Strategies for Periodontal Risk Assessment and Prognosis

Early detection and proper management of periodontal disease can help patients maintain
their natural dentition.
By Yusuke Hamada, DDS, MSD, Takaaki Kishimoto, DDS, PhD, Hawra Alqallaf, DDS and Vanchit John,
BDS, MDS, DDS, MSD On Aug 25, 2017

Early detection and proper management of periodontal disease can help patients maintain their
natural dentition
PURCHASE COURSE
This course was published in the September 2017 issue and expires September 2020. The authors
have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is
electronically mediated.
OBJECTIVES
After reading this course, the participant should be able to:

1. Explain the various periodontal prognosis systems, as well as risk factors affecting
treatment and prognoses.
2. Discuss the prevalence of peri-implant disease, and treatments that can improve a tooth’s
prognosis.
3. Detail the challenges in establishing an absolute prognostic value for periodontal patients.

Determining a tooth’s prognosis is a critical step in patient care that is established after a
diagnosis has been made, but before treatment has been planned and presented. Because
periodontal disease is a multifactorial condition, establishing a periodontal prognosis involves
both art and science. Further complicating matters, periodontal prognostic outcomes also depend
on the individual’s risk factors and his or her compliance with biofilm control. With the goal of
improved outcomes, this article will review the literature surrounding classification systems that
can be used to assess periodontal prognosis.

Although dental implants represent a viable solution for many patients with periodontally
compromised dentition, these are not necessarily lifelong restorations. Peri-implant mucositis and
peri-implantitis are common complications following implant placement. Derks and
Tomasi1 reported the prevalence of peri-implant mucositis and peri-implantitis at 19% to 65%.
These are the most common pathological conditions that lead to soft- and hard-tissue loss around
implants and compromise the functional and esthetic outcome of implant therapy.
Growing recognition that implants are not a panacea for either full or complete edentulism has led
to renewed interest in saving teeth by using established therapies to improve the periodontal
prognosis. Assuming they are supported by appropriate maintenance, the literature indicates that
high survival and success rates can be achieved with compromised teeth. 2–4 Early detection and
proper management of periodontal conditions are critical to successful outcomes. Toward this
goal, identifying the prognosis of each tooth — as well as systemic and local risk factors for
disease progression — are critical during active periodontal treatment and supportive periodontal
therapy (SPT).

PERIODONTAL PROGNOSIS
According to The Merriam-Webster Dictionary, “Prognosis” is defined as “the prospect of
recovery as anticipated from the usual course of disease or peculiarities of the case.” In medicine,
however, the term is commonly defined by the mortality rate. Although many periodontal
prognosis systems have been developed, most of the prognoses are based on tooth mortality (i.e.,
extractions).5–8 Assigning an accurate prognosis for each tooth benefits patients and clinicians by
providing information on whether proposed periodontal and restorative treatment promises the
likelihood of a successful long-term outcome. That said, in this era of evidence-based dentistry,
there is no gold standard for periodontal prognosis tools. Because disease progression is affected
by many factors — including systemic conditions, local influences and the practitioner’s skill
level — it is virtually impossible to establish an absolute prognostic value. Accordingly, Samet
and Jotkowitz9 introduced the term “relative prognostic value.” The idea is to help practitioners
identify teeth that appear to have a more favorable treatment outcome, as opposed to those more
severely compromised by disease.

Tabel 1. McGuire and Nunn Classification System

Prognosis One or more of the following for Each Category
Good Control of the etiologic factors and enough
clinical and radiographical periodontal support
to enable the tooth to be maintained by the
patient and clinician with proper maintenance
Fair Approximately 25% attachment loss, as
measured clinically and radiographically. Class I
furcation involvement. The severity of the
furcation involvement would allow adequate
maintenance.
Poor 50% attachment loss and Class II furcations. The
location and degree of the furcations would
accommodate proper maintenance- although
with difficulty
Questionable >50% attachment loss, poor crown/root ratio,
Class II (not easily accessed) or Class III
furcation involvement. Class II mobility or
 more; significant root proximity
Hopeless Severe attachment loss; extraction performed
or suggested

Among the various periodontal prognosis systems, the one most widely used was proposed by
McGuire and Nunn in 1996.6 It consists of five categories that include good, fair, poor,
questionable and hopeless (Table 1). In this system, clinicians assign each tooth to a category
based on their ability to control the etiology of disease, attachment loss, presence of furcation
involvement, crown/root ratio, and the degree of tooth mobility. Over five years, the researchers
evaluated the accuracy of prognostic values in 100 periodontal patients. Prognostic categories
were assigned following active periodontal therapy and prior to initiating the SPT phase. The
study demonstrated that prognostic values are not stable over time, especially for teeth that are
categorized as fair, poor or questionable; in fact, only 50% of teeth assigned into one of these
three prognoses remained in the same category during subsequent assessments.

FIGURE
1A. Clinical view of localized severe chronic periodontitis on tooth #23.
The authors identified possible clinical factors that led to the altering of the initially assigned
prognosis. These included smoking, diabetes, probing depth, furcation involvement and
parafunctional habits. One of the study’s limitations was that regenerative treatment — such as
guided tissue regeneration and the utilization of growth factors around teeth — was not
performed. In periodontal patients, it is well established that regenerative procedures on certain
defects can lead to bone fill and clinical attachment level gain, and thus improve a tooth’s
prognosis (Figures 1A and 1B and Figures 2A and 2B). 10,11 Another limitation was the
classification utilized teeth mortality, which is usually determined (and affected) by the clinician
and his or her treatment philosophy.

FIGURE 1B.(Left)Radiograph of tooth #23 from the patient in Figure 1A, with evidence of
vertical bone defect. FIGURES 2A (Center) and 2B (Right). Clinical (A) and radiographic
(B) views of #23 one year after guided tissue regeneration with demineralized freeze-dried bone
allograft and amnionchorion membrane.
In order to account for these limitations, Kwok and Caton 12 proposed a prognosis system based on
future periodontal stability with treatment (Table 2). Unlike McGuire’s and Nunn’s classification,
Kwok’s and Caton’s model focuses on how periodontal disease activity is suppressed by
controlling systemic and local factors. These include patient compliance, smoking status and
diabetic conditions as general factors, with deep probing depth, plaque retentive factors, mobility
and trauma from occlusion considered as local factors. As is evident from these classifications,
periodontal prognosis is dynamic because systemic and local risk factors are not permanent
conditions. For example, glycemic control in a patient with diabetes might worsen during the
periodontal maintenance phase, possibly contributing to progression of periodontal disease.
Conversely, the prognosis of each tooth might improve if a patient quits smoking.

Tabel 1. Kwok and Caton Classification System

Prognosis Classification
Favorable Can be stabilized with comprehensive
periodontal treatment/ maintenance, and with
less chance of future breakdown
Questionable Influenced by local and/ or systemic factors
that may or may not be controlled; the
periodontium can be maintained with proper
care
Unfavorable Influenced by local and/or systemic factors that
cannot be controlled
Hopeless Must be extracted
Periodontal conditions — such as probing depth, attachment level, bleeding on probing (BOP)
and furcation involvement — are confirmed at each maintenance appointment. Thus, identifying
a tooth’s prognosis only during the initial appointment does not allow adequate judgment of the
probability of tooth survival, as this requires continuous monitoring of potential changes.
Determining the prognosis at multiple appointments is also necessary because periodontal
destruction does not occur at the same rate. Goodson et al 13 evaluated disease progression in 22
subjects with untreated periodontitis for one year, with each subject receiving monthly
measurements of probing depth and attachment levels. Of the subject sites, 82.8% did not show
any progression in probing depths, 11.5% improved significantly and 5.7% increased in depth.
Socransky et al14 cast doubt on the linear progression of periodontitis by proposing that a random
burst of destructive periodontal conditions might occur at certain periods in a patient’s life. It was
also emphasized that continuous monitoring of periodontal conditions longitudinally is important
to maintaining natural dentition. Understanding specific progressive patterns of periodontitis with
continuous monitoring, early detection and proper management of the patient’s individual risk
factors are essential components of successful treatment.

RISKS FOR DISEASE PROGRESSION

While it is accepted that the primary etiology of periodontitis is bacterial infection and a
susceptible host response,15,16 the initiation and rate of destruction is affected by systemic and local
risk factors. These include smoking, uncontrolled diabetes mellitus, interleukin-1 genotype,
BOP, poor oral hygiene, deep probing depth (> 6 mm), severity of alveolar bone loss, age,
socioeconomic status and iatrogenic factors (Table 3).
A number of studies have discussed each factor’s relationship to disease progression. However
the outcomes indicate that some of these results are conflicting. 17 In a day-to-day clinical setting,
many clinicians simply equalize risk of disease progression with the severity of clinical
attachment loss. In other words, if a patient presents with little or no periodontal destruction, it is
anticipated that he or she is at low risk of future breakdown, whereas a patient with severe
periodontal tissue destruction is expected to have a higher risk of future disease. The American
Academy of Periodontology (AAP) defines risk assessment as, “The process by which qualitative
or quantitative assessments are made of the likelihood for adverse events to occur as a result of
exposure to specified health hazards or by the absence of beneficial influences.” The AAP
guideline also notes that risk assessment is a necessary part of each examination, as it contributes
to predicting future disease progression. 18 Ultimately, assessment reduces the complexity of
periodontal treatment and improves communication between general practitioners, dental
hygienists and periodontists.

RISK ASSESSMENT MODELS

In 2002, Page et al19 published a periodontal risk calculator that included more than 10 risk
factors, including smoking, age, diabetic condition, history of periodontal procedures, probing
depth, BOP, type of restorations and bone height, among others. Using a computer-based system,
risk was established on a scale of 1 (lowest) to 5 (highest). Following publication of that article,
Page and Martin20 introduced the Oral Health Information Suite (OHIS), which provides a disease
score on scale of 1 (health) to 100 (severe periodontal condition). More than 500 subjects were
investigated (with up to 15 years of follow-up) to evaluate the relationship between the scale and
actual tooth loss. The study showed that OHIS risk and disease scores provided an accurate and
valid means of evaluating tooth loss and disease progression. The risk of disease and disease state
score were calculated and described as objective numbers that can be used in devising
interventions. This is a useful communication tool for general practitioners, dental hygienists and
periodontists, especially when managing patients who are seen at multiple offices. A possible
limitation is that it can be difficult to become familiar with the details of this system. Although it
has been shown to be accurate, assessment tools need to be simple enough to allow efficient
chairside use.

Lang and Tonetti21 introduced a Periodontal Risk Assessment (PRA) model that evaluates the risk
of periodontal breakdown based on a combination of six parameters: percentage of BOP, total
sites of residual pockets > 5 mm, number of teeth lost, bone loss in relation to the patient’s age,
systemic/genetic condition, and environmental factors (e.g., smoking status). This tool is used to
assess risk following active periodontal therapy and prior to SPT. It does not require any specific
formula to calculate risk and is easy to fill out chairside. In addition, it is relatively easy to
visualize the degree of risk. However, this system has several disadvantages. Because clinicians
initiate PRA after active periodontal therapy, for example, this tool is not a good indicator for
treatment planning or active periodontal therapy. In addition, while the six parameters have been
shown to be major risk factors, patient compliance and local plaque-retentive factors are not
included in the criteria.

In a retrospective study, Matuliene et al 22 evaluated the validity of PRA with 160 patients for an
average of 9.5 years. Based on the PRA system, all subjects were assigned to low-, moderate- or
high-risk profile following active periodontal therapy. Most patients with low and moderate risk
had a twice-yearly recall interval, while more than half of the high-risk patients were seen three to
four times per year. During the SPT phase, 2.59 teeth per patient were lost in the high-risk group;
by comparison, 1.02 teeth per patient were lost in the moderate-risk group, while the low-risk
patients lost an average of 1.18 teeth. Based on this study, if a patient is categorized in the high-
risk group, a standard three- or four-month recall might not prove sufficient to prevent future
breakdown of periodontal tissue. Thus, recall intervals should be based on disease activity,
residual risk factors and patient compliance — not on insurance coverage.

As noted, there is no gold standard in periodontal risk assessment tools because there are
advantages and disadvantages to each system. The goal of using an assessment tool is to provide
more predictable care and facilitate communication between dental teams and specialists.
Although periodontal risk evaluation is a powerful tool for periodontal and restorative treatment,
it must be appreciated that caries, endodontic failures, fractured teeth and similar conditions also
affect a patient’s prognosis. Risk assessment and prognosis systems need to account for these
conditions as well.

Technological advances also allow clinicians to utilize noninvasive methods — such as salivary
biomarker tests — to assess periodontal conditions. Various host-related cytokines and
biomarkers have been detected in the progression of periodontal disease. Studies have shown a
positive relationship between salivary biomarkers and the severity of periodontitis, 23,24 and, unlike
a blood examination, saliva collection does not require any special training. Thus, it appears that
salivary tests can be used in the diagnosis of periodontal disease and to better understand risk
assessment. In addition, disease stability during maintenance can be monitored, along with the
evaluation of treatment outcomes. In the future, personalized therapy that includes salivary
examination seems likely to improve the quality of periodontal care. 25

PRACTICE RECOMMENDATIONS
Although this article has emphasized the importance of risk analysis, specific guidelines for
periodontal treatment — including the timing of referral to a specialist — are challenging due to
the disease’s multifactorial nature. In a study of periodontal status, treatment, and when patients
were referred to periodontists, Dockter et al 26 found that among 100 newly referred patients, 74%
were diagnosed with severe periodontitis and needed to have teeth extracted due to the severity of
disease. This suggests that diagnosis, treatment and timely referral to a specialist were not
satisfactory.

At the time of initial examination, during nonsurgical periodontal treatment and throughout SPT,
clinicians need to consider the risks of disease development and possible need for referral.
Although many periodontal patients can be managed appropriately by general practitioners, there
is no single best treatment for every patient. Accordingly, the authors of this paper propose
instructions that clinicians can use in referral decisions (Table 4). These are intended to foster a
multidisciplinary approach with the goal of improved care.

In conclusion, determining a periodontal prognosis requires an evidence-based evaluation that

utilizes data from a thorough clinical and radiographic examination. Risk assessment is an
ongoing process that requires clinicians to be knowledgeable of the various — and dynamic —
factors that influence the disease state. Together, these evaluations will help ensure appropriate
periodontal treatment and optimal outcomes.
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From Decisions in Dentistry. September 2017;3(9):46–50