Periodontal Disease Risk Developed by PreViser, Inc. Courtesy PreViser Corporation, all rights reserved
Overview <ul><li>What is risk? </li></ul><ul><li>What are the clinical implications? </li></ul><ul><li>How is risk determi...
What is Risk? <ul><li>General Context </li></ul><ul><ul><li>The likelihood of suffering harm or loss </li></ul></ul><ul><l...
Risk, Diagnosis, and the Natural History of Disease Risk  predicts  health status at a  future  time Diagnosis is a  descr...
Risk + Disease = 3 rd  Dimension Courtesy PreViser Corporation, all rights reserved Health Status Yes Yes Yes High No Yes ...
Clinical Implications Diagnosis is used to determine treatment for existing “visible” lesions  ( Reparative treatment ) Co...
Clinical Implications <ul><li>Risk is used to: </li></ul><ul><li>Justify treatment </li></ul><ul><li>Modulate intensity an...
Justify Treatment ???? <ul><li>If everyone is  low  risk, then no one requires treatment, regardless of health status </li...
Is Periodontal Disease Risk Stratified? <ul><li>Using the NHANES III database, Albandar, et al ( J Periodontol  1999; 70: ...
Periodontal Disease Risk Risk to remain healthy is 40% Courtesy PreViser Corporation, all rights reserved 0 10 20 30 40 50...
Periodontal Disease Risk, cont. Courtesy PreViser Corporation, all rights reserved 0 5 10 15 20 25 30 35 40 45 30-34 35-39...
Treatment Intensity and Aggressiveness <ul><li>An Example </li></ul><ul><li>Treatment for a 75 year old patient with gener...
Preventative Treatment <ul><li>Preventative treatment targets risk factors where risk factors are defined as, </li></ul><u...
Preventative Treatment <ul><li>Preventative treatment applied before detectable disease occurs or during another stage of ...
Doomed by high risk? <ul><li>It is possible to be at high risk and not suffer the consequences of terminal disease by mana...
How is Risk Determined? <ul><li>Subjective opinion, the current method, is highly variable leading to the conclusion that ...
Clinicians vs. OHIS™ Risk Assessment <ul><li>Study group of 107 patients with broad range of risk for periodontitis </li><...
Clinicians’ vs. OHIS™ Risk Assessment, cont. <ul><li>3 Groups of expert evaluators </li></ul><ul><ul><li>6 periodontists w...
107 Patient Records, Risk Assessed using OHIS™ Three Expert Groups Subjectively Assess Same Patients Courtesy PreViser Cor...
107 Patient Records, Risk Assessed using OHIS™ Three Expert Groups Subjectively Assess Same Patients 6 Practicing Experts ...
107 Patient Records, Risk Assessed using OHIS™ Three Expert Groups Subjectively Assess Same Patients Courtesy PreViser Cor...
107 Patient Records, Risk Assessed using OHIS™ Three Expert Groups Subjectively Assess Same Patients 36 General Dentists “...
Practitioner evaluation over-estimating risk by 2 scores Practitioner evaluation under-estimating risk by 1 score Over- Es...
Validity and Accuracy of OHIS™ Determined Risk <ul><li>523 subjects enrolled in the Veterans Affairs Dental Longitudinal S...
Validity and Accuracy of OHIS™ Determined Risk, cont. <ul><li>Changes in periodontal status determined by comparing baseli...
Mean Bone Loss Risk 5 Risk 4 Risk 3 Risk 2 A measure of disease severity Courtesy PreViser Corporation, all rights reserve...
Percentage of Sites with Bone Loss A measure of disease extent Courtesy PreViser Corporation, all rights reserved 15% 20% ...
Mean Tooth Loss Risk 5 Risk 4 Risk 3 Risk 2 Courtesy PreViser Corporation, all rights reserved 0.0% 5.0% 10.0% 15.0% 20.0%...
Percentage of Subjects with Tooth Loss Courtesy PreViser Corporation, all rights reserved 0% 10% 20% 30% 40% 50% 60% 70% 8...
Summary <ul><li>Risk and disease are distinct entities that when combined provide a more comprehensive description of heal...
Summary, cont. <ul><li>Diagnosis leads to reparative treatment whereas risk guides preventive treatment and modulates trea...
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Periodontal Disease Risk

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  • An introductory explanation of risk as it relates to periodontal disease. The power point was prepared in January 2006.
  • The presentation consists of three main topics – the definition of risk, its clinical implications, and how it is determined. The determination of risk includes PreViser’s Expert and Validation studies. The use of OHIS™ is not included.
  • Two distinct types of risk exist in health care. One is the risk for disease that I call “risk” and the second is the predicted treatment outcome that I call “prognosis”. Unfortunately prognosis is used to describe both types of risk. This is unfortunate because the determination of risk and prognosis are different. For example risk is determined from risk factors, which are involved in the disease process whereas prognosis is determined from factors of the healing process. Hence risk is the susceptibility to disease and prognosis is the healing capacity. This slide series does not include slides to explain the distinction between risk and prognosis. This slide series only explains risk, which is accentuated by the text color change.
  • This diagram of the natural history of disease is used to illustrate diagnosis and risk. These definitions establish risk and diagnosis as distinct entities based on time and actual disease status (current) versus predicted disease status (future).
  • Risk level and disease (health status) creates a 3 rd dimension to describe health status. Risk and disease are distinct entities, which means that both are needed to fully describe a patient’s health status including current and future time frames. There is a natural tendency to equate the level of risk with disease severity. For example severe disease is commonly paired with high risk and health with low risk. However health cannot always mean low risk, as health must always precede severe disease.
  • Visible includes all clinical diagnostic methods to detect disease. Histopathologic changes occur in advance of being clinically detectable. Hence it is impossible to truly know that a patient is healthy.
  • Other examples in health care include drugs to lower cholesterol or hypertension, exercise, and nutrition.
  • The groups on the horizontal axis represent risk groups 1 through 5. The white triangles represent the percentage of subjects with risk 1, 2, 3, 4, and 5.
  • Risk assigned by the 6 practicing experts varied with low-risk patients over-reported and high-risk patient under-reported.
  • Risk assigned by the 10 PreViser founders varied with a pattern similar to the experts.
  • Risk assigned by the 36 general dentists varied the most.
  • Analyzing only those subjects with risk score 3 revealed that clinicians over-estimate and under-estimate risk. Since risk is an integral component in determining treatment this information leads to the conclusion that some patients do not receive proper care.
  • Risk 1 is not shown, as too few subjects were in the study. The risk groups are distinctly different and in rank order. The p-value for the study is .00001.
  • The reduced slope that occurs between year 9 and year 15 may be due to tooth loss.
  • Risk 1 is not shown, as too few subjects were in the study. The risk groups are distinctly different and in rank order. The p-value for the study is .00001.
  • OHIS™ is the only validated objective method to determine risk.
  • Periodontal Disease Risk

    1. 1. Periodontal Disease Risk Developed by PreViser, Inc. Courtesy PreViser Corporation, all rights reserved
    2. 2. Overview <ul><li>What is risk? </li></ul><ul><li>What are the clinical implications? </li></ul><ul><li>How is risk determined? </li></ul>Courtesy PreViser Corporation, all rights reserved
    3. 3. What is Risk? <ul><li>General Context </li></ul><ul><ul><li>The likelihood of suffering harm or loss </li></ul></ul><ul><li>Health Care Context </li></ul><ul><ul><li>The likelihood of a worse health status during the natural history of disease ( risk ) </li></ul></ul><ul><ul><li>The likelihood of an undesired treatment outcome ( prognosis ) </li></ul></ul>Courtesy PreViser Corporation, all rights reserved
    4. 4. Risk, Diagnosis, and the Natural History of Disease Risk predicts health status at a future time Diagnosis is a description of health status at the current time Courtesy PreViser Corporation, all rights reserved Health Initial Stage Detectable Stage Moderate Disease Severe Disease Terminal Disease
    5. 5. Risk + Disease = 3 rd Dimension Courtesy PreViser Corporation, all rights reserved Health Status Yes Yes Yes High No Yes Yes Moderate No Yes Yes Low Risk Level Severe Mild Health Risk-Disease Grid
    6. 6. Clinical Implications Diagnosis is used to determine treatment for existing “visible” lesions ( Reparative treatment ) Courtesy PreViser Corporation, all rights reserved Health Initial Stage Detectable Stage Moderate Disease Severe Disease Terminal Disease
    7. 7. Clinical Implications <ul><li>Risk is used to: </li></ul><ul><li>Justify treatment </li></ul><ul><li>Modulate intensity and aggressiveness </li></ul><ul><li>Determine treatment to prevent future lesions </li></ul><ul><li>( Preventative treatment ) </li></ul>Courtesy PreViser Corporation, all rights reserved Health Initial Stage Detectable Stage Moderate Disease Severe Disease Terminal Disease
    8. 8. Justify Treatment ???? <ul><li>If everyone is low risk, then no one requires treatment, regardless of health status </li></ul><ul><li>If everyone is high risk, then each patient needs the same preventative treatment and reparative treatment is based on the existing lesions </li></ul><ul><li>When risk for disease is stratified then treatment needs vary with those at high risk needing more care compared to those at low risk </li></ul>Courtesy PreViser Corporation, all rights reserved
    9. 9. Is Periodontal Disease Risk Stratified? <ul><li>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) </li></ul><ul><ul><li>65% were Healthy </li></ul></ul><ul><ul><li>22% had Beginning Periodontitis </li></ul></ul><ul><ul><li>13% had Moderate to Severe Periodontitis </li></ul></ul><ul><li>When the same data is viewed by age cohort, … </li></ul>Courtesy PreViser Corporation, all rights reserved
    10. 10. Periodontal Disease Risk Risk to remain healthy is 40% Courtesy PreViser Corporation, all rights reserved 0 10 20 30 40 50 60 70 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 % of Age Cohort Periodontitis Linear trend line Risk for Periodontitis is 60%
    11. 11. Periodontal Disease Risk, cont. Courtesy PreViser Corporation, all rights reserved 0 5 10 15 20 25 30 35 40 45 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 % of Age Cohort Linear trend line Moderate to Severe Periodontitis Beginning Periodontitis Risk for Beginning Periodontitis is 35% Risk for Moderate to Severe Periodontitis is 25%
    12. 12. Treatment Intensity and Aggressiveness <ul><li>An Example </li></ul><ul><li>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. </li></ul>Courtesy PreViser Corporation, all rights reserved
    13. 13. Preventative Treatment <ul><li>Preventative treatment targets risk factors where risk factors are defined as, </li></ul><ul><li>An environmental, behavioral, or biologic factor, which if present directly increase 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, Community Dent Oral Epidemiol 1998 </li></ul>Courtesy PreViser Corporation, all rights reserved
    14. 14. Preventative Treatment <ul><li>Preventative treatment applied before detectable disease occurs or during another stage of disease that is reversible can prevent irreversible lesions that require reparative treatment. For example: </li></ul><ul><li>Personal daily oral hygiene </li></ul><ul><li>Periodontal maintenance care </li></ul>Courtesy PreViser Corporation, all rights reserved Health Initial Stage Detectable Stage Moderate Disease Severe Disease Terminal Disease
    15. 15. Doomed by high risk? <ul><li>It is possible to be at high risk and not suffer the consequences of terminal disease by management of the risk factors. For example: </li></ul><ul><ul><li>Daily personal oral hygiene for bacterial plaque </li></ul></ul><ul><ul><li>Smoking cessation </li></ul></ul><ul><ul><li>Blood-sugar control for diabetes </li></ul></ul><ul><ul><li>Periodontal surgery to eliminate pockets </li></ul></ul>Courtesy PreViser Corporation, all rights reserved
    16. 16. How is Risk Determined? <ul><li>Subjective opinion, the current method, is highly variable leading to the conclusion that treatment may be misapplied for some patients, which is understandable since - </li></ul><ul><li>The professional literature provides a list of risk factors but no validated objective method to correlate multiple factors for clinical use </li></ul>Courtesy PreViser Corporation, all rights reserved
    17. 17. Clinicians vs. OHIS™ Risk Assessment <ul><li>Study group of 107 patients with broad range of risk for periodontitis </li></ul><ul><ul><li>Full mouth periodontal charting </li></ul></ul><ul><ul><li>Medical and dental histories </li></ul></ul><ul><ul><li>Full mouth periapical radiographs with bitewings </li></ul></ul><ul><ul><li>Clinical photographs </li></ul></ul>Persson GR et al. Assessing periodontal disease risk. J Am Dent Assoc 2003 Courtesy PreViser Corporation, all rights reserved
    18. 18. Clinicians’ vs. OHIS™ Risk Assessment, cont. <ul><li>3 Groups of expert evaluators </li></ul><ul><ul><li>6 periodontists with national and international clinical, academic, and military experience </li></ul></ul><ul><ul><li>10 periodontists who participated in the development of the OHIS™ tool </li></ul></ul><ul><ul><li>36 private practice general dentists who referred patients to periodontists </li></ul></ul><ul><li>Risk was assessed on a 1 (low) to 5 (high) scale by clinicians and OHIS™ </li></ul>Courtesy PreViser Corporation, all rights reserved
    19. 19. 107 Patient Records, Risk Assessed using OHIS™ Three Expert Groups Subjectively Assess Same Patients Courtesy PreViser Corporation, all rights reserved OHIS™
    20. 20. 107 Patient Records, Risk Assessed using OHIS™ Three Expert Groups Subjectively Assess Same Patients 6 Practicing Experts Courtesy PreViser Corporation, all rights reserved OHIS™
    21. 21. 107 Patient Records, Risk Assessed using OHIS™ Three Expert Groups Subjectively Assess Same Patients Courtesy PreViser Corporation, all rights reserved 6 Practicing Experts OHIS™ 10 PreViser Founders
    22. 22. 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 6 Practicing Experts OHIS™ 10 PreViser Founders
    23. 23. Practitioner evaluation over-estimating risk by 2 scores Practitioner evaluation under-estimating risk by 1 score Over- Estimated Risk = Inappropriate Treatment Under- Estimated Risk = Inappropriate Treatment Practitioner evaluation over-estimating risk by 1 score Practitioner evaluation under-estimating risk by 2 scores For OHIS™ assessed patients with Risk Score of 3.. Conclusion: Clinicians can’t assess the risk of future disease Courtesy PreViser Corporation, all rights reserved Risk Calculator Score = 3 General Dentist (5 Patient Evaluations… Expert Periodontists (5 Patient Evaluations per data point) Previser Founder’s (5 Patient Evaluations…) 20% Agreement with OHIS™
    24. 24. Validity and Accuracy of OHIS™ Determined Risk <ul><li>523 subjects enrolled in the Veterans Affairs Dental Longitudinal Study who had only routine care </li></ul><ul><ul><li>Periodontal pocket depth measurements </li></ul></ul><ul><ul><li>Digitized full-mouth radiographs with bitewings </li></ul></ul><ul><ul><li>Medical and dental histories </li></ul></ul><ul><li>Risk was assessed at baseline using OHIS™ </li></ul>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
    25. 25. Validity and Accuracy of OHIS™ Determined Risk, cont. <ul><li>Changes in periodontal status determined by comparing baseline data to data at 3, 9, and 15 years </li></ul><ul><ul><li>Alveolar bone loss (mean bone loss, percentage of sites with bone loss per subject) </li></ul></ul><ul><ul><li>Tooth loss (mean percent tooth loss, percentage of subjects with tooth loss in each risk group) </li></ul></ul>Courtesy PreViser Corporation, all rights reserved
    26. 26. Mean Bone Loss Risk 5 Risk 4 Risk 3 Risk 2 A measure of disease severity Courtesy PreViser Corporation, all rights reserved 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% Year 3 Year 9 Year 15 Mean Percent (±SE) Alveolar Bone Loss
    27. 27. Percentage of Sites with Bone Loss A measure of disease extent Courtesy PreViser Corporation, all rights reserved 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% Year 3 Year 9 Year 15 % Sites with Bone Loss Risk 5 Risk 4 Risk 3 Risk 2
    28. 28. Mean Tooth Loss Risk 5 Risk 4 Risk 3 Risk 2 Courtesy PreViser Corporation, all rights reserved 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% Year 3 Year 9 Year 15 Mean % (±SE) Tooth Loss
    29. 29. Percentage of Subjects with Tooth Loss Courtesy PreViser Corporation, all rights reserved 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Year 3 Year 9 Year 15 % of subjects Risk 5 Risk 4 Risk 3 Risk 2
    30. 30. Summary <ul><li>Risk and disease are distinct entities that when combined provide a more comprehensive description of health status, which can be used to provide better care </li></ul><ul><li>Risk is determined from risk factors where diagnosis is determined from (“visible”) clinical signs and symptoms </li></ul>Courtesy PreViser Corporation, all rights reserved
    31. 31. Summary, cont. <ul><li>Diagnosis leads to reparative treatment whereas risk guides preventive treatment and modulates treatment intensity and aggressiveness </li></ul><ul><li>Because the population is stratified by risk for periodontal disease, treatment should be customized based on a validated objective method that determines the unique risk level and disease status of each patient </li></ul>Courtesy PreViser Corporation, all rights reserved
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