if you can measure it, you can manage it measuring periodontal status to manage periodontal...

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 Manage Periodontal TreatmentManage Periodontal Treatment

Courtesy PreViser Corporation, all rights reserved

Why Measure Periodontal Why Measure Periodontal Status?Status?

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


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? (Was treatment successful?)treatment? (Was treatment successful?)


Existing Measurement Existing Measurement MethodsMethods

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


Assigning Severity for 1 SiteAssigning Severity for 1 Site Periodontal disease severity is typically determined by dentists Periodontal disease severity is typically determined by dentists

from pocket depth and bone level, not CAL and no study has been from pocket depth and bone level, not CAL and no study has been published to correlate these two measurement methods. How do published to correlate these two measurement methods. How do dentists assign periodontal status using pocket and bone dentists assign periodontal status using pocket and bone measures?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?

Pocket Depth

<5 mm 5-7 mm >7 mm

Radiographic Bone Height (CEJ to bone crest)

>4 mm

2-4 mm

< 2 mm

Mild periodontitis

Moderate periodontitis

Mild periodontitis

Severe periodontitis


ConclusionsConclusions

The exercise revealed that The exercise revealed that periodontal status using a text periodontal status using a text description is which of the following:description is which of the following: Objective and consistentObjective and consistent Objective with variationObjective with variation Subjective with variationSubjective with variation Subjective and consistentSubjective and consistent


The Multiple Site DilemmaThe Multiple Site Dilemma How do you describe and rank a dentition by severity How do you describe and rank a dentition by severity

and extent where the severity for each quadrant has and extent where the severity for each quadrant has been assigned? Is this a simple and easy process? Is been assigned? Is this a simple and easy process? Is the description clear and unambiguous?the description clear and unambiguous?

Quadrant

Example UR UL LL LR

ASevere

PeriodontitisModerate



Periodontitis

BSevere

PeriodontitisSevere

PeriodontitisMild

PeriodontitisMild

Periodontitis

CModerate

PeriodontitisMild

PeriodontitisMild

PeriodontitisMild

Periodontitis

DSevere

PeriodontitisSevere


PeriodontitisMild

PeriodontitisCourtesy PreViser Corporation, all rights reserved

MissingMissing

HealthHealth GingivitisGingivitis

Mild PeriodontitisMild Periodontitis Moderate PeriodontitisModerate Periodontitis

Severe PeriodontitisSevere Periodontitis

The Multiple Site Dilemma, The Multiple Site Dilemma, cont.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 The PreViser Method for 1 SiteSite

A value is another method to describe severity.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?

Pocket Depth

<5 mm 5-7 mm >7 mm

Radiographic

Bone Height (CEJ to bone crest)

>4 mm

2-4 mm

< 2 mm


The PreViser Method for 1 The PreViser Method for 1 SiteSite

The PreViser method assigns severity in the The PreViser method assigns severity in the following rank order, which also facilitates following rank order, which also facilitates ranking a dentition by severity and extent.ranking a dentition by severity and extent.

Severity is ranked from lowest (1) to highest (5)

Pocket Depth

<5 mm 5-7 mm >7 mm

Radiographic

Bone Height (CEJ to bone crest)

>4 mm 4 5 5

2-4 mm 3 4 5

< 2 mm 1 or 2 3 4


The PreViser MethodThe PreViser Method

Perio Status

Severity Text Nomenclature

1 Health Health

2-3 Gingivitis Gingivitis

4-10 MildPeriodontitis

Localized Mild PeriodontitisGeneralized Mild Periodontitis

11-36 ModeratePeriodontitis

Localized Mild and Moderate PeriodontitisLocalized Moderate PeriodontitisGeneralized Mild to Moderate PeriodontitisGeneralized Mild and Localized Moderate PeriodontitisGeneralized Moderate Periodontitis

37-100

SeverePeriodontitis

Localized Mild and Severe PeriodontitisLocalized Moderate and Severe PeriodontitisLocalized Severe PeriodontitisGeneralized Mild to Severe PeriodontitisGeneralized Mild and Localized Severe PeriodontitisGeneralized Moderate to Severe PeriodontitisGeneralized Moderate and Localized Severe PeriodontitisGeneralized Severe Periodontitis


HealthHealth

GingivitisGingivitis

Mild PeriodontitisMild Periodontitis

Moderate PeriodontitisModerate Periodontitis


Right Left

Maxilla

Mandible

LA

ULUR

UA

LLLR

Periodontal Status: 64Text: Generalized Moderate and Localized Severe

SummarySummary The PreViser Method is:The PreViser Method is:

ObjectiveObjective ConsistentConsistent ConciseConcise ComparativeComparative Clinically usefulClinically useful

The PreViser Method is not perfect, but it is The PreViser Method is not perfect, but it is practical and there is little value added when more practical and there is little value added when more information is utilized since for 5 levels of severity information is utilized since for 5 levels of severity there are:there are: 210 combinations for 6 sextants, which means that only 2 210 combinations for 6 sextants, which means that only 2

combinations correspond to 1 scorecombinations correspond to 1 score 35,960 combinations for 28 teeth35,960 combinations for 28 teeth 15,625 permutations (sequence is important) for 6 15,625 permutations (sequence is important) for 6

sextantssextants 28 x 1028 x 101818 permutations for 28 teeth permutations for 28 teeth


What About Risk for What About Risk for Periodontitis?Periodontitis?

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 stage advanced and possibly terminal stage OROR periodontitis is a risk factor for another diseaseperiodontitis is a risk factor for another disease 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 when allall patients are high risk. patients are high risk.

BUT, are all patients at high risk for BUT, are all patients at high risk for periodontal disease? How should periodontal disease? How should treatment be modified based on risk treatment be modified based on risk level? level?


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

Using the NHANES III database, Albandar, et al Using the NHANES III database, Albandar, et al ((J J

PeriodontolPeriodontol 1999; 70: 13-29) 1999; 70: 13-29) reported the prevalence of reported the prevalence of Periodontitis in the adult population (30 years and Periodontitis in the adult population (30 years and older)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

A common interpretation is 35% of the population A common interpretation is 35% of the population is at risk for periodontitis and 13% is high riskis at risk for periodontitis and 13% is high risk

However, when the same data is viewed by age However, when the same data is viewed by age cohort,cohort,


Prevalence of Periodontitis, Prevalence of Periodontitis, 1990’s*1990’s*

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

Courtesy PreViser Corporation, all rights reserved* Albandar et al, J Periodontol 1999

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 Periodontitis Prevalence by Severity, 1990’s*by Severity, 1990’s*

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


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.* Albandar et al, J Periodontol 1999

Summary Risk Distribution Summary Risk Distribution

High Risk25%

Low Risk40%

Moderate Risk35%


Is risk assessed by dentists accurate?Is risk determined by PreViser accurate?

Practitioner evaluation over-

estimating risk by 2 scores

Practitioner evaluation

over-estimating risk by 1

score

Practitioner evaluation

under-estimating risk

by 1 score

Practitioner evaluation under-

estimating risk by 2 scores

Previser Founder’s

Expert Periodontists

5 Patient Evaluations per data point

General Dentist

Over-estimation of risk results in over-treatment

Risk Assessment by Dentists is Not Reliably Risk Assessment by Dentists is Not Reliably AccurateAccurate

Under-estimation of risk results in under-treatment


PreViser Risk Assessment is Objective and PreViser Risk Assessment is Objective and AccurateAccurate

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

% Sites with Bone 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

% Subjects with Tooth Loss


523 subjects followed for 15 years and who self-reported receiving no periodontal treatment

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%


Mean

Perc

en

t (±

SE)

Alv

eola

r B

on

e L

oss

Mean Bone Loss Risk 5

Risk 4

Risk 3

Risk 2

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%


Mean

% (

±S

E)

Tooth

Loss Mean Tooth Loss

Risk 5

Risk 4

Risk 3

Risk 2

Treatment Needs Increase with Treatment Needs Increase with Advancing Risk and Disease SeverityAdvancing Risk and Disease Severity

Very Low Moderate High VeryVery Low Moderate High VeryLow HighLow High

Risk LevelRisk Level

Periodontal Status


Moderate Moderate PeriodontitisPeriodontitis



HealthHealth

Treatment Intensity Treatment Intensity

Tre

atm

en

t In

ten

sit

yTre

atm

en

t In

ten

sit

y


Managing Patients With Periodontal Managing Patients With Periodontal DiseaseDisease

Periodontal Periodontal StatusStatus





HealthHealth Very Low Moderate High Very Low Moderate High VeryVery Low Low HighHigh

Risk LevelRisk LevelWhen treatment is initiated during the early stages of disease, When treatment is initiated during the early stages of disease, success is more likely, treatment is more conservative, and success is more likely, treatment is more conservative, and fewer teeth are lostfewer teeth are lost









Risk LevelRisk LevelRisk predicts the future severity of disease, which means Risk predicts the future severity of disease, which means periodontal disease is more likely to progress for high-risk periodontal disease is more likely to progress for high-risk patients and a greater intensity of preventive and reparative patients and a greater intensity of preventive and reparative treatment is needed, which may require the skills of a treatment is needed, which may require the skills of a periodontist periodontist Courtesy PreViser Corporation, all rights reserved








Risk LevelRisk LevelEvery patient currently with severe periodontitis at a previous time Every patient currently with severe periodontitis at a previous time had disease that was less severe and waiting until the patient has had disease that was less severe and waiting until the patient has severe disease to initiate treatment or refer includes a higher severe disease to initiate treatment or refer includes a higher likelihood of an upset patient, dentist, and periodontist because of likelihood of an upset patient, dentist, and periodontist because of treatment and outcomestreatment and outcomes


Current

Previous




Moderate PeriodontitisModerate Periodontitis




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 Courtesy PreViser Corporation, all rights reserved

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

PreViser and Determining an PreViser and Determining an OutcomeOutcome

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.


Risk scorePeriodontal status

Data points 1 to 4Data points 1 to 4

if you can measure it, you can manage it measuring periodontal status to manage periodontal...

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assigning severity

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combination of pocket

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