periodontal disease risk

Periodontal Disease RiskPeriodontal Disease Risk

Developed by PreViser, Inc.Developed by PreViser, Inc.

Courtesy PreViser Corporation, all rights reserved

OverviewOverview

What is risk?What is risk?

What are the clinical implications?What are the clinical implications?

How is risk determined?How is risk determined?


What is Risk?What is Risk?

General ContextGeneral Context The likelihood of suffering harm or lossThe likelihood of suffering harm or loss

Health Care ContextHealth Care Context The likelihood of a worse health status The likelihood of a worse health status

during the natural history of disease (during the natural history of disease (riskrisk)) The likelihood of an undesired treatment The likelihood of an undesired treatment

outcome (outcome (prognosisprognosis))


Risk, Diagnosis, and the Risk, Diagnosis, and the Natural History of DiseaseNatural History of Disease

Health InitialStage

DetectableStage

ModerateDisease

SevereDisease

TerminalDisease

Risk predicts health status at a future time

Diagnosis is a description of health status at the current time


Risk + Disease = 3Risk + Disease = 3rdrd DimensionDimension

Risk-Disease Risk-Disease GridGrid

Health StatusHealth Status

HealthHealth MildMild SevereSevere

RiskRisk

LevelLevel

LowLow YesYes YesYes NoNo

ModerateModerate YesYes YesYes NoNo

HighHigh YesYes YesYes YesYes


Clinical ImplicationsClinical Implications

Health InitialStage

DetectableStage

ModerateDisease

SevereDisease

TerminalDisease

Diagnosis is used to determine treatment for existing “visible” lesions (Reparative treatment)


Clinical ImplicationsClinical Implications

Health InitialStage

DetectableStage

ModerateDisease

SevereDisease

TerminalDisease

Risk is used to:• Justify treatment• Modulate intensity and aggressiveness• Determine treatment to prevent future lesions (Preventative treatment) Courtesy PreViser Corporation, all rights reserved

Justify Treatment ????Justify Treatment ????

If everyone is If everyone is lowlow risk, then no one requires risk, then no one requires treatment, regardless of health statustreatment, regardless of health status

If everyone is If everyone is highhigh risk, then each patient risk, then each patient needs the same preventative treatment and needs the same preventative treatment and reparative treatment is based on the existing reparative treatment is based on the existing lesionslesions

When risk for disease is When risk for disease is stratifiedstratified then then treatment needs vary with those at high risk treatment needs vary with those at high risk needing more care compared to those at low needing more care compared to those at low riskrisk


Is Periodontal Disease Risk Is Periodontal Disease Risk Stratified?Stratified?

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 prevalence of Periodontitis in reported the prevalence of Periodontitis in the adult population (30 years and older)the adult population (30 years and older) 65%65% were Healthy were Healthy 22%22% had Beginning Periodontitis had Beginning 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

Beginning Periodontitis

Risk for Beginning Periodontitis is 35%Risk for Beginning Periodontitis is 35%

Risk for Moderate to Severe Periodontitis is 25%Risk for Moderate to Severe Periodontitis is 25%


Treatment Intensity and Treatment Intensity and AggressivenessAggressiveness

An ExampleAn Example

Treatment for a 75 year old patient with Treatment for a 75 year old patient with generalized 6 mm pockets may be generalized 6 mm pockets may be limited to periodontal maintenance limited to periodontal maintenance whereas surgery may be selected for a whereas surgery may be selected for a 35 year old patient with the same 35 year old patient with the same conditions when the risk level of the conditions when the risk level of the older patient is much lower than the older patient is much lower than the younger patient.younger patient.


Preventative TreatmentPreventative Treatment Preventative treatment targets risk factors Preventative treatment targets risk factors

where risk factors are defined as,where risk factors are defined as, An environmental, behavioral, or biologic An environmental, behavioral, or biologic

factor, which if present directly increase the factor, which if present directly increase the probability of a disease occurring, and if probability of a disease occurring, and if absent or removed reduces the probability. absent or removed reduces the probability. Risk factors are part of the causal chain, or Risk factors are part of the causal chain, or expose the host to the causal chain. Once expose the host to the causal chain. Once disease occurs, removal of a risk factor may disease occurs, removal of a risk factor may not result in a cure. not result in a cure. Beck, Community Dent Oral Beck, Community Dent Oral Epidemiol 1998Epidemiol 1998


Preventative TreatmentPreventative Treatment

Health InitialStage

DetectableStage

ModerateDisease

SevereDisease

TerminalDisease

Preventative treatment applied before detectable disease occurs or during another stage of disease that is reversible can prevent irreversible lesions that require reparative treatment. For example:• Personal daily oral hygiene• Periodontal maintenance care


Doomed by high risk?Doomed by high risk?

It is possible to be at high risk and It is possible to be at high risk and not suffer the consequences of not suffer the consequences of terminal disease by management of terminal disease by management of the risk factors. For example:the risk factors. For example: Daily personal oral hygiene for bacterial Daily personal oral hygiene for bacterial

plaqueplaque Smoking cessationSmoking cessation Blood-sugar control for diabetesBlood-sugar control for diabetes Periodontal surgery to eliminate pocketsPeriodontal surgery to eliminate pockets


How is Risk Determined?How is Risk Determined?

Subjective opinion, the current Subjective opinion, the current method, is highly variable leading to method, is highly variable leading to the conclusion that treatment may the conclusion that treatment may be misapplied for some patients, be misapplied for some patients, which is understandable since -which is understandable since -

The professional literature provides a The professional literature provides a list of risk factors but no validated list of risk factors but no validated objective method to correlate objective method to correlate multiple factors for clinical usemultiple factors for clinical use


Clinicians vs. OHIS™ Risk Clinicians vs. OHIS™ Risk AssessmentAssessment

Study group of 107 patients with Study group of 107 patients with broad range of risk for periodontitisbroad range of risk for periodontitis Full mouth periodontal chartingFull mouth periodontal charting Medical and dental historiesMedical and dental histories Full mouth periapical radiographs with Full mouth periapical radiographs with

bitewingsbitewings Clinical photographsClinical photographs

Persson GR et al. Assessing periodontal disease risk. J Am Dent Assoc 2003


Clinicians’ vs. OHIS™ Risk Clinicians’ vs. OHIS™ Risk Assessment, cont.Assessment, cont.

3 Groups of expert evaluators3 Groups of expert evaluators 6 periodontists with national and 6 periodontists with national and

international clinical, academic, and international clinical, academic, and military experiencemilitary experience

10 periodontists who participated in the 10 periodontists who participated in the development of the OHIS™ tooldevelopment of the OHIS™ tool

36 private practice general dentists who 36 private practice general dentists who referred patients to periodontistsreferred patients to periodontists

Risk was assessed on a 1 (low) to 5 Risk was assessed on a 1 (low) to 5 (high) scale by clinicians and OHIS™(high) scale by clinicians and OHIS™


0%

10%

20%

30%

40%

50%

60%

GROUP

5

A B CGROUP

3

A B CGROUP

2

A B CGROUP

1

A B CGROUP

4

A B C

Risk Calculator107 Patient Records, Risk Assessed using OHIS™

Three Expert Groups Subjectively Assess Same Patients

OHIS™


107 Patient Records, Risk Assessed using OHIS™


0%

10%

20%

30%

40%

50%

60%

GROUP

5

A B CGROUP

3

A B CGROUP

2

A B CGROUP

1

A B CGROUP

4

A B C

Risk Calculator

6 Practicing Experts

OHIS™





OHIS™

0%

10%

20%

30%

40%

50%

60%

GROUP

5

A B CGROUP

3

A B CGROUP

2

A B CGROUP

1

A B CGROUP

4

A B C

Risk Calculator

10 PreViser Founders





OHIS™

10 PreViser Founders

36 General Dentists “Periodontally Aware”0%

10%

20%

30%

40%

50%

60%

GROUP

5

A B CGROUP

3

A B CGROUP

2

A B CGROUP

1

A B CGROUP

4

A B C

Risk Calculator


RiskCalculatorScore = 3

General Dentist(5 Patient Evaluations…

Expert Periodontists(5 Patient Evaluations per data point)

Previser Founder’s(5 Patient Evaluations…)

Practitioner evaluation

over-estimating risk by 2 scores


under-estimating risk by 1

score

Over-Estimated

Risk = Inappropriate

Treatment

Under-Estimated

Risk = Inappropriate

Treatment


over-estimating risk by 1

score


under-estimating risk by 2 scores

20% Agreement with OHIS™

For OHIS™

assessed patients with Risk Score of 3..

Conclusion: Clinicians

can’t assess the risk of

future diseaseCourtesy PreViser Corporation, all rights reserved

Validity and Accuracy of Validity and Accuracy of OHIS™ Determined RiskOHIS™ Determined Risk

523 subjects enrolled in the Veterans 523 subjects enrolled in the Veterans Affairs Dental Longitudinal Study who had Affairs Dental Longitudinal Study who had only routine careonly routine care

Periodontal pocket depth measurementsPeriodontal pocket depth measurements Digitized full-mouth radiographs with bitewingsDigitized full-mouth radiographs with bitewings Medical and dental historiesMedical and dental histories

Risk was assessed at baseline using OHIS™Risk was assessed at baseline using OHIS™

Page et al. Validity and accuracy of a risk calculator in predicting periodontal disease. J Am Dent Assoc 2002

Page et al. Longitudinal validation of a risk calculator for periodontal disease. J Clin Periodontol 2003


Validity and Accuracy of Validity and Accuracy of OHIS™ Determined Risk, cont.OHIS™ Determined Risk, cont.

Changes in periodontal status determined Changes in periodontal status determined by comparing baseline data to data at 3, 9, by comparing baseline data to data at 3, 9, and 15 yearsand 15 years

Alveolar bone loss (mean bone loss, percentage Alveolar bone loss (mean bone loss, percentage of sites with bone loss per subject)of sites with bone loss per subject)

Tooth loss (mean percent tooth loss, percentage Tooth loss (mean percent tooth loss, percentage of subjects with tooth loss in each risk group)of subjects with tooth loss in each risk group)


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


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

Percentage of Sites with Bone Percentage of Sites with Bone LossLoss

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

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

Percentage of Subjects with Tooth Percentage of Subjects with Tooth LossLoss


SummarySummary

Risk and disease are distinct entities Risk and disease are distinct entities that when combined provide a more that when combined provide a more comprehensive description of health comprehensive description of health status, which can be used to provide status, which can be used to provide better carebetter care

Risk is determined from risk factors Risk is determined from risk factors where diagnosis is determined from where diagnosis is determined from (“visible”) clinical signs and symptoms (“visible”) clinical signs and symptoms


Summary, cont.Summary, cont.

Diagnosis leads to reparative treatment Diagnosis leads to reparative treatment whereas risk guides preventive whereas risk guides preventive treatment and modulates treatment treatment and modulates treatment intensity and aggressivenessintensity and aggressiveness

Because the population is stratified by Because the population is stratified by risk for periodontal disease, treatment risk for periodontal disease, treatment should be customized based on a should be customized based on a validated objective method that validated objective method that determines the unique risk level and determines the unique risk level and disease status of each patientdisease status of each patient


periodontal disease risk

Documents

periodontal disease

periodontitis risk

stage of disease

high risk

detectable disease

list of risk factors

clinical implications

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