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All Risks Are Not Created Equal
When it comes to risk, there are different gradients. While many things may increase the risk or likelihood of patients developing periodontal disease, caries, or oral cancer, only a few are considered causal. Causality is difficult to establish and must meet strict criteria. A risk factor is considered causal if it a) precedes the disease, b) demonstrates a mechanism of action upon the disease and c) can be modified to prevent or moderate future disease.1 An example of a causal risk factor for periodontal disease is smoking.1 Most people begin a smoking habit by age 18; nicotine from smoking impairs the body’s chronic immune response while triggering an inflammatory cascade of chronic immune responses; and smoking cessation has been shown to arrest periodontal disease and improve treatment outcomes.2
There are some risk factors for oral diseases and conditions that have not been proven causal, yet the factor and the disease often occur together. This is referred to as an association.3 The best example of this is periodontal disease and cardiovascular disease (CVD). Many people with periodontal disease have CVD and vice versa. Yet it is unclear if periodontal disease precedes CVD; the age of onset is generally similar for both. There does appear to be a common potential mechanism of action: inflammation. However, no studies demonstrate that treating periodontal disease can prevent or modify the course of CVD.1
Many factors play a role in oral disease that are neither casual nor associative yet still influence onset, severity, and outcome (Table 1). The lack of dental insurance and/or the inability to pay for dental services impacts oral health. Untreated periodontal disease and caries can lead to pain and tooth loss. Undiagnosed oral cancer can result in disfigurement or death. People with special needs, mental illnesses, cognitive impairments, and physical or developmental disabilities are groups that might lack dental insurance and consequently might have some of the most severe disease.
What Risk Assessments Do I Need to Conduct?
Oral diseases are some of the most prevalent conditions affecting adults and children today (Table 2). Every patient should be evaluated for their risks for periodontal disease, dental caries, and oral cancer. Because risk is fluid, assessment should be done on some level at each visit. However, after an initial baseline, the frequency and depth of each future assessment will depend on the currently identified risk. For example, people who smoke will be at a higher risk for both periodontal disease and oral cancer and may need more aggressive screenings than an individual who has never smoked and/or has no other risk factors present.
In determining the risk for current and future periodontal disease, it is well established that the two strongest risk factors are smoking and having diabetes.1 Individuals who smoke are about four times more likely than nonsmokers to develop periodontal disease. Heavy smokers often have the most severe cases.2 In recent years, it has been shown that people exposed to secondhand smoke are also at an increased risk for periodontal disease.6 People with diabetes are significantly more likely to develop periodontitis.1 For those diagnosed with diabetes in their youth, data indicate that nearly a third will have some periodontal disease by time they are in their mid-thirties.7 Individuals with the poorest glycemic control appear to be at the greatest risk.1 Both smoking and poorly controlled diabetes may negatively affect treatment outcomes.1,2 Smoking cessation and improvements in blood sugar appear to have a positive effect on the disease.1,7 Periodontal risk can be assessed through good questions in the medical history. Table 3 outlines the questions to assess the risk from smoking and Table 4 outlines questions for diabetes.
It is now recognized that caries is a multifactorial, complex disease that is not easily prevented or arrested by simply suggesting better brushing and flossing. A more sophisticated look at caries finds it results from an imbalance in the factors that contribute the demineralization/remineralization process. Caries management by risk assessment (CAMBRA) has emerged as a best practice for identifying at-risk patients and developing interventions and preventive strategies at the earliest possible stage of disease. CAMBRA evaluates the caries balance/imbalance on three variables: disease indicators, risk factors, and protective factors. Table 5 highlights key information to be acquired on each variable.8
Tobacco, alcohol, and exposure to the human papillomavirus (HPV) are the top risk factors for the development of oral cancer.4 According to the American Cancer Society, heavy tobacco use (smoking and spit tobacco) is still one of the strongest risk factors for oral cancer, along with heavy use of alcohol. Seven out of 10 patients with oral cancer are heavy drinkers, and being both a heavy drinker and smoker makes a person up to 100 times more likely to develop oral cancer.9 Table 3 and Table 6 highlight the information needed to assess smoking and alcohol risks.
In recent years, a trend toward younger individuals being diagnosed with oral cancer has emerged. This is believed to be from a previous infection from the same strain of HPV that causes cervical cancer. The US Centers for Disease Control and Prevention (CDC) estimates that about 7% of people will have an oral HPV infection and about 1% will be infected with the type that causes cancer. The CDC also estimates that 80% of sexually active adults aged 14 to 44 have had oral sex with an opposite-sex partner.10 Therefore, regarding HPV, it is prudent to assume everyone is at risk.
When evaluating risk, there are cultural, societal, psychological, and physical factors that can affect lifestyle and either put an individual at an increased risk for oral and systemic diseases or be barriers to effective treatment. These should also be taken into consideration. With children, the elderly, and the developmentally challenged, it will be important to consult with caregivers to elicit the most accurate information.
Risk assessment is a vital piece of the overall assessment process. Identifying the specific factors that contribute to oral diseases and conditions provides the basis for personalized strategies that prevent, modify, or arrest disease.
About the Author
Carol A. Jahn, RDH, MS, is a lifelong ADHA member who has had many roles and elected positions including ADHA treasurer. Currently, she is the ADHA’s representative to the International Federation of Dental Hygiene. She is employed by Water Pik, Inc. as senior professional relations manager. She can be reached at firstname.lastname@example.org.
1. Genco RJ, Genco FD. Common risk factors in the management of periodontal and associated systemic diseases: the dental setting and interprofessional collaboration. J Evid Base Dent Pract. 2014;I4S:4-16.
2. Johnson GK, Hill M. Cigarette smoking and the periodontal patient. J Peridontol. 2004;75:196-209.
3. Brunette DM. Causation, association, and oral health-systemic disease connections. In: M Glick M. (ed.): The Oral-Systemic Health Connection: A Guide to Patient Care. Hanover Park, Ill.: Quintessence Publishing Co Inc., 2014.
4. Centers for Disease Control and Prevention. Oral health: preventing cavities, gum disease, tooth loss, and oral cancers. Available at: www.cdc.gov/chronicdisease/resources/publications/aag/doh.htm. Accessed Oct. 7, 2014.
5. Eke P, Dye BA, Wel L, et al. Prevalence of periodontitis in adults in the United States: 2009-2010. J Dent Res. 2012;91:907-908.
6. Sanders AE, Slade GD, Beck JD, Austsdottir H. Secondhand smoke and periodontal disease: atherosclerosis risk in communities study. Am J Public Health. 2011;101(Suppl 1):S339-S346.
7. Lalla E, Cheng B, Lal S et al. Periodontal changes in children and adolescents with diabetes. Diabetes Care. 2006;29:295-299.
8. Hurlbutt M, Young DA. A best practices approach to caries management. J Evid Base Dent Pract. 2014;I4:77-86.
9. American Cancer Society. Oral cavity and oropharyngeal cancer. Available at: www.cancer.org/cancer/oralcavityandoropharyngealcancer/index. Accessed Oct. 8, 2014.
10. Centers for Disease Control and Prevention. Human papillomavirus and oropharyngeal fact sheet. Available at: www.cdc.gov/std/hpv/stdfact-hpvandoropharyngealcancer.htm. Accessed Oct. 8, 2014.