Risk and Periodontal Disease Management

Risk and Periodontal Risk and Periodontal Disease ManagementDisease Management

Courtesy PreViser Corporation, all rights reserved

Issues to be PresentedIssues to be Presented

Why knowledge of a patient’s risk for Why knowledge of a patient’s risk for periodontitis is required to determine periodontitis is required to determine treatmenttreatment

Why an accurate periodontal diagnosis Why an accurate periodontal diagnosis is insufficient to determine treatmentis insufficient to determine treatment

How risk is determinedHow risk is determined How risk is used to determine How risk is used to determine

treatmenttreatment Periodontal disease managementPeriodontal disease management


Risk and the Natural History of Risk and the Natural History of Periodontal DiseasePeriodontal Disease

HealthInitial

disease stage

Gingivitis Mild periodontiti

s

Risk predicts the progression from health to severe periodontitis


Moderate periodontiti

s

Severe periodontiti

s

Treatment Implications of Treatment Implications of RiskRisk

If risk is low, then treatment may not be If risk is low, then treatment may not be required, as disease is not expected to required, as disease is not expected to progressprogress

If risk is high, then treatment is required, as If risk is high, then treatment is required, as disease is expected to progress to a more disease is expected to progress to a more advanced and possibly terminal stageadvanced and possibly terminal stage Hence, every patient receiving aggressive Hence, every patient receiving aggressive

periodontal treatment has been determined to be periodontal treatment has been determined to be high riskhigh risk

Furthermore, a standard treatment protocol for a Furthermore, a standard treatment protocol for a specific periodontal diagnosis can be established specific periodontal diagnosis can be established when all patients are high riskwhen all patients are high risk



With advancing age the prevalence of gingivitis decreases and periodontitis increases, which has been interpreted that risk for periodontitis is high.

Prevalence of Periodontitis, Prevalence of Periodontitis, 1950’s*1950’s*

* Marshall-Day et al, J Periodontol 1955

GingivitisPeriodontitis

Tooth loss

Are all patients high risk for Are all patients high risk for periodontal disease?periodontal disease?

Using the NHANES III database, Albandar, Using the NHANES III database, Albandar, et al et al ((J PeriodontolJ Periodontol 1999; 70: 13-29) 1999; 70: 13-29) reported the reported the prevalence of Periodontitis in the adult prevalence of Periodontitis in the adult population (30 years and older)population (30 years and older) 65%65% were Healthy were Healthy 22%22% had Mild Periodontitis had Mild Periodontitis 13%13% had Moderate to Severe Periodontitis had Moderate to Severe Periodontitis

When the same data is viewed by age When the same data is viewed by age cohort, …cohort, …


Periodontal Disease RiskPeriodontal Disease Risk

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

% o

f A

ge C

oh

ort

Periodontitis

Linear trend line

Risk to remain healthy is 40%Risk to remain healthy is 40%

Risk for Periodontitis is 60%Risk for Periodontitis is 60%


Periodontal Disease Risk, Cont.Periodontal Disease Risk, Cont.

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

% o

f A

ge C

oh

ort

Linear trend line

Moderate to Severe Periodontitis

Beginning Periodontitis

Risk for Mild Periodontitis is 35%Risk for Mild Periodontitis is 35%

Risk for Moderate to Severe Periodontitis is 25%Risk for Moderate to Severe Periodontitis is 25%


Distribution of Risk for Distribution of Risk for PeriodontitisPeriodontitis

High Risk25%

Low Risk40%

Moderate Risk35%


SummarySummary

Risk predicts the progression of Risk predicts the progression of diseasedisease

Risk justifies treatmentRisk justifies treatment Risk for periodontitis is stratified Risk for periodontitis is stratified

across the US populationacross the US population Treatment must be personalized for Treatment must be personalized for

each patient and it must be based on each patient and it must be based on the patient’s unique risk profile and the patient’s unique risk profile and disease severitydisease severity


Do Dentists Accurately Do Dentists Accurately Determine the Risk for Determine the Risk for

Periodontitis?Periodontitis? Study group of 107 patients with Study group of 107 patients with

broad range of risk for periodontitisbroad range of risk for periodontitis Full mouth periodontal chartingFull mouth periodontal charting Medical and dental historiesMedical and dental histories Full mouth periapical radiographs with Full mouth periapical radiographs with

bitewingsbitewings Clinical photographsClinical photographs

Persson GR et al. Assessing periodontal disease risk. J Am Dent Assoc 2003


Persson StudyPersson Study

3 Groups of expert evaluators3 Groups of expert evaluators 6 periodontists with national and 6 periodontists with national and

international clinical, academic, and international clinical, academic, and military experiencemilitary experience

10 periodontists who participated in the 10 periodontists who participated in the development of the OHIS™ tooldevelopment of the OHIS™ tool

36 private practice general dentists who 36 private practice general dentists who referred patients to periodontistsreferred patients to periodontists

Risk was assessed on a 1 (low) to 5 Risk was assessed on a 1 (low) to 5 (high) scale by clinicians and OHIS™(high) scale by clinicians and OHIS™


107 Patient Records, Risk Assessed using OHIS™

Three Expert Groups Subjectively Assess Same Patients

6 Practicing Experts

OHIS™

10 PreViser Founders

36 General Dentists “Periodontally Aware”0%

10%

20%

30%

40%

50%

60%

GROUP

5

A B CGROUP

3

A B CGROUP

2

A B CGROUP

1

A B CGROUP

4

A B C

Risk Calculator


RiskCalculatorScore = 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


under-estimating risk by 1

score

Over-Estimated

Risk = Inappropriate

Treatment

Under-Estimated

Risk = Inappropriate

Treatment


over-estimating risk by 1

score


under-estimating risk by 2 scores

20% Agreement with OHIS™

For OHIS™

assessed patients with Risk Score of 3..

Conclusion: Clinicians

can’t assess the risk of

future diseaseCourtesy PreViser Corporation, all rights reserved

Current Risk Assessment Current Risk Assessment MethodMethod

Current method is subjective Current method is subjective judgmentjudgment

The literature only provides a The literature only provides a laundry list of risk factors with no laundry list of risk factors with no guidance how to determine riskguidance how to determine risk

Hence, it is not surprising that the Hence, it is not surprising that the current method of risk assessment current method of risk assessment is generally an unreliable predictor is generally an unreliable predictor of the future disease stateof the future disease state


DiagnosisDiagnosis

HealthInitial

disease stage

Gingivitis Mild periodontiti

s


Moderate periodontiti

s

Severe periodontiti

s

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.

Disease StateDisease State

Severe PeriodontitisSevere Periodontitis

Moderate PeriodontitisModerate Periodontitis

Mild PeriodontitisMild Periodontitis

GingivitisGingivitis

HealthHealth

Diagnosis vs. RiskDiagnosis vs. Risk

Current Current FutureFuture

TimeTime

Worse

Better

Same

Diagnosisdescribes

Riskpredicts

Based on:Based on: Signs and Symptoms Signs and Symptoms Risk Risk FactorsFactors


Determining Diagnosis and Determining Diagnosis and RiskRisk

Signs and SymptomsSigns and Symptoms Bleeding on Bleeding on

probingprobing Periodontal Periodontal

pocketspockets Alveolar bone lossAlveolar bone loss PainPain Gingival swellingGingival swelling

Risk FactorsRisk Factors Cigarette smoking Cigarette smoking DiabetesDiabetes StressStress Poor oral hygienePoor oral hygiene Periodontal Periodontal

pocketspockets HeredityHeredity


What is a Risk Factor?What is a Risk Factor?

Risk factor is often used as a general term Risk factor is often used as a general term meaning those characteristics that strongly meaning those characteristics that strongly associate with groups of individuals who associate with groups of individuals who have disease compared to those who do have disease compared to those who do not. Risk terminology includes:not. Risk terminology includes: Risk FactorRisk Factor Background CharacteristicBackground Characteristic Risk IndicatorRisk Indicator Risk Markers or Risk PredictorsRisk Markers or Risk Predictors


Risk Factor DefinitionRisk Factor Definition

An environmental, behavioral, or biologic An environmental, behavioral, or biologic factor confirmed by temporal sequence, factor confirmed by temporal sequence, usually in longitudinal studies, which if usually in longitudinal studies, which if present directly increases the probability of a present directly increases the probability of a disease occurring, and if absent or removed disease occurring, and if absent or removed reduces the probability. Risk factors are part reduces the probability. Risk factors are part of the causal chain, or expose the host to the of the causal chain, or expose the host to the causal chain. Once disease occurs, removal causal chain. Once disease occurs, removal of a risk factor may not result in a cure. of a risk factor may not result in a cure.

Beck JD. Community Dent Oral Epidemiol 1998


Background Characteristics Background Characteristics DefinitionDefinition

Associated with a higher probability Associated with a higher probability of disease, but cannot be modified. of disease, but cannot be modified. Also referred to as a determinant.Also referred to as a determinant. AgeAge GenderGender Socioeconomic StatusSocioeconomic Status Familial history and genetic factorsFamilial history and genetic factors


Risk Indicator DefinitionRisk Indicator Definition

A possible risk factor not yet A possible risk factor not yet confirmed in published studies. A confirmed in published studies. A plausible correlate of disease plausible correlate of disease identified in cross-sectional studies.identified in cross-sectional studies. OsteoporosisOsteoporosis HIV and AIDSHIV and AIDS Frequency of visits to the dentistFrequency of visits to the dentist


Risk Markers and Predictors Risk Markers and Predictors DefinitionDefinition

A characteristic strongly correlated A characteristic strongly correlated with an increased probability of with an increased probability of future disease but is not part of the future disease but is not part of the causal chain.causal chain. Bleeding on probingBleeding on probing Clinical attachment lossClinical attachment loss


Risk and Disease - Distinct Risk and Disease - Distinct EntitiesEntities

Risk-Disease Risk-Disease GridGrid

Periodontal StatusPeriodontal Status

HealthHealthMild Mild

PeriodontitiPeriodontitiss

Moderate to Moderate to Severe Severe

PeriodontitisPeriodontitis

RiskRisk

LevelLevel

LowLow YesYes YesYes NoNo

ModerateModerate YesYes YesYes NoNo

HighHigh YesYes YesYes YesYes


Validity and Accuracy of Validity and Accuracy of OHIS™ Determined RiskOHIS™ Determined Risk

523 subjects enrolled in the Veterans 523 subjects enrolled in the Veterans Affairs Dental Longitudinal Study who had Affairs Dental Longitudinal Study who had only routine careonly routine care

Periodontal pocket depth measurementsPeriodontal pocket depth measurements Digitized full-mouth radiographs with bitewingsDigitized full-mouth radiographs with bitewings Medical and dental historiesMedical and dental histories

Risk was assessed at baseline using OHIS™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


Validity and Accuracy of Validity and Accuracy of OHIS™ Determined Risk, cont.OHIS™ Determined Risk, cont.

Changes in periodontal status determined Changes in periodontal status determined by comparing baseline data to data at 3, 9, by comparing baseline data to data at 3, 9, and 15 yearsand 15 years

Alveolar bone loss (mean bone loss, percentage Alveolar bone loss (mean bone loss, percentage of sites with bone loss per subject)of sites with bone loss per subject)

Tooth loss (mean percent tooth loss, percentage Tooth loss (mean percent tooth loss, percentage of subjects with tooth loss in each risk group)of subjects with tooth loss in each risk group)


Mean Bone LossMean Bone Loss

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

Perc

en

t (±

SE)

Alv

eola

r B

on

e L

oss Risk 5

Risk 4

Risk 3

Risk 2

A measure of disease severity


15%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%


% S

ites

wit

h B

on

e L

oss

Risk 5

Risk 4

Risk 3

Risk 2

Percentage of Sites with Bone Percentage of Sites with Bone LossLoss

A measure of disease extent


0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%


Mean

% (

±S

E)

Tooth

Loss Risk 5

Risk 4

Risk 3

Risk 2

Mean Tooth LossMean Tooth Loss


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% o

f su

bje

cts

Risk 5

Risk 4

Risk 3

Risk 2

Percentage of Subjects with Tooth Percentage of Subjects with Tooth LossLoss


0

1

2

3

4

5

6

7

Total teeth Periodontally affected Periodontally unaffected

Nu

mb

er

of

teeth

lost

Risk 2

Risk 3

Risk 4

Risk 5

Mean Number of Teeth LostMean Number of Teeth Lost

Only 26% did not have periodontal disease at baseline


SummarySummary

Risk is distinct from diagnosisRisk is distinct from diagnosis The methods to determine risk and The methods to determine risk and

diagnosis are differentdiagnosis are different Risk cannot be accurately Risk cannot be accurately

determined from diagnosisdetermined from diagnosis OHIS™ accurately determines risk for OHIS™ accurately determines risk for

periodontitisperiodontitis


OHIS™ is Practical for Clinical OHIS™ is Practical for Clinical UseUse

Only 23 data points, all of which are Only 23 data points, all of which are obtained during a routine periodontal obtained during a routine periodontal examinationexamination

Data entry, transmission over the Data entry, transmission over the Internet between the dentist’s Internet between the dentist’s computer and OHIS™ server takes computer and OHIS™ server takes less than 5 minutes and can be done less than 5 minutes and can be done at the convenience of staffat the convenience of staff


Data Required by OHIS™Data Required by OHIS™

SmokingSmoking DiabetesDiabetes Subgingival calculusSubgingival calculus Subgingival Subgingival

restorationsrestorations PocketsPockets Furcation Furcation

involvementsinvolvements Vertical bone lesionsVertical bone lesions

AgeAge Radiographic bone Radiographic bone

heightheight History of periodontal History of periodontal

surgery for pocketssurgery for pockets Oral hygieneOral hygiene Dental care frequencyDental care frequency Bleeding on probingBleeding on probing


OHIS™ Disease ScoreOHIS™ Disease Score

OHIS™ calculates a score that is OHIS™ calculates a score that is representative of the severity and extent of representative of the severity and extent of periodontal disease based the deepest pocket periodontal disease based the deepest pocket and greatest bone loss for each sextantand greatest bone loss for each sextant

The score ranges from 1 for health to 100 for The score ranges from 1 for health to 100 for severe periodontitissevere periodontitis

An increase in the score is indicative of An increase in the score is indicative of worsening disease status, whereas a worsening disease status, whereas a decrease is indicative of improvementdecrease is indicative of improvement



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3232 3131 3030 2929 2828 2727 2626 2525 2424 2323 2222 2121 2020 1919 1818 1717

170

Tooth#

FacialLingual

LingualFacial

Tooth#

OHIS™ Disease Score = 21

Text-Linguistic Diagnosis = Localized Moderate Periodontitis



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207

Tooth#

FacialLingual

LingualFacial

Tooth#


Text-Linguistic Diagnosis = Generalized Moderate Periodontitis



11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616

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Tooth#

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Tooth#


Text-Linguistic Diagnosis = Generalized Moderate to Severe Periodontitis


SummarySummary

Risk and disease scores can be used to monitor Risk and disease scores can be used to monitor periodontal status simply and quicklyperiodontal status simply and quickly

A high risk score or an increase predicts A high risk score or an increase predicts worsening disease and a higher disease score worsening disease and a higher disease score and that the current treatment is not and that the current treatment is not effectively managing the risk factorseffectively managing the risk factors

An increase in disease score indicates that the An increase in disease score indicates that the current treatment is not maintaining current treatment is not maintaining periodontal status and a change in treatment is periodontal status and a change in treatment is indicatedindicated


Clinical ImplicationsClinical Implications

Health InitialStage

DetectableStage

ModerateDisease

SevereDisease

TerminalDisease

Diagnosis is used to determine treatment for existing “visible” lesions (Reparative treatment)


Clinical Implications, cont.Clinical Implications, cont.

Health InitialStage

DetectableStage

ModerateDisease

SevereDisease

TerminalDisease

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 Incorporating Risk Concepts into Treatment Planninginto Treatment Planning

Risk is the fundamental principle that should Risk is the fundamental principle that should justify treatmentjustify treatment Low risk means that disease is unlikely to progress Low risk means that disease is unlikely to progress

and justification for treatment is minimally supportedand justification for treatment is minimally supported High risk means that disease is likely to progress and High risk means that disease is likely to progress and

justification for treatment is maximally supportedjustification for treatment is maximally supported Risk is used to determine preventive Risk is used to determine preventive

interventionsinterventions Risk is also used to modulate the intensity and Risk is also used to modulate the intensity and

aggressiveness of reparative treatmentaggressiveness of reparative treatment


Treatment Intensity and Treatment Intensity and AggressivenessAggressiveness

An ExampleAn Example

Treatment for a 75 year old patient with Treatment for a 75 year old patient with generalized 6 mm pockets may be generalized 6 mm pockets may be limited to periodontal maintenance limited to periodontal maintenance whereas surgery may be selected for a whereas surgery may be selected for a 35 year old patient with the same 35 year old patient with the same conditions when the risk level of the conditions when the risk level of the older patient is much lower than the older patient is much lower than the younger patient.younger patient.


Doomed by high risk?Doomed by high risk?

It is possible to be at high risk and not suffer It is possible to be at high risk and not suffer the consequences of terminal disease by the consequences of terminal disease by management of the risk factors. For management of the risk factors. For example:example: Drugs to lower blood pressure and cholesterol Drugs to lower blood pressure and cholesterol

can prevent cardiovascular eventscan prevent cardiovascular events Blood-sugar control can prevent diabetic Blood-sugar control can prevent diabetic

complicationscomplications Daily personal oral hygiene controls bacterial Daily personal oral hygiene controls bacterial

plaque preventing caries and periodontitisplaque preventing caries and periodontitis Periodontal surgery that eliminates pockets Periodontal surgery that eliminates pockets

improves plaque control effectiveness to prevent improves plaque control effectiveness to prevent periodontitisperiodontitis


Periodontal Disease Periodontal Disease Management GoalsManagement Goals

Preservation of bone and teethPreservation of bone and teeth Prevent surgeryPrevent surgery Prevent inflammationPrevent inflammation Repair damaging effects of Repair damaging effects of

periodontitisperiodontitis


Periodontal Referrals 1980 vs. Periodontal Referrals 1980 vs. 20002000

Greater loss of teeth at the initial Greater loss of teeth at the initial periodontal examinationperiodontal examination

More severe periodontitis at the More severe periodontitis at the initial periodontal examinationinitial periodontal examination

More teeth were planned for More teeth were planned for extractionextraction

Cobb C et al. J Periodontol 2003; 74: 1470-1474


Severe PeriodontitisSevere Periodontitis

Every patient who has severe periodontitis Every patient who has severe periodontitis had, at a prior time, mild periodontitis, and had, at a prior time, mild periodontitis, and before that was healthy. The progression of before that was healthy. The progression of disease could have been predicted by risk, disease could have been predicted by risk, which would have allowed for more timely which would have allowed for more timely and effective treatment.and effective treatment.

Periodontitis is generally slowly progressive, Periodontitis is generally slowly progressive, which may obscure disease worsening, which may obscure disease worsening, especially when 168 pockets and bone especially when 168 pockets and bone height measurements need to be compared.height measurements need to be compared.


SummarySummaryWithholding 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

% o

f A

ge C

oh

ort

Healthy, no risk

Healthy, at-risk

Periodontitis


SummarySummary

An accurate determination of risk and its An accurate determination of risk and its change over time is required to properly and change over time is required to properly and dynamically plan treatment for periodontitisdynamically plan treatment for periodontitis

An accurate determination of periodontal An accurate determination of periodontal status including its change over time is status including its change over time is required to dynamically establish proper required to dynamically establish proper treatment recommendationstreatment recommendations

OHIS™ provides a simple and accurate OHIS™ provides a simple and accurate method to document risk, disease status and method to document risk, disease status and any changes that occurany changes that occur


SummarySummary

Risk predicts the progression of diseaseRisk predicts the progression of disease Risk justifies treatmentRisk justifies treatment Risk for periodontitis is stratified across a Risk for periodontitis is stratified across a

populationpopulation Risk cannot be determined from diagnostic Risk cannot be determined from diagnostic

findingsfindings Risk and diagnosis are required to Risk and diagnosis are required to

determine treatmentdetermine treatment Treatment must be personalized for each Treatment must be personalized for each

patientpatient


Date post:	20-Dec-2014
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Risk and Periodontal Disease Management

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