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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. How is periodontal status described in terms of disease severity and extent? How has periodontal status changed over time? Has it improved?

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If You Can Measure It, You Can Manage It

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  1. If You Can Measure It, You Can Manage It Measuring Periodontal Status to Benefit Your Professional Well-Being

  2. 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? • Did periodontal status improve following treatment? • Was treatment successful?

  3. Periodontist Self-knowledge of treatment effectiveness for decision-making Informing the patient including explaining changes in periodontal status Informing the referring general dentist General dentist 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 The Value of Measurement

  4. 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 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 Existing Measurement Method *The AAP defines CAL as clinical attachment loss, where other authors define CAL as clinical attachment level

  5. Interpreting Clinical Measurements • 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 • <10% of sites may worsen • Some sites may improve • >90% of sites typically are unchanged

  6. Periodontal Status for 1 Site • How are 5 choices selected from Health, Gingivitis, and Mild, Moderate, and Severe Periodontitis used to fill 9 cells in the table?

  7. PreViser’s Method for 1 Site • *Health is distinguished from gingivitis by bleeding on probing

  8. The Multiple Site Dilemma • For the examples of site-severity listed in the table, can you describe and rank by severity and extent?

  9. The PreViser Solution • 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

  10. Conclusions • 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

  11. PreViser’s Solution • 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 • 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

  12. Courtesy PreViser Corporation, all rights reserved

  13. PreViser Determines Risk, Too • When dentists determine risk for periodontal disease, they use their subjective clinical judgment • The PreViser method uses a standardized objective means

  14. Risk Calculator Score = 3 5 Patient Evaluations per data point Expert Periodontists Previser Founder’s General Dentist Risk Assessment by Subjective Judgment* Practitioner evaluation over-estimating risk by 2 scores * Persson et al. J Am Dent Assoc 2003 Practitioner evaluation over-estimating risk by 1 score Subjective judgment is not reliably accurate Practitioner evaluation under-estimating risk by 1 score Practitioner evaluation under-estimating risk by 2 scores Courtesy PreViser Corporation, all rights reserved

  15. 8.0% 7.0% 6.0% 5.0% Mean Percent (±SE) Alveolar Bone Loss 4.0% 3.0% 2.0% 1.0% 0.0% Year 3 Year 9 Year 15 PreViser Risk Assessment*Mean Bone Loss Risk 5 A measure of disease severity Risk 4 Risk 3 Risk 2 * Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003 Courtesy PreViser Corporation, all rights reserved

  16. 70% Risk 5 65% Risk 4 60% Risk 3 55% Risk 2 50% 45% % Sites with Bone Loss 40% 35% 30% 25% 20% 15% Year 3 Year 9 Year 15 PreViser Risk Assessment*% of Sites with Bone Loss A measure of disease extent * Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003 Courtesy PreViser Corporation, all rights reserved

  17. 30.0% 25.0% 20.0% Mean % (±SE) Tooth Loss 15.0% 10.0% 5.0% 0.0% Year 3 Year 9 Year 15 PreViser Risk Assessment*Mean Tooth Loss Risk 5 Risk 4 Risk 3 Risk 2 * Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003 Courtesy PreViser Corporation, all rights reserved

  18. 100% 90% Risk 5 80% Risk 4 70% Risk 3 60% % of subjects 50% 40% Risk 2 30% 20% 10% 0% Year 3 Year 9 Year 15 PreViser Risk Assessment*% of Subjects with Tooth Loss * Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003 Courtesy PreViser Corporation, all rights reserved

  19. The PreViser Solution Risk score: 4 Disease State: 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. Courtesy PreViser Corporation, all rights reserved

  20. Treatment Implications of Risk • 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 • 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? Courtesy PreViser Corporation, all rights reserved

  21. Prevalence of Periodontitis, 1950’s* Gingivitis Periodontitis Tooth loss 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 Courtesy PreViser Corporation, all rights reserved

  22. 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% were Healthy or had Gingivitis • 22% had Mild Periodontitis • 13% had Moderate to Severe Periodontitis • When the same data is viewed by age cohort, … Courtesy PreViser Corporation, all rights reserved

  23. Risk for Periodontitis is 60% 70 60 50 % of Age Cohort 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 Periodontal Disease Risk Risk to remain healthy is 40% Courtesy PreViser Corporation, all rights reserved

  24. Risk for Mild Periodontitis is 35% 45 Moderate to Severe Periodontitis 40 Mild Periodontitis 35 Linear trend line 30 % of Age Cohort 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 Periodontal Disease Risk, Cont. Courtesy PreViser Corporation, all rights reserved

  25. Distribution of Risk for Periodontitis Courtesy PreViser Corporation, all rights reserved

  26. Incorporating Risk Concepts into Treatment Planning • 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 • 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 Courtesy PreViser Corporation, all rights reserved

  27. Remaining Healthy Withholding preventative treatment from healthy, at-risk patients denies them the opportunity to remain healthy and prevent complex reparative treatment 100% 90% 80% 70% Healthy, no risk 60% Healthy, at-risk % of Age Cohort 50% Periodontitis 40% 30% 20% 10% 0% <30 30-39 40-49 50-59 >59 Age Cohort Courtesy PreViser Corporation, all rights reserved

  28. Summary • 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 Courtesy PreViser Corporation, all rights reserved

  29. Managing Periodontitis Patients • 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

  30. Managing Patients With Periodontal Disease Disease State 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

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