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Periodontal Disease Risk. Developed by PreViser, Inc. Courtesy PreViser Corporation, all rights reserved. Overview. What is risk? What are the clinical implications? How is risk determined?. Courtesy PreViser Corporation, all rights reserved. What is Risk?. General Context

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periodontal disease risk

Periodontal Disease Risk

Developed by PreViser, Inc.

Courtesy PreViser Corporation, all rights reserved

overview
Overview
  • What is risk?
  • What are the clinical implications?
  • How is risk determined?

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what is risk
What is Risk?
  • General Context
    • The likelihood of suffering harm or loss
  • Health Care Context
    • The likelihood of a worse health status during the natural history of disease (risk)
    • The likelihood of an undesired treatment outcome (prognosis)

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risk diagnosis and the natural history of disease

Severe

Disease

Initial

Stage

Detectable

Stage

Terminal

Disease

Moderate

Disease

Health

Risk, Diagnosis, and the Natural History of Disease

Diagnosis is a description of health status at the current time

Risk predicts health status at a future time

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risk disease 3 rd dimension
Risk + Disease = 3rd Dimension

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clinical implications

Severe

Disease

Initial

Stage

Detectable

Stage

Terminal

Disease

Moderate

Disease

Health

Clinical Implications

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

(Reparative treatment)

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clinical implications7

Severe

Disease

Initial

Stage

Detectable

Stage

Terminal

Disease

Moderate

Disease

Health

Clinical Implications
  • Risk is used to:
  • Justify treatment
  • Modulate intensity and aggressiveness
  • Determine treatment to prevent future lesions
  • (Preventative treatment)

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justify treatment
Justify Treatment ????
  • If everyone is low risk, then no one requires treatment, regardless of health status
  • If everyone is high risk, then each patient needs the same preventative treatment and reparative treatment is based on the existing lesions
  • When risk for disease is stratified then treatment needs vary with those at high risk needing more care compared to those at low risk

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is periodontal disease risk stratified
Is Periodontal Disease Risk Stratified?
  • 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
    • 22% had Beginning Periodontitis
    • 13% had Moderate to Severe Periodontitis
  • When the same data is viewed by age cohort, …

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periodontal disease risk10

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%

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periodontal disease risk cont

Risk for Beginning Periodontitis is 35%

45

Moderate to Severe Periodontitis

40

Beginning 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.

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treatment intensity and aggressiveness
Treatment Intensity and Aggressiveness

An Example

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

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preventative treatment
Preventative Treatment
  • Preventative treatment targets risk factors where risk factors are defined as,
  • An environmental, behavioral, or biologic factor, which if present directly increase the probability of a disease occurring, and if absent or removed reduces the probability. Risk factors are part of the causal chain, or expose the host to the causal chain. Once disease occurs, removal of a risk factor may not result in a cure. Beck, Community Dent Oral Epidemiol 1998

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preventative treatment14

Severe

Disease

Initial

Stage

Detectable

Stage

Terminal

Disease

Moderate

Disease

Health

Preventative Treatment
  • 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

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doomed by high risk
Doomed by high risk?
  • It is possible to be at high risk and not suffer the consequences of terminal disease by management of the risk factors. For example:
    • Daily personal oral hygiene for bacterial plaque
    • Smoking cessation
    • Blood-sugar control for diabetes
    • Periodontal surgery to eliminate pockets

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how is risk determined
How is Risk Determined?
  • Subjective opinion, the current method, is highly variable leading to the conclusion that treatment may be misapplied for some patients, which is understandable since -
  • The professional literature provides a list of risk factors but no validated objective method to correlate multiple factors for clinical use

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clinicians vs ohis risk assessment
Clinicians vs. OHIS™ Risk Assessment
  • Study group of 107 patients with broad range of risk for periodontitis
    • Full mouth periodontal charting
    • Medical and dental histories
    • Full mouth periapical radiographs with bitewings
    • Clinical photographs

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

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clinicians vs ohis risk assessment cont
Clinicians’ vs. OHIS™ Risk Assessment, cont.
  • 3 Groups of expert evaluators
    • 6 periodontists with national and international clinical, academic, and military experience
    • 10 periodontists who participated in the development of the OHIS™ tool
    • 36 private practice general dentists who referred patients to periodontists
  • Risk was assessed on a 1 (low) to 5 (high) scale by clinicians and OHIS™

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slide19

OHIS™

107 Patient Records, Risk Assessed using OHIS™

Three Expert Groups Subjectively Assess Same Patients

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slide20

OHIS™

107 Patient Records, Risk Assessed using OHIS™

Three Expert Groups Subjectively Assess Same Patients

6 Practicing Experts

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slide21

OHIS™

6 Practicing Experts

10 PreViser Founders

107 Patient Records, Risk Assessed using OHIS™

Three Expert Groups Subjectively Assess Same Patients

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slide22

OHIS™

6 Practicing Experts

10 PreViser Founders

107 Patient Records, Risk Assessed using OHIS™

Three Expert Groups Subjectively Assess Same Patients

36 General Dentists “Periodontally Aware”

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slide23

Expert Periodontists

(5 Patient Evaluations per data point)

Previser Founder’s

(5 Patient Evaluations…)

General Dentist

(5 Patient Evaluations…

Risk

Calculator

Score = 3

20% Agreement with OHIS™

For OHIS™assessed patients with Risk Score of 3..

Practitioner evaluation over-estimating risk by 2 scores

Practitioner evaluation over-estimating risk by 1 score

Over-

Estimated

Risk =

Inappropriate

Treatment

Under-

Estimated

Risk =

Inappropriate

Treatment

Practitioner evaluation under-estimating risk by 1 score

Conclusion: Clinicians can’t assess the risk offuture disease

Practitioner evaluation under-estimating risk by 2 scores

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validity and accuracy of ohis determined risk
Validity and Accuracy of OHIS™ Determined Risk
  • 523 subjects enrolled in the Veterans Affairs Dental Longitudinal Study who had only routine care
    • Periodontal pocket depth measurements
    • Digitized full-mouth radiographs with bitewings
    • Medical and dental histories
  • 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

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validity and accuracy of ohis determined risk cont
Validity and Accuracy of OHIS™ Determined Risk, cont.
  • Changes in periodontal status determined by comparing baseline data to data at 3, 9, and 15 years
    • Alveolar bone loss (mean bone loss, percentage of sites with bone loss per subject)
    • Tooth loss (mean percent tooth loss, percentage of subjects with tooth loss in each risk group)

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mean bone loss

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

Mean Bone Loss

Risk 5

A measure of disease severity

Risk 4

Risk 3

Risk 2

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percentage of sites with bone loss

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

Percentage of Sites with Bone Loss

A measure of disease extent

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mean tooth loss

30.0%

25.0%

20.0%

Mean % (±SE) Tooth Loss

15.0%

10.0%

5.0%

0.0%

Year 3

Year 9

Year 15

Mean Tooth Loss

Risk 5

Risk 4

Risk 3

Risk 2

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percentage of subjects with tooth loss

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

Percentage of Subjects with Tooth Loss

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summary
Summary
  • Risk and disease are distinct entities that when combined provide a more comprehensive description of health status, which can be used to provide better care
  • Risk is determined from risk factors where diagnosis is determined from (“visible”) clinical signs and symptoms

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summary cont
Summary, cont.
  • Diagnosis leads to reparative treatment whereas risk guides preventive treatment and modulates treatment intensity and aggressiveness
  • Because the population is stratified by risk for periodontal disease, treatment should be customized based on a validated objective method that determines the unique risk level and disease status of each patient

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