Association of Dental Public Health European - eadph.org · Association of Dental Public Health...

Rome, September 24th 2011 16° International Congress

Rome, September 24r th 201116° International Congress

A periodontal risk assessment protocol

Roberto Farina, D.D.S. Ph.D. M.Sc. Leonardo Trombelli, D.D.S. Ph.D.

[email protected] www.unife.it/parodontologia www.unife.it/docenti/roberto.farina

European Association of Dental Public Health

ww.unife.it/parodontolww unife it/parodontolww unife it/docenti/t rob//

Female, 34 years A periodontal risk assessment protocol

2006

2009

A periodontal risk assessment protocol risk assessm2006

2009

2006

2009


Mean annual attachment loss rate in untreated subjects

Löe H, Anerud A, Boysen H, Morrison E. Natural history of periodontal disease in man. Rapid, moderate and no loss of attachment in Sri Lankan laborers 14 to 46 years of age. Journal of Clinical Periodontology 1986;13:431-445.

Age

Annual attachment loss

14-19 25-29 30-34 35-39

0.8

0

0.4

lt lossss

1.0

0.2

0.6

20-24 40-44 45


Mean annual attachment loss rate in untreated subjects

Löe H, Anerud A, Boysen H, Morrison E. Natural history of periodontal disease in man. Rapid, moderate and no loss of attachment in Sri Lankan laborers 14 to 46 years of age. Journal of Clinical Periodontology 1986;13:431-445.

Age

0.06 (0.04 – 0.09) mm/year

Mean annual attachment loss rate

0.18 (0.05 – 0.52) mm/year

0.65 (0.13 – 1.04) mm/year

No progression group

Moderate progression group

Rapid progression group

Well maintained (499 patients)

(0-3 teeth lost)

Downhill (76 patients)

(4 to 9 teeth lost)

Extreme downhill (25 patients)

(10 to 23 teeth lost)

Mean n° teeth lost during SPT

0.68 5.7 13.3

n° lost teeth 342 435 333 Distribution (%) of lost teeth according to initial prognosis

questionable favourable questionable favourable questionable favourable

79.5 20.5 57.2 42.8 43.5 56.5


Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. Journal of Periodontology 1978;49:225-237.

600 patients undergone periodontal treatment at least 15 years previously (age range: 12-73 years; mean duration of supportive periodontal therapy: 22 years)

Retrospective identification of teeth with a questionable prognosis

furcation involvement

deep non-eradicable pocket

extensive bone loss

marked mobility + deep pockets


(0-3 teeth lost)


(4 to 9 teeth lost)



n° questionable teeth initially present

1592 385 164

Patient grouping according to the n° of teeth lost during SPT


Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. Journal of Periodontology 1978;49:225-237.

600 patients undergone periodontal treatment at least 15 years previously (age range: 12-73 years; mean duration of supportive periodontal therapy: 22 years)

Retrospective identification of teeth with a questionable prognosis

furcation involvement

deep non-eradicable pocket

extensive bone loss

marked mobility + deep pockets


(0-3 teeth lost)


(4 to 9 teeth lost)



n° questionable teeth initially present

1592 385 164

MAINTAINED: 35.3%

MAINTAINED: 11.6%

MAINTAINED: 82.9%

Patient grouping according to the n° of teeth lost during SPT


How could we anticipate the rate of periodontal disease progression (prognosis)?

American Academy of Periodontology statement on risk assessment

Utilizing risk assessment helps dental professionals predict the potential for developing periodontal diseases and allows them to focus on early identification and to provide proactive, targeted treatment for patients who are at risk for progressive/aggressive diseases.

The AAP believes the clinical use of risk assessment will become a component of all comprehensive dental and periodontal evaluations as well as part of all periodic dental and periodontal examinations.

American Academy of Periodontology American Academy of Periodontology statement on risk assessment. Journal of Periodontology 2008;79:202.



Clinical history

Clini

cal c

ondit

ion

WORSE PROGNOSIS MORE THERAPY

WORSE RESPONSE TO THERAPY

BETTER PROGNOSIS LESS THERAPY

BETTER RESPONSE TO THERAPY

patient #1 patient #2

Page RC, Martin JA, Loeb CF. Use of risk assessment in attaining and maintaining oral health. Compendium of Continuing Education in Dentistry 2004;25:657-660, 663-666, 669; quiz 670.

true putative Specific bacterial species Gene polymorphisms

Smoke Age Diabetes (insufficient metabolic control)

Socio-economic status

Race/ethnicity Gender Psycho-social factors Osteoporosis/ osteopenia Obesity

Tonetti & Claffey 2005


Risk factor

Heitz-Mayfield et al. 2005

Environmental or individual characteristic which directly increases (when present) or decreases (when absent) the probability of a subject to be affected by a disease.

Beck 1994

Risk indicator Factor which may predict the progression of a disease, either spontaneous or under treatment.

Papapanou 2005

true putative Bleeding on probing Presence of periodontal

pathogens

Number of periodontal pockets Bone loss / age ratio

Gingival crevicular fluid components

PRA Lang & Tonetti 2003

PPRD Renvert et al. 2004

PRC Persson et al. 2003

BoP%

PPD>6mm

tooth loss prop. bone loss

smoking

syst./Genet.

tooth loss

PPD>4mm bone loss/age

env./Smok.

BoP

UniFe Farina et al. 2007

Trombelli et al. 2009

The use of objective methods for risk assessment improves the accuracy of risk evaluation


- Validity of Periodontal Assessment Tool® (PAT®) in predicting periodontal disease -

Page R, Krall EA, Martin J, Mancl L, Garcia RI. Validity of Periodontal Assessment Tool® (PAT®) in predicting periodontal disease. Journal of the American Dental Association 2002;133:569-576.

record charts of 523 patients aged 25 to 74 years

(101 smokers, 9 diabetics)

with different periodontal status

follow-up: 15 years

% of patients undergone 1 or no periodontal treatment through the follow-up period: !80%


0,00

0,02

0,04

0,06

0,08

3 9 15

Mean bone loss

for patients assigned a PAT® risk score 2-5

Mean tooth loss

for patients assigned a PAT® risk score 2-5

0,00

0,05

0,10

0,15

0,20

0,25

0,30

3 9 15

% teeth lost

% sites

years

- Validity of Periodontal Assessment Tool® (PAT®) in predicting periodontal disease -

years

2 3

4

5

2 3 4

5

Page R, Krall EA, Martin J, Mancl L, Garcia RI. Validity of Periodontal Assessment Tool® (PAT®) in predicting periodontal disease. Journal of the American Dental Association 2002;133:569-576.


- Risk assesment according to the UniFe method -

UniFe (unife.it/parodontologia) smoking status

(n° cig/day) diabetic status (serum HbA1c)

n° of pockets with PPD! 5mm BoP score (%) bone loss/age

ratio

0-4 0-4 0-4 0-4 0-8 sum: 0-2

risk score 1 sum: 3-5

risk score 2

LOW RISK

MEDIUM-LOW RISK

MEDIUM RISK

MEDIUM-HIGH RISK

HIGH RISK

sum: 6-8 risk score 3



+ + + +


Trombelli L, Farina R, Ferrari S, Pasetti P, Calura G Comparison between two methods for periodontal risk assessment. Minerva Stomatologica 2009;58:277-287

107 patients (34 ", 73 #; mean age: 45.5 ± 9.9 years)

Trombelli L, Farina R, Ferrari S, Pasetti P, Calura G. Comparison between two methods for periodontal risk assessment. Minerva Stomatologica 2009;58:277-287.


- Agreement between UniFe and PAT® methods -

0

20

40

60

80

1 2 3

4 (3.7%)

n° patients

4 5

2 (1.9%)

2 (1.9%)

26 (24.3%)

73 (68.2%)

risk score

Distribution of patients according to UniFe risk scores

0

20

40

60

80

1 2 3

0 (0%)

n° patients

4 5

2 (1.9%)

6 (5.6%)

30 (28.0%)

69 (64.5%)

risk score

Distribution of patients according to PAT® risk scores

Trombelli L, Farina R, Ferrari S, Pasetti P, Calura G. Comparison between two methods for periodontal risk assessment. Minerva Stomatologica 2009;58:277-287.


- Agreement between UniFe and PAT® methods -

0

10

20

30

40

50

60

70

80

90

DIFF (risk scoreUniFe – risk scorePAT® ) -2 -1 0

4 (3.7%)

n° patients

+1 +2

10 (9.3%)

80 (74.8%)

12 (11.2%)

1 (0.9%)

k(Landis & Koch 1977) = 0.70


Gender: #

Age: 45 yearsAge: 45 years

Never smoked

Diabetic (type 2, non-controlled) ,

genotype: heterozygote g yp yg (IL-1$ +4845 , IL-1% -511, IL-1% +3953)

Diagnosis: Generalized Aggressive Periodontitis

423 332 323 312 212 223 322 223 322 323 322

Post tx

Pre tx

buccal

215 414 324 425 423 323 326 625 423 431 726

425 213 323 323 322 223 313 322 223 323 322

Post tx

Pre tx

!"#"$"#%

424 324 425 424 423 424 236 635 523 315 626

324 425 413 316 545 576 1076 665 535 514 794 321 325 524 343 323 313 323 213 333 313 322 222 212 312 321 323 323

Post tx

Pre tx

&'(("#%

lingual

334 435 533 345 543 213 324 215 316 625 544 556 355 433

Post tx

Pre tx

333 323 332 333 313 212 212 313 222 232 332 222 323 212

Pre-treatment risk profile

Risk assessment BEFORE initial therapy

7


16

Pre-treatment risk profile

Risk assessment AFTER initial therapy

7


Retrospective evaluation of a cohort of 160 periodontitis patients

HIGH RISK (36.9%, n= 59)

fully compliant with SPT not compliant with SPT

100%

84.5%

15.5%

42.5% 47.5%

LOW RISK (6.9%, n= 11)

MODERATE RISK (56.2%, n= 90)

1.18 ± 1.89

0.80 ± 1.25

2.21 ± 3.21

1.71 ± 2.18

3.57 ± 5.02


Matuliene G, Studer R, Lang NP, Schmidlin K, Pjetursson BE, Salvi GE, Brägger U, Zwahlen M. Significance of Periodontal Risk Assessment on the recurrence of periodontitis and tooth loss. Journal of Clinical Periodontology 2010;37:191–199.

Number of teeth lost

3 1 3 3 1 3 3 1 3 3 1 3 2 1 3 2 1 2 2 1 3 3 1 3 4 1 3 4 1 5 4 1 3

3 1 4 3 1 4 3 1 3 4 1 3 2 1 2 3 1 3 2 1 2 2 1 3 3 1 3 31 3 4 3 6 palatal

buccal

lingual

buccal

Re-evaluation after 4 years of supportive periodontal therapy

3 2 3 2 1 2 2 1 2 2 1 2 2 1 3 2 1 1 2 1 1 1 1 1 1 1 2 2 1 2 2 1 2 2 1 1 3 1 2 2 2 3

2 2 2 3 1 3 3 1 2 3 1 3 3 1 2 2 1 2 2 1 1 2 1 1 1 1 2 2 1 2 2 1 2 3 1 3 4 3 3 3 2 3

General conclusions, clinical implications A periodontal risk assessment protocol

Periodontal risk assessment may help clinicians to identify subjects with an impaired periodontal prognosis as well as determine the impact of treatment on periodontal prognosis;

Longitudinal studies where patients with different periodontal status are long-term evaluated are needed to validate the current methods for periodontal risk assessment.

Preliminary data from retrospective studies seem to indicate that UniFe method represents a simplified and reliable tool for periodontal risk assesment;

Giovanni Franceschetti, DDS PhD Maria Elena Guarnelli, DDS Francesco Malaguti, DDS Luigi Minenna, DDS MSc Mattia Pramstraller, DDS Alessandro Rizzi, DDS Alessandro Scabbia, DDS Anna Simonelli, DDS Leonardo Trombelli, DDS PhD

Acknowledgements

Thank you for your attention

[email protected] www.unife.it/parodontologia www.unife.it/docenti/roberto.farina

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