Risk in periodontics
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“Risk Assessment and Prognosis”- Guest lecture delivered at Vokkaligara Sangha Dental College and Hospital, Bangalore on 28/01/2016 and at “Perio Avalokan” held in Vishnu Dental College, Bhimavaram on 06/02/2016.
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Risk in periodontics
- 1. MDS;DNB Professor and Head Periodontics SVSIDS, Mahbubnagar Telangana
- 3. “A range of host-related factors can influence the onset, clinical presentation, and rate of periodontal disease progression. These factors include, but are not limited to, smoking, poorly controlled diabetes, poor oral hygiene, extent and severity of alveolar bone loss, positive family history, proportion of pocket probing depths >6 mm, age, gender, and gingival bleeding” American Academy of Periodontology statement on risk assessment. J Periodontol. 2008 Feb;79(2):202.
- 4. ~ Causing a condition ~ influences outcome Mak K, Kum CK. How to Appraise a Prognostic Study. World J Surg 2005; 29: 567–56. RISK & PROGNOSIS
- 5. OBJECTIVES RISK & PROGNOSIS RISK ASSESSMENT- WHAT,WHY AND WHEN?
- 6. WHY RISK? Why is he in the clinics? He has Periodontitis Why periodontitis? There are local deposits Why are there deposits? His plaque control is deficient RISK & PROGNOSIS
- 7. RISK & PROGNOSIS RISK: Probability that an individual will develop a specific disease in a given period. PERIODONTAL RISK: “This issue is important since “factors such as risk and other criteria have been suggested for referral.”* *Martin JA et al. Periodontal diagnosis affected by variation in terminology. J Periodontol. 2013 May;84(5):606-13.
- 8. Behavior, omission, or deficiency that if corrected, eliminated, or avoided would have prevented the fatality Any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease Mossman K. The Complexity Paradox: The More Answers We Find, the More Questions We Have. Oxford University Press. RISK & PROGNOSIS
- 11. RISK & PROGNOSIS
- 12. RISK & PROGNOSIS *Krieger N. Soc Sci Med. 1994 Oct;39(7):887-903.
- 13. *Krieger N. Soc Sci Med. 1994 Oct;39(7):887-903.
- 14. RISK is the possibility of harm the starting point for analysing the cause of disease justifies treatment RISK & PROGNOSIS
- 15. PROGNOSIS Prediction of probable course, duration, and outcome of a disease based on a general knowledge of the pathogenesis of the disease and the presence of risk factors for the disease. RISK & PROGNOSIS
- 16. Uncertainty is the other side of Prognosis* *Smith AK et al. Uncertainty--the other side of prognosis. Engl J Med. 2013 27;368(26):2448-50. **Italiano A. Prognostic or predictive? It's time to get back to definitions! J Clin Oncol. 2011 10;29(35):4718. Greek πρόγνωσις "fore-knowing, foreseeing“ Rx provider predicts that how the patient will progress over time A PROGNOSTIC FACTOR** is a clinical or biologic characteristic that is objectively measurable and that provides information on the likely outcome of the cancer disease RISK & PROGNOSIS
- 17. RISK & PROGNOSIS
- 18. “MCGUIRE AND NUNN’’ STUDIES PROGNOSIS OF THE TEETH STUDIED CHANGED VERY LITTLE FROM INITIAL TO 5 TO 8 YEARS. “GOOD” PROGNOSIS IS HIGHLY PREDICTABLE SURVIVAL TIME FOR TEETH THAT WERE LOST WAS APPROXIMATELY 5 YEARS POST-TREATMENT “WAIT & SEE” WITH GENETIC POLYMORPHISMS RISK & PROGNOSIS
- 19. CERTAIN QUESTIONABLE HOPELESS McGuire & Nunn 1996 GOOD QUESTIONABLE HOPELESS Becker et al 1984 MAINTAINED DOWNHILL EXTREME DOWNHILL Hirschfeld 1978 RISK & PROGNOSIS
- 20. GOOD QUESTIONABLE HOPELESS McGuire & Nunn 1996,99 FAIR POOR GOOD QUESTIONABLE HOPELESS Checchi et al 2002 RISK & PROGNOSIS
- 21. Prediction of Prognosis* *Hirschfeld A, et al. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978; 49: 225-23 **McGuire M K. Prognosis versus actual outcome. J Periodontol 1991; 62: 51-58. Easier to predict the prognosis for single-rooted teeth Molar teeth were four times more likely to be affected than all other teeth combined Anterior teeth respond better to periodontal treatment and are less likely to be lost The poorest results occurred for the maxillary bicuspids and molars RISK & PROGNOSIS
- 22. RISK ASSESSMENT- WHAT,WHY AND WHEN? Risk assessment has been defined as the “process by which qualitative or quantitative assessments are made of the likelihood for adverse events to occur as a result of exposure to specified health hazards or by the absence of beneficial influences”* *American Academy of Periodontology statement on risk assessment. American Academy of Periodontology J Periodontol. 2008 Feb; 79(2):202. What
- 23. “Risk assessment goes beyond the identification of the existence of disease and its severity, and considers factors that may influence future progression of disease” “Identifying adverse changes in risk factors, which might be suggestive of disease onset or progression is an important clinical concept” What
- 24. Risk Calculator Score 3 Overestimating risk by 2 scores Underestimating risk by 1 score Over- Estimated Risk Under- Estimated Risk Overestimating risk by 1 score Underestimating risk by 2 scores Why Persson GR et al. Assessing periodontal disease risk. J Am Dent Assoc 2003
- 25. *Persson GR et al. Assessing periodontal disease risk. J Am Dent Assoc 2003 **Jill Shiffer Nield-Gehrig, Donald E. Willmann. Foundations of Periodontics for the Dental Hygienist Clinicians can’t assess the risk of future disease* All interacting factors should be accounted for** Quantification of all risk and prognostic factors can better assess periodontitis** Why
- 26. COMPONENTS OF RISK ASSESSMENT* * Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicators of risk in caries management. J Dent Educ 2001;65(10):1126-32. How
- 27. How
- 28. How
- 29. Use
- 30. Use
- 31. Use
- 32. Use
- 33. ValidityThe NHANES III* database reported the prevalence of Periodontitis in the adult population as 65% were Healthy 22% had Mild Periodontitis 13% had Moderate to Severe Periodontitis * Albandar, et al. J Periodontol 1999; 70: 13-29 .
- 35. ValidityRisk Scores before and after therapy* *
- 36. ValidityRisk Scores and Patient Perception* * Nagarajan S, Chandra RV. Perception of oral health related quality of life (OHQoL-UK) among periodontal risk patients before and after periodontal therapy. Community Dent Health 2012 Mar;29(1):90-4.
- 37. Application Establish Baseline status ↓Risk scores = proper therapy
- 38. Limitations & Future Directions Risk assessment models have not yet been validated in longitudinal studies* Research is needed to determine the most effective way to incorporate risk assessment* Incorporation of risk into clinical practice has the potential to substantially alter the traditional approach to periodontal care delivery* It is anticipated that this will reduce the need for complex periodontal procedures and the cost of periodontal care** *Kye et al. J Evid Base Dent Pract 2012:S1: [2-11]: 1532-3382. **American Academy of Periodontology statement on risk assessment. J Periodontol. 2008 Feb; 79(2):202.
Editor's Notes
- Path of influencec
- In 1991 McGuire evaluated the outcome of treatment in 100 patients that were followed up for a mean of 7 years following active treatment. In the second part of this study the authors attempted to investigate the accuracy of a statistical model that would consider several explanatory variables such as, furcation involvement, pocket depth, percentage of bone loss, mobility, crown to root ratio and root proximity, based on the data published previously[8]. The model was very accurate in predicting prognosis (approximately 80%), especially in non-molar teeth. When scrutinizing the results, the authors found that the accuracy of the model was significantly compromised when teeth with good prognosis were excluded from the analysis (< 50%). In the third part of the study the authors extended the follow-up to 16 years. This extended observation time increased the number of teeth lost to 131 of the 2509 initially present. The average survival time for teeth that were lost was approximately 5 years post treatment.
- When an evaluator scored a test subject as being risk level 3 this agreement with OHIS is shown by the dot appearing in the red circle. If the evaluator scored 4 or 5, the dot is shown above the horizontal line in the inner or outer circle, respectively. If the evaluator scored 1 or 2, the dot is shown below the horizontal line in the inner or outer circle, respectively. It is notable that agreement with OHIS was only 20%, a level of agreement with a 1 to 5 scale that could have been achieved through a coin toss. Most evaluators underestimated risk, while some over-estimated risk. These data indicate that even expert clinicians rate poorly in their judgment of risk and, as a consequence, are likely providing treatment that are inappropriate for many patients. However, these findings should not be unexpected or alarming to dentists because the professional dental literature only provides a laundry list of risk factors with no practical methodology suggested on how to determine risk, leaving the dentist no method other than his or her subjective judgment. , some assigned the same risk as OHIS™, and some overestimated risk. This implies that treatment would be inappropriate for a large number of patients, since clinicians cannot accurately assess the risk of future disea
- Page et al (2002) Periodontal Risk Calculator (PRC) is the basis for Previser; 11 factors are considered. Lang and Tonetti (2003) Periodontal Risk Assessment (PRA): 6 factors: Full-mouth BOP %, PD * 5mm, tooth loss, radiographic bone loss-to-age ratio, systemic and/or genetic conditions, smoking Functional periodontal pentagon risk diagram (PPRD) with five periodontal risk vectors was created For UniFe risk calculation, the ''parameter scores'' assigned to smoking status, diabetic status, number of sites with probing depth 5 mm, bleeding on probing score (BoP) and bone loss/age, were added and the sum was referred to a ''risk score'', ranging from 1 (low risk) to 5 (highrisk). PAT(R) generated a risk score on a scale from 1 (lowest risk) to 5 (highest risk).
- 1SHM½IH46% 8 factors: Full-mouth BOP %, PD * 5mm, tooth loss, CAL to age ratio, smoking, DM, dental status - systemic factors interplay, psychosocial factors Modified periodontal risk assessment score (PRAS).
- That periodontal disease severity is highly stratified in the population can be seen from NHANES III, in which Albandar and colleagues determined that 65% of the US adult population over the age of 30 was periodontally healthy, 22% had mild periodontitis, and 13% had moderate to severe periodontitis.
- Diagnosis describes the current disease state where risk predicts the expected future disease state, which could be better, worse, or the same. Diagnosis is determined from signs and symptoms, whereas risk assessment uses risk factors. Risk level and disease (health status) creates a 3rd dimension to describe health status. Risk and disease are distinct entities, which means that both are needed to fully describe a patient’s health status including current and future time frames. There is a natural tendency to equate the level of risk with disease severity. For example severe disease is commonly paired with high risk and health with low risk. However health cannot always mean low risk, as health must always precede severe disease.
- The study population consisted of 183 patients reporting to the outpatient department of periodontics, who were grouped into low, moderate and high risk patients based on the periodontal risk assessment model. The patients were asked to complete the OHQoL-UK 16 questionnaire before and after periodontal therapy. The change in the patient perception of quality of life before and after treatment was assessed. RESULTS: Periodontitis had a considerable negative impact on the quality of life of patients in the high risk group in comparison to low and moderate risk groups (p < 0.001). Treatment brought about an improvement in the OHQoL scores in the moderate and high risk group.