1. If You Can Measure It, You Can Manage It Measuring Periodontal Status to Manage Periodontal Treatment Courtesy PreViser Corporation, all rights reserved

2. Why Measure Periodontal Status? Periodontist Periodontist Self-knowledge of treatment effectiveness for decision-making Self-knowledge of treatment effectiveness for decision-making Informing the patient including explaining changes in periodontal status Informing the patient including explaining changes in periodontal status Informing the referring general dentist Informing the referring general dentist General dentist General dentist Self-knowledge of treatment effectiveness for decision-making including determining when to refer to a periodontist Informing the patient including explaining changes in periodontal status Courtesy PreViser Corporation, all rights reserved

3. Common Issues for Clinicians How is periodontal status described in terms of disease severity and extent? How is periodontal status described in terms of disease severity and extent? How has periodontal status changed over time? How has periodontal status changed over time? Has it improved? Has it improved? Has it worsened? Has it worsened? Has it remained stable? Has it remained stable? Did periodontal status improve following treatment? (Was treatment successful?) Did periodontal status improve following treatment? (Was treatment successful?) Courtesy PreViser Corporation, all rights reserved

4. Existing Measurement Methods AAP Description AAP Description Severity: Severity: Slight: CAL* 1-2 mm Slight: CAL* 1-2 mm Moderate: CAL 3-4 mm Moderate: CAL 3-4 mm Severe: CAL ≥5 mm Severe: CAL ≥5 mm Extent: Extent: Localized: ≤30% of sites Localized: ≤30% of sites Generalized: >30% of sites Generalized: >30% of sites Clinical Practice Clinical Practice Periodontal charting is not consistently done in general practices Pocket depth rather than CAL is measured 168 pocket depth measurements are needed for a 28-tooth dentition Radiographs are also utilized *The AAP defines CAL as clinical attachment loss, where other authors define CAL as clinical attachment level Courtesy PreViser Corporation, all rights reserved

5. Assigning Severity for 1 Site Periodontal disease severity is typically determined by dentists from pocket depth and bone level, not CAL and no study has been published to correlate these two measurement methods. How do dentists assign periodontal status using pocket and bone measures? Periodontal disease severity is typically determined by dentists from pocket depth and bone level, not CAL and no study has been published to correlate these two measurement methods. How do dentists assign periodontal status using pocket and bone measures? Using severity categories health, gingivitis, mild, moderate, and severe periodontitis what is the severity for each combination of pocket depth and radiographic bone height? Pocket Depth <5 mm5-7 mm>7 mm Radiographic Bone Height (CEJ to bone crest) >4 mm 2-4 mm < 2 mm Mild periodontitis Moderate periodontitis Mild periodontitis Severe periodontitis Courtesy PreViser Corporation, all rights reserved

6. Conclusions The exercise revealed that periodontal status using a text description is which of the following: The exercise revealed that periodontal status using a text description is which of the following: Objective and consistent Objective and consistent Objective with variation Objective with variation Subjective with variation Subjective with variation Subjective and consistent Subjective and consistent Courtesy PreViser Corporation, all rights reserved

7. The Multiple Site Dilemma How do you describe and rank a dentition by severity and extent where the severity for each quadrant has been assigned? Is this a simple and easy process? Is the description clear and unambiguous? How do you describe and rank a dentition by severity and extent where the severity for each quadrant has been assigned? Is this a simple and easy process? Is the description clear and unambiguous? Quadrant ExampleURULLLLR A Severe Periodontitis Moderate Periodontitis B Severe Periodontitis Mild Periodontitis C Moderate Periodontitis Mild Periodontitis D Severe Periodontitis Moderate Periodontitis Mild Periodontitis Courtesy PreViser Corporation, all rights reserved

8. Missing HealthGingivitis Mild Periodontitis Moderate Periodontitis Severe Periodontitis The Multiple Site Dilemma, cont. How do you describe each of these dentitions? Is this a simple and easy process? Is the description clear and unambiguous? Courtesy PreViser Corporation, all rights reserved

9. The PreViser Method for 1 Site A value is another method to describe severity. A value is another method to describe severity. Using a 1(low)-5(high) scale, what is the rank by severity for each combination of pocket depth and bone height? Pocket Depth <5 mm5-7 mm>7 mm Radiographic Bone Height (CEJ to bone crest) >4 mm 2-4 mm < 2 mm Courtesy PreViser Corporation, all rights reserved

10. The PreViser Method for 1 Site The PreViser method assigns severity in the following rank order, which also facilitates ranking a dentition by severity and extent. The PreViser method assigns severity in the following rank order, which also facilitates ranking a dentition by severity and extent. Severity is ranked from lowest (1) to highest (5) Pocket Depth <5 mm5-7 mm>7 mm Radiographic Bone Height (CEJ to bone crest) >4 mm 455 2-4 mm 345 < 2 mm 1 or 234 Courtesy PreViser Corporation, all rights reserved

11. The PreViser Method Perio Status SeverityText Nomenclature 1 Health 2-3 Gingivitis 4-10 Mild Periodontitis Localized Mild Periodontitis Generalized Mild Periodontitis 11-36 Moderate Periodontitis Localized Mild and Moderate Periodontitis Localized Moderate Periodontitis Generalized Mild to Moderate Periodontitis Generalized Mild and Localized Moderate Periodontitis Generalized Moderate Periodontitis 37- 100 Severe Periodontitis Localized Mild and Severe Periodontitis Localized Moderate and Severe Periodontitis Localized Severe Periodontitis Generalized Mild to Severe Periodontitis Generalized Mild and Localized Severe Periodontitis Generalized Moderate to Severe Periodontitis Generalized Moderate and Localized Severe Periodontitis Generalized Severe Periodontitis Courtesy PreViser Corporation, all rights reserved Health Gingivitis Mild Periodontitis Moderate Periodontitis Severe Periodontitis Right Left Maxilla Mandible LA UL UR UA LL LR Periodontal Status: 64 Text: Generalized Moderate and Localized Severe

12. Summary The PreViser Method is: The PreViser Method is: Objective Objective Consistent Consistent Concise Concise Comparative Comparative Clinically useful Clinically useful The PreViser Method is not perfect, but it is practical and there is little value added when more information is utilized since for 5 levels of severity there are: The PreViser Method is not perfect, but it is practical and there is little value added when more information is utilized since for 5 levels of severity there are: 210 combinations for 6 sextants, which means that only 2 combinations correspond to 1 score 210 combinations for 6 sextants, which means that only 2 combinations correspond to 1 score 35,960 combinations for 28 teeth 35,960 combinations for 28 teeth 15,625 permutations (sequence is important) for 6 sextants 15,625 permutations (sequence is important) for 6 sextants 28 x 10 18 permutations for 28 teeth 28 x 10 18 permutations for 28 teeth Courtesy PreViser Corporation, all rights reserved

13. What About Risk for Periodontitis? If risk is low, then treatment may not be required, as disease is not expected to progress 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 OR periodontitis is a risk factor for another disease If risk is high, then treatment is required, as disease is expected to progress to a more advanced and possibly terminal stage OR periodontitis is a risk factor for another disease Hence, every patient receiving aggressive periodontal treatment has been determined to be high risk 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. Furthermore, a standard treatment protocol for a specific periodontal diagnosis can be established when all patients are high risk. BUT, are all patients at high risk for periodontal disease? How should treatment be modified based on risk level? BUT, are all patients at high risk for periodontal disease? How should treatment be modified based on risk level? Courtesy PreViser Corporation, all rights reserved

14. 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) 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 or had Gingivitis 65% were Healthy or had Gingivitis 22% had Mild Periodontitis 22% had Mild Periodontitis 13% had Moderate to Severe Periodontitis 13% had Moderate to Severe Periodontitis A common interpretation is 35% of the population is at risk for periodontitis and 13% is high risk A common interpretation is 35% of the population is at risk for periodontitis and 13% is high risk However, when the same data is viewed by age cohort, However, when the same data is viewed by age cohort, Courtesy PreViser Corporation, all rights reserved

15. Prevalence of Periodontitis, 1990’s* 0 10 20 30 40 50 60 70 30-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485-90 Age Cohort % of Age Cohort Periodontitis Linear trend line Courtesy PreViser Corporation, all rights reserved * Albandar et al, J Periodontol 1999 Data from the 1990’s implies that the risk for periodontitis is 60%, not 35%, and not 100%, as was thought in the 1950’s.

16. Periodontitis Prevalence by Severity, 1990’s* 0 5 10 15 20 25 30 35 40 45 30-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485-90 Age Cohort % of Age Cohort Linear trend line Moderate to Severe Periodontitis Mild Periodontitis Courtesy PreViser Corporation, all rights reserved Furthermore, periodontitis severity is stratified, which implies risk for disease severity is stratified too. This data implies that the risk is 35% for mild periodontitis and 25% for moderate to severe periodontitis. * Albandar et al, J Periodontol 1999

17. Summary Risk Distribution Courtesy PreViser Corporation, all rights reserved Is risk assessed by dentists accurate? Is risk determined by PreViser accurate?

18. Practitioner evaluation over-estimating risk by 2 scores Practitioner evaluation over- estimating risk by 1 score Practitioner evaluation under- estimating risk by 1 score Practitioner evaluation under-estimating risk by 2 scores Previser Founder’s Expert Periodontists 5 Patient Evaluations per data point General Dentist Over-estimation of risk results in over-treatment Risk Assessment by Dentists is Not Reliably Accurate Under-estimation of risk results in under-treatment Courtesy PreViser Corporation, all rights reserved

19. PreViser Risk Assessment is Objective and Accurate 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% Year 3Year 9Year 15 % Sites with Bone Loss Risk 5 Risk 4 Risk 3 Risk 2 % Sites with Bone Loss 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Year 3Year 9Year 15 % of subjects Risk 5 Risk 4 Risk 3 Risk 2 % Subjects with Tooth Loss Courtesy PreViser Corporation, all rights reserved 523 subjects followed for 15 years and who self-reported receiving no periodontal treatment 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% Year 3Year 9Year 15 Mean Percent (±SE) Alveolar Bone Loss Mean Bone Loss Risk 5 Risk 4 Risk 3 Risk 2 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% Year 3Year 9Year 15 Mean % (±SE) Tooth Loss Mean Tooth Loss Risk 5 Risk 4 Risk 3 Risk 2

20. Treatment Needs Increase with Advancing Risk and Disease Severity Very Low Moderate High Very Low High Risk Level Risk Level Periodontal Status Severe Periodontitis Moderate Periodontitis Mild Periodontitis GingivitisHealth Treatment Intensity Courtesy PreViser Corporation, all rights reserved

21. Managing Patients With Periodontal Disease Periodontal Status Severe Periodontitis Moderate Periodontitis Mild Periodontitis GingivitisHealth Very Low Moderate High Very Very Low Moderate High Very Low High Low High Risk Level Risk Level When treatment is initiated during the early stages of disease, success is more likely, treatment is more conservative, and fewer teeth are lost Courtesy PreViser Corporation, all rights reserved

22. Managing Patients With Periodontal Disease Periodontal Status Severe Periodontitis Moderate Periodontitis Mild Periodontitis GingivitisHealth Very Low Moderate High Very Very Low Moderate High Very Low High Low High Risk Level Risk Level Risk predicts the future severity of disease, which means periodontal disease is more likely to progress for high-risk patients and a greater intensity of preventive and reparative treatment is needed, which may require the skills of a periodontist Courtesy PreViser Corporation, all rights reserved

23. Managing Patients With Periodontal Disease Periodontal Status Severe Periodontitis Moderate Periodontitis Mild Periodontitis GingivitisHealth Very Low Moderate High Very Very Low Moderate High Very Low High Low High Risk Level Risk Level Every patient currently with severe periodontitis at a previous time had disease that was less severe and waiting until the patient has severe disease to initiate treatment or refer includes a higher likelihood of an upset patient, dentist, and periodontist because of treatment and outcomes Courtesy PreViser Corporation, all rights reserved Current Previous

24. Managing Patients With Periodontal Disease Periodontal Status Severe Periodontitis Moderate Periodontitis Mild Periodontitis GingivitisHealth Very Low Moderate High Very Very Low Moderate High Very Low High Low High Risk Level Risk Level Treatment including the need for referral to a periodontist should be based on risk and disease where color coded cells identify treatment needs in increasing order: dark green, light green, yellow, and red Courtesy PreViser Corporation, all rights reserved PreViser is the only objective and consistently accurate method to determine the combination of risk and disease severity-extent

25. PreViser and Determining an Outcome The change in risk score and periodontal status is an outcome measure that can help a clinician improve treatment decisions and explain why treatment is needed to a patient. Courtesy PreViser Corporation, all rights reserved Risk score Periodontal status

26. Data points 1 to 4

27. Data points 5 to 11

28. Data points 12 to 23