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Rome, September 24th 2011 16° International Congress
Rome, September 24r th 201116° International Congress
A periodontal risk assessment protocol
Roberto Farina, D.D.S. Ph.D. M.Sc. Leonardo Trombelli, D.D.S. Ph.D.
roberto.farina@unife.it www.unife.it/parodontologia www.unife.it/docenti/roberto.farina
European Association of Dental Public Health
ww.unife.it/parodontolww unife it/parodontolww unife it/docenti/t rob//
A periodontal risk assessment protocol
Mean annual attachment loss rate in untreated subjects
Löe H, Anerud A, Boysen H, Morrison E. Natural history of periodontal disease in man. Rapid, moderate and no loss of attachment in Sri Lankan laborers 14 to 46 years of age. Journal of Clinical Periodontology 1986;13:431-445.
Age
Annual attachment loss
14-19 25-29 30-34 35-39
0.8
0
0.4
lt lossss
1.0
0.2
0.6
20-24 40-44 45
A periodontal risk assessment protocol
Mean annual attachment loss rate in untreated subjects
Löe H, Anerud A, Boysen H, Morrison E. Natural history of periodontal disease in man. Rapid, moderate and no loss of attachment in Sri Lankan laborers 14 to 46 years of age. Journal of Clinical Periodontology 1986;13:431-445.
Age
0.06 (0.04 – 0.09) mm/year
Mean annual attachment loss rate
0.18 (0.05 – 0.52) mm/year
0.65 (0.13 – 1.04) mm/year
No progression group
Moderate progression group
Rapid progression group
Well maintained (499 patients)
(0-3 teeth lost)
Downhill (76 patients)
(4 to 9 teeth lost)
Extreme downhill (25 patients)
(10 to 23 teeth lost)
Mean n° teeth lost during SPT
0.68 5.7 13.3
n° lost teeth 342 435 333 Distribution (%) of lost teeth according to initial prognosis
questionable favourable questionable favourable questionable favourable
79.5 20.5 57.2 42.8 43.5 56.5
A periodontal risk assessment protocol
Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. Journal of Periodontology 1978;49:225-237.
600 patients undergone periodontal treatment at least 15 years previously (age range: 12-73 years; mean duration of supportive periodontal therapy: 22 years)
Retrospective identification of teeth with a questionable prognosis
furcation involvement
deep non-eradicable pocket
extensive bone loss
marked mobility + deep pockets
Well maintained (499 patients)
(0-3 teeth lost)
Downhill (76 patients)
(4 to 9 teeth lost)
Extreme downhill (25 patients)
(10 to 23 teeth lost)
n° questionable teeth initially present
1592 385 164
Patient grouping according to the n° of teeth lost during SPT
A periodontal risk assessment protocol
Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. Journal of Periodontology 1978;49:225-237.
600 patients undergone periodontal treatment at least 15 years previously (age range: 12-73 years; mean duration of supportive periodontal therapy: 22 years)
Retrospective identification of teeth with a questionable prognosis
furcation involvement
deep non-eradicable pocket
extensive bone loss
marked mobility + deep pockets
Well maintained (499 patients)
(0-3 teeth lost)
Downhill (76 patients)
(4 to 9 teeth lost)
Extreme downhill (25 patients)
(10 to 23 teeth lost)
n° questionable teeth initially present
1592 385 164
MAINTAINED: 35.3%
MAINTAINED: 11.6%
MAINTAINED: 82.9%
Patient grouping according to the n° of teeth lost during SPT
A periodontal risk assessment protocol
How could we anticipate the rate of periodontal disease progression (prognosis)?
American Academy of Periodontology statement on risk assessment
Utilizing risk assessment helps dental professionals predict the potential for developing periodontal diseases and allows them to focus on early identification and to provide proactive, targeted treatment for patients who are at risk for progressive/aggressive diseases.
The AAP believes the clinical use of risk assessment will become a component of all comprehensive dental and periodontal evaluations as well as part of all periodic dental and periodontal examinations.
American Academy of Periodontology American Academy of Periodontology statement on risk assessment. Journal of Periodontology 2008;79:202.
A periodontal risk assessment protocol
A periodontal risk assessment protocol
Clinical history
Clini
cal c
ondit
ion
WORSE PROGNOSIS MORE THERAPY
WORSE RESPONSE TO THERAPY
BETTER PROGNOSIS LESS THERAPY
BETTER RESPONSE TO THERAPY
patient #1 patient #2
Page RC, Martin JA, Loeb CF. Use of risk assessment in attaining and maintaining oral health. Compendium of Continuing Education in Dentistry 2004;25:657-660, 663-666, 669; quiz 670.
true putative Specific bacterial species Gene polymorphisms
Smoke Age Diabetes (insufficient metabolic control)
Socio-economic status
Race/ethnicity Gender Psycho-social factors Osteoporosis/ osteopenia Obesity
Tonetti & Claffey 2005
A periodontal risk assessment protocol
Risk factor
Heitz-Mayfield et al. 2005
Environmental or individual characteristic which directly increases (when present) or decreases (when absent) the probability of a subject to be affected by a disease.
Beck 1994
Risk indicator Factor which may predict the progression of a disease, either spontaneous or under treatment.
Papapanou 2005
true putative Bleeding on probing Presence of periodontal
pathogens
Number of periodontal pockets Bone loss / age ratio
Gingival crevicular fluid components
PRA Lang & Tonetti 2003
PPRD Renvert et al. 2004
PRC Persson et al. 2003
BoP%
PPD>6mm
tooth loss prop. bone loss
smoking
syst./Genet.
tooth loss
PPD>4mm bone loss/age
env./Smok.
BoP
UniFe Farina et al. 2007
Trombelli et al. 2009
The use of objective methods for risk assessment improves the accuracy of risk evaluation
A periodontal risk assessment protocol
- Validity of Periodontal Assessment Tool® (PAT®) in predicting periodontal disease -
Page R, Krall EA, Martin J, Mancl L, Garcia RI. Validity of Periodontal Assessment Tool® (PAT®) in predicting periodontal disease. Journal of the American Dental Association 2002;133:569-576.
record charts of 523 patients aged 25 to 74 years
(101 smokers, 9 diabetics)
with different periodontal status
follow-up: 15 years
% of patients undergone 1 or no periodontal treatment through the follow-up period: !80%
A periodontal risk assessment protocol
0,00
0,02
0,04
0,06
0,08
3 9 15
Mean bone loss
for patients assigned a PAT® risk score 2-5
Mean tooth loss
for patients assigned a PAT® risk score 2-5
0,00
0,05
0,10
0,15
0,20
0,25
0,30
3 9 15
% teeth lost
% sites
years
- Validity of Periodontal Assessment Tool® (PAT®) in predicting periodontal disease -
years
2 3
4
5
2 3 4
5
Page R, Krall EA, Martin J, Mancl L, Garcia RI. Validity of Periodontal Assessment Tool® (PAT®) in predicting periodontal disease. Journal of the American Dental Association 2002;133:569-576.
A periodontal risk assessment protocol
- Risk assesment according to the UniFe method -
UniFe (unife.it/parodontologia) smoking status
(n° cig/day) diabetic status (serum HbA1c)
n° of pockets with PPD! 5mm BoP score (%) bone loss/age
ratio
0-4 0-4 0-4 0-4 0-8 sum: 0-2
risk score 1 sum: 3-5
risk score 2
LOW RISK
MEDIUM-LOW RISK
MEDIUM RISK
MEDIUM-HIGH RISK
HIGH RISK
sum: 6-8 risk score 3
sum: 9-14 risk score 4
sum: 15-24 risk score 5
+ + + +
A periodontal risk assessment protocol
Trombelli L, Farina R, Ferrari S, Pasetti P, Calura G Comparison between two methods for periodontal risk assessment. Minerva Stomatologica 2009;58:277-287
107 patients (34 ", 73 #; mean age: 45.5 ± 9.9 years)
Trombelli L, Farina R, Ferrari S, Pasetti P, Calura G. Comparison between two methods for periodontal risk assessment. Minerva Stomatologica 2009;58:277-287.
A periodontal risk assessment protocol
- Agreement between UniFe and PAT® methods -
0
20
40
60
80
1 2 3
4 (3.7%)
n° patients
4 5
2 (1.9%)
2 (1.9%)
26 (24.3%)
73 (68.2%)
risk score
Distribution of patients according to UniFe risk scores
0
20
40
60
80
1 2 3
0 (0%)
n° patients
4 5
2 (1.9%)
6 (5.6%)
30 (28.0%)
69 (64.5%)
risk score
Distribution of patients according to PAT® risk scores
Trombelli L, Farina R, Ferrari S, Pasetti P, Calura G. Comparison between two methods for periodontal risk assessment. Minerva Stomatologica 2009;58:277-287.
A periodontal risk assessment protocol
- Agreement between UniFe and PAT® methods -
0
10
20
30
40
50
60
70
80
90
DIFF (risk scoreUniFe – risk scorePAT® ) -2 -1 0
4 (3.7%)
n° patients
+1 +2
10 (9.3%)
80 (74.8%)
12 (11.2%)
1 (0.9%)
k(Landis & Koch 1977) = 0.70
A periodontal risk assessment protocol
Gender: #
Age: 45 yearsAge: 45 years
Never smoked
Diabetic (type 2, non-controlled) ,
genotype: heterozygote g yp yg (IL-1$ +4845 , IL-1% -511, IL-1% +3953)
Diagnosis: Generalized Aggressive Periodontitis
423 332 323 312 212 223 322 223 322 323 322
Post tx
Pre tx
buccal
215 414 324 425 423 323 326 625 423 431 726
425 213 323 323 322 223 313 322 223 323 322
Post tx
Pre tx
!"#"$"#%
424 324 425 424 423 424 236 635 523 315 626
324 425 413 316 545 576 1076 665 535 514 794 321 325 524 343 323 313 323 213 333 313 322 222 212 312 321 323 323
Post tx
Pre tx
&'(("#%
lingual
334 435 533 345 543 213 324 215 316 625 544 556 355 433
Post tx
Pre tx
333 323 332 333 313 212 212 313 222 232 332 222 323 212
Pre-treatment risk profile
Risk assessment BEFORE initial therapy
7
A periodontal risk assessment protocol
16
Pre-treatment risk profile
Risk assessment AFTER initial therapy
7
A periodontal risk assessment protocol
Retrospective evaluation of a cohort of 160 periodontitis patients
HIGH RISK (36.9%, n= 59)
fully compliant with SPT not compliant with SPT
100%
84.5%
15.5%
42.5% 47.5%
LOW RISK (6.9%, n= 11)
MODERATE RISK (56.2%, n= 90)
1.18 ± 1.89
0.80 ± 1.25
2.21 ± 3.21
1.71 ± 2.18
3.57 ± 5.02
A periodontal risk assessment protocol
Matuliene G, Studer R, Lang NP, Schmidlin K, Pjetursson BE, Salvi GE, Brägger U, Zwahlen M. Significance of Periodontal Risk Assessment on the recurrence of periodontitis and tooth loss. Journal of Clinical Periodontology 2010;37:191–199.
Number of teeth lost
3 1 3 3 1 3 3 1 3 3 1 3 2 1 3 2 1 2 2 1 3 3 1 3 4 1 3 4 1 5 4 1 3
3 1 4 3 1 4 3 1 3 4 1 3 2 1 2 3 1 3 2 1 2 2 1 3 3 1 3 31 3 4 3 6 palatal
buccal
lingual
buccal
Re-evaluation after 4 years of supportive periodontal therapy
3 2 3 2 1 2 2 1 2 2 1 2 2 1 3 2 1 1 2 1 1 1 1 1 1 1 2 2 1 2 2 1 2 2 1 1 3 1 2 2 2 3
2 2 2 3 1 3 3 1 2 3 1 3 3 1 2 2 1 2 2 1 1 2 1 1 1 1 2 2 1 2 2 1 2 3 1 3 4 3 3 3 2 3
General conclusions, clinical implications A periodontal risk assessment protocol
Periodontal risk assessment may help clinicians to identify subjects with an impaired periodontal prognosis as well as determine the impact of treatment on periodontal prognosis;
Longitudinal studies where patients with different periodontal status are long-term evaluated are needed to validate the current methods for periodontal risk assessment.
Preliminary data from retrospective studies seem to indicate that UniFe method represents a simplified and reliable tool for periodontal risk assesment;
Giovanni Franceschetti, DDS PhD Maria Elena Guarnelli, DDS Francesco Malaguti, DDS Luigi Minenna, DDS MSc Mattia Pramstraller, DDS Alessandro Rizzi, DDS Alessandro Scabbia, DDS Anna Simonelli, DDS Leonardo Trombelli, DDS PhD
Acknowledgements
Thank you for your attention
roberto.farina@unife.it www.unife.it/parodontologia www.unife.it/docenti/roberto.farina