Transcript If You Can Measure It, You Can Manage It

If You Can Measure It, You
Can Manage It
Measuring Periodontal Status to
Benefit Your Professional Well-Being
Common Issues for Clinicians
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How is periodontal status described in terms of
disease severity and extent?
How has periodontal status changed over time?
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Has it improved?
Has it worsened?
Has it remained stable?
Did periodontal status improve following
treatment?
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Was treatment successful?
The Value of Measurement
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Periodontist
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Self-knowledge of
treatment effectiveness for
decision-making
Informing the patient
including explaining
changes in periodontal
status
Informing the referring
general dentist
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General dentist
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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
Existing Measurement Method
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AAP Description
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Clinical Practice
Severity:
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Slight: CAL* 1-2 mm
Moderate: CAL 3-4 mm
Severe: CAL ≥5 mm
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Periodontal charting is
not consistently done in
general practices
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Extent:
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Localized: ≤30% of sites
Generalized: >30% of sites
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*The AAP defines CAL as clinical
attachment loss, where other authors
define CAL as clinical attachment level
Pocket depth rather than
CAL is measured
168 pocket depth
measurements are
needed for a 28-tooth
dentition
Radiographs are also
utilized
Interpreting Clinical Measurements
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How do dentists determine and describe the
periodontal status of one site?
How do dentists determine and describe the
periodontal status of 28 teeth (or 168 sites)?
How do dentists describe periodontal status
change for a 28-tooth dentition, considering that
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<10% of sites may worsen
Some sites may improve
>90% of sites typically are unchanged
Periodontal Status for 1 Site
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How are 5 choices selected from Health, Gingivitis, and
Mild, Moderate, and Severe Periodontitis used to fill 9
cells in the table?
Pocket Depth
<5 mm
Bone
Height
(CEJ to bone
crest)
>4 mm
2-4 mm
< 2 mm
5-7 mm
>7 mm
PreViser’s Method for 1 Site
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*Health is distinguished from gingivitis by
bleeding on probing
Pocket Depth
Radiographic
Bone Height
(CEJ to bone
crest)
<5 mm
5-7 mm
>7 mm
>4 mm
Moderate
Periodontitis
Severe
Periodontitis
Severe
Periodontitis
2-4 mm
Mild
Periodontitis
Moderate
Periodontitis
Severe
Periodontitis
< 2 mm
Health or
Gingivitis*
Mild
Periodontitis
Moderate
Periodontitis
The Multiple Site Dilemma
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For the examples of site-severity listed in the table, can
you describe and rank by severity and extent?
Site
Example
1
2
3
4
A
Severe
Periodontitis
Moderate
Periodontitis
Moderate
Periodontitis
Moderate
Periodontitis
B
Severe
Periodontitis
Severe
Periodontitis
Mild
Periodontitis
Mild
Periodontitis
C
Moderate
Periodontitis
Mild
Periodontitis
Mild
Periodontitis
Mild
Periodontitis
D
Severe
Periodontitis
Severe
Periodontitis
Moderate
Periodontitis
Mild
Periodontitis
The PreViser Solution
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Even if you found this example easy, 70 examples are possible for 4
sites, 35,960 examples exist when each tooth counts as 1 site in a
28-tooth dentition, and 1,000 times this number when all 168 sites
are used
Site
Example
1
2
3
4
Gen mod to
sev (82)
Severe
Periodontitis
Moderate
Periodontitis
Moderate
Periodontitis
Moderate
Periodontitis
Gen mild to
sev (87)
Severe
Periodontitis
Severe
Periodontitis
Mild
Periodontitis
Mild
Periodontitis
Gen mild to
mod (26)
Moderate
Periodontitis
Mild
Periodontitis
Mild
Periodontitis
Mild
Periodontitis
Gen mod to
sev (92)
Severe
Periodontitis
Severe
Periodontitis
Moderate
Periodontitis
Mild
Periodontitis
Conclusions
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There is no evidence that periodontal status is
determined consistently and accurately by
dentists
There is no simple way to describe small
changes whether comparing the periodontal
status of one patient over time or two patients
regardless of time-frame
No method is used that describes periodontal
status numerically
PreViser’s Solution
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OHIS™ calculates a score that is representative of the
severity and extent of periodontal disease based on the
deepest pocket and greatest bone loss for each sextant
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The method is objective and hence consistent
The use of ranges for pocket depth and bone height reduces the
error margin from inaccurate measurement
The score ranges from 1 for health to 100 for severe
periodontitis
A numeric score simplifies comparisons, explanations,
and the creation of treatment guidelines including
referral to a periodontist
The PreViser scoring system can be used to determine
treatment effectiveness
OHIS™
Disease
Score
1
Severity
Text Nomenclature
Health
Health
Gingivitis
Gingivitis
4-10
Beginning
Periodontitis
Localized Beginning Periodontitis
Generalized Beginning Periodontitis
11-36
Moderate
Periodontitis
Localized Beginning and Moderate Periodontitis
Localized Moderate Periodontitis
Generalized Beginning to Moderate Periodontitis
Generalized Beginning and Localized Moderate Periodontitis
Generalized Moderate Periodontitis
37-100
Severe
Periodontitis
Localized Beginning and Severe Periodontitis
Localized Moderate and Severe Periodontitis
Localized Severe Periodontitis
Generalized Beginning to Severe Periodontitis
Generalized Beginning and Localized Severe Periodontitis
Generalized Moderate to Severe Periodontitis
Generalized Moderate and Localized Severe Periodontitis
Generalized Severe Periodontitis Courtesy PreViser Corporation, all rights reserved
2-3
PreViser Determines Risk, Too
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When dentists determine risk for
periodontal disease, they use their
subjective clinical judgment
The PreViser method uses a standardized
objective means
Practitioner
evaluation overestimating risk
by 2 scores
Risk Assessment by
Subjective Judgment*
* Persson et al. J Am Dent Assoc 2003
Practitioner
evaluation
overestimating risk
by 1 score
Risk
Calculator
Score = 3
Practitioner
evaluation
underestimating risk
by 1 score
Practitioner
evaluation
underestimating risk
by 2 scores
Subjective judgment is
not reliably accurate
5 Patient Evaluations
per data point
Expert Periodontists
Previser Founder’s
General Dentist
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PreViser Risk Assessment*
Mean Bone Loss
Mean Percent (±SE) Alveolar Bone Loss
8.0%
7.0%
A measure of disease severity
Risk 5
6.0%
5.0%
Risk 4
Risk 3
4.0%
Risk 2
3.0%
2.0%
1.0%
0.0%
Year 3
Year 9
* Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003
Year 15
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PreViser Risk Assessment*
% of Sites with Bone Loss
70%
65%
A measure of disease extent
Risk 5
Risk 4
% Sites with Bone Loss
60%
Risk 3
55%
Risk 2
50%
45%
40%
35%
30%
25%
20%
15%
Year 3
Year 9
* Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003
Year 15
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PreViser Risk Assessment*
Mean Tooth Loss
30.0%
Mean % (±SE) Tooth Loss
25.0%
Risk 5
20.0%
15.0%
Risk 4
10.0%
Risk 3
5.0%
Risk 2
0.0%
Year 3
Year 9
* Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003
Year 15
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PreViser Risk Assessment*
% of Subjects with Tooth Loss
100%
90%
Risk 5
80%
Risk 4
% of subjects
70%
Risk 3
60%
50%
40%
Risk 2
30%
20%
10%
0%
Year 3
Year 9
* Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003
Year 15
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The PreViser Solution
Risk score:
Disease State:
4
64
The PreViser risk and disease scores provide a means to document and explain a
patient’s periodontal status in easily understood terms. Additionally the graph
displays changes in status to determine if the patient’s status is stable, improving,
or worsening.
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Treatment Implications of Risk
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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
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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
Are all patients at high risk for periodontal
disease?
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Prevalence of Periodontitis, 1950’s*
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
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Are all patients high risk for
periodontal disease?
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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)
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65% were Healthy or had Gingivitis
22% had Mild Periodontitis
13% had Moderate to Severe Periodontitis
When the same data is viewed by age cohort, …
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Periodontal Disease Risk
Risk for Periodontitis is 60%
% of Age Cohort
70
60
50
40
Risk to remain healthy is 40%
30
20
Periodontitis
Linear trend line
10
0
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
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Periodontal Disease Risk, Cont.
Risk for Mild Periodontitis is 35%
45
Mild Periodontitis
% of Age Cohort
40
Moderate to Severe
Periodontitis
35
Linear trend line
30
25
20
15
10
Risk for Moderate to Severe Periodontitis is 25%
5
0
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
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Distribution of Risk for Periodontitis
High Risk
25%
Low Risk
40%
Moderate
Risk
35%
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Incorporating Risk Concepts into
Treatment Planning
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Risk is the fundamental principle that can be
used to justify the intensity and aggressiveness
of treatment where a diagnosis of disease can
be made
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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 can be used to determine preventive
interventions
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Remaining Healthy
Withholding preventative treatment from healthy, at-risk
patients denies them the opportunity to remain healthy and
prevent complex reparative treatment
100%
90%
% of Age Cohort
80%
70%
Healthy, no risk
60%
Healthy, at-risk
50%
Periodontitis
40%
30%
20%
10%
0%
<30
30-39
40-49
50-59
>59
Age Cohort
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Summary
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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
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Managing Periodontitis Patients
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When treatment is initiated during the early
stages of disease, success is more likely,
treatment is more conservative, and fewer teeth
are lost
Risk predicts the future severity of disease
Most patients are referred when disease is
severe resulting in more tooth loss and
treatment that is complex and expensive
Treatment including the need for referral to a
periodontist should be based on risk and disease
Managing Patients With Periodontal Disease
Disease State
Severe Periodontitis
Moderate Periodontitis
Mild Periodontitis
Gingivitis
Health
Very
Low
Low
Moderate
Risk Level
High
Very
High
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
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