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A new tool offers a computerized, evidence-based approach to calculating perio risk - By Daniel McCann
Until a year ago, Thomas Schoen, D.D.S., of Wabasha, Minn., was used to going it alone when it came to diagnosing his patients' periodontal problems. He regarded the standard guidelines for soft-tissue management programs—which are primarily based on the number of pockets, their depth and the presence of bleeding—as much too simplistic.

While such plans might suggest that clinicians also consider factors such as smoking and oral health habits, "they don't tell you how or when to take them into account," continues Dr. Schoen. "For example, how much weight do you give to the fact that a person has diabetes that's controlled? Is that an issue or not? And what's the impact of someone who smokes five packs of cigarettes a day vs. three cigarettes? Those types of things are hard to quantify—especially when you start mixing three or four risk factors together—and come up with an appropriate treatment plan."

So for the better part of his 20-plus years in practice, Dr. Schoen relied on his own judgment and growing experience—often to his hygienists' baffled frustration. "I was driving them crazy. They'd say, 'The last patient who had 5-millimeter pockets you did surgery on, but for this one you're only doing a prophy with a little root planing?'"

Going high-tech

Then last summer, Dr. Schoen learned about a new company called PreViser Corp., based in Mount Vernon, Wash., which was founded to provide dentists with a computerized, evidence-based approach to calculating patients' periodontal disease risk and severity. (The company also assesses patients' risk for caries, root surface defects and tooth fracture.)

Dr. Schoen learned that dentists interested in the service can go to the company's Web site, www.previser.com, and download an application called the Oral Health Information Suite. Clinicians then create a HIPAA-compliant patient record and enter nine data points (smoking history, presence of diabetes, record of periodontal surgery, deepest pocket, maximum bone loss per sextant, age, lesions, furcations and bleeding on probing).

At that point, says Carl Loeb, PreViser's chief operating officer, "the dentist hits the submit button and sends us the data over the Internet." Each patient's score for periodontal disease is algorithmically calculated. "We are taking the risk factors, such as smoking and diabetes status, that have been identified and researched for periodontal disease and we are weighing the impact of those based on the patient's age, pocket depths and bone loss measurements," says Mr. Loeb.

PreViser generates two scores for periodontal disease: risk is gauged on a one-to-five scale of increasing jeopardy, and for patients with the disease, its severity is measured from one (low) to 100.

Patients' risk and disease scores are tabulated in a matter of seconds and rerouted to the doctor. (PreViser charges doctors an annual fee of $6 per patient for unlimited assessments.) "We're also able to suggest therapeutic interventions," says Mr. Loeb. "They are based on the state of the literature and organized according to those which are 'generally most effective,' those that 'may be effective' and those 'less likely to be effective.' The system is designed as a decision-support tool. We also collect the therapeutic interventions that have been performed since the last time a risk assessment was done, and based on changes in the risk and disease scores we can tell how effective those treatments were. And we use that data to modify the algorithms that assess risk, calibrate disease and recommend therapies. So the system learns from what is actually working."

Calculating risk

Mr. Loeb explains that the company's founders—among them, Roy Page, D.D.S., past president of the International Association for Dental Research and former editor in chief of the Journal of Periodontal Research—began working on the Periodontal Risk Calculator (PRC) in 1997.

In 2003 they patented the methodology. That same year a study of the accuracy and validity of the PRC, titled "Longitudinal validation of a risk calculator for periodontal disease," was published in the Journal of Clinical Periodontology (2003; 30; 819-827). The research centered on clinical records and radiographs of 523 people enrolled in the U.S. Department of Veterans Affairs' Dental Longitudinal Study of Oral Health and Disease, which covered 15 years. Patient data from their initial exams were entered into the PRC and risk scores ranging from one to five were calculated for each person. Researchers found the PRC to be a strong predictor of periodontal problems. For instance, "by year 15, 83 percent of subjects in risk group 5 had lost one or more periodontally affected teeth compared to 20.2 percent of subjects in group 2."

Scientists concluded that "risk scores calculated using the PRC and information gathered during a standard periodontal examination predict future periodontal status with a high level of accuracy and validity."

Another study, "Assessing Periodontal Disease Risk: A Comparison of Clinicians' Assessment Versus a Computerized Tool," published in the Journal of the American Dental Association (May, vol. 134, pps. 575-582), found the PRC to be more accurate than experienced clinicians' diagnoses: "Expert clinicians varied greatly in evaluating risk and, relative to the PRC, they appeared to underestimate periodontitis risk, especially for high-risk patients. … Use of the PRC over time may be expected to result in more uniform and accurate periodontal clinical decision-making, improved oral health, reduction in the need for complex therapy and reduction in health-care costs."

Those findings were key for Dr. Schoen as he considered the PreViser tool for his practice. "I looked at the studies before I leaped to make sure this was sound science." After scrutinizing the papers, he decided "this is what we really need to do."

Today, while Dr. Schoen's patient assessments are often in line with the PRC, the tool provides added data to back up his suggested treatments. "I might get back, for example, a response that says, 'We did a study that followed people with that set of parameters for 15 years, and those that went to dentist four times for gum surgery and scaling and root planing were healthy, whereas those who just had prophys or scaling and root planing ended up losing teeth.'"

Still, Dr. Schoen doesn't always rubber-stamp PreViser's suggestions. "I mean [the PRC] is like the gauges on an airplane. You're still flying the airplane, but instead of looking out the window and sticking your finger in the air to gauge your speed, this gives you a heckuva lot more information to make a much more informed decision. This also helps me know that I'm neither under-treating or over-treating patients."

Also, providing patients with a number for their disease risk and, if applicable, one for the severity of their disease (which can be charted over time to demonstrate the efficacy of treatments) helps make the doctor's findings tangible and easy to understand.

"Patient acceptance has been significantly higher [with the PRC]," Dr. Schoen reports. "More people are getting the recommended scaling and root planing, so my hygiene schedule, which used to have holes in it, is very full right now. The patients have a number to hang on to, and that's like a second opinion. Compliance is way up, too, and that's making my patients healthier, which helps me want to go to work."