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 How risk is determined How risk is used to determine treatment Periodontal disease management 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 Courtesy PreViser Corporation, all rights reserved

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

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 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. Courtesy PreViser Corporation, all rights reserved

Prevalence of Periodontitis, 1950’s*
Gingivitis Periodontitis Tooth loss 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. 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

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, … 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. Courtesy PreViser Corporation, all rights reserved

Periodontal Disease Risk
Risk for Periodontitis is 60% 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 to remain healthy is 40% 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. Courtesy PreViser Corporation, all rights reserved

Periodontal Disease Risk, Cont.
Risk for Mild Periodontitis is 35% 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 Beginning Periodontitis Moderate to Severe Periodontitis Linear trend line Risk for Moderate to Severe Periodontitis is 25% 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. Courtesy PreViser Corporation, all rights reserved

Distribution of Risk for Periodontitis
This information is presented on the pie chart. Courtesy PreViser Corporation, all rights reserved

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 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

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 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. Persson GR et al. Assessing periodontal disease risk. J Am Dent Assoc 2003 Courtesy PreViser Corporation, all rights reserved

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™ 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. Courtesy PreViser Corporation, all rights reserved

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

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

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 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. Courtesy PreViser Corporation, all rights reserved

Moderate periodontitis
Diagnosis Initial disease stage Severe periodontitis Health Mild periodontitis Moderate periodontitis Gingivitis 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. 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

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

Determining Diagnosis and Risk
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 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. Courtesy PreViser Corporation, all rights reserved

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 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

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 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. Courtesy PreViser Corporation, all rights reserved

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 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. Courtesy PreViser Corporation, all rights reserved

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 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. Courtesy PreViser Corporation, all rights reserved

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 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. Courtesy PreViser Corporation, all rights reserved

Risk and Disease - Distinct Entities
Risk-Disease Grid Periodontal Status Health Mild Periodontitis Moderate to Severe Periodontitis Risk Level Low Yes No Moderate High Risk level and disease (health status) creates a 3rd 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. Courtesy PreViser Corporation, all rights reserved

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™ 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™. 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

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) 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. Courtesy PreViser Corporation, all rights reserved

Mean Bone Loss A measure of disease severity Year 3 Year 9 Year 15
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 Risk 5 A measure of disease severity Risk 4 Risk 3 Risk 2 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 < 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. Courtesy PreViser Corporation, all rights reserved

Percentage of Sites with Bone Loss
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 A measure of disease extent 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. Courtesy PreViser Corporation, all rights reserved

Mean Tooth Loss Year 3 Year 9 Year 15 Mean % (±SE) Tooth Loss 30.0%
5.0% 10.0% 15.0% 20.0% 25.0% 30.0% Year 3 Year 9 Year 15 Mean % (±SE) Tooth Loss Risk 5 The effect on tooth loss parallels bone loss where the rank order is maintained at each time period. Risk 4 Risk 3 Risk 2 Courtesy PreViser Corporation, all rights reserved

Percentage of Subjects with Tooth Loss
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 Rank order accurately predicted the percentage of subjects with tooth loss at each time period. Courtesy PreViser Corporation, all rights reserved

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

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 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

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 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

Data Required by OHIS™ Age Smoking Radiographic bone height 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 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. Courtesy PreViser Corporation, all rights reserved

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 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

OHIS™ Disease Score OHIS™ Disease Score = 21
Text-Linguistic Diagnosis = Localized Moderate Periodontitis 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 Tooth# Facial Lingual 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 424 433 425 436 313 423 323 322 312 222 212 213 223 624 523 333 333423 212212 324 414 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 170 Courtesy PreViser Corporation, all rights reserved

Text-Linguistic Diagnosis = Generalized Moderate Periodontitis Disease State Score = Text-Linguistic Diagnosis = Generalized Moderate Periodontitis 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 315 335 525 535 415 513 524 313 333 334 514 534 414 434 435 544 456 655 545 425 515 555 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 Tooth# Facial Lingual 207 Courtesy PreViser Corporation, all rights reserved

Text-Linguistic Diagnosis = Generalized Moderate to Severe Periodontitis Disease State Score = Text-Linguistic Diagnosis = Generalized Moderate to Severe Periodontitis Tooth# Facial Lingual 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 538 558 735 845 535 545 536 525 625 526 425 424 636 626 435 434 333 444 436 446 635 645 335 426 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 111A Courtesy PreViser Corporation, all rights reserved

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 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

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

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

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 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

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. 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

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 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 Courtesy PreViser Corporation, all rights reserved

Periodontal Disease Management Goals
Preservation of bone and teeth Prevent surgery Prevent inflammation Repair damaging effects of periodontitis The goals of periodontal disease management include: Preservation of bone and teeth Prevent surgery Prevent inflammation Repair damaging effects of periodontitis Courtesy PreViser Corporation, all rights reserved

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 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. Cobb C et al. J Periodontol 2003; 74: Courtesy PreViser Corporation, all rights reserved

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. 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. Courtesy PreViser Corporation, all rights reserved

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% % of Age Cohort Healthy, at-risk 50% Periodontitis This slide shows that we should not wait until disease is visible. Prevention can maintain a healthy periodontal status. 40% 30% 20% 10% 0% <30 30-39 40-49 50-59 >59 Age Cohort Courtesy PreViser Corporation, all rights reserved

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 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

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 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

Risk and Periodontal Disease Management

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