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Risk and Periodontal Disease Management

Risk and Periodontal Disease Management. Courtesy PreViser Corporation, all rights reserved. Issues to be Presented. Why knowledge of a patient’s risk for periodontitis is required to determine treatment Why an accurate periodontal diagnosis is insufficient to determine treatment

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Risk and Periodontal Disease Management

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  1. Risk and Periodontal Disease Management Courtesy PreViser Corporation, all rights reserved

  2. Issues to be Presented • Why knowledge of a patient’s risk for periodontitis is required to determine treatment • Why an accurate periodontal diagnosis is insufficient to determine treatment • How risk is determined • How risk is used to determine treatment • Periodontal disease management Courtesy PreViser Corporation, all rights reserved

  3. Risk and the Natural History of Periodontal Disease Risk predicts the progression from health to severe periodontitis Initial disease stage Severe periodontitis Moderate periodontitis Mild periodontitis Health Gingivitis Courtesy PreViser Corporation, all rights reserved

  4. Treatment Implications of Risk • If risk is low, then treatment may not be required, as disease is not expected to progress • If risk is high, then treatment is required, as disease is expected to progress to a more advanced and possibly terminal stage • Hence, every patient receiving aggressive periodontal treatment has been determined to be high risk • Furthermore, a standard treatment protocol for a specific periodontal diagnosis can be established when all patients are high risk Courtesy PreViser Corporation, all rights reserved

  5. Prevalence of Periodontitis, 1950’s* Gingivitis Periodontitis Tooth loss With advancing age the prevalence of gingivitis decreases and periodontitis increases, which has been interpreted that risk for periodontitis is high. * Marshall-Day et al, J Periodontol 1955 Courtesy PreViser Corporation, all rights reserved

  6. Are all patients high risk for periodontal disease? • Using the NHANES III database, Albandar, et al (J Periodontol 1999; 70: 13-29) reported the prevalence of Periodontitis in the adult population (30 years and older) • 65% were Healthy • 22% had Mild Periodontitis • 13% had Moderate to Severe Periodontitis • When the same data is viewed by age cohort, … Courtesy PreViser Corporation, all rights reserved

  7. Risk for Periodontitis is 60% 70 60 50 % of Age Cohort 40 30 20 Periodontitis Linear trend line 10 0 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-90 Age Cohort Periodontal Disease Risk Risk to remain healthy is 40% Courtesy PreViser Corporation, all rights reserved

  8. Risk for Mild Periodontitis is 35% 45 Moderate to Severe Periodontitis 40 Beginning Periodontitis 35 Linear trend line 30 % of Age Cohort 25 20 15 10 Risk for Moderate to Severe Periodontitis is 25% 5 0 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-90 Age Cohort Periodontal Disease Risk, Cont. Courtesy PreViser Corporation, all rights reserved

  9. Distribution of Risk for Periodontitis Courtesy PreViser Corporation, all rights reserved

  10. Summary • Risk predicts the progression of disease • Risk justifies treatment • Risk for periodontitis is stratified across the US population • Treatment must be personalized for each patient and it must be based on the patient’s unique risk profile and disease severity Courtesy PreViser Corporation, all rights reserved

  11. Do Dentists Accurately Determine the Risk for Periodontitis? • Study group of 107 patients with broad range of risk for periodontitis • Full mouth periodontal charting • Medical and dental histories • Full mouth periapical radiographs with bitewings • Clinical photographs Persson GR et al. Assessing periodontal disease risk. J Am Dent Assoc 2003 Courtesy PreViser Corporation, all rights reserved

  12. Persson Study • 3 Groups of expert evaluators • 6 periodontists with national and international clinical, academic, and military experience • 10 periodontists who participated in the development of the OHIS™ tool • 36 private practice general dentists who referred patients to periodontists • Risk was assessed on a 1 (low) to 5 (high) scale by clinicians and OHIS™ Courtesy PreViser Corporation, all rights reserved

  13. OHIS™ 6 Practicing Experts 10 PreViser Founders 107 Patient Records, Risk Assessed using OHIS™ Three Expert Groups Subjectively Assess Same Patients 36 General Dentists “Periodontally Aware” Courtesy PreViser Corporation, all rights reserved

  14. Expert Periodontists (5 Patient Evaluations per data point) Previser Founder’s (5 Patient Evaluations…) General Dentist (5 Patient Evaluations… Risk Calculator Score = 3 20% Agreement with OHIS™ For OHIS™assessed patients with Risk Score of 3.. Practitioner evaluation over-estimating risk by 2 scores Practitioner evaluation over-estimating risk by 1 score Over- Estimated Risk = Inappropriate Treatment Under- Estimated Risk = Inappropriate Treatment Practitioner evaluation under-estimating risk by 1 score Conclusion: Clinicians can’t assess the risk offuture disease Practitioner evaluation under-estimating risk by 2 scores Courtesy PreViser Corporation, all rights reserved

  15. Current Risk Assessment Method • Current method is subjective judgment • The literature only provides a laundry list of risk factors with no guidance how to determine risk • Hence, it is not surprising that the current method of risk assessment is generally an unreliable predictor of the future disease state Courtesy PreViser Corporation, all rights reserved

  16. Diagnosis Initial disease stage Severe periodontitis Moderate periodontitis Mild periodontitis Health Gingivitis A periodontal diagnosis describes the current periodontal status, which is limited in accuracy by the sensitivity of the measurement systems and the dynamic non-linear disease process that can cycle between breakdown and healing. It does not predict future periodontal status. Courtesy PreViser Corporation, all rights reserved

  17. Disease State Severe Periodontitis Moderate Periodontitis Mild Periodontitis Gingivitis Worse Same Better Health Current Future Time Diagnosis vs. Risk Diagnosis describes Risk predicts Based on: Signs and Symptoms Risk Factors Courtesy PreViser Corporation, all rights reserved

  18. Signs and Symptoms Bleeding on probing Periodontal pockets Alveolar bone loss Pain Gingival swelling Risk Factors Cigarette smoking Diabetes Stress Poor oral hygiene Periodontal pockets Heredity Determining Diagnosis and Risk Courtesy PreViser Corporation, all rights reserved

  19. What is a Risk Factor? • Risk factor is often used as a general term meaning those characteristics that strongly associate with groups of individuals who have disease compared to those who do not. Risk terminology includes: • Risk Factor • Background Characteristic • Risk Indicator • Risk Markers or Risk Predictors Courtesy PreViser Corporation, all rights reserved

  20. Risk Factor Definition An environmental, behavioral, or biologic factor confirmed by temporal sequence, usually in longitudinal studies, which if present directly increases the probability of a disease occurring, and if absent or removed reduces the probability. Risk factors are part of the causal chain, or expose the host to the causal chain. Once disease occurs, removal of a risk factor may not result in a cure. Beck JD. Community Dent Oral Epidemiol 1998 Courtesy PreViser Corporation, all rights reserved

  21. Background Characteristics Definition • Associated with a higher probability of disease, but cannot be modified. Also referred to as a determinant. • Age • Gender • Socioeconomic Status • Familial history and genetic factors Courtesy PreViser Corporation, all rights reserved

  22. Risk Indicator Definition • A possible risk factor not yet confirmed in published studies. A plausible correlate of disease identified in cross-sectional studies. • Osteoporosis • HIV and AIDS • Frequency of visits to the dentist Courtesy PreViser Corporation, all rights reserved

  23. Risk Markers and Predictors Definition • A characteristic strongly correlated with an increased probability of future disease but is not part of the causal chain. • Bleeding on probing • Clinical attachment loss Courtesy PreViser Corporation, all rights reserved

  24. Risk and Disease - Distinct Entities Courtesy PreViser Corporation, all rights reserved

  25. Validity and Accuracy of OHIS™ Determined Risk • 523 subjects enrolled in the Veterans Affairs Dental Longitudinal Study who had only routine care • Periodontal pocket depth measurements • Digitized full-mouth radiographs with bitewings • Medical and dental histories • Risk was assessed at baseline using OHIS™ Page et al. Validity and accuracy of a risk calculator in predicting periodontal disease. J Am Dent Assoc 2002 Page et al. Longitudinal validation of a risk calculator for periodontal disease. J Clin Periodontol 2003 Courtesy PreViser Corporation, all rights reserved

  26. Validity and Accuracy of OHIS™ Determined Risk, cont. • Changes in periodontal status determined by comparing baseline data to data at 3, 9, and 15 years • Alveolar bone loss (mean bone loss, percentage of sites with bone loss per subject) • Tooth loss (mean percent tooth loss, percentage of subjects with tooth loss in each risk group) Courtesy PreViser Corporation, all rights reserved

  27. 8.0% 7.0% 6.0% 5.0% Mean Percent (±SE) Alveolar Bone Loss 4.0% 3.0% 2.0% 1.0% 0.0% Year 3 Year 9 Year 15 Mean Bone Loss Risk 5 A measure of disease severity Risk 4 Risk 3 Risk 2 Courtesy PreViser Corporation, all rights reserved

  28. 70% Risk 5 65% Risk 4 60% Risk 3 55% Risk 2 50% 45% % Sites with Bone Loss 40% 35% 30% 25% 20% 15% Year 3 Year 9 Year 15 Percentage of Sites with Bone Loss A measure of disease extent Courtesy PreViser Corporation, all rights reserved

  29. 30.0% 25.0% 20.0% Mean % (±SE) Tooth Loss 15.0% 10.0% 5.0% 0.0% Year 3 Year 9 Year 15 Mean Tooth Loss Risk 5 Risk 4 Risk 3 Risk 2 Courtesy PreViser Corporation, all rights reserved

  30. 100% 90% Risk 5 80% Risk 4 70% Risk 3 60% % of subjects 50% 40% Risk 2 30% 20% 10% 0% Year 3 Year 9 Year 15 Percentage of Subjects with Tooth Loss Courtesy PreViser Corporation, all rights reserved

  31. 7 6 Risk 2 5 Risk 3 4 Risk 4 Number of teeth lost 3 Risk 5 2 1 0 Total teeth Periodontally affected Periodontally unaffected Mean Number of Teeth Lost Only 26% did not have periodontal disease at baseline Courtesy PreViser Corporation, all rights reserved

  32. Summary • Risk is distinct from diagnosis • The methods to determine risk and diagnosis are different • Risk cannot be accurately determined from diagnosis • OHIS™ accurately determines risk for periodontitis Courtesy PreViser Corporation, all rights reserved

  33. OHIS™ is Practical for Clinical Use • Only 23 data points, all of which are obtained during a routine periodontal examination • Data entry, transmission over the Internet between the dentist’s computer and OHIS™ server takes less than 5 minutes and can be done at the convenience of staff Courtesy PreViser Corporation, all rights reserved

  34. Smoking Diabetes Subgingival calculus Subgingival restorations Pockets Furcation involvements Vertical bone lesions Age Radiographic bone height History of periodontal surgery for pockets Oral hygiene Dental care frequency Bleeding on probing Data Required by OHIS™ Courtesy PreViser Corporation, all rights reserved

  35. OHIS™ Disease Score • OHIS™ calculates a score that is representative of the severity and extent of periodontal disease based the deepest pocket and greatest bone loss for each sextant • The score ranges from 1 for health to 100 for severe periodontitis • An increase in the score is indicative of worsening disease status, whereas a decrease is indicative of improvement Courtesy PreViser Corporation, all rights reserved

  36. OHIS™ Disease Score = 21 Text-Linguistic Diagnosis = Localized Moderate Periodontitis OHIS™ Disease Score Tooth# Facial Lingual Lingual Facial Tooth# 170 Courtesy PreViser Corporation, all rights reserved

  37. OHIS™ Disease Score = 36 Text-Linguistic Diagnosis = Generalized Moderate Periodontitis OHIS™ Disease Score Tooth# Facial Lingual Lingual Facial Tooth# 207 Courtesy PreViser Corporation, all rights reserved

  38. OHIS™ Disease Score = 92 Text-Linguistic Diagnosis = Generalized Moderate to Severe Periodontitis OHIS™ Disease Score Tooth# Facial Lingual Lingual Facial Tooth# 111A Courtesy PreViser Corporation, all rights reserved

  39. Summary • Risk and disease scores can be used to monitor periodontal status simply and quickly • A high risk score or an increase predicts worsening disease and a higher disease score and that the current treatment is not effectively managing the risk factors • An increase in disease score indicates that the current treatment is not maintaining periodontal status and a change in treatment is indicated Courtesy PreViser Corporation, all rights reserved

  40. Severe Disease Initial Stage Detectable Stage Terminal Disease Moderate Disease Health Clinical Implications Diagnosis is used to determine treatment for existing “visible” lesions (Reparative treatment) Courtesy PreViser Corporation, all rights reserved

  41. Severe Disease Initial Stage Detectable Stage Terminal Disease Moderate Disease Health Clinical Implications, cont. • Risk is used to: • Justify treatment • Modulate intensity and aggressiveness • Determine treatment to prevent future lesions • (Preventative treatment) Courtesy PreViser Corporation, all rights reserved

  42. Incorporating Risk Concepts into Treatment Planning • Risk is the fundamental principle that should justify treatment • Low risk means that disease is unlikely to progress and justification for treatment is minimally supported • High risk means that disease is likely to progress and justification for treatment is maximally supported • Risk is used to determine preventive interventions • Risk is also used to modulate the intensity and aggressiveness of reparative treatment Courtesy PreViser Corporation, all rights reserved

  43. Treatment Intensity and Aggressiveness An Example Treatment for a 75 year old patient with generalized 6 mm pockets may be limited to periodontal maintenance whereas surgery may be selected for a 35 year old patient with the same conditions when the risk level of the older patient is much lower than the younger patient. Courtesy PreViser Corporation, all rights reserved

  44. Doomed by high risk? • It is possible to be at high risk and not suffer the consequences of terminal disease by management of the risk factors. For example: • Drugs to lower blood pressure and cholesterol can prevent cardiovascular events • Blood-sugar control can prevent diabetic complications • Daily personal oral hygiene controls bacterial plaque preventing caries and periodontitis • Periodontal surgery that eliminates pockets improves plaque control effectiveness to prevent periodontitis Courtesy PreViser Corporation, all rights reserved

  45. Periodontal Disease Management Goals • Preservation of bone and teeth • Prevent surgery • Prevent inflammation • Repair damaging effects of periodontitis Courtesy PreViser Corporation, all rights reserved

  46. Periodontal Referrals 1980 vs. 2000 • Greater loss of teeth at the initial periodontal examination • More severe periodontitis at the initial periodontal examination • More teeth were planned for extraction Cobb C et al. J Periodontol 2003; 74: 1470-1474 Courtesy PreViser Corporation, all rights reserved

  47. Severe Periodontitis • Every patient who has severe periodontitis had, at a prior time, mild periodontitis, and before that was healthy. The progression of disease could have been predicted by risk, which would have allowed for more timely and effective treatment. • Periodontitis is generally slowly progressive, which may obscure disease worsening, especially when 168 pockets and bone height measurements need to be compared. Courtesy PreViser Corporation, all rights reserved

  48. Summary Withholding preventative treatment from healthy, at-risk patients denies them the opportunity to remain healthy and prevent complex reparative treatment 100% 90% 80% 70% Healthy, no risk 60% Healthy, at-risk % of Age Cohort 50% Periodontitis 40% 30% 20% 10% 0% <30 30-39 40-49 50-59 >59 Age Cohort Courtesy PreViser Corporation, all rights reserved

  49. Summary • An accurate determination of risk and its change over time is required to properly and dynamically plan treatment for periodontitis • An accurate determination of periodontal status including its change over time is required to dynamically establish proper treatment recommendations • OHIS™ provides a simple and accurate method to document risk, disease status and any changes that occur Courtesy PreViser Corporation, all rights reserved

  50. Summary • Risk predicts the progression of disease • Risk justifies treatment • Risk for periodontitis is stratified across a population • Risk cannot be determined from diagnostic findings • Risk and diagnosis are required to determine treatment • Treatment must be personalized for each patient Courtesy PreViser Corporation, all rights reserved

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