Modifiable Risk Factors Of Periodontal disease

Periodontal disease and the susceptibility to have this disease are different from person to person. This includes different risk factors and the host’s response if has the disease. Analysis of the 2009–2010 National Health and Nutrition Examination Survey (NHANES) shows that 47% of U.S. adults age 30 and older had periodontitis, including 8.7% with mild disease, 30% with moderate periodontitis, and 8.5% with severe disease.

The recognition that differences in susceptibility are responsible for differences in prevalence and severity led to the study of factors associated with periodontal disease, independent of the effects of confounding variables. Independent risk factors include systemic diseases and conditions — such as diabetes mellitus, obesity, metabolic syndrome and osteoporosis — and lifestyle factors, including smoking and alcohol use. Since most risk factors are modifiable and are found in a large number of patients with periodontal disease, identifying and managing risk has become integral to therapy. ( )

Many of these risk factors can be modified and have an impact on susceptibility and treatment. This includes environmental factors. Smoking is the most important environmental — and modifiable — risk factor for periodontal disease. Studies that examined the effect of smoking on periodontal disease provide a clear association as follows: current and former smokers exhibit different risk profiles; in addition, the negative effect of smoking on periodontal health is cumulative and proportional to the amount of smoking. On average (and independent of the effect of age, gender and amount of dental plaque), smokers are at 2.5 times greater risk of developing severe periodontal disease than nonsmokers (never-smokers). The odds for periodontitis for current smokers are higher than for former smokers, 3.97 versus 1.68 respectively. The odds for developing periodontal disease range from 2.0 to 7.0, depending on number of cigarettes smoked per day and years of smoking).

There are also systemic factors that can be modified. Diabetes is the most significant systemic — and modifiable — risk factor for periodontal disease. Compared with other patient groups, periodontal disease is more common in individuals with diabetes — for example, young adults with diabetes are twice as likely to develop periodontal disease as those without diabetes. Individuals age 45 and older with poorly controlled (A1c >9) diabetes are 2.9 times more likely than those without diabetes to have severe periodontitis. This almost doubles when you add smoking to an individual’s risks factors.  Patients with diabetes should be educated that their risk of developing periodontal disease is high, and that if they are diagnosed with a periodontal condition, glycemic control may be difficult and poses a significant risk for complications.

The most important risk factor for type 2 diabetes is obesity. A systematic review and meta-analysis of the literature concluded that obesity — measured as increased body mass index (BMI) — is associated with increased severity of periodontal disease.19 Insulin resistance mediates the increased risk for type 2 diabetes and periodontal disease in obese individuals.20 Accordingly, waist circumference — a measure of central obesity/abdominal fat more closely related to insulin resistance than whole body BMI — is more closely associated with periodontal disease than raw BMI score. ( )

Another risk factor is Osteoporosis which is a condition in which bone mineral density is dropping to a point of mechanical failure. Although the evidence supporting osteoporosis as risk factors for periodontal disease is not as clear, it nevertheless points to an association between osteoporosis and periodontal disease. This association is mediated by estrogen, calcium and vitamin D. Information on skeletal BMD, hormonal and vitamin supplementation status should be ascertained as part of a complete medical history of the patient.

Other modifiable risk factors include dietary, alcohol and psychological factors. Analyses of large population-based datasets reveals that reduced calcium intake and low serum calcium levels are associated with increased risk for periodontal disease.26 Low dietary calcium intake has been associated with increased attachment loss in a dose-dependent manner in a representative sample of the U.S. population.27 Low dietary intake of vitamins C and D are also associated with increased risk for periodontal disease. Alcohol consumption is associated with a moderate risk of periodontal disease (30%), as measured by gingival recession and clinical attachment loss.30,31 Periodontal disease risk is associated with the amount of alcohol consumed, not the type of alcohol. Increased risk of periodontal disease is seen in individuals who drink more than five alcoholic beverages per week, compared to those who drink less or not at all. Psychological stress, distress, and depression have been reported to increase the risk for periodontal disease.32 A large population-based study reported that individuals experiencing high financial stress exhibited increased severity of periodontal disease compared to those with less financial stress.32 A systematic review of available evidence reports that cross-sectional and case-control studies showed a positive correlation between stress and periodontal disease.

In review, there are several modifiable risk factors that both dentist should look for in their patients and patients should be aware of to lessen their risk.