and Microbiology,
Oxford Dental College & Hospitals,
Bangalore, Karnataka, India.
Dr. Ahmed Taher El-Hassan.
M.Sc (Oral Sciences-Periodontics),
Diplomate of American Board of
Periodontics, NOBE, WREB.
Assistant Professor, Benghazi University,
Benghazi, Libya.
Dr. Aisha Ahmed.
MB.ChB
ECFMG Certified Physician.
Department of Medicine, Faculty of
Medicine, Sebha University, Sebha,
Libya.
Dr. Bandar M.A. AL-Makramani.
BOS, HOD, MDSc, Ph.D
Assistant Professor, Fixed Prosthodontics,
Department of Prosthodontics, College
of Dentistry, Jazan University, Kingdom
of Saudi Arabia.
Dr. Fatma Mojtaba Al Said.
BOS., MPH (USA),
Faculty of Dentistry, Sebha University,
Sebha, Libya.
Dr. Franciso AL.
College of Dentistry, Jizan University,
KSA
Dr. Fuad Al Sanabani.
MSc, PhD
Department of Oral and Maxillofacial
Prosthodontics, Jazan University, Jazan,
Kingdom of Saudi Arabia
Dr. Ismail Abbas Darout.
DDS, Ph.D. (Dr .odont),
Postdoc Peria, Associate Professor
and Head, Department of Preventive
Dental Sciences, College of Dentistry,
Jazan University, Kingdom of Saudi
Arabia.
Dr. Khaled Awidat Abdalla.
B.D.S., C.E.S., DuODF (France),
Assistant Professor, Department of
Oral Biology and Orthodontics,
Sebha University, Sebha, Libya.
Dr. Manohar Murugan
M.Sc. (Microbiology), Ph.D.,
Assistant Professor, Department of
Medical Microbiology, Faculty
of Medicine, Sebha University, Sebha,
Libya.
Powered by TCPDF (www.tcpdf.org)
Dr. MOHAMMAD NAZISH ALAM.
BOS., MOS.
Asst. Prof, Department of Periodontics,
College of Dentistry, Jazan university
Dr. Nagabushan.
B.D.S., M.D.S
(Oral Medicine and Radiology),
Department of Oral Medicine and Radiology,
India.
Dr. Neha.
MOS.,
Department Of Periodontics and lmplantology,
Surendera Dental College and Research Institute,
Sriganganagar, Rajasthan.
Dr. R. Ganesh.
B.D.S., M.D.S. (Pedodontics)
Reader, Department of Pediatric and
Preventive dentistry, SRM University,
Tamil Nadu, India.
Dr. Rashmi Rai.
BOS., MOS.
Senior lecturer, public health dentistry,lndex
institute of dental sciences, Indore
Dr. Santosh Kumar.BB
BOS, MOS (Peria), M.Perio RCSEd (U.K),
MICOI (U.S.A) ), Specialist Periodontist and
lmplantologist, Kuwait.
Dr. Salhya Selhuraman.
B.D.S, M.A, PG0CA,
Surendra Dental College and Research
Institute, Sriganganagar, Rajasthan. India.
Dr. Shaesta Begum.
BOS, MOS (Periodontics),
Reader, Depatment of Periodontics, Farooqia
Dental College & Hospital, Mysore, Karnataka.
India.
Dr. Shamimul Hasan.
BOS, MOS
Assistant Professor, Department of Oral
Medicine and Radiology, Faculty of Dentistry,
Jamia Milia lslamia, New Delhi.India
Dr. Soumya K Nair.
B.D.S., MOS.,
Private practitioner, Mysore, India.
Dr. Suchelra N. Malleshi.
B.D.S., M.D.S (Oral Medicine and Radiology),
Department of Oral Medicine and Radiology,
J.S.S Dental College, Karnataka, India.
Dr. Supriya Ebenezer.
BOS., MOS.
Reader, Department of Periodontics,
Mathrusri Ramabai Ambedkar Dental
College and Hospital, Bangalore, India.
Dr. Syed Ali Peeran.
M.D.S. (Prostho)., MBA(HA), M.Phil (H.A),
Department of Prosthodontics, Assistant
Professor, Jazan University, Jazan, KSA.
Dr. Syed Kuduruthullah. S.K
M.0.S.(Oral Path)
Lecturer, Ajman University,
Ajman, U.A.E.
Dr. Syed Nahid Basheer.
BOS., MOS.
Assistant Professor, Department of Restorative
Dental Science, College of Dentistry, Jazan
University, Gizan, Kingdom of Saudi Arabia.
Dr. Syeda Nikhat Mohammadi.
BOS., MOS.
Senior lecturer, public health dentistry,
Pravara institute of dental sciences, Loni.
Maharashtra.
Dr. Tazeen.D
B.D.S., M.D.S (Peria).
Assistant Professor, Department of Periodontics,
Jazan University, Jazan, KSA.
Prof. Dr. Abdul Hafeez Khan
M.Sc., Ph.D.
Chairman, Department of Parasitology, Faculty
of Medicine, Sebha University, Sebha, Libya.
Prof. Dr. Abdul Hafeez Khan
M.Sc., Ph.D.
Chairman, Department of Parasitology, Faculty
of Medicine, Sebha University, Sebha, Libya.
Prof. Dr. Madhumala Thiruneervannan
BOS., M.D.S (Peria),
Head, Department of Periodontics, Vinayaka
Mission's Sankarachariyar Dental College,
Salem, India.
Prof. Dr. Marei Hamad Al Mugrabi.
B.D.S., M.Dent.Sc. (Periodontics-Dublin),Ph.D.
Head, Department of Periodontics, Benghazi
University, Libya.
Prof. Dr. Nurgul KOMERIK.
DDS., Ph.D.
Post Doc. Biruni University, Dental School,
Dept. of Oral Surgery, Istanbul, TURKEY
Prof. Dr. P.G. Naveen Kumar.
B.D.S., M.D.S., (Community Dentistry),
Head, Department of Community and
Preventive dentistry, College of Dental
Sciences, Davangere, Karnataka, India.
Prof. Dr. PC Anila Namboodiripad.
BDS, MDS., Department of Oral and M axillofacial
Pathology, India
Prof. Dr. R Thiruneervannan
BDS., MDS.
Principal, Vinayaka Mission's Sankarachariyar Dental
College, Salem, Tamil Nadu, India.
Prof. Dr. Syed Khalid Alla!.
MDS.
Associate Fellow AAID, Department of oral
mplantology, Vivekenanda dental college,
TN, India
Prof. Dr. V.Gopinalh.
M.D.S.
Professor, Department of Periodontology and
lmplantology, Chhattisgarh dental college
and research institute, Rajnandgaon, India
Prof. DR.V.HARIKRISHNA.
M.D.S.
Department of Orthodontics and Dentofacial
Orthopaedics. Chhattisgarh Dental college
and research institute, Rajnandgaon, India.
Chapter 42
CHAPTER
39 Periodontal Risk Assessment
Chapter Outline:
Definitions and Terminology.
RATIONALE OF PERIODONTAL RISK ASSESSMENT.
Methods to assess periodontal risk.
Periodontal Risk Calculator (PRC).
• PreViser.
• Periodontal Assessment Tool (PAT).
• Periodontal Risk Assessment (PRA) model.
• Calculating the patient’s individual periodontal risk
assessment (PRA).
• Periodontal Risk Assessment model by Chandra.
• Simplified (UniFe) method for periodontal risk
assessment.
The patient’s risk assessment for incidence or
recurrence of periodontal disease should be evaluated
on the basis of multiple clinical conditions. The entire
spectrum of risk factors and risk indicators should be
considered simultaneously.
The role of risk factors and risk assessment in
prediction of clinical periodontal outcome has created
huge interest. The point to be noted is that risk factors
are associated with a disease but do not necessarily
cause the disease. Though our understanding of risk
elements has expanded, the identification of groups or
individuals at risk of disease progression is still a
challenge.
Definitions and Terminology:
Risk factor can be defined as any environmental,
behavioral, or biologic factor that, when present,
increases the likelihood that an individual will develop
the disease. (Novak K & Novak M)
Periodontics & Oral Implantology
Periodontal Risk Assessment
Syed Wali Peeran, Karthikeyan Ramalingam
& Fatma Ahmed
• Periodontal Disease Risk Assessment Test
(Perio.org)
• Sonicare/ Philips CARE tools for risk assessment
(www.philpsoralhealthcare.com)
• Periodontal Risk Assessment with neural
networks:
Review Questions.
• Essay questions.
• Short notes.
Principal references and suggested further reading.
 Risk factor can be defined as Environmental or
individual characteristic which directly increases
(when present) or decreases (when absent) the
probability of a subject to be affected by a
disease. (Beck 1994)
 Risk factor is a factor that increases the
probability of that disease developing in a given
individual (like smoking, poor oral hygiene). It is
biologically related to the occurrence of the
event. (Burt 1991)
 Risk factor is defined as “any characteristic,
behavior or exposure with an association to a
particular disease. The relationship is not
necessarily causal in nature. (Brownson & Pettiti
1998)
 A risk factor is thought to be causal for a
disease. As such, it should satisfy two criteria: 1) it
is biologically plausible as a causal agent for
disease and, 2) it has been shown to precede the
development of disease in prospective (forward
design) clinical studies. (Philstrom 2001)
1
Treatment consideration in Periodontology Section - VI

 Risk indicator is a factor which may predict the Interventional studies give the strongest evidence
progression of a disease, either spontaneous or to establish a causal relationship of a risk factor. It can
under treatment. (Papapanou 2005) also provide evidence for clinical benefit by elimination of
that risk factor. For a factor to be considered as risk, the
 A risk indicator is a factor that is biologically
exposure must occur before disease onset.
plausible as a causative agent for disease but has
only been shown to be associated with disease in RATIONALE OF PERIODONTAL RISK
cross-sectional studies. (Philstrom 2001)
ASSESSMENT:
 Relative risk is the probability of developing
disease if one is exposed to a given factor It varies among patients and is a function of both
compared with the probability of developing the acquired and intrinsic risk factors
disease if one is not exposed to the factor.
(Philstrom 2001)
 An odds ratio is defined as the odds of having
disease if one is exposed to a risk factor
compared with the odds of having the disease if
one is not exposed to the same factor. (Philstrom
2001)
 Risk is defined as “the probability that an event
will occur in the future, or the probability that an
individual develops a given disease or experiences Fig.39-1: Difference between diagnosis and risk
a change in health status during a specified interval assessment
The following are the most accepted risk elements:
of time.”(Albandar JM, 2002)
 Age.
 Risk marker/ indicator is a factor that indicates
an increased probability of acquiring the disease; it  Gender.
does not imply cause and effect (like host defense  Genetic factors.
products within the periodontal tissues or  Host response.
crevicular fluid). It indicates the presence of, or  Infection with HIV.
exposure to, risk factors. (Burt 1991).  Open proximal tooth contacts and Food impaction.
 Osteoporosis.
 Risk assessment is a way of examining risks so
that they may be avoided, reduced, or managed.  Poor-controlled diabetes (Type I and II).
(Philstrom 2001)  Socio-economic status.
 Specific pathogenic bacteria like P.gingivalis,
 Risk assessment is defined as “the process by T.forsythia, A.actinomycetamcomitans and microbial
which qualitative or quantitative assessments are tooth deposits
made of the likelihood for adverse events to occur  Stress.
as a result of exposure to specified health hazards  Tobacco smoking.
or by the absence of beneficial Borrel and Papapanou have made a distinction
influences.” (American Academy of between
Periodontology 2008)
 Putative risk factors (non-modifiable
 According to the Medical Subject Headings background factors like age, gender, genetic
(MeSH), risk assessment can be defined as the polymorphisms)
qualitative or quantitative estimation of the
 Modifiable risk factors (environmental,
likelihood of adverse effects that may result from
acquired and behavioral factors like
exposure to specified health hazards or from the microbiota, smoking, diabetes mellitus,
absence of beneficial influences. osteoporosis, HIV infection, psychosocial factors).
2 Periodontics & Oral Implantology
Chapter 39 Periodontal Risk Assessment

Fig.39-2: Risk factors for chronic periodontitis

Tonetti and Claffey have proposed that Methods to assess periodontal risk:
 True risk factors – specific bacterial species, American Academy of Periodontology(AAP)
smoke, diabetes (insufficient metabolic control). statement on risk assessment - Utilizing risk
assessment helps dental professionals predict the
 Putative risk factors – gene polymorphisms, age,
potential for developing periodontal diseases and
socio-economitatus, race/ethnicity, gender,
allows them to focus on early identification and to
psycho-social factors, osteoporosis/osteopenia, provide proactive, targeted treatment for patients
obesity. who are at risk for progressive/ aggressive diseases.
Novak considered The AAP believes the clinical use of risk
 Smoking, diabetes, pathogenic bacteria and assessment will become a component of all
microbial tooth deposits as risk factors. comprehensive dental and periodontal evaluations as
well as part of all periodic dental and periodontal
 Age, gender, socio-economic status, stress and examinations.
genetic factors as risk determinants.
Many multi-factorial risk assessment models
 HIV infection, osteoporosis and infrequent dental have been created to include relevant risk factors for
visits as risk indicators. future disease progression. Such models can identify the
susceptibility of patients for incidence or recurrence of
Heitz-Mayfield et al considered,
periodontal disease. These models take into account
 True risk indicators – bleeding on probing, varying parameters related to periodontal infection,
number of periodontal pockets. host response, genetic traits and disease signs.
 Putative risk indicators – presence of Some of the current methods include
periodontal pathogens, bone loss/age ratio,  Periodontal Risk Calculator (PRC) and Periodontal
components of gingival crevicular fluid. Assessment Tool (PAT),
 The hexagonal risk diagram for Periodontal Risk
Diabetes mellitus, cigarette smoking, genetic
Assessment (PRA)
influences, race, specific bacteria, low-education and
 The PreViser Risk Calculator TM
inadequate dental attendance are considered recently
as the established major risk factors for chronic  Periodontal risk assessment model developed by
Chandra
periodontitis. The rest of the risk elements should be
 Simplified method (UniFe) – (University of Ferrara)
confirmed with longitudinal studies in the future.
for periodontal risk assessment.
Periodontics & Oral Implantology 3
Treatment consideration in Periodontology
Periodontal Risk Calculator (PRC):
Page et al developed a computer-based risk
assessment tool called PRC. It is used to assess risk in
an objective and quantitative manner.
They reported that “calculation of risk is a
multi-step process involving mathematical algorithms
that use 9 risk factors.”
The risk calculation is based on mathematical
algorithms that assign relative weights to 9 factors
including patient age, history of smoking, diagnosis of
diabetes, history of periodontal surgery, pocket depth,
furcation involvement, restorations or calculus below
gingival margins, radiographic bone height and vertical
bone lesions.
PRC assigns the risk at an individual level on a
scale from 1 (lowest risk) to 5 (highest risk).
Disadvantages of PRC:
 Some of the elements used in PRC are not yet
proven to be a risk factor
 The mode of risk calculation is quite complex.
 It appeared to be self-modifying and learn to
adapt when more patients are entered into the
system, treated and followed over time.
 This prognostic value generated by this tool was
in the absence of definitive periodontal treatment
over the follow-up period and on assumption
that baseline values did not change over time.
Fig.39-3: Previser.com
4 Periodontics & Oral Implantology
Section - VI
PreViser:
PreViser.com was the first interactive
online tool for perio risk assessment. Periodontal
Risk Calculator was introduced by Page and
colleagues in 2002. Few studies have validated the
PreViser suite of assessments.
The individual record is created online for
each patient. The first assessment may take around 3
minutes, but subsequent data entry takes only
seconds.
The traditional system of 6 pocket depth
measurements per tooth is reduced to the deepest
pocket for each sextant. PAT also needs the greatest
distance from the bone crest to the CEJ determined
by radiographs, again using one measurement from
each sextant. This reading has 3 categories: <2mm,
2-4mm, and >4mm.
The data entered includes,
 History of smoking.
 Diabetes status including HbA1C score.
 Prior periodontal treatment.
 The deepest probing depth in each quadrant
and bleeding.
 Eyeball measure of bone loss.
With this data, 2 Gum Disease Risk and
Health Assessment Scores are provided. The Gum
Disease Risk Score ranges from 1 (very low risk) to
5 (very high risk). This score predicts the probability
of the periodontal condition that will deteriorate
without professional care.
The Gum Disease Score ranges from 1 to 100.
 Score of 1 – health with no bleeding, no
pockets, and no bone loss.
 Score 2-3 – inflammation without bone loss or
pocketing.
 Score 4-100 – current disease or past disease.
The Gum Health Stability Score indicates
duration of time; the patient has been periodontally
stable.
Treatment interventions are provided as an
option including most likely, likely or least likely to
be effective based on the provided data.
For maintenance visits, previous data can be
preloaded, so that the clinician just inputs the changed
data. PreViser offers a 30-day free trial after which
there is a practice charge and per-patient charge.
Chapter 39
Periodontal Risk Assessment (PRA) model:
Lang & Tonetti proposed the periodontal risk
assessment model in 2003. It is a functional diagram with 6
vectors based on six parameters (clinical, systemic and
environmental factors). All these parameters are weighted
equally to determine a person’s risk for progression of
periodontal disease. It is available for no cost at www.perio-
tools.com/PRA .
It could be used to individualize risk and customize
recall visits. It will be useful to optimize periodontal care,
reduce treatment costs, avoid treatment, overestimation
and minimize recurrence of periodontal disease and tooth
loss.
The PRA takes into consideration the following 6
factors percentage of Full-mouth bleeding on probing, PD ≥
5mm, tooth loss, radiographic bone loss-to-age ratio,
systemic and/or genetic conditions and smoking.
The risk factors (Each factor has a minor, moderate and
high-risk profiles) include:
 Percentage of sites with bleeding on probing
• <10% of surfaces – low risk.
• >25% - high risk for periodontal breakdown.
 Prevalence of residual pockets greater than 4mm
• Upto 4 residual pockets are at low risk.
• With more than 8 residual pockets are at high
risk for recurrent disease.
 Loss of teeth from a total of 28 teeth:
• Upto 4 teeth lost are at low risk.
• More than 8 teeth lost are at high risk.
 Loss of periodontal support in relation to the patient’s
age (Bone loss divided by age = factor):
• Upto 0.25 – low risk.
• 0.5 – moderate risk.
• 1.0 – high risk.
 Systemic and genetic conditions
• If known, it is considered as a risk indicator for
recurrent disease.
• If not known or absent, it is not taken into
account for risk assessment.
 Environmental factors like cigarette smoking.
• Non-smokers and former smokers (more
than 5 years since cessation) have low risk.
• Occasional smokers (< 10 cigarettes per day)
and moderate smokers (10-19 cigarettes per
day) are at moderate risk.
• Heavy smokers (smoking more than one pack
per day) are at high risk.
Periodontics & Oral Implantology
Periodontal Risk Assessment
Fig.39-4: https://www.perio-tools.com/pra/en/
It evaluates the risk of recurrence of
periodontal disease at a patient level. It classifies
patients into a low-risk, moderate-risk, and high-risk
profiles. The combined evaluation of these factors
provides an individualized total risk profile after active
periodontal therapy.
Calculating the patient’s individual periodontal
risk assessment (PRA):
There is an online periodontal risk assessment tool
based on Lang & Tonetti risk assessment model at
http://www.perio-tools.com/pra/en/. The users can fill
up the risk factors and get the periodontal risk
instantly.
 Low PRA patient has all parameters in the low-
risk category or one parameter in the moderate
risk category. (BOP is 15%, 4 pockets >5mm, 2
missing teeth, Bone factor is 0.25, No systemic
factors, Non-smoker).
 Moderate PRA patient has at least two
parameters in the moderate category or one
parameter in the high-risk category.
 High PRA patient has at least two parameters
in the high-risk category. (BOP is 32%, 10
pockets >5mm, 10 missing teeth, Bone factor is
1.25, No Systemic factors, Occasional smokers).
Evaluating all the risk factors creates a polygon
or spider web diagram to help the clinician to
determine the risk for disease progression. The visual
image will contribute to discuss the existing condition
with the patient.
5
 Treatment consideration in Periodontology Section - VI
A low or no risk patient has a diagram with a focus
on first and second center rings of the polygon. As
the specific areas of risk increases, the shape of the
web changes, with outward dips depicting high risk.
Below are few functional diagrams depicting low
risk(Fig 39-5), medium risk(Fig 39-6) and high
risk(Fig 39-7).

Fig.39-7: High PRA patient

Clinical reviews:
PRA model has been validated by several clinical
research studies.
Costa FO et al reported that 18.6% - 21.3%
Fig.39-5: Low PRA patient patients under high risk had greater recurrence of
periodontitis and tooth loss. They included bleeding on
probing, smoking and diabetes, tooth loss, bone loss/age
ratio as variables for tooth loss.
Matuliene et al reported that 49.2% of high-risk
patients, 42.2% of medium risk patients and 18.2% of
low-risk patients had recurrence of periodontal disease
and teeth loss. They considered only smoking as a good
predictor for recurrence of periodontitis.
Jansson and Norderyd concluded that PRA
model overestimated the risk of disease recurrence.
However, this study has a limitation due to small sample
size of 20 patients.
Fig.39-6: Medium PRA patient
If the patient has all the 6 risk factors, the polygon
will be balanced but full indicating a high risk. Disadvantages of PRA model:
If the data collected at the baseline and recall visits It was adapted only to patients in the
are compared, the risk for recurrence of periodontal maintenance phase by entering the several risk elements
disease can be estimated. The progression of into the functional diagram.
periodontitis was defined as an interproximal clinical AL ≥ Lang et al in their recent systemic review
3mm mm in ≥ 2 teeth between two different observation indicated that risk assessment tools such as the
points (Fifth European Workshop of Periodontology). Periodontal Risk Calculator or the Periodontal Risk
This model can be effective in monitoring Assessment ( http://www.perio-tools.com/PRA/en/
individual risk variables in relation to recurrence of index.asp ) predicted the periodontitis progression and
periodontitis and tooth loss. tooth loss in treated populations.

6 Periodontics & Oral Implantology

Chapter 39
Periodontal Risk Assessment model by Chandra:
In 2007, Chandra proposed a new model based
on PRA by Lang & Tonetti. It records the following 8
parameters,
 Full-mouth: Percentage of sites with bleeding on
probing
 Number of sites with pocket depth ≥ 5mm
 Number of teeth lost
 Clinical attachment loss/age ratio
 Diabetic Mellitus
 Smoking status
 Dental status-Other systemic factors interplay
and risk determinants
 Psychosocial factors
Disadvantages:
 Can be used only during maintenance therapy to
evaluate the progression of periodontal disease
 It could not be applied to the patient who visits the
dental clinic for the first time.
Simplified (UniFe) method for periodontal risk
assessment:
In 2009. Trombelli et al proposed this new
objective method to simplify the risk assessment. It is
based on 5 parameters from patient’s medical history
and clinical recordings to which parameter scores are
given.
 Smoking status – non-smoker/former smoker/
current smoker. If current smoker, the daily
consumption of cigarettes is recorded.
• Non-smoker – 0
• Former smoker – 1
• 1 – 9 cigarettes per day – 2
• 10-19 cigarettes per day – 3
• ≥ 20 cigarettes per day - 4
 Diabetic status (Type 1 & 2) – non-diabetic/
controlled diabetic (HbA1c <7% at last exam)/
poorly controlled diabetic (HbA1c ≥ 7% at last
exam)
• Non-diabetic – 0
• Controlled diabetic – 2
• Poorly controlled diabetic - 4
Periodontics & Oral Implantology
Periodontal Risk Assessment
 Number of sites with probing depth ≥ 5mm.
The probing depth is from the gingival margin to
the bottom of the pocket. It is usually recorded
on 6 aspects of each tooth (mesio-buccal, mid-
buccal, disto-buccal, mesio-lingual, mid-buccal,
disto-lingual). It is better to you a manual
pressure-sensitive probe like Hu-Friedy CP 12
probe.
• 0-1 pockets – 0
• 2-4 pockets – 1
• 5-7 pockets – 2
• 8-10 pockets – 3
• > 10 pockets – 4
 Bleeding on probing score – recorded as
positive when bleeding was present after probe
insertion. It is calculated as a percentage of
positive sites over the total number of probed
sites.
• 0-5% - 0
• 6-16% - 1
• 17-24% - 2
• 25-36% - 3
• > 36% - 4
 Bone loss/age – records the number of teeth
with a distance from CEJ to alveolar crest ≥
4mm on at least one interproximal aspect
(mesial or distal), as measured on radiographs.
Age was expressed in years.
Tab.39-1: Bone loss/age
The algebraic sum of all parameter scores gives the
5 risk scores.
 Risk Score 1 – low risk (0-2)
 Risk Score 2 – low-medium risk (3-5)
 Risk Score 3 – medium risk (6-8)
 Risk Score 4 – medium-high risk (9-14)
 Risk Score 5 – high risk (15-24)
7
Treatment consideration in Periodontology
Disadvantages:
 The number of parameters included in risk
computation is limited
 Relative predictive value of each parameter in
contributing the overall risk score was arbitrarily
assigned
 The summative or negative interaction between
the considered risk factors/indicators were not
accounted for during risk calculation.
 Parameters like pockets and bone defects have
only little value in prediction of disease
progression.
 It has to be validated by longitudinal studies with
untreated patients of differing periodontal status.
 Can be used only during maintenance therapy to
evaluate the progression of periodontal disease
 It could not be applied to the patient who visits
the dental clinic for the first time.
Periodontal Disease Risk Assessment Test
(Perio.org):
The American Academy of Periodontology
(AAP) offers an online, periodontal disease risk
assessment test.
It covers 12 questions on age, sex, bleeding
gums, loose teeth, recession, smoking, dental visits,
flossing, health conditions (heart disease, osteoporosis,
osteopenia, high stress or diabetes), history of gum
infection, tooth extractions and family members with
gum disease.
After answering the questions, the user should
click the get report button. The report indicates low,
medium or high risk. The report also describes risks
and symptoms of gum disease and what can be done
about the disease.
This risk assessment tool is a guide for
consumer to educate them about gum disease and
suggest they see a dentist or periodontist for complete
examination.
Disadvantages:
 The risk model is not scientifically validated.
8 Periodontics & Oral Implantology
Section - VI
Fig.39-8: Periodontal Disease Risk Assessment Test
Sonicare/ Philips CARE tools for risk
assessment (www.philpsoralhealthcare.com)
These are online CARE tools (Customized
Assessment and Risk Evaluator). A team of dentists
and hygienists worked to develop this tool based on
scientific evidence and best practices.
It consists of several yes or no questions
asked about the patient, which are entered into the
record. Some of the questions asked about
periodontal disease are as follows,
 Does the patient have a current or past
diagnosis of periodontal disease?
 Has the patient lost teeth excluding 3rd
molars or teeth removed for orthodontic
purposes?
 Does the patient have radiographic bone loss?
Choices are none, <20%, 20-40% or >40%
 Does the patient have clinical and/or
radiographic evidence of furcation involvement
on any teeth?
 Does the patient have tooth mobility? Choices
are none, 1-2 teeth, 3-5 teeth or >6 teeth.
 Does the patient have any pathological
migration of teeth?
 How many periodontal pockets with depths
>5mm does the patient have? Choices are
none, 1-3 or >4
 Does the patient have gingival inflammation
with bleeding upon probing on four or more
teeth?
 Does the patient have generalized gingivitis
(>50% of gingival tissue involved)?
 Does the patient have gingival recession (more
than 2mm on any teeth)?
 Does the patient have any unprompted gingival
pain?
Chapter 39 Periodontal Risk Assessment

Fig.39-9: Sonicare/ Philips CARE tools for risk assessment

On pressing the calculate button after entering the

relevant answers, the assessment is calculated in a 4-
level scoring system – low, medium, high and extremely
high risk.
 Low risk – it means that the patient does not
have any disease indicators or risk factors for
periodontal disease in the immediate future. The
biofilm challenge is low. This may also mean that
your patient may have one or more protective
factors that help prevent or arrest the disease Fig.39-10: Sonicare/ Philips CARE tools for risk assessment

process. Next, the recommended clinical guidelines can

 Moderate risk - patient may demonstrate one or be reviewed for the assessed risk level
more specific disease indicators, and one or more
specific risk factors that may create moderate risk
for the development or progression of periodontal
disease in the future. You may want to refer this
patient to a periodontal specialist.
 High risk - Your patient may be at HIGH RISK
for periodontal disease(s). This means your patient
may have some form of periodontal disease as
characterized by one or more specific disease
indicators, and one or more specific risk factor
that create high risk for progression of the
disease. Referral to a periodontal specialist may be
necessary.
 Extreme risk - Your patient may be at
EXTREME RISK for periodontal disease(s). This
means your patient may have periodontal disease
as characterized by severe bone loss and mobility
on several teeth. Referral to a periodontal Fig.39-11: Sonicare/ Philips CARE tools-Care protocol suggestion
specialist may be necessary. A suggested care protocol can be customized by
selecting the treatment options, oral hygiene
recommendations, and suggested products

Periodontics & Oral Implantology 9

Treatment consideration in Periodontology
Fig.39-12: Sonicare/ Philips CARE tools for risk assessment-
Set protocol
Finally, the form can be customized with practice
details and ready to be printed or saved as a pdf.
Fig.39-13: Sonicare/ Philips CARE tools for risk assessment-
Customized patient handout
Disadvantages:
•The risk model is not scientifically validated.
DentoRisk:
Lindskog and coworkers developed a
computerized risk assessment and prognostication
program (DentoRisk) that is used in conjunction with
a skin test for inflammatory reactivity (DentoTest).
This model used a combination of 20 factors, which
are both systemic and local predictors.
10 Periodontics & Oral Implantology
Section - VI
Periodontal Risk Assessment with neural
networks:
Neural networks could be used for problems
when traditional methods cannot provide solution. A
rule-based decision is not always possible in many
clinical situations.
They are computational devices that are in use
for classification and survival prediction in many
biomedical situations like colon cancer.
Feed-forward networks has hidden layers. It
can perform linear and non-linear relationships.
Properly trained back propagation error networks
can give reasonable answers when presented with
inputs that they have never seen. The network can be
trained with a representative set of input/target pairs
and get good results without training the network on
all possible pairs.
Two such popular networks are Levenberg
Marquardt (LM) & Scaled Conjugate Gradient
Algorithms.
It can be used for periodontal risk assessment.
It can assess the burden of predicting periodontal risk
from an array of risk factors.
A well-trained feed-forward back-propagation
artificial neural network using LM algorithm may be
used as an alternative to predict future risk of
periodontal destruction, in scenarios where specialist
opinion is not possible.
Clinical implications:
Periodontal risk assessment may help clinicians
to identify subjects with impaired periodontal
prognosis as well as to determine the impact of
treatment on periodontal prognosis. Such risk
assessment models have molded the repair model of
periodontal care into a wellness model, giving
importance to prevention.
Trombelli et al did a comparative study
between UniFe and PAT scoring. They reported a
good agreement between both methods. The
difference in risk score was significantly explained by
parameter scores of bleeding on probing and bone
loss/age. They assumed that the risk factors/indicators
that may affect the onset of periodontal disease are
the same that are involved in the progression of the
disease status.
Chapter 39 Periodontal Risk Assessment

 Assessment of risk factors should be made

Systemic predictors Local Predictors analyzing all the major elements like age,
 Age in relation to  Bacterial plaque-Oral gender, genetic factors, specific pathogenic
history of chronic hygiene. microbes, smoking, diabetes mellitus,
periodontitis.  Endodontic pathology.
osteoporosis, HIV infection and psycho-social
 Family history of factors. The existence of risk factors may
 Furcation involvement.
chronic periodontitis. modify the treatment plan.
 Angular bony
 Systemic diseases and destruction.  Risk assessment models like PRA could be
related diagnoses. applied during maintenance phase.
 Radiographic marginal
 Result of skin bone levels.
provocation test.
 Periodontal probing Conclusion:
 Patient co-operation depth.
and disease awareness. To conclude, the established risk factors for
 Bleeding on probing.
 Socio economic status. periodontitis are specific pathogenic bacteria,
 Increased tooth cigarette smoking and diabetes mellitus. There are
 Smoking. mobility. contradictions regarding the other risk elements,
 Clinicians experience.  Marginal dental without any distinction among risk factors
restorartions. responsible for incidence and progression of
 missing teeth. periodontal disease.
 Abutment teeth. Further research with longitudinal and
 Presence of purulence. interventional studies will throw light and decide the
future course of periodontal risk assessment. By
Tab.39-2: Periodontal Risk Predictors (Modified from using these risk assessment tools, you can assess the
Lindskog et al., 2010)
level of disease, risk of further progression, measure
Studies reveal that absence of bleeding on
success of treatment and efficiency of self-care by the
probing may indicate periodontal stability during
maintenance therapy. Hence, the tools should be able patient.
to differentiate periodontal disease progression from Review Questions:
periodontal risk. The presence of bleeding on probing Essay questions:
between 20 – 30% indicates high degree of disease
1. Define risk assessment. Describe the
progression, higher risk for further attachment loss at
Periodontal Risk Calculator (PRC).
single sites.
Short notes:
Page et al have reported that a patient with
worse prognosis will require more therapy and their 2. What are the risk factors for chronic
response to therapy is worse. If the patient has better periodontitis.
prognosis, they need less therapy and respond better 3. Write briefly about the Periodontal Risk
to therapy. Assessment (PRA) model.
Dannan suggests 3 steps namely – diagnosis,
periodontal risk assessment, and prediction of
disease progression.
 Diagnostic elements include plaque score, probing
pocket depth, level of clinical attachment,
bleeding on probing, bone level, and other
periodontal indices for a comprehensive
examination and proper treatment planning.
Periodontics & Oral Implantology 11
Treatment consideration in Periodontology
Principal references and suggested further
reading:
 Albandar JM. Global risk factors and risk indicators
for periodontal diseases. Periodontol 2000 2002;
29:177-206.
 American Academy of Periodontology statement on
risk assessment. J Periodontol 2008; 79:202.
 Brownson RC, Pettiti, D. B. Applied epidemiology:
theory to practice. New York: Oxford University
Press; 1998.
 Chapple ILC. Periodontal disease diagnosis: current
status and future developments. J Dent 1997; 25:
3-15.
 Costa FO et al. Periodontal risk assessment model in
a sample of regular and irregular compliers under
maintenance therapy: a 3-year prospective study. J
Periodontol 2012; 83: 292-300.
 Dannan A. Periodontal risk assessment; are we on
the right track? AOSR 2011; 1: 3: 162-167.
 Jansson H, Norderyd O. Evaluation of a periodontal
risk assessment model in subjects with severe
periodontitis. A 5-year retrospective study. Swed
Dent J 2008; 32: 1–7
 Kye W, Davidson R, Martin J, Engebretson S.
Current status of periodontal risk assessment. J Evid
Based Dent Pract. 2012 Sep;12(3 Suppl):2-11.
 Lang NP, Suvan JE, Tonetti MS. Risk factor
assessment tools for the prevention of periodontitis
progression a systematic review. J Clin Periodontol
2015; 42 (Suppl. 16): S59–S70.
12 Periodontics & Oral Implantology
Section - VI
 Lindskog S, Blomlöf J, Persson I, Niklason A, Hedin
A, Ericsson L, Ericsson M, Järncrantz B, Palo U,
Tellefsen G, Zetterström O, Blomlöf L.Validation of
an algorithm for chronic periodontitis risk assessment
and prognostication: risk predictors, explanatory
values, measures of quality, and clinical use. J
Periodontol. 2010 Apr;81(4):584-93.
 Newman MG, Takei HH, Klokkevold PR, Carranza
FA, editors. Carranza's Clinical Periodontology. 10
ed. St. Louis, Missouri: Elsevier Inc; 2006.
 O’Hehir TE. Periodontal Risk assessment: examples
of available programs. Creating a Perio Program for
your practice. Part VI. Hygienetown. November 2014;
3 – 5.
 Page R, Krall EA, Martin J, Mancl L, Garcia RI. Validity
of Periodontal Assessment Tool® (PAT®) in
predicting periodontal disease. Journal of the
American Dental Association 2002;133:569-576.
 Pihlstrom BL. Periodontal risk assessment, diagnosis
and treatment planning. Periodontol 2000.
2001;25:37-58.
 Rajesh S, Mathur LK, Nair MA, Rai N, Mathur A.
Periodontitis Risk Assessment using two artificial
Neural Networks-A Pilot Study. International Journal
Of Dental Clinics 2010:2(4):36-40.
 Trombelli L, Farina R, Ferrari S, Pasetti P, Calura G.
Comparison between two methods for periodontal
risk assessment. Minerva Stomatol 2009; 58: 277-87.