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

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


2-4 2-4 mmmm

Mild Mild PeriodontitiPeriodontiti

ss

Moderate Moderate PeriodontitiPeriodontiti

ss


ss

< 2 < 2 mmmm

Health orHealth or

Gingivitis*Gingivitis*


ss


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



ss


ss


ss

BBSevere Severe



ss


ss


ss

CCModerate Moderate



ss


ss


ss

DDSevere Severe



ss


ss


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)


ss


ss


ss


ss

Gen mild to Gen mild to sev (87)sev (87)


ss


ss


ss


ss

Gen mild to Gen mild to mod (26)mod (26)


ss


ss


ss


ss

Gen mod to Gen mod to sev (92)sev (92)


ss


ss


ss


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


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


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

Courtesy PreViser Corporation, all rights reserved

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


under-estimating risk by 1

score


over-estimating risk by 1

score


under-estimating risk by 2 scores

Risk Assessment Risk Assessment by Subjective by Subjective

Judgment*Judgment*


* 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%


% 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


0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%


Mean

% (

±S

E)

Tooth

Loss Risk 5

Risk 4

Risk 3

Risk 2

PreViser Risk Assessment*PreViser Risk Assessment*Mean Tooth LossMean Tooth 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

PreViser Risk Assessment*PreViser Risk Assessment*% of Subjects with Tooth Loss% of Subjects with Tooth Loss


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


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?



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, …


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%


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%


Distribution of Risk for Distribution of Risk for PeriodontitisPeriodontitis

High Risk25%

Low Risk40%

Moderate Risk35%


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


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


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


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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