If You Can Measure It, You Can Manage It

Transcript If You Can Measure It, You Can Manage It

If You Can Measure It, You Can Manage It Measuring Periodontal Status to Manage Periodontal Treatment

Why Measure Periodontal Status?

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

Common Issues for Clinicians

   How is periodontal status described in terms of disease severity and extent?

How has periodontal status changed over time?

 Has it improved?

  Has it worsened?

Has it remained stable?

Existing Measurement Methods

 AAP Description   Severity:    Slight: CAL* 1-2 mm Moderate: CAL 3-4 mm Severe: CAL ≥5 mm Extent:   Localized: ≤30% of sites Generalized: >30% of sites  *The AAP defines CAL as clinical attachment

loss

, where other authors 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 define CAL as clinical attachment

level

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?

Using severity categories health, gingivitis, mild, moderate, and severe periodontitis what is the severity for each combination of pocket depth and radiographic bone height?

>4 mm Radiographic Bone Height (CEJ to bone crest) 2-4 mm < 2 mm <5 mm Moderate periodontitis Mild periodontitis Pocket Depth 5-7 mm >7 mm Severe periodontitis Mild periodontitis Courtesy PreViser Corporation, all rights reserved

Conclusions



The exercise revealed that periodontal status using a text description is which of the following:

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?

Example A B C D UR Severe Periodontitis Severe Periodontitis Moderate Periodontitis Severe Periodontitis Quadrant UL Moderate Periodontitis LL Moderate Periodontitis Severe Periodontitis Mild Periodontitis Severe Periodontitis Mild Periodontitis Mild Periodontitis Moderate Periodontitis LR Moderate Periodontitis Mild Periodontitis Mild Periodontitis Mild Periodontitis Courtesy PreViser Corporation, all rights reserved

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?

The PreViser Method for 1 Site

 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?

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.

Severity is ranked from lowest (1) to highest (5) >4 mm Radiographic Bone Height (CEJ to bone crest) 2-4 mm < 2 mm <5 mm 4 3 1 or 2 Pocket Depth 5-7 mm 5 4 3 >7 mm 5 5 4 Courtesy PreViser Corporation, all rights reserved

The PreViser Method

Periodontal Status: 64 Text: Generalized Moderate and Localized Severe Right UR LR Maxilla UA UL Left LL Health Gingivitis Mild Periodontitis Moderate Periodontitis Severe Periodontitis

Perio Status 1 2-3 4-10 11-36 37 100 Severity Health Gingivitis Mild Periodontitis Moderate Periodontitis Severe Periodontitis Text Nomenclature Health Gingivitis Localized Mild Periodontitis Generalized Mild Periodontitis Localized Mild and Moderate Periodontitis Localized Moderate Periodontitis Generalized Mild to Moderate Periodontitis Generalized Mild and Localized Moderate Periodontitis Generalized Moderate 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

Summary

  The PreViser Method is:      Objective Consistent Concise Comparative 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:     210 combinations for 6 sextants, which means that only 2 combinations correspond to 1 score 35,960 combinations for 28 teeth 15,625 permutations (sequence is important) for 6 sextants 28 x 10 18 permutations for 28 teeth Courtesy PreViser Corporation, all rights reserved

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 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 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?

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% 22% 13%

were Healthy or had Gingivitis had Mild Periodontitis had Moderate to Severe Periodontitis 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, Courtesy PreViser Corporation, all rights reserved

Prevalence of Periodontitis, 1990’s*

70 60 50 40 30 20 10 Periodontitis Linear trend line 0 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

Age Cohort

70-74 75-79 80-84 85-90

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.

Periodontitis Prevalence by Severity, 1990’s*

45 40 35 30 25 20 15 10 Mild Periodontitis Moderate to Severe Periodontitis Linear trend line 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

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.

Summary Risk Distribution

High Risk 25% Low Risk 40% Moderate Risk 35% Is risk assessed by dentists accurate?

Is risk determined by PreViser accurate?

Risk Assessment by Dentists is Not Reliably Accurate

Practitioner evaluation over-estimating risk by 2 scores Practitioner evaluation over estimating risk by 1 score

Over-estimation of risk results in over-treatment

5 Patient Evaluations per data point Expert Periodontists Previser Founder’s General Dentist Practitioner evaluation under estimating risk by 1 score Practitioner evaluation under-estimating risk by 2 scores

PreViser Risk Assessment is Objective and Accurate 523 subjects followed for 15 years and who self-reported receiving no periodontal treatment

8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0%

Mean Bone Loss

Year 3 30.0% 25.0%

Mean Tooth Loss

Year 9 20.0% 15.0% 10.0% 5.0% 0.0% Year 3 Year 9 Risk 5 Risk 4 Risk 3 Risk 2 Year 15 Risk 5 Risk 4 Risk 3 Risk 2 Year 15 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15%

% Sites with Bone Loss

Year 3 Year 9

% Subjects with Tooth Loss

Year 3 Risk 5 Risk 4 Risk 3 Risk 2 Year 15 Risk 5 Risk 4 Risk 3 Risk 2 Year 9 Year 15

Treatment Needs Increase with Advancing Risk and Disease Severity

Periodontal Status

Severe Periodontitis Moderate Periodontitis Treatment Intensity Mild Periodontitis Gingivitis Health Very Low Moderate High Very Low High

Managing Patients With Periodontal Disease

Periodontal Status

Severe Periodontitis Moderate Periodontitis Mild Periodontitis Gingivitis Health Very Low Moderate High Very Low High

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

Managing Patients With Periodontal Disease

Periodontal Status

Severe Periodontitis Moderate Periodontitis Mild Periodontitis Gingivitis Health Very Low Moderate High Very Low High

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

Managing Patients With Periodontal Disease

Current

Periodontal Status

Severe Periodontitis Moderate Periodontitis Mild Periodontitis Gingivitis Previous Health Very Low Moderate High Very Low High

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

Managing Patients With Periodontal Disease

PreViser is the only objective and consistently accurate method to determine the combination of risk and disease severity-extent

Periodontal Status

Severe Periodontitis Moderate Periodontitis Mild Periodontitis Gingivitis Health Very Low Moderate High Very Low High

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 and Determining an Outcome

Risk score Periodontal status

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.

Data points 1 to 4

Data points 5 to 11

Data points 12 to 23

If You Can Measure It, You Can Manage It

Transcript If You Can Measure It, You Can Manage It