If You Can Measure It, You Can Manage It Measuring Periodontal Status to Benefit Your Professional...
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If You Can Measure It, You If You Can Measure It, You Can Manage ItCan Manage It
Measuring Periodontal Status to Measuring Periodontal Status to Benefit Your Professional Well-Benefit Your Professional Well-
BeingBeing
Common Issues for Common Issues for CliniciansClinicians
How is periodontal status described in How is periodontal status described in terms of disease severity and extent?terms of disease severity and extent?
How has periodontal status changed over How has periodontal status changed over time?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 Did periodontal status improve following treatment?treatment? Was treatment successful?Was treatment successful?
The Value of MeasurementThe Value of Measurement
PeriodontistPeriodontist Self-knowledge of Self-knowledge of
treatment effectiveness treatment effectiveness for decision-makingfor decision-making
Informing the patient Informing the patient including explaining including explaining changes in periodontal changes in periodontal statusstatus
Informing the referring Informing the referring general dentistgeneral dentist
General dentistGeneral dentist Self-knowledge of Self-knowledge of
treatment effectiveness treatment effectiveness for decision-making for decision-making including determining including determining when to refer to a when to refer to a periodontistperiodontist
Informing the patient Informing the patient including explaining including explaining changes in periodontal changes in periodontal statusstatus
Existing Measurement Existing Measurement MethodMethod
AAP DescriptionAAP Description Severity:Severity:
Slight: CAL* 1-2 mmSlight: CAL* 1-2 mm Moderate: CAL 3-4 mmModerate: CAL 3-4 mm Severe: CAL Severe: CAL ≥5 mm≥5 mm
Extent:Extent: Localized: ≤30% of sitesLocalized: ≤30% of sites Generalized: >30% of Generalized: >30% of
sitessites
Clinical PracticeClinical Practice Periodontal charting Periodontal charting
is not consistently is not consistently done in general done in general practicespractices
Pocket depth rather Pocket depth rather than CAL is measuredthan CAL is measured
168 pocket depth 168 pocket depth measurements are measurements are needed for a 28-needed for a 28-tooth dentitiontooth dentition
Radiographs are also Radiographs are also utilizedutilized
*The AAP defines CAL as clinical *The AAP defines CAL as clinical attachment attachment lossloss, where other authors , where other authors define CAL as clinical attachment define CAL as clinical attachment levellevel
Interpreting Clinical Interpreting Clinical MeasurementsMeasurements
How do dentists determine and describe the How do dentists determine and describe the periodontal status of one site?periodontal status of one site?
How do dentists determine and describe the How do dentists determine and describe the periodontal status of 28 teeth (or 168 sites)?periodontal status of 28 teeth (or 168 sites)?
How do dentists describe periodontal status How do dentists describe periodontal status change for a 28-tooth dentition, considering change for a 28-tooth dentition, considering thatthat <10% of sites may worsen<10% of sites may worsen Some sites may improveSome sites may improve >90% of sites typically are unchanged>90% of sites typically are unchanged
Periodontal Status for 1 SitePeriodontal Status for 1 Site How are 5 choices selected from Health, How are 5 choices selected from Health,
Gingivitis, and Mild, Moderate, and Severe Gingivitis, and Mild, Moderate, and Severe Periodontitis used to fill 9 cells in the table?Periodontitis used to fill 9 cells in the table?
Pocket DepthPocket Depth
<5 mm<5 mm 5-7 mm5-7 mm >7 mm>7 mm
Bone Bone Height Height (CEJ to (CEJ to bone crest)bone crest)
>4 mm>4 mm
2-4 mm2-4 mm
< 2 mm< 2 mm
PreViser’s Method for 1 SitePreViser’s Method for 1 Site *Health is distinguished from gingivitis by *Health is distinguished from gingivitis by
bleeding on probingbleeding on probing
Pocket DepthPocket Depth
<5 mm<5 mm 5-7 mm5-7 mm >7 mm>7 mm
RadiographiRadiographic Bone c Bone
HeightHeight (CEJ (CEJ to bone crest)to bone crest)
>4 mm>4 mmModerate Moderate
PeriodontitiPeriodontitiss
Severe Severe PeriodontitiPeriodontiti
ss
SevereSevere
PeriodontitiPeriodontitiss
2-4 2-4 mmmm
Mild Mild PeriodontitiPeriodontiti
ss
Moderate Moderate PeriodontitiPeriodontiti
ss
Severe Severe PeriodontitiPeriodontiti
ss
< 2 < 2 mmmm
Health orHealth or
Gingivitis*Gingivitis*
Mild Mild PeriodontitiPeriodontiti
ss
Moderate Moderate PeriodontitiPeriodontiti
ss
The Multiple Site DilemmaThe Multiple Site Dilemma For the examples of site-severity listed in the table, For the examples of site-severity listed in the table,
can you describe and rank by severity and extent?can you describe and rank by severity and extent?
SiteSite
ExamplExamplee
11 22 33 44
AASevere Severe
PeriodontitiPeriodontitiss
Moderate Moderate PeriodontitiPeriodontiti
ss
Moderate Moderate PeriodontitiPeriodontiti
ss
Moderate Moderate PeriodontitiPeriodontiti
ss
BBSevere Severe
PeriodontitiPeriodontitiss
Severe Severe PeriodontitiPeriodontiti
ss
Mild Mild PeriodontitiPeriodontiti
ss
Mild Mild PeriodontitiPeriodontiti
ss
CCModerate Moderate
PeriodontitiPeriodontitiss
Mild Mild PeriodontitiPeriodontiti
ss
Mild Mild PeriodontitiPeriodontiti
ss
Mild Mild PeriodontitiPeriodontiti
ss
DDSevere Severe
PeriodontitiPeriodontitiss
Severe Severe PeriodontitiPeriodontiti
ss
Moderate Moderate PeriodontitiPeriodontiti
ss
Mild Mild PeriodontitiPeriodontiti
ss
The PreViser SolutionThe PreViser Solution Even if you found this example easy, 70 examples are Even if you found this example easy, 70 examples are
possible for 4 sites, 35,960 examples exist when each tooth 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 counts as 1 site in a 28-tooth dentition, and 1,000 times this number when all 168 sites are usednumber when all 168 sites are used
SiteSite
ExamplExamplee
11 22 33 44
Gen mod to Gen mod to sev (82)sev (82)
Severe Severe PeriodontitiPeriodontiti
ss
Moderate Moderate PeriodontitiPeriodontiti
ss
Moderate Moderate PeriodontitiPeriodontiti
ss
Moderate Moderate PeriodontitiPeriodontiti
ss
Gen mild to Gen mild to sev (87)sev (87)
Severe Severe PeriodontitiPeriodontiti
ss
Severe Severe PeriodontitiPeriodontiti
ss
Mild Mild PeriodontitiPeriodontiti
ss
Mild Mild PeriodontitiPeriodontiti
ss
Gen mild to Gen mild to mod (26)mod (26)
Moderate Moderate PeriodontitiPeriodontiti
ss
Mild Mild PeriodontitiPeriodontiti
ss
Mild Mild PeriodontitiPeriodontiti
ss
Mild Mild PeriodontitiPeriodontiti
ss
Gen mod to Gen mod to sev (92)sev (92)
Severe Severe PeriodontitiPeriodontiti
ss
Severe Severe PeriodontitiPeriodontiti
ss
Moderate Moderate PeriodontitiPeriodontiti
ss
Mild Mild PeriodontitiPeriodontiti
ss
ConclusionsConclusions
There is no evidence that periodontal There is no evidence that periodontal status is determined consistently and status is determined consistently and accurately by dentists accurately by dentists
There is no simple way to describe small There is no simple way to describe small changes whether comparing the changes whether comparing the periodontal status of one patient over time periodontal status of one patient over time or two patients regardless of time-frameor two patients regardless of time-frame
No method is used that describes No method is used that describes periodontal status numericallyperiodontal status numerically
PreViser’s SolutionPreViser’s Solution
OHIS™ calculates a score that is representative of OHIS™ calculates a score that is representative of the severity and extent of periodontal disease the severity and extent of periodontal disease based on the deepest pocket and greatest bone based on the deepest pocket and greatest bone loss for each sextantloss for each sextant The method is objective and hence consistentThe method is objective and hence consistent The use of ranges for pocket depth and bone height The use of ranges for pocket depth and bone height
reduces the error margin from inaccurate measurementreduces the error margin from inaccurate measurement The score ranges from 1 for health to 100 for The score ranges from 1 for health to 100 for
severe periodontitissevere periodontitis A numeric score simplifies comparisons, A numeric score simplifies comparisons,
explanations, and the creation of treatment explanations, and the creation of treatment guidelines including referral to a periodontistguidelines including referral to a periodontist
The PreViser scoring system can be used to The PreViser scoring system can be used to determine treatment effectivenessdetermine treatment effectiveness
OHIS™OHIS™
DiseasDisease e
ScoreScore
SeveritySeverity Text NomenclatureText Nomenclature
11 HealthHealth HealthHealth
2-32-3 GingivitisGingivitis GingivitisGingivitis
4-104-10 BeginningBeginning
PeriodontitPeriodontitisis
Localized Beginning PeriodontitisLocalized Beginning Periodontitis
Generalized Beginning PeriodontitisGeneralized Beginning Periodontitis
11-3611-36 ModerateModerate
PeriodontitPeriodontitisis
Localized Beginning and Moderate PeriodontitisLocalized Beginning and Moderate Periodontitis
Localized Moderate PeriodontitisLocalized Moderate Periodontitis
Generalized Beginning to Moderate PeriodontitisGeneralized Beginning to Moderate Periodontitis
Generalized Beginning and Localized Moderate Generalized Beginning and Localized Moderate PeriodontitisPeriodontitis
Generalized Moderate PeriodontitisGeneralized Moderate Periodontitis
37-10037-100 SevereSevere
PeriodontitPeriodontitisis
Localized Beginning and Severe PeriodontitisLocalized Beginning and Severe Periodontitis
Localized Moderate and Severe PeriodontitisLocalized Moderate and Severe Periodontitis
Localized Severe PeriodontitisLocalized Severe Periodontitis
Generalized Beginning to Severe PeriodontitisGeneralized Beginning to Severe Periodontitis
Generalized Beginning and Localized Severe Generalized Beginning and Localized Severe PeriodontitisPeriodontitis
Generalized Moderate to Severe PeriodontitisGeneralized Moderate to Severe Periodontitis
Generalized Moderate and Localized Severe Generalized Moderate and Localized Severe PeriodontitisPeriodontitis
Generalized Severe PeriodontitisGeneralized Severe Periodontitis
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PreViser Determines Risk, PreViser Determines Risk, TooToo
When dentists determine risk for When dentists determine risk for periodontal disease, they use their periodontal disease, they use their subjective clinical judgmentsubjective clinical judgment
The PreViser method uses a The PreViser method uses a standardized objective meansstandardized objective means
RiskCalculatorScore = 3
Practitioner evaluation
over-estimating risk by 2 scores
Practitioner evaluation
under-estimating risk by 1
score
Practitioner evaluation
over-estimating risk by 1
score
Practitioner evaluation
under-estimating risk by 2 scores
Risk Assessment Risk Assessment by Subjective by Subjective
Judgment*Judgment*
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* Persson et al. J Am Dent Assoc 2003
Subjective judgment is not reliably accurate
Previser Founder’s
Expert Periodontists
5 Patient Evaluations per data point
General Dentist
PreViser Risk Assessment*PreViser Risk Assessment*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
Courtesy PreViser Corporation, all rights reserved* Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003
15%
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
70%
Year 3 Year 9 Year 15
% S
ites
wit
h B
on
e L
oss
Risk 5
Risk 4
Risk 3
Risk 2
PreViser Risk Assessment*PreViser Risk Assessment*% of Sites with Bone Loss% of Sites with Bone Loss
A measure of disease extent
Courtesy PreViser Corporation, all rights reserved* Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
Year 3 Year 9 Year 15
Mean
% (
±S
E)
Tooth
Loss Risk 5
Risk 4
Risk 3
Risk 2
PreViser Risk Assessment*PreViser Risk Assessment*Mean Tooth LossMean Tooth Loss
Courtesy PreViser Corporation, all rights reserved* Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Year 3 Year 9 Year 15
% o
f su
bje
cts
Risk 5
Risk 4
Risk 3
Risk 2
PreViser Risk Assessment*PreViser Risk Assessment*% of Subjects with Tooth Loss% of Subjects with Tooth Loss
Courtesy PreViser Corporation, all rights reserved* Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003
The PreViser SolutionThe PreViser Solution
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.
Risk score: 4Disease State: 64
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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
Are all patients at high risk for periodontal Are all patients at high risk for periodontal disease?disease?
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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 or had Gingivitis were Healthy or had Gingivitis 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, …
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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%
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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
Mild 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%
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Distribution of Risk for Distribution of Risk for PeriodontitisPeriodontitis
High Risk25%
Low Risk40%
Moderate Risk35%
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Incorporating Risk Concepts Incorporating Risk Concepts into Treatment Planninginto Treatment Planning
Risk is the fundamental principle that can be Risk is the fundamental principle that can be used to justify the intensity and used to justify the intensity and aggressiveness of treatment where a aggressiveness of treatment where a diagnosis of disease can be made diagnosis of disease can be made Low risk means that disease is unlikely to progress Low risk means that disease is unlikely to progress
and justification for treatment is minimally and justification for treatment is minimally supportedsupported
High risk means that disease is likely to progress High risk means that disease is likely to progress and justification for treatment is maximally and justification for treatment is maximally supportedsupported
Risk can be used to determine preventive Risk can be used to determine preventive interventionsinterventions
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Remaining HealthyRemaining HealthyWithholding 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
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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
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Managing Periodontitis Managing Periodontitis PatientsPatients
When treatment is initiated during the When treatment is initiated during the early stages of disease, success is more early stages of disease, success is more likely, treatment is more conservative, and likely, treatment is more conservative, and fewer teeth are lostfewer teeth are lost
Risk predicts the future severity of diseaseRisk predicts the future severity of disease Most patients are referred when disease is Most patients are referred when disease is
severe resulting in more tooth loss and severe resulting in more tooth loss and treatment that is complex and expensivetreatment that is complex and expensive
Treatment including the need for referral Treatment including the need for referral to a periodontist should be based on risk to a periodontist should be based on risk and diseaseand disease
Managing Patients With Periodontal Managing Patients With Periodontal DiseaseDisease
Disease Disease StateState
Severe PeriodontitisSevere Periodontitis
Moderate Moderate PeriodontitisPeriodontitis
Mild PeriodontitisMild Periodontitis
GingivitisGingivitis
HealthHealth Very Low Moderate High Very Low Moderate High VeryVery Low Low HighHigh
Risk LevelRisk LevelTreatment including the need for referral to a periodontist Treatment including the need for referral to a periodontist should be based on risk and disease where color coded cells should be based on risk and disease where color coded cells identify treatment needs in increasing order: dark green, light identify treatment needs in increasing order: dark green, light green, yellow, and redgreen, yellow, and red
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