For more on this topic, go to www.dentaleconomics.com and search using the following key words: periodontal disease, periodontal risk factors, Richard H. Nagelberg, DDS.
Many risk factors increase the likelihood of periodontal disease development, as well as 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, and previous history of active perio disease.
The primary reasons to consider risk factors for periodontal disease are to understand the likelihood of its development and progression, and the predictability of favorable treatment outcomes. It is important to understand that risk factors don't cause gum disease; they increase the likelihood that it will occur.
All risk factors are not created equal. Diabetes and smoking are the biggest risk factors for periodontal disease, increasing the occurrence, severity, and speed of onset and progression. The No. 1 systemic condition that increases susceptibility to periodontal disease is diabetes. The No. 1 systemic condition adversely affected by periodontal disease is also diabetes.
Poorly controlled diabetic people have a much higher incidence of diabetic complications including heart attack, stroke, blindness, kidney failure, and periodontal disease. Hyperglycemia leads to gum tissue breakdown, decreased ability of the body to defend itself against the pathogenic bacteria, and a reduced ability to repair damaged gum tissues. Unfortunately, periodontal disease also contributes to poor glycemic control by increasing insulin resistance, creating a vicious cycle.
Smoking is the No. 1 environmental and behavioral risk factor for periodontal disease, increasing the rate of bone resorption, chronic inflammation, and suppression of antibodies, which facilitates bacterial flourishing. Other risk factors play important roles as well. Many common medications contribute to xerostomia, reducing the protective properties of saliva.
Heredity and stress can reduce immune system function. Hormonal variations such as those that occur during pregnancy and menopause increase inflammation. Poor oral hygiene and faulty dentistry increase biofilm accumulation.
Multiple risk factors do not increase the risk of disease in an additive manner, but rather exponentially. Patients having three risk factors such as stress, poor oral hygiene, and faulty dentistry are not three times more likely to develop periodontal disease than those without these risk factors; they are approximately 27 times more likely to have perio disease occur or worsen rapidly. A patient with four risk factors is 64 times more likely to have periodontal disease develop or progress.
When we control risks; however, we reduce the chances of periodontal disease occurring in an exponential manner. For patients with four risk factors, eliminating even one risk factor improves the prognosis considerably, by knocking 64 down to 27. Eliminate one more risk factor and disease likelihood goes from 27 to nine.
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 spoor oral hygiene to the development of perio disease.
Smoking cessation, dietary counseling, and correcting faulty dental work also constitute risk factor modification. The inability to modify certain risk factors such as heredity, medications, and previous history of active perio disease should not discourage risk factor identification. Even if we cannot change a patient's risk factors, identifying them gives us a better idea of our chances of achieving favorable periodontal treatment results and an understanding of the likelihood of disease recurrence.
Using new technologies such as DNA testing of periodontal pathogens (OralDNA Labs, oraldna.com) enables us to provide individualized care. For the patient with several risk factors, identifying the specific bacteria responsible for the disease provides us with information including the virulence and tissue invasiveness of their pathogens. This salivary diagnostic DNA test also helps us identify the proper antimicrobial adjunctive agents, enhancing favorable treatment outcomes.
Treatment planning for patients with perio disease and undertaking therapy without risk factor identification and management is similar to a physician attempting to manage a patient with diabetes or high blood pressure, without the data provided by blood tests or an examination of their diet, lifestyle, and family history. Risk factor identification and management impacts treatment planning, maintenance protocols, and increases the predictability of achieving favorable treatment results. That is the real bottom line — the care we provide for patients, every time they give us the privilege of providing care for them.
Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 27 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact Dr. Nagelberg at [email protected].
