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The Oral Health Information The Oral Health Information Suite™Suite™
The Oral Health Information The Oral Health Information Suite™Suite™
Its Use in the Management of Its Use in the Management of
Periodontal DiseasePeriodontal Disease
The The OOral ral HHealth ealth IInformation nformation SSuite™uite™
What is OHIS™?What is OHIS™?
When and How is it used?When and How is it used?
Why should OHIS™ be used?Why should OHIS™ be used? Benefits from OHIS™ useBenefits from OHIS™ use
WhatWhat is OHIS™? is OHIS™? A patent protected Internet-accessed information A patent protected Internet-accessed information
system that is comprised of a suite of related tools system that is comprised of a suite of related tools for the major oral health conditions including:for the major oral health conditions including: CariesCaries Periodontal diseasePeriodontal disease Oral cancerOral cancer
Each tool includes:Each tool includes: A scientifically derived mathematic algorithm using A scientifically derived mathematic algorithm using
objective quantitative measurements to determine risk level objective quantitative measurements to determine risk level A list of recommended interventions, stack-ranked by three A list of recommended interventions, stack-ranked by three
levels of effectiveness based on the published literature and levels of effectiveness based on the published literature and current standards of care for the patient’s unique conditions current standards of care for the patient’s unique conditions
WhatWhat is OHIS™?, cont. is OHIS™?, cont. OHIS was designed to be easily incorporated OHIS was designed to be easily incorporated
into the normal workflow utilizing information into the normal workflow utilizing information of a traditional examination and of a traditional examination and accommodating the unique characteristics accommodating the unique characteristics and needs of the patient, clinician, and and needs of the patient, clinician, and treatment procedures.treatment procedures.
Unique for clinical dentistry by virtue of Unique for clinical dentistry by virtue of quantifying the risk for future disease in quantifying the risk for future disease in addition to quantifying the current periodontal addition to quantifying the current periodontal disease state.disease state. Provides the means to measure oral health care Provides the means to measure oral health care
and determine its valueand determine its value Facilitates quality care and continuous Facilitates quality care and continuous
improvement improvement
What is the Current What is the Current Treatment Flow and How Treatment Flow and How
Would it Change with Would it Change with OHIS™?OHIS™?
Current Treatment FlowCurrent Treatment Flow
Treatment Plan Finalized
Treatment Provided
Examination
Diagnosis
Re-
OHIS™ Treatment FlowOHIS™ Treatment Flow
OHIS™ is an intelligent self-correcting system, as outcomes information determined in “Analysis” is used to refine risk assessment and appropriate treatment including the rank order of effectiveness.
Examination
Treatment Plan Finalized
Treatment Provided
OHIS™ Processin
g
Report Returned to Clinician’s Computer
Algorithm Refinement
sAnalysis
Diagnosis
Re-
OHIS™ and HIPAA OHIS™ and HIPAA ComplianceCompliance
Compliance with HIPAA is accomplished by Compliance with HIPAA is accomplished by de-identifying the examination and de-identifying the examination and treatment information sent to OHIS™. treatment information sent to OHIS™.
The clinician’s computer is the only site The clinician’s computer is the only site where information that identifies the patient where information that identifies the patient resides. resides.
OHIS™ assigns a unique 32-character OHIS™ assigns a unique 32-character identification number to locate the records identification number to locate the records of a patient. of a patient. This creates a secure means to transfer a This creates a secure means to transfer a
patient’s entire collection of records, as only the patient’s entire collection of records, as only the patient and clinician have access to both the patient and clinician have access to both the identification number and identity of the patient.identification number and identity of the patient.
Who Developed OHIS?Who Developed OHIS?
How is it Obtained?How is it Obtained?
www.previser.comwww.previser.com
How Does OHIS™ Technology How Does OHIS™ Technology Enhance Current Practice Enhance Current Practice
Methods?Methods? DiagnosisDiagnosis
Risk AssessmentRisk Assessment Disease and RiskDisease and Risk
Treatment PlansTreatment Plans Incorporating risk conceptsIncorporating risk concepts
Current Diagnostic MethodCurrent Diagnostic Method
Clinical ConditionClinical Condition Data PointsData Points
Pocket depthPocket depth 28 X 6 = 28 X 6 = 168168
Tooth mobilityTooth mobility 28 X 1 = 28 X 1 = 2828
RecessionRecession 28 X 2 = 28 X 2 = 5656
FurcationsFurcations 4 X 3 + 6 X 2 = 4 X 3 + 6 X 2 = 2424
Attached gingivaAttached gingiva 28 + 14 = 28 + 14 = 4242
Plaque scorePlaque score 28 X 4 = 28 X 4 = 112112
Bleeding pointsBleeding points 28 X 4 = 28 X 4 = 112112
Radiographic bone lossRadiographic bone loss 28 X 2 = 28 X 2 = 5656
TOTALTOTAL 598598
The Basis for Text-Linguistic The Basis for Text-Linguistic DiagnosesDiagnoses
5 Severity States5 Severity States HealthHealth GingivitisGingivitis Beginning PeriodontitisBeginning Periodontitis Moderate PeriodontitisModerate Periodontitis Severe PeriodontitisSevere Periodontitis
2 Extent States2 Extent States LocalizedLocalized GeneralizedGeneralized
Text-Linguistic ConnectionsText-Linguistic Connections AndAnd ToTo Yields
17 Text-Linguistic 17 Text-Linguistic DiagnosesDiagnoses
SeveritySeverity Text NomenclatureText Nomenclature
HealthHealth HealthHealth
GingivitisGingivitis GingivitisGingivitis
BeginningBeginning
PeriodontitisPeriodontitisLocalized Beginning PeriodontitisLocalized Beginning Periodontitis
Generalized Beginning PeriodontitisGeneralized Beginning Periodontitis
ModerateModerate
PeriodontitisPeriodontitisLocalized 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 PeriodontitisGeneralized Beginning and Localized Moderate Periodontitis
Generalized Moderate PeriodontitisGeneralized Moderate Periodontitis
SevereSevere
PeriodontitisPeriodontitisLocalized 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 PeriodontitisGeneralized Beginning and Localized Severe Periodontitis
Generalized Moderate to Severe PeriodontitisGeneralized Moderate to Severe Periodontitis
Generalized Moderate and Localized Severe PeriodontitisGeneralized Moderate and Localized Severe Periodontitis
Generalized Severe PeriodontitisGeneralized Severe Periodontitis
Can Clinicians Determine a Can Clinicians Determine a Periodontal Diagnosis Quickly Periodontal Diagnosis Quickly
and With a High Level of and With a High Level of Agreement?Agreement?
Please determine a periodontal diagnosis Please determine a periodontal diagnosis from the periodontal charting and full from the periodontal charting and full mouth radiographs on the following mouth radiographs on the following slides. slides.
Thank you.Thank you.
What is Your Diagnosis?What is Your Diagnosis?
11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616
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3232 3131 3030 2929 2828 2727 2626 2525 2424 2323 2222 2121 2020 1919 1818 1717
170
Tooth#
FacialLingual
LingualFacial
Tooth#
OHIS™ Disease Score = 21
Text-Linguistic Diagnosis = Localized Moderate Periodontitis
What is Your Diagnosis?What is Your Diagnosis?
11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616
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3232 3131 3030 2929 2828 2727 2626 2525 2424 2323 2222 2121 2020 1919 1818 1717
207
Tooth#
FacialLingual
LingualFacial
Tooth#
OHIS™ Disease Score = 36
Text-Linguistic Diagnosis = Generalized Moderate Periodontitis
What is Your Diagnosis?What is Your Diagnosis?
11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616
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3232 3131 3030 2929 2828 2727 2626 2525 2424 2323 2222 2121 2020 1919 1818 1717
111A
Tooth#
FacialLingual
LingualFacial
Tooth#
OHIS™ Disease Score = 92
Text-Linguistic Diagnosis = Generalized Moderate to Severe Periodontitis
What is Your Diagnosis?What is Your Diagnosis?
11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616
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535377
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636355
535355
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535355
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3232 3131 3030 2929 2828 2727 2626 2525 2424 2323 2222 2121 2020 1919 1818 1717
111B
Tooth#
FacialLingual
LingualFacial
Tooth#
OHIS™ Disease Score = 97
Text-Linguistic Diagnosis = Generalized Severe Periodontitis
Current Diagnostic Method Current Diagnostic Method SummarySummary
Time-consuming process to document Time-consuming process to document clinical findings, which at a minimum clinical findings, which at a minimum consists of 168 pocket depth consists of 168 pocket depth measurementsmeasurements
No standard and simple method exists to No standard and simple method exists to describe one set of nearly 600 data pointsdescribe one set of nearly 600 data points Wide variation exists in the determination of Wide variation exists in the determination of
a diagnosisa diagnosis
Current Diagnostic Method Current Diagnostic Method SummarySummary
Text nomenclature for diagnosis is Text nomenclature for diagnosis is complicated and not very complicated and not very descriptivedescriptive Text-based diagnoses are insufficiently Text-based diagnoses are insufficiently
precise to compare a single patient precise to compare a single patient over time or multiple patients, as over time or multiple patients, as similar conditions may be described by similar conditions may be described by the same diagnosisthe same diagnosis
OHIS™ Diagnostic MethodOHIS™ Diagnostic Method OHIS™ presents a standardized, objective, and OHIS™ presents a standardized, objective, and
simplified method for summarizing results of the simplified method for summarizing results of the standard periodontal examination into a clear, 1 standard periodontal examination into a clear, 1 – 100 scale describing the disease state– 100 scale describing the disease state
No special tests are required, and only 13 data No special tests are required, and only 13 data points are needed to quantify a periodontal points are needed to quantify a periodontal diagnosisdiagnosis
A numeric and text periodontal diagnosis can be A numeric and text periodontal diagnosis can be obtained in seconds after the data is recordedobtained in seconds after the data is recorded
Martin JA et al. A numeric method to describe a periodontal disease state. In preparation
OHIS™ Diagnostic Method, OHIS™ Diagnostic Method, cont.cont.
The method uses the combination of The method uses the combination of sextant severity diagnoses, which includes:sextant severity diagnoses, which includes: Health, Gingivitis, and Beginning, Moderate, and Health, Gingivitis, and Beginning, Moderate, and
Severe Periodontitis, and whereSevere Periodontitis, and where Sextant severity diagnosis is based on:Sextant severity diagnosis is based on:
Deepest pocketDeepest pocket Greatest radiographic bone height distance from Greatest radiographic bone height distance from
the cemento-enamel junctionthe cemento-enamel junction Bleeding on probingBleeding on probing
3 level scale 3 level scale
Bitewings are minimally required although some loss of accuracy will occur
Assignment of a Assignment of a Sextant Severity DiagnosisSextant Severity Diagnosis
Bone Height Distance from CEJBone Height Distance from CEJ
<2mm<2mm 2-4mm2-4mm >4mm>4mm
PockePocket t
DepthDepth
<5mm<5mm Gingivitis*Beginning
PeriodontitisModerate
Periodontitis
5-7mm5-7mm Beginning Periodontitis
Moderate Periodontitis
Severe Periodontitis
>7mm>7mm Moderate Periodontitis
Severe Periodontitis
Severe Periodontitis
* Bleeding on probing exists * Bleeding on probing exists
Assignment of a Assignment of a Sextant Severity DiagnosisSextant Severity Diagnosis
Bone Height Distance from CEJBone Height Distance from CEJ
<2mm<2mm 2-4mm2-4mm >4mm>4mm
PockePocket t
DepthDepth
<5mm<5mm Health*Beginning
PeriodontitisModerate
Periodontitis
5-7mm5-7mm Beginning Periodontitis
Moderate Periodontitis
Severe Periodontitis
>7mm>7mm Moderate Periodontitis
Severe Periodontitis
Severe Periodontitis
* Bleeding on probing does not exist* Bleeding on probing does not exist
Why Sextant Diagnosis is Why Sextant Diagnosis is UsedUsed
28 teeth listed in order of their diagnosis is 28 teeth listed in order of their diagnosis is 552828=3.7x10=3.7x101919 permutations permutations
28 teeth grouped and counted by 28 teeth grouped and counted by diagnosis is diagnosis is 35,96035,960 combinations combinations
Sextants listed in order of their diagnosis Sextants listed in order of their diagnosis is is 5566=15,625=15,625 permutations permutations
Sextants grouped and counted by Sextants grouped and counted by diagnosis is diagnosis is 210210 combinations combinations Approximately Approximately 22 combinations of sextant combinations of sextant
diagnosis correspond to diagnosis correspond to 11 disease score in the disease score in the 1-100 scale1-100 scale
The non-uniformity of the scale occurs as a The non-uniformity of the scale occurs as a condition of combinationscondition of combinations
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
PeriodontitPeriodontitisis
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
PeriodontitPeriodontitisis
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
What Diagnosis Would You What Diagnosis Would You Assign?Assign?
4 sextants have severe periodontitis and 2 have 4 sextants have severe periodontitis and 2 have gingivitisgingivitis 94 disease score and Generalized severe 94 disease score and Generalized severe
periodontitisperiodontitis 3 sextants have severe periodontitis and 3 have 3 sextants have severe periodontitis and 3 have
gingivitis gingivitis 84 disease score and Generalized severe 84 disease score and Generalized severe
periodontitisperiodontitis 2 sextants have severe periodontitis, 2 have 2 sextants have severe periodontitis, 2 have
beginning periodontitis, and 2 have gingivitisbeginning periodontitis, and 2 have gingivitis 71 disease score and Generalized beginning to 71 disease score and Generalized beginning to
severe periodontitissevere periodontitis
Disease Score and its Disease Score and its HistoryHistory
OHIS™ Diagnostic OHIS™ Diagnostic Method SummaryMethod Summary
Streamlines the diagnostic process into a Streamlines the diagnostic process into a more efficient and effective clinical practicemore efficient and effective clinical practice The disease score and its history are more readily The disease score and its history are more readily
comprehended than the typical periodontal comprehended than the typical periodontal charting, radiographs, and text nomenclaturecharting, radiographs, and text nomenclature
Establishes a standard and objective means Establishes a standard and objective means that can be applied to all patientsthat can be applied to all patients
A change in the disease score reflects an A change in the disease score reflects an improving, stable or worsening health improving, stable or worsening health conditioncondition
Is an Accurate Diagnosis All Is an Accurate Diagnosis All that is Required to Determine that is Required to Determine
Treatment?Treatment?
StagesInvisible Visible
DiagnosisLimited or No Signs
Signs and Symptoms
Loss
Disease Severity Initiation Beginning Moderate Severe
Health Disease Progression
Health-Disease
Continuum
The Health-Disease The Health-Disease ContinuumContinuum
Diagnosis is the determination of the existence of Diagnosis is the determination of the existence of diseasedisease
Disease does not exist until tissue destruction occursDisease does not exist until tissue destruction occurs Lesions must exceed the threshold of measurement Lesions must exceed the threshold of measurement
for a diagnosis to be madefor a diagnosis to be made
StagesInvisible Visible
DiagnosisLimited or No Signs
Signs and Symptoms
Loss
Disease Severity Initiation Beginning Moderate Severe
Health Disease Progression
Health-Disease
Continuum
The Health-Disease The Health-Disease ContinuumContinuum
Diagnosis identifies severity; drives reparative Diagnosis identifies severity; drives reparative treatment treatment
A diagnosis describes the current, static, disease A diagnosis describes the current, static, disease statestate
However,……..However,……..
StagesInvisible Visible
DiagnosisLimited or No Signs
Signs and Symptoms
Loss
Disease Severity Initiation Beginning Moderate Severe
Health Disease Progression
Health-Disease
Continuum
The Health-Disease The Health-Disease ContinuumContinuum
Disease is a dynamic non-linear process that can Disease is a dynamic non-linear process that can cycle between breakdown and healingcycle between breakdown and healing
During the earliest stages of the disease process, During the earliest stages of the disease process, reversibility or healing may be possible reversibility or healing may be possible
• Tooth demineralization ----------------------> • Sub-clinical inflammatory lesion ---------------> • Abnormal cell division ---------------------------> • Coronary artery plaque and inflammation --->
CariesGingivitisCancerMyocardial Infarction
StagesInvisible Visible
DiagnosisLimited or No Signs
Signs and Symptoms
Loss
Disease Severity Initiation Beginning Moderate Severe
Health Disease Progression
Health-Disease
Continuum
The Health-Disease The Health-Disease ContinuumContinuum
Diagnosis of a lesion at its earliest stage will be after Diagnosis of a lesion at its earliest stage will be after the initiation of the disease processthe initiation of the disease process
Risk predicts the future disease state; drives Risk predicts the future disease state; drives preventative treatmentpreventative treatment
A healthy patient at-risk for disease would be denied A healthy patient at-risk for disease would be denied the opportunity to prevent disease if interventions the opportunity to prevent disease if interventions are withheld until a diagnosis is obtainedare withheld until a diagnosis is obtained
What is Required to What is Required to Determine Treatment Determine Treatment
Needs?Needs? Accurate diagnosisAccurate diagnosis Accurate risk determinationAccurate risk determination Understanding patient desiresUnderstanding patient desires Knowledge of the likelihood that Knowledge of the likelihood that
treatment interventions will treatment interventions will result in the desired outcomeresult in the desired outcome
Is the OHIS™ Risk Is the OHIS™ Risk Assessment Method Valid Assessment Method Valid
and Accurate?and Accurate?
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%
Year 3 Year 9 Year 15
% 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%
Year 3 Year 9 Year 15
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%
Year 3 Year 9 Year 15
% o
f su
bje
cts
Risk 5
Risk 4
Risk 3
Risk 2
Percentage of Subjects with Tooth Percentage of Subjects with Tooth LossLoss
0
1
2
3
4
5
6
7
Total teeth Periodontally affected Periodontally unaffected
Nu
mb
er
of
teeth
lost
Risk 2
Risk 3
Risk 4
Risk 5
Mean Number of Teeth LostMean Number of Teeth Lost
Only 26% did not have periodontal disease at baseline
How is Risk Distinguished How is Risk Distinguished from Diagnosis?from Diagnosis?
Disease StateDisease State
Severe PeriodontitisSevere Periodontitis
Moderate PeriodontitisModerate Periodontitis
Beginning PeriodontitisBeginning Periodontitis
GingivitisGingivitis
HealthHealth
Diagnosis vs. RiskDiagnosis vs. Risk
Current Current FutureFuture
TimeTime
Worse
Better
Same
Diagnosisdescribes
Riskpredicts
Based on:Based on: Signs and Symptoms Signs and Symptoms Risk Risk FactorsFactors
Signs and Symptoms vs. Risk Signs and Symptoms vs. Risk FactorsFactors
Signs and Signs and SymptomsSymptoms
Bleeding on Bleeding on probingprobing
PocketsPockets Bone lossBone loss PainPain SwellingSwelling
Risk FactorsRisk Factors Smoking Smoking DiabetesDiabetes Pathogenic Pathogenic
bacteriabacteria PocketsPockets
What is a Risk Factor?What is a Risk Factor?
Risk factor is often used as a general term Risk factor is often used as a general term meaning those characteristics that strongly meaning those characteristics that strongly associate with groups of individuals who associate with groups of individuals who have disease compared to those who do have disease compared to those who do not. Risk terminology includes:not. Risk terminology includes: Risk FactorRisk Factor Background CharacteristicBackground Characteristic Risk IndicatorRisk Indicator Risk Markers or Risk PredictorsRisk Markers or Risk Predictors
Risk Factor DefinitionRisk Factor Definition
An environmental, behavioral, or biologic An environmental, behavioral, or biologic factor confirmed by temporal sequence, factor confirmed by temporal sequence, usually in longitudinal studies, which if usually in longitudinal studies, which if present directly increases the probability of a present directly increases the probability of a disease occurring, and if absent or removed disease occurring, and if absent or removed reduces the probability. Risk factors are part reduces the probability. Risk factors are part of the causal chain, or expose the host to the of the causal chain, or expose the host to the causal chain. Once disease occurs, removal causal chain. Once disease occurs, removal of a risk factor may not result in a cure. of a risk factor may not result in a cure.
Beck JD. Community Dent Oral Epidemiol 1998
Background Characteristics Background Characteristics DefinitionDefinition
Associated with a higher probability Associated with a higher probability of disease, but cannot be modified. of disease, but cannot be modified. Also referred to as a determinant.Also referred to as a determinant. AgeAge GenderGender Socioeconomic StatusSocioeconomic Status Familial history and genetic factorsFamilial history and genetic factors
Risk Indicator DefinitionRisk Indicator Definition
A possible risk factor not yet A possible risk factor not yet confirmed in published studies. A confirmed in published studies. A plausible correlate of disease plausible correlate of disease identified in cross-sectional studies.identified in cross-sectional studies. OsteoporosisOsteoporosis HIV and AIDSHIV and AIDS Frequency of visits to the dentistFrequency of visits to the dentist
Risk Markers and Predictors Risk Markers and Predictors DefinitionDefinition
A characteristic strongly correlated A characteristic strongly correlated with an increased probability of with an increased probability of future disease but is not part of the future disease but is not part of the causal chain.causal chain. Bleeding on probingBleeding on probing Clinical attachment lossClinical attachment loss
Risk AssessmentRisk Assessment
Risk cannot be determined from disease Risk cannot be determined from disease severityseverity Every patient who has disease was, at a prior time, Every patient who has disease was, at a prior time,
healthy, hence - healthy, hence - It is possible to be high risk AND low disease severityIt is possible to be high risk AND low disease severity
Risk assessment is used to develop a Risk assessment is used to develop a preventive intervention program to prevent preventive intervention program to prevent disease before it occursdisease before it occurs
Risk Level modulates the aggressiveness and Risk Level modulates the aggressiveness and frequency of treatmentfrequency of treatment
OHIS™ Risk AssessmentOHIS™ Risk Assessment A future disease state is effected when A future disease state is effected when
treatment is applied or withheld treatment is applied or withheld
OHIS™ risk assessment predicts the on-set OHIS™ risk assessment predicts the on-set and progression of periodontal disease for and progression of periodontal disease for patients who have no more than routine patients who have no more than routine dental caredental care
Predicting treatment effectiveness is a Predicting treatment effectiveness is a different type of risk assessment not different type of risk assessment not currently determined by OHIS™currently determined by OHIS™
The OHIS™ risk score ranges from 1 for very The OHIS™ risk score ranges from 1 for very low risk to 5 for very high risk low risk to 5 for very high risk
Current Risk Assessment Current Risk Assessment MethodMethod
By subjective judgmentBy subjective judgment Based primarily on disease severity and Based primarily on disease severity and
extentextent This is understandable, as the literature This is understandable, as the literature
only provides a laundry list of risk only provides a laundry list of risk factors with no guidance how to factors with no guidance how to determine riskdetermine risk
It is not surprising that the current It is not surprising that the current method of risk assessment is generally method of risk assessment is generally an unreliable predictor of the future an unreliable predictor of the future disease statedisease state
OHIS™ Risk Assessment OHIS™ Risk Assessment CriteriaCriteria
Accurate and valid predictor of a future disease state Accurate and valid predictor of a future disease state when no more than routine dental care is providedwhen no more than routine dental care is provided
Time required for data collection and input must add Time required for data collection and input must add no more than 5 minutes to a traditional periodontal no more than 5 minutes to a traditional periodontal examination and the procedure must be easily examination and the procedure must be easily incorporated into the normal pattern of work flowincorporated into the normal pattern of work flow
Risk assessment information must be useful to create Risk assessment information must be useful to create treatment recommendations that reduce risk and treatment recommendations that reduce risk and prevent disease incidence and progressionprevent disease incidence and progression
Martin et al. The development and utility of an assessment tool for risk of periodontal disease. In preparation.
OHIS™ Criteria for Use of OHIS™ Criteria for Use of FactorsFactors
Scientific basis supported by publication in Scientific basis supported by publication in refereed scientific journalrefereed scientific journal
Information obtainable during traditional Information obtainable during traditional periodontal examination without use of periodontal examination without use of special or laboratory testingspecial or laboratory testing
Sufficiently high weight to impact risk Sufficiently high weight to impact risk scorescore
Useful to create treatment Useful to create treatment recommendations that reduce risk and recommendations that reduce risk and prevent disease incidence and progressionprevent disease incidence and progression
Factors Used by OHIS™ to Factors Used by OHIS™ to Determine Risk and Recommend Determine Risk and Recommend
TreatmentTreatment
SmokingSmoking DiabetesDiabetes Subgingival calculusSubgingival calculus Subgingival restorationsSubgingival restorations PocketsPockets Furcation involvementsFurcation involvements Vertical bone lesionsVertical bone lesions
AgeAge Radiographic bone Radiographic bone
heightheight History of periodontal History of periodontal
surgery for pocketssurgery for pockets Oral hygieneOral hygiene Dental care frequencyDental care frequency
Why Were Some Why Were Some Factors Not Used?Factors Not Used?
Scientific Basis Not Scientific Basis Not Supported by a Refereed Supported by a Refereed
PublicationPublication RaceRace GenderGender Gingival crevicular componentsGingival crevicular components Bleeding pointsBleeding points Oral hygiene indicesOral hygiene indices SuppurationSuppuration Gingival rednessGingival redness Lamina duraLamina dura
Information Not Typically Information Not Typically ObtainedObtained
Genetic testing (PST®)Genetic testing (PST®) Polymorphoneuclear leucocyte disordersPolymorphoneuclear leucocyte disorders Gingival crevicular componentsGingival crevicular components Bleeding pointsBleeding points Oral hygiene indicesOral hygiene indices Clinical attachment lossClinical attachment loss Bacteria CulturingBacteria Culturing
Low Prevalence, Which Would Low Prevalence, Which Would Not Affect Accuracy of the Risk Not Affect Accuracy of the Risk
Score for a Large PopulationScore for a Large Population
Occlusion-related pathologyOcclusion-related pathology HIV and AIDSHIV and AIDS MedicationsMedications PregnancyPregnancy OsteoporosisOsteoporosis
Not Useful to Create Treatment Not Useful to Create Treatment RecommendationsRecommendations
RaceRace Socio-economic statusSocio-economic status Clinical attachment lossClinical attachment loss
OHIS™ Risk Assessment OHIS™ Risk Assessment Method SummaryMethod Summary
OHIS™ presents a standardized, valid, and OHIS™ presents a standardized, valid, and accurate method to determine risk levelaccurate method to determine risk level
Risk levels range from 1 for very low risk to 5 for Risk levels range from 1 for very low risk to 5 for very high risk very high risk
The time required for data collection and The time required for data collection and input adds no more than 5 minutes to a input adds no more than 5 minutes to a traditional periodontal examination and is traditional periodontal examination and is easily incorporated into the normal work easily incorporated into the normal work flowflow
Risk level and disease state are determined Risk level and disease state are determined from only 23 data pointsfrom only 23 data points
What Data does OHIS™ What Data does OHIS™ Require and How is it Require and How is it
Entered into the System?Entered into the System?
Data points 1 to 4Data points 1 to 4
Data points 5 to 11Data points 5 to 11
Data points 12 to 23Data points 12 to 23
Incorporating Risk Concepts Incorporating Risk Concepts into Treatment Planninginto Treatment Planning
Risk is the fundamental principle that should Risk is the fundamental principle that should justify treatmentjustify treatment Low risk means that disease is unlikely to progress Low risk means that disease is unlikely to progress
and justification for treatment is minimally supportedand justification for treatment is minimally supported High risk means that disease is likely to progress and High risk means that disease is likely to progress and
justification for treatment is maximally supportedjustification for treatment is maximally supported Risk is used to determine preventive Risk is used to determine preventive
interventionsinterventions Risk is also used to modulate the intensity and Risk is also used to modulate the intensity and
aggressiveness of reparative treatmentaggressiveness of reparative treatment
Risk and TreatmentRisk and Treatment Treating disease generally involves Treating disease generally involves
repairrepair Repair may increase the risk of new Repair may increase the risk of new
diseasedisease Risk should drive preventive treatmentRisk should drive preventive treatment Reduction in risk is accomplished by Reduction in risk is accomplished by
managing risk factorsmanaging risk factors Risk reduction can intercept invisible Risk reduction can intercept invisible
disease processesdisease processes
Both Risk and Disease are Both Risk and Disease are Important Important
The severity of disease is used to The severity of disease is used to determine how much and what type of determine how much and what type of treatment is neededtreatment is needed
Risk is used to determine how Risk is used to determine how conservative or aggressive treatment conservative or aggressive treatment should beshould be
With or without disease, risk is used to With or without disease, risk is used to determine the best treatment to prevent determine the best treatment to prevent new disease from occurringnew disease from occurring
Treatment Needs Increase with Treatment Needs Increase with Advancing Risk and Disease StateAdvancing Risk and Disease State
Very Low Moderate High VeryVery Low Moderate High VeryLow HighLow High
Risk LevelRisk Level
Disease StateDisease State
Severe PeriodontitisSevere Periodontitis
Moderate PeriodontitisModerate Periodontitis
Beginning PeriodontitisBeginning Periodontitis
GingivitisGingivitis
HealthHealth
Treatment Intensity Treatment Intensity and Aggressivenessand Aggressiveness
Tre
atm
en
t In
ten
sit
y
Tre
atm
en
t In
ten
sit
y
an
d A
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ressiv
en
ess
an
d A
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Current vs. OHIS™ Method of Current vs. OHIS™ Method of Identifying Treatment NeedIdentifying Treatment Need
Current Method
OHIS™ Method
Severity and Extent of Disease
Reparative TreatmentStandard Preventative
Treatment
Severity and Extent of Disease
Risk factors and risk level
Reparative Treatment
Preventative Treatment
How Can a Clinician How Can a Clinician Correlate Diagnosis, Risk, Correlate Diagnosis, Risk,
and Treatment Needsand Treatment Needs
Treatment Stratification Treatment Stratification MatrixMatrix
Very low risk
Low risk Risk = 2Disease = 11-36
Risk = 2Disease = 4-10
Risk = 3Disease = 4-10
Risk = 3Disease = 2-3
Risk = 1Disease = 4-10
Risk = 1Disease = 2-3
Risk = 1Disease = 1
Risk = 2Disease = 2-3
Risk = 2Disease = 1
Risk = 3Disease = 1
Moderate risk
High risk
Risk = 3Disease = 37-100
Risk = 3Disease = 11-36
Risk = 4Disease = 37-100
Risk = 4Disease = 11-36
Risk = 4Disease = 4-10
Risk = 5Disease = 37-100
Risk = 5Disease = 11-36
Risk = 5Disease = 4-10
Very high risk
Severe Periodontitis
Moderate Periodontitis
Beginning Periodontitis
GingivitisHealth
Risk = 1Disease = 11-36
Risk = 2Disease = 37-100
Risk = 4Disease = 2-3
Risk = 4Disease = 1
Patients in these categories are borderline for treatment complexity
Patients in these categories have routine needs generally requiring basic clinical skills and experience
Patients in these categories have the most complex needs generally requiring advanced clinical skills and experience
It is possible but unlikely to observe patients with these disease and risk profiles
Cannot be currently measured
Cannot occur
How Can OHIS™ Assist in How Can OHIS™ Assist in the Determination of the Determination of
Treatment?Treatment?
OHIS™ Assisted Treatment OHIS™ Assisted Treatment PlanningPlanning
A list of commonly used treatment A list of commonly used treatment procedures for the patient’s risk factors procedures for the patient’s risk factors and conditions grouped by three levels of and conditions grouped by three levels of expected effectiveness is provided as an expected effectiveness is provided as an aid to the dentist in decision making aid to the dentist in decision making
Treatment should be targeted to the Treatment should be targeted to the existing factors and conditionsexisting factors and conditions
Risk is used to modify treatment intensity Risk is used to modify treatment intensity and aggressivenessand aggressiveness
Using the Scores in Treatment Using the Scores in Treatment PlanningPlanning
Identifies the effectiveness of treatmentIdentifies the effectiveness of treatment Lower scores are indicative of improvement and Lower scores are indicative of improvement and
the possibility that the current condition can be the possibility that the current condition can be maintained or continue to improve with the current maintained or continue to improve with the current treatment plantreatment plan
Higher scores are indicative of a worse situation Higher scores are indicative of a worse situation and the need for different treatment and the need for different treatment
While a lower risk score is desirable, it is possible While a lower risk score is desirable, it is possible for a patient’s risk to remain high without the for a patient’s risk to remain high without the disease worseningdisease worsening
Risk score change corresponds to an increase or Risk score change corresponds to an increase or decrease of more than 20% making it less sensitive decrease of more than 20% making it less sensitive than the 100-point disease scorethan the 100-point disease score
Guidelines for Referral to a Guidelines for Referral to a PeriodontistPeriodontist
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
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 Referral to a periodontist should be based Referral to a periodontist should be based
on Risk and Diseaseon Risk and Disease
Guidelines for Referral to a Guidelines for Referral to a Periodontist, cont.Periodontist, cont.
Establish protocol for your practice such Establish protocol for your practice such as:as: A threshold for risk regardless of disease state A threshold for risk regardless of disease state
score (e.g. risk ≥4)score (e.g. risk ≥4) A threshold for an increase in risk (e.g. risk A threshold for an increase in risk (e.g. risk
change ≥1)change ≥1) A threshold for the disease state score (e.g. A threshold for the disease state score (e.g.
disease state ≥11)disease state ≥11) A threshold for an increase in the disease state A threshold for an increase in the disease state
score (e.g. disease state score change ≥10)score (e.g. disease state score change ≥10)
Is OHIS™ Needed?Is OHIS™ Needed? The need and value of OHIS™ is not The need and value of OHIS™ is not
intuitively apparent, as clinicians routinely intuitively apparent, as clinicians routinely diagnose, formulate treatment plans, and diagnose, formulate treatment plans, and predict outcomes. predict outcomes.
Furthermore there is evidence that oral Furthermore there is evidence that oral health has improved.health has improved.
However, wide variation and inaccuracy However, wide variation and inaccuracy exists for diagnosis and risk assessment, exists for diagnosis and risk assessment, suggestive that some patients receive un-suggestive that some patients receive un-needed care and others fail to receive needed care and others fail to receive needed care.needed care.
Is OHIS™ Needed?, cont.Is OHIS™ Needed?, cont. An information system that determines An information system that determines
outcomes is non-existent, which denies outcomes is non-existent, which denies the clinician and patient from an accurate the clinician and patient from an accurate understanding of oral health changes, understanding of oral health changes, favorable and unfavorable, that are favorable and unfavorable, that are attributable to treatment and behavioral attributable to treatment and behavioral decisions. decisions.
Dentistry has been practiced within this Dentistry has been practiced within this information void for decades resulting in information void for decades resulting in the deterioration of the authority and the deterioration of the authority and profitability of dentists.profitability of dentists.
Is OHIS™ Needed?, cont.Is OHIS™ Needed?, cont. Periodontal treatment can prevent tooth lossPeriodontal treatment can prevent tooth loss A standard uniform application of treatment A standard uniform application of treatment
procedures harms some patientsprocedures harms some patients A decision to determine treatment that does A decision to determine treatment that does
not include an accurate assessment of risk not include an accurate assessment of risk harms patientsharms patients
Risk assessment is distinctly different from Risk assessment is distinctly different from diagnosis and is not determined with diagnosis and is not determined with consistent accuracy by a clinician using consistent accuracy by a clinician using subjective judgmentsubjective judgment
Acceptance of the validity of these statements Acceptance of the validity of these statements means you believe quality care requires use of means you believe quality care requires use of OHIS™OHIS™
OHIS™ BenefitsOHIS™ Benefits
OHIS™ creates an opportunity for clinicians to OHIS™ creates an opportunity for clinicians to establish their method of determining oral establish their method of determining oral health care excellence and the development health care excellence and the development of practice policies based on actual clinical of practice policies based on actual clinical outcomes, which might prevent organizations outcomes, which might prevent organizations from imposing conflicting standards. from imposing conflicting standards.
Dentists who provide exceptional care Dentists who provide exceptional care measured by outcomes could justify higher measured by outcomes could justify higher fees and use the information to market their fees and use the information to market their expertise. expertise.
OHIS™ Benefits, cont.OHIS™ Benefits, cont.
Numeric scores Numeric scores Simplify the clinician’s explanation of Simplify the clinician’s explanation of
disease and risk disease and risk Are more easily and readily understood Are more easily and readily understood
by the patient compared to traditional by the patient compared to traditional text-linguistic descriptionstext-linguistic descriptions
The enhanced understanding would be The enhanced understanding would be expected to result in a higher expected to result in a higher commitment to treatment and greater commitment to treatment and greater participation by the patient in their own participation by the patient in their own disease prevention and health disease prevention and health improvement. improvement.
OHIS™ Benefits, cont.OHIS™ Benefits, cont.
A patient traditionally determines oral A patient traditionally determines oral care excellence from their subjective care excellence from their subjective interpretation of the clinical facility, interpretation of the clinical facility, service experience, resolution of service experience, resolution of symptoms or changes perceived with symptoms or changes perceived with the senses, and the whiteness of their the senses, and the whiteness of their teeth. teeth.
A patient could, for the first time, A patient could, for the first time, determine quality care by the change determine quality care by the change from pre-treatment to post-treatment from pre-treatment to post-treatment scores. scores.
SummarySummary
OHIS™ is an efficient, effective, and OHIS™ is an efficient, effective, and accurate method to:accurate method to: Document a periodontal conditionDocument a periodontal condition Diagnose periodontal diseaseDiagnose periodontal disease Predict a future periodontal disease Predict a future periodontal disease statestate Determine treatment dynamicallyDetermine treatment dynamically Communicate with a patientCommunicate with a patient
Summary, cont.Summary, cont.
OHIS™ was designed for clinical OHIS™ was designed for clinical utility by:utility by: Providing accurate and valid diagnostic, Providing accurate and valid diagnostic,
risk, and treatment informationrisk, and treatment information Utilization takes little time and fits Utilization takes little time and fits
within normal procedures and work flow.within normal procedures and work flow. OHIS™ should be used routinelyOHIS™ should be used routinely OHIS™ can improve oral health care OHIS™ can improve oral health care
quality and preserve the status of quality and preserve the status of the private practice clinicianthe private practice clinician
www.previser.comwww.previser.com
Click to downloadClick to download
Contact Contact InformationInformation
Web site URLWeb site URL www.previser.comwww.previser.com
Online supportOnline support http://http://support.previser.comsupport.previser.com
Support by phoneSupport by phone 360.661.5763360.661.5763
Support by emailSupport by email support@previser.comsupport@previser.com
Corporate addressCorporate address
PreViser CorporationPreViser Corporation
20849 Cascade Ridge 20849 Cascade Ridge DriveDrive
Mount Vernon, WA Mount Vernon, WA 9827498274
Corporate phoneCorporate phone 360.941.4715360.941.4715
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