Risk and Periodontal Disease Management Courtesy PreViser Corporation, all rights reserved
Issues to be Presented <ul><li>Why knowledge of a patient’s risk for periodontitis is required to determine treatment </li...
Risk and the Natural History of Periodontal Disease Health Initial disease stage Gingivitis Mild periodontitis Risk predic...
Treatment Implications of Risk <ul><li>If risk is low, then treatment may not be required, as disease is not expected to p...
Prevalence of Periodontitis, 1950’s* Courtesy PreViser Corporation, all rights reserved With advancing age the prevalence ...
Are all patients high risk for periodontal disease? <ul><li>Using the NHANES III database, Albandar, et al  ( J Periodonto...
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...
Distribution of Risk for Periodontitis Courtesy PreViser Corporation, all rights reserved
Summary <ul><li>Risk predicts the progression of disease </li></ul><ul><li>Risk justifies treatment </li></ul><ul><li>Risk...
Do Dentists Accurately Determine the Risk for Periodontitis? <ul><li>Study group of 107 patients with broad range of risk ...
Persson Study <ul><li>3 Groups of expert evaluators </li></ul><ul><ul><li>6 periodontists with national and international ...
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...
Current Risk Assessment Method <ul><li>Current method is subjective judgment </li></ul><ul><li>The literature only provide...
Diagnosis Health Initial disease stage Gingivitis Mild periodontitis Courtesy PreViser Corporation, all rights reserved Mo...
Diagnosis vs. Risk Diagnosis describes Risk predicts Based on: Signs and Symptoms  Risk Factors Courtesy PreViser Corporat...
Determining Diagnosis and Risk <ul><li>Signs and Symptoms </li></ul><ul><li>Bleeding on probing </li></ul><ul><li>Periodon...
What is a Risk Factor? <ul><li>Risk factor is often used as a general term meaning those characteristics that strongly ass...
Risk Factor Definition <ul><li>An environmental, behavioral, or biologic factor confirmed by temporal sequence, usually in...
Background Characteristics Definition <ul><li>Associated with a higher probability of disease, but cannot be modified.  Al...
Risk Indicator Definition <ul><li>A possible risk factor not yet confirmed in published studies.  A plausible correlate of...
Risk Markers and Predictors Definition <ul><li>A characteristic strongly correlated with an increased probability of futur...
Risk and Disease - Distinct Entities Courtesy PreViser Corporation, all rights reserved Periodontal Status Yes Yes Yes Hig...
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...
Mean Number of Teeth Lost Only 26% did not have periodontal disease at baseline Courtesy PreViser Corporation, all rights ...
Summary <ul><li>Risk is distinct from diagnosis </li></ul><ul><li>The methods to determine risk and diagnosis are differen...
OHIS™ is Practical for Clinical Use <ul><li>Only 23 data points, all of which are obtained during a routine periodontal ex...
Data Required by OHIS™ <ul><li>Smoking </li></ul><ul><li>Diabetes </li></ul><ul><li>Subgingival calculus </li></ul><ul><li...
OHIS™ Disease Score <ul><li>OHIS™ calculates a score that is representative of the severity and extent of periodontal dise...
OHIS™ Disease Score 170 Tooth# Facial Lingual Lingual Facial Tooth# Courtesy PreViser Corporation, all rights reserved 17 ...
OHIS™ Disease Score 207 Tooth# Facial Lingual Lingual Facial Tooth# Courtesy PreViser Corporation, all rights reserved 17 ...
OHIS™ Disease Score 111A Tooth# Facial Lingual Lingual Facial Tooth# Courtesy PreViser Corporation, all rights reserved 17...
Summary <ul><li>Risk and disease scores can be used to monitor periodontal status simply and quickly </li></ul><ul><li>A h...
Clinical Implications Diagnosis is used to determine treatment for existing “visible” lesions  ( Reparative treatment ) Co...
Clinical Implications, cont. <ul><li>Risk is used to: </li></ul><ul><li>Justify treatment </li></ul><ul><li>Modulate inten...
Incorporating Risk Concepts into  Treatment Planning <ul><li>Risk is the fundamental principle that should justify treatme...
Treatment Intensity and Aggressiveness <ul><li>An Example </li></ul><ul><li>Treatment for a 75 year old patient with gener...
Doomed by high risk? <ul><li>It is possible to be at high risk and not suffer the consequences of terminal disease by mana...
Periodontal Disease Management Goals <ul><li>Preservation of bone and teeth </li></ul><ul><li>Prevent surgery </li></ul><u...
Periodontal Referrals 1980 vs. 2000 <ul><li>Greater loss of teeth at the initial periodontal examination </li></ul><ul><li...
Severe Periodontitis <ul><li>Every patient who has severe periodontitis had, at a prior time, mild periodontitis, and befo...
Summary Withholding preventative treatment from healthy, at-risk patients denies them the opportunity to remain healthy an...
Summary <ul><li>An accurate determination of risk and its change over time is required to properly and dynamically plan tr...
Summary <ul><li>Risk predicts the progression of disease </li></ul><ul><li>Risk justifies treatment </li></ul><ul><li>Risk...
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Risk and Periodontal Disease Management

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  • The specific issues to be covered in this program include: 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
  • Note that health is indistinguishable from the initial disease stage, which is preclinical. Risk is a prediction of a future event that is typically an unwanted outcome. It is expressed verbally (low, high) or numerically (20 in 100, 85%). Risk can be used in periodontal care to express the likelihood of the progression from health to disease or any current disease state to a more severe state of disease. Accurate assessment of risk is an essential and integral part of diagnosis and treatment planning. Over- or under-assessment of risk likely results in inappropriate treatment of some patients. There is evidence that traditional risk assessment by subjective clinician judgment is inadequate for use in clinical decision making.
  • Risk justifies treatment. 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.
  • Historically, it was assumed that with advancing age the prevalence of gingivitis decreased and periodontitis increased, and that without intervention gingivitis inevitably would progress to severe periodontitis. This engendered the view that all adults with gingivitis were presumed to be at high risk for periodontal disease.
  • Not only do we now know that gingivitis does not always lead to periodontitis, we also know that the ultimate severity of disease varies for individual patients. That periodontal disease severity is highly stratified in the population can be seen from NHANES III, in which Albandar and colleagues determined that 65% of the US adult population over the age of 30 was periodontally healthy, 22% had mild periodontitis, and 13% had moderate to severe periodontitis. Whereas disease severity is stratified within the population, so too must the disease risk vary, and when the NHANES data are viewed by age cohort this distribution of disease risk can be determined.
  • Because NHANES indicates that the percentage of the population diagnosed with periodontitis increases linearly from 22% for the 30- to 34-year-old age cohort to 57% for the 85- to 90-year old age cohort, it must be true that approximately 60% of the 30- to 34-year old cohort were at risk of periodontitis, even if only 22% had actually developed the disease by age 34.
  • The data also distinguishes mild from moderate to severe periodontitis, which allows for the conclusion that the risk for mild periodontitis is 35% and 25% for moderate to severe periodontitis.
  • This information is presented on the pie chart.
  • 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
  • In order for risk assessment to have clinical utility, it must be accurate. Traditionally, risk has been assessed by expert clinical judgment. The utility of such subjective assessment of risk has been studied and reported on by Persson and colleagues. A study group of 107 patients was enrolled that exhibited a wide range of risk and disease severity. Records acquired for the study group included full mouth periodontal charting, medical and dental histories, full mouth periapical radiographs with bitewings, and clinical photographs.
  • A comprehensive periodontal examination was performed on each subject and a risk score ranging from 1 (very low risk) to 5 (very high risk) was calculated for each subject using the PreViser method. 3 groups of expert evaluators were assembled. One group included 6 periodontists with national and international clinical, academic, and military experience. A second group included 10 periodontists who participated in the development of the OHIS™ risk assessment tool and were expected to have enhanced knowledge of risk. The third group included 36 private practice general dentists who referred patients to periodontists. The clinicians were asked to determine the risk for periodontitis using the same 5-point scale.
  • For all risk groups, determined by OHIS™ every group of dentists exhibited very wide variation in assessing risk. The percentage of patients who were placed in risk groups 3 and 4 by two groups of periodontists was clustered around the proportion of patients placed in these groups by OHIS. However, only one periodontist placed as many subjects in risk group 5 as OHIS and none of the periodontists placed as few subjects in risk group 2 as OHIS. Data points for general dentists were spread across the entire range. Data points for the periodontists indicated that, as a group, they seriously underestimated actual disease risk, with the reasonable presumption that if treatment was based on an inaccurate assumption of risk, patients would have received inadequate treatment.
  • When an evaluator scored a test subject as being risk level 3 this agreement with OHIS is shown by the dot appearing in the red circle. If the evaluator scored 4 or 5, the dot is shown above the horizontal line in the inner or outer circle, respectively. If the evaluator scored 1 or 2, the dot is shown below the horizontal line in the inner or outer circle, respectively. It is notable that agreement with OHIS was only 20%, a level of agreement with a 1 to 5 scale that could have been achieved through a coin toss. Most evaluators underestimated risk, while some over-estimated risk. These data indicate that even expert clinicians rate poorly in their judgment of risk and, as a consequence, are likely providing treatment that are inappropriate for many patients. However, these findings should not be unexpected or alarming to dentists because the professional dental literature only provides a laundry list of risk factors with no practical methodology suggested on how to determine risk, leaving the dentist no method other than his or her subjective judgment. , some assigned the same risk as OHIS™, and some overestimated risk. This implies that treatment would be inappropriate for a large number of patients, since clinicians cannot accurately assess the risk of future disease.
  • Clinicians use their subjective judgment to determine risk, which is the default to a lack of information in the literature to guide clinicians. Hence, it is not surprising that the current method of risk assessment is generally an unreliable predictor of the future disease state.
  • A periodontal diagnosis describes the current periodontal status, which is limited in accuracy by the sensitivity of the measurement systems and the dynamic nonlinear disease process that can cycle between breakdown and healing. Diagnosis is not a reliable guide to future periodontal status, which can only be predicted when diagnosis is considered in addition to risk.
  • Diagnosis describes the current disease state where risk predicts the expected future disease state, which could be better, worse, or the same. Diagnosis is determined from signs and symptoms, whereas risk assessment uses risk factors.
  • Signs and symptoms of periodontal disease include bleeding on probing, the presence of periodontal pockets, alveolar bone loss, pain, and gingival swelling. Risk factors for periodontal disease include cigarette smoking, diabetes, stress, poor oral hygiene, the presence of periodontal pockets, and heredity. Because the signs and symptoms of periodontal disease are not equivalent to the risk factors for periodontal disease, the method to determine a diagnosis of periodontal disease differs from the method to determine the risk for periodontal disease. Therefore, a comprehensive evaluation of periodontal status requires separate determinations for diagnosis and risk, which together comprise a broader description of a patient’s periodontal status than diagnosis alone.
  • 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
  • An excellent working definition of risk factor has been stated by Beck. 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.
  • Background characteristics are associated with a higher probability of disease but they cannot be modified. They are also called determinants. Examples include age, gender, socioeconomic status, and familial history and genetic factors.
  • A risk indicator is a possible risk factor not yet confirmed in published studies. A risk indicator is a plausible correlate of disease identified in cross-sectional studies. Examples include osteoporosis, HIV and AIDS, and frequency of visits to the dentist.
  • Risk markers have a characteristic strongly correlated with an increased probability of future disease but they are not part of the causal chain. Examples are bleeding on probing and clinical attachment loss.
  • 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.
  • We previously showed that dentist exhibit wide variation when determining the risk for periodontitis, which is indicative that subjective assessment is not an accurate method. In this study we sought to determine the validity and accuracy of the OHIS™ method of risk assessment. We acquired records for 523 subjects who were enrolled in the Veterans Affairs Dental Longitudinal Study. Less than 10% of these subjects self-reported having any periodontal treatment. The records included periodontal pocket depth measurements, digitized full-mouth radiographs with bitewings and medical and dental histories. Risk was assessed at baseline using OHIS™.
  • Changes in periodontal status were determined by comparing baseline data to data at 3, 9, and 15 years. We determined mean alveolar bone loss, the percentage of sites with bone loss per subject and mean percent tooth loss and the percentage of subjects with tooth loss in each risk group.
  • The data was plotted for each risk group at the 3 time periods. Since only 2 subjects were in risk group 1, the data is not shown. The p-value for the study was &lt;.00001. This slide shows that mean bone loss was in rank order by risk and this was maintained at each time period. Mean bone loss is a measure of disease severity.
  • Rank order was maintained for the percentage of sites with bone loss. The change in slope probably reflects tooth loss. The percentage of sites with bone loss is a measure of disease extent.
  • The effect on tooth loss parallels bone loss where the rank order is maintained at each time period.
  • Rank order accurately predicted the percentage of subjects with tooth loss at each time period.
  • 74% of all teeth extracted were periodontally affected at baseline. The loss of these teeth was accurately predicted by OHIS™. The loss of periodontally unaffected teeth showed little variation for each risk group.
  • 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
  • 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.
  • The 23 data points required by OHIS are age, smoking history, diabetes diagnosis, oral hygiene, dental care frequency, the presence of subgingival calculus or restorations, periodontal pockets, bleeding on probing, furcation involvements, radiographic bone height, vertical bone lesions, and history of periodontal surgery to reduce pockets.
  • 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
  • OHIS™ establishes a quick and simple method to document a patients current and future periodontal status. In this case the OHIS™ Disease State Score = 21 with a Text-Linguistic Diagnosis = Localized Moderate Periodontitis
  • Disease State Score = 36 Text-Linguistic Diagnosis = Generalized Moderate Periodontitis
  • Disease State Score = 92 Text-Linguistic Diagnosis = Generalized Moderate to Severe Periodontitis
  • 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
  • Lesions must be visible to diagnostic methods to diagnose disease. Prior to this stage, histopathologic changes occur in advance of being clinically detectable. Hence it is impossible to truly know that a patient is healthy.
  • Risk is not based on signs and symptoms, or diagnosis. Risk is determined from risk factors and is used to justify treatment, modulate treatment intensity and aggressiveness, and determine treatment to prevent future lesions.
  • 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
  • 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.
  • High risk does not guarantee the that disease will occur or worsen. Managing the risk factors can prevent the occurrence and progression of disease. Examples include 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
  • The goals of periodontal disease management include: Preservation of bone and teeth Prevent surgery Prevent inflammation Repair damaging effects of periodontitis
  • Unfortunately the current method of referring patients to a periodontist is based on disease severity, not risk. When comparing referrals from 1980 to 2000, Cobb showed that patients had greater loss of teeth at the initial periodontal examination, more severe periodontitis at the initial periodontal examination, and more teeth were planned for extraction. Obviously dentists need a better method to determine periodontal treatment including referral.
  • For example, 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. One problem is that periodontitis is generally slowly progressive, which may obscure disease worsening, especially when 168 pockets and bone height measurements need to be compared. This is strong proof for an objective method to determine risk and describe periodontal status, where changes can be readily interpreted to guide treatment.
  • This slide shows that we should not wait until disease is visible. Prevention can maintain a healthy periodontal status.
  • 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
  • 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
  • Risk and Periodontal Disease Management

    1. 1. Risk and Periodontal Disease Management Courtesy PreViser Corporation, all rights reserved
    2. 2. Issues to be Presented <ul><li>Why knowledge of a patient’s risk for periodontitis is required to determine treatment </li></ul><ul><li>Why an accurate periodontal diagnosis is insufficient to determine treatment </li></ul><ul><li>How risk is determined </li></ul><ul><li>How risk is used to determine treatment </li></ul><ul><li>Periodontal disease management </li></ul>Courtesy PreViser Corporation, all rights reserved
    3. 3. Risk and the Natural History of Periodontal Disease Health Initial disease stage Gingivitis Mild periodontitis Risk predicts the progression from health to severe periodontitis Courtesy PreViser Corporation, all rights reserved Moderate periodontitis Severe periodontitis
    4. 4. Treatment Implications of Risk <ul><li>If risk is low, then treatment may not be required, as disease is not expected to progress </li></ul><ul><li>If risk is high, then treatment is required, as disease is expected to progress to a more advanced and possibly terminal stage </li></ul><ul><ul><li>Hence, every patient receiving aggressive periodontal treatment has been determined to be high risk </li></ul></ul><ul><ul><li>Furthermore, a standard treatment protocol for a specific periodontal diagnosis can be established when all patients are high risk </li></ul></ul>Courtesy PreViser Corporation, all rights reserved
    5. 5. Prevalence of Periodontitis, 1950’s* Courtesy PreViser Corporation, all rights reserved 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 Gingivitis Periodontitis Tooth loss
    6. 6. Are all patients high risk for periodontal disease? <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 Mild 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
    7. 7. 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%
    8. 8. 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 Mild Periodontitis is 35% Risk for Moderate to Severe Periodontitis is 25%
    9. 9. Distribution of Risk for Periodontitis Courtesy PreViser Corporation, all rights reserved
    10. 10. Summary <ul><li>Risk predicts the progression of disease </li></ul><ul><li>Risk justifies treatment </li></ul><ul><li>Risk for periodontitis is stratified across the US population </li></ul><ul><li>Treatment must be personalized for each patient and it must be based on the patient’s unique risk profile and disease severity </li></ul>Courtesy PreViser Corporation, all rights reserved
    11. 11. Do Dentists Accurately Determine the Risk for Periodontitis? <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
    12. 12. Persson Study <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
    13. 13. 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
    14. 14. 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™
    15. 15. Current Risk Assessment Method <ul><li>Current method is subjective judgment </li></ul><ul><li>The literature only provides a laundry list of risk factors with no guidance how to determine risk </li></ul><ul><li>Hence, it is not surprising that the current method of risk assessment is generally an unreliable predictor of the future disease state </li></ul>Courtesy PreViser Corporation, all rights reserved
    16. 16. Diagnosis Health Initial disease stage Gingivitis Mild periodontitis Courtesy PreViser Corporation, all rights reserved Moderate periodontitis Severe periodontitis 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.
    17. 17. Diagnosis vs. Risk Diagnosis describes Risk predicts Based on: Signs and Symptoms Risk Factors Courtesy PreViser Corporation, all rights reserved Disease State Severe Periodontitis Moderate Periodontitis Mild Periodontitis Gingivitis Health Current Future Time Worse Better Same
    18. 18. Determining Diagnosis and Risk <ul><li>Signs and Symptoms </li></ul><ul><li>Bleeding on probing </li></ul><ul><li>Periodontal pockets </li></ul><ul><li>Alveolar bone loss </li></ul><ul><li>Pain </li></ul><ul><li>Gingival swelling </li></ul><ul><li>Risk Factors </li></ul><ul><li>Cigarette smoking </li></ul><ul><li>Diabetes </li></ul><ul><li>Stress </li></ul><ul><li>Poor oral hygiene </li></ul><ul><li>Periodontal pockets </li></ul><ul><li>Heredity </li></ul>Courtesy PreViser Corporation, all rights reserved
    19. 19. What is a Risk Factor? <ul><li>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: </li></ul><ul><ul><li>Risk Factor </li></ul></ul><ul><ul><li>Background Characteristic </li></ul></ul><ul><ul><li>Risk Indicator </li></ul></ul><ul><ul><li>Risk Markers or Risk Predictors </li></ul></ul>Courtesy PreViser Corporation, all rights reserved
    20. 20. Risk Factor Definition <ul><li>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. </li></ul><ul><li>Beck JD. Community Dent Oral Epidemiol 1998 </li></ul>Courtesy PreViser Corporation, all rights reserved
    21. 21. Background Characteristics Definition <ul><li>Associated with a higher probability of disease, but cannot be modified. Also referred to as a determinant. </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Gender </li></ul></ul><ul><ul><li>Socioeconomic Status </li></ul></ul><ul><ul><li>Familial history and genetic factors </li></ul></ul>Courtesy PreViser Corporation, all rights reserved
    22. 22. Risk Indicator Definition <ul><li>A possible risk factor not yet confirmed in published studies. A plausible correlate of disease identified in cross-sectional studies. </li></ul><ul><ul><li>Osteoporosis </li></ul></ul><ul><ul><li>HIV and AIDS </li></ul></ul><ul><ul><li>Frequency of visits to the dentist </li></ul></ul>Courtesy PreViser Corporation, all rights reserved
    23. 23. Risk Markers and Predictors Definition <ul><li>A characteristic strongly correlated with an increased probability of future disease but is not part of the causal chain. </li></ul><ul><ul><li>Bleeding on probing </li></ul></ul><ul><ul><li>Clinical attachment loss </li></ul></ul>Courtesy PreViser Corporation, all rights reserved
    24. 24. Risk and Disease - Distinct Entities Courtesy PreViser Corporation, all rights reserved Periodontal Status Yes Yes Yes High No Yes Yes Moderate No Yes Yes Low Risk Level Moderate to Severe Periodontitis Mild Periodontitis Health Risk-Disease Grid
    25. 25. 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
    26. 26. 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
    27. 27. 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
    28. 28. 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
    29. 29. 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
    30. 30. 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
    31. 31. Mean Number of Teeth Lost Only 26% did not have periodontal disease at baseline Courtesy PreViser Corporation, all rights reserved 0 1 2 3 4 5 6 7 Total teeth Periodontally affected Periodontally unaffected Number of teeth lost Risk 2 Risk 3 Risk 4 Risk 5
    32. 32. Summary <ul><li>Risk is distinct from diagnosis </li></ul><ul><li>The methods to determine risk and diagnosis are different </li></ul><ul><li>Risk cannot be accurately determined from diagnosis </li></ul><ul><li>OHIS™ accurately determines risk for periodontitis </li></ul>Courtesy PreViser Corporation, all rights reserved
    33. 33. OHIS™ is Practical for Clinical Use <ul><li>Only 23 data points, all of which are obtained during a routine periodontal examination </li></ul><ul><li>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 </li></ul>Courtesy PreViser Corporation, all rights reserved
    34. 34. Data Required by OHIS™ <ul><li>Smoking </li></ul><ul><li>Diabetes </li></ul><ul><li>Subgingival calculus </li></ul><ul><li>Subgingival restorations </li></ul><ul><li>Pockets </li></ul><ul><li>Furcation involvements </li></ul><ul><li>Vertical bone lesions </li></ul><ul><li>Age </li></ul><ul><li>Radiographic bone height </li></ul><ul><li>History of periodontal surgery for pockets </li></ul><ul><li>Oral hygiene </li></ul><ul><li>Dental care frequency </li></ul><ul><li>Bleeding on probing </li></ul>Courtesy PreViser Corporation, all rights reserved
    35. 35. OHIS™ Disease Score <ul><li>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 </li></ul><ul><li>The score ranges from 1 for health to 100 for severe periodontitis </li></ul><ul><li>An increase in the score is indicative of worsening disease status, whereas a decrease is indicative of improvement </li></ul>Courtesy PreViser Corporation, all rights reserved
    36. 36. OHIS™ Disease Score 170 Tooth# Facial Lingual Lingual Facial Tooth# Courtesy PreViser Corporation, all rights reserved 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 433 414 324 414 324 313 322 313 212 213 212 212 212212 212 212 312 312 312 313 323 313 333423 333 424 333 424 424 333 624 523 313 323 313 223 213 222 212 222 212 222 212 222 312 222 313 322 313 323 313 423 425 436 424 433 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 OHIS™ Disease Score = 21 Text-Linguistic Diagnosis = Localized Moderate Periodontitis
    37. 37. OHIS™ Disease Score 207 Tooth# Facial Lingual Lingual Facial Tooth# Courtesy PreViser Corporation, all rights reserved 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 555 514 555 525 535 425 535 514 515 515 525 535 515 525 515 515 515 515 425 415 545 414 545 514 655 525 456 415 524 544 525 535 415 535 414 435 414 434 414 434 514 534 315 334 313 333 513 524 415 535 525 535 525 535 315 335 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 OHIS™ Disease Score = 36 Text-Linguistic Diagnosis = Generalized Moderate Periodontitis
    38. 38. OHIS™ Disease Score 111A Tooth# Facial Lingual Lingual Facial Tooth# Courtesy PreViser Corporation, all rights reserved 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 635 635 335 426 333 424 333 424 333 424 333 424 333 424 333 424 333 424 434 424 444 434 545 535 545 535 545 535 635 645 436 446 333 444 434 434 435 435 636 626 425 424 526 525 625 535 536 525 535 535 535 545 735 845 538 558 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 OHIS™ Disease Score = 92 Text-Linguistic Diagnosis = Generalized Moderate to Severe Periodontitis
    39. 39. Summary <ul><li>Risk and disease scores can be used to monitor periodontal status simply and quickly </li></ul><ul><li>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 </li></ul><ul><li>An increase in disease score indicates that the current treatment is not maintaining periodontal status and a change in treatment is indicated </li></ul>Courtesy PreViser Corporation, all rights reserved
    40. 40. 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
    41. 41. Clinical Implications, cont. <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
    42. 42. Incorporating Risk Concepts into Treatment Planning <ul><li>Risk is the fundamental principle that should justify treatment </li></ul><ul><ul><li>Low risk means that disease is unlikely to progress and justification for treatment is minimally supported </li></ul></ul><ul><ul><li>High risk means that disease is likely to progress and justification for treatment is maximally supported </li></ul></ul><ul><li>Risk is used to determine preventive interventions </li></ul><ul><li>Risk is also used to modulate the intensity and aggressiveness of reparative treatment </li></ul>Courtesy PreViser Corporation, all rights reserved
    43. 43. 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
    44. 44. 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>Drugs to lower blood pressure and cholesterol can prevent cardiovascular events </li></ul></ul><ul><ul><li>Blood-sugar control can prevent diabetic complications </li></ul></ul><ul><ul><li>Daily personal oral hygiene controls bacterial plaque preventing caries and periodontitis </li></ul></ul><ul><ul><li>Periodontal surgery that eliminates pockets improves plaque control effectiveness to prevent periodontitis </li></ul></ul>Courtesy PreViser Corporation, all rights reserved
    45. 45. Periodontal Disease Management Goals <ul><li>Preservation of bone and teeth </li></ul><ul><li>Prevent surgery </li></ul><ul><li>Prevent inflammation </li></ul><ul><li>Repair damaging effects of periodontitis </li></ul>Courtesy PreViser Corporation, all rights reserved
    46. 46. Periodontal Referrals 1980 vs. 2000 <ul><li>Greater loss of teeth at the initial periodontal examination </li></ul><ul><li>More severe periodontitis at the initial periodontal examination </li></ul><ul><li>More teeth were planned for extraction </li></ul>Cobb C et al. J Periodontol 2003; 74: 1470-1474 Courtesy PreViser Corporation, all rights reserved
    47. 47. Severe Periodontitis <ul><li>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. </li></ul><ul><li>Periodontitis is generally slowly progressive, which may obscure disease worsening, especially when 168 pockets and bone height measurements need to be compared. </li></ul>Courtesy PreViser Corporation, all rights reserved
    48. 48. Summary Withholding preventative treatment from healthy, at-risk patients denies them the opportunity to remain healthy and prevent complex reparative treatment 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <30 30-39 40-49 50-59 >59 Age Cohort % of Age Cohort Healthy, no risk Healthy, at-risk Periodontitis Courtesy PreViser Corporation, all rights reserved
    49. 49. Summary <ul><li>An accurate determination of risk and its change over time is required to properly and dynamically plan treatment for periodontitis </li></ul><ul><li>An accurate determination of periodontal status including its change over time is required to dynamically establish proper treatment recommendations </li></ul><ul><li>OHIS™ provides a simple and accurate method to document risk, disease status and any changes that occur </li></ul>Courtesy PreViser Corporation, all rights reserved
    50. 50. Summary <ul><li>Risk predicts the progression of disease </li></ul><ul><li>Risk justifies treatment </li></ul><ul><li>Risk for periodontitis is stratified across a population </li></ul><ul><li>Risk cannot be determined from diagnostic findings </li></ul><ul><li>Risk and diagnosis are required to determine treatment </li></ul><ul><li>Treatment must be personalized for each patient </li></ul>Courtesy PreViser Corporation, all rights reserved

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