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DEFINITIONS AND TERMINOLOGY
Risk determinant: A risk factor that cannot be modified (eg, genetic factors, sex, age).2
Risk factor: Environmental, behavioral, or biologic factors that increase the likelihood of developing the disease; identified through longitudinal studies and confirmed to be present before the onset of the disease (eg, smoking, diabetes, pathogenic bacteria).
Risk indicator: A putative risk factor that is correctly identified through cross-sectional study designs.
Risk marker or risk predictor: Characteristics or factors that have the ability to predict individuals at high risk for disease, but are not part of the causal chain.3
Risk assessment is an essential component of periodontal patient management due to a number of local and systemic factors that can potentially affect the manifestation and progression of the disease. Accounting for these factors is an important step toward the delivery of optimal periodontal care.1 In this chapter, the main risk factors, risk determinants, risk indicators, and risk markers are reviewed. The association between them and the onset and progression of periodontal disease is discussed, as well as the impact on treatment outcomes. It should be highlighted that this chapter is based on the current knowledge, and if new evidence emerges in the future, some of these factors may be classified under a different category.
Box 4-1 lists examples of risk factors, risk determinants, risk indicators, and risk markers or predictors for periodontal disease.
BOX 4-1 Classification of the main risk factors, risk determinants, risk indicators, and risk markers for periodontal disease
| Risk factors | Risk determinants | Risk indicators | Risk markers |
| SmokingDiabetesPathogenic bacteria | GeneticsAgeSexRace | ObesityOsteoporosisStressAlcohol useRheumatoid arthritis | Bleeding on probingProbing depthFurcation involvement |
Risk Factors
SMOKING
Smoking is a well-documented risk factor for periodontal disease. The effects of smoking on the periodontal status can be classified as local and systemic.
Local effects
At the local level, smokers demonstrate increased supragingival4 as well as subgingival calculus formation.5 Additionally, the presence of nicotine has an effect on gingival fibroblasts, demonstrating an increase in gingival mediated collagen degradation. This action is mediated through the activation of matrix metalloproteinases (MMPs) and redistribution of the tissue inhibitors of metalloproteinases (TIMPs) to the cell membrane. Interestingly, this action is enhanced by the presence of Porphyromonas gingivalis.6 With regard to the often observed fibrotic clinical appearance of the gingival tissues in smokers,