Periospectives July-September 2013 : Page 18

FOR YOUR PRACTICE Careful risk assessment leads to effective preventive care strategies A recent study published in the Journal of Dental Research provides new insight into the role of risk assessment in the prevention of periodontitis. In the study titled “Patient Stratification for Preventive Care in Dentistry,” patients were classified as high-risk for periodontal disease if they had one or more of three commonly observed risk factors: smoking, diabetes, or the Interleukin-1 (IL-1) genotype. Patients were considered low-risk if they did not possess any of the three risk factors. Loss of teeth was assessed as the consequence of moderate to severe periodontal disease. The findings indicated that low-risk individuals did not experience a significant difference in tooth loss rates whether they received one preventive dental visit or two. However, high-risk individuals saw better periodontal health outcomes when they visited the dentist twice a year or more. The study results support the need for careful risk assessment in determining treatment planning in order to help deliver personalized, preventive dental care. Recently the AAP spoke with the lead author of the study, AAP member Dr. William Giannobile. The study implies that patients at high risk for periodontal disease – those who had at least one of the three risk factors identified – may need more than two preventive cleanings per year. How should these patients be managed? Our study included patients who had never been diagnosed with periodontal disease and tracked their development over a 16-year period. During this time, we found that those patients classified as high-risk benefited from increased preventive treatments. As periodontists, we know that assessing for risk is a crucial part of delivering preventive care. We also know that patients who exhibit signs of advancing disease such as increased bleeding, progressive pocketing, and bone loss may require Dr. William V. Dr V Giannobile Dr. William V. Giannobile is the lead author of “Patient Stratification for Preventive Care in Dentistry,” which was published recently in the Journal of Dental Research . He previously served as an Associate Editor of the Journal of Periodontology for 10 years, has published extensively in periodontology, and has won numerous prestigious honors and awards including the AAP’s Distinguished Scientist award in 2010. He is the immediate past president of the AAP Foundation. Dr. Giannobile is the Najjar Endowed Professor of Dentistry and Biomedical Engineering at the University of Michigan. AAP Perio spectives | 18

Important Study Provides Insight On Risk Assessment And Preventive Care

Dr. William V. Giannobile

Careful risk assessment leads to effective preventive care strategies

A recent study published in the Journal of Dental Research provides new insight into the role of risk assessment in the prevention of periodontitis. In the study titled “Patient Stratification for Preventive Care in Dentistry,” patients were classified as high-risk for periodontal disease if they had one or more of three commonly observed risk factors: smoking, diabetes, or the Interleukin-1 (IL-1) genotype. Patients were considered low-risk if they did not possess any of the three risk factors. Loss of teeth was assessed as the consequence of moderate to severe periodontal disease.

The findings indicated that low-risk individuals did not experience a significant difference in tooth loss rates whether they received one preventive dental visit or two. However, high-risk individuals saw better periodontal health outcomes when they visited the dentist twice a year or more. The study results support the need for careful risk assessment in determining treatment planning in order to help deliver personalized, preventive dental care.

Recently the AAP spoke with the lead author of the study, AAP member Dr. William Giannobile.

The study implies that patients at high risk for periodontal disease – those who had at least one of the three risk factors identified– may need more than two preventive cleanings per year. How should these patients be managed?

Our study included patients who had never been diagnosed with periodontal disease and tracked their development over a 16-year period. During this time, we found that those patients classified as high-risk benefited from increased preventive treatments. As periodontists, we know that assessing for risk is a crucial part of delivering preventive care. We also know that patients who exhibit signs of advancing disease such as increased bleeding, progressive pocketing, and bone loss may require More intensive and frequent treatment. As a result, I believe that many existing guidelines we hold for high-risk patients, such as recommending three to four preventive visits per year, will continue to hold true. As more risk assessment tools become available for dental professionals, combined with increased patient education, our ability to deliver personalized periodontal management will improve.

Will these findings affect how dental professionals perform comprehensive periodontal evaluations?

Risk assessment is a key component of the comprehensive periodontal evaluation. Based on this study, I hope that practitioners will continue to consider whether or not an individual has a greater risk for progressive periodontal disease and tooth loss in their treatment planning. The researchers of this study believe that the consideration of clinical, systemic, and genetic markers of disease can assist us in better customizing our diagnoses and subsequent therapy strategies for patients.

Of the three risk factors included in this study, does one affect the development and progression of periodontal disease more than the others? Why?

We have known that smoking is a major risk factor for periodontitis and tooth loss for many years. We noted that about two-thirds of the patients in the study who lost the most teeth were IL-1 genotype positive smokers. While smoking, diabetes, and genetics were not strong risk factors individually, when combined with another risk factor, the overall risk for tooth loss increased. Having two or more risk factors, but not any single risk factor, also increased the cost of dental care.

Should patients expect genetic screening at the periodontist’s office?

It is clear that genetics play a very important role in periodontal disease susceptibility. Hopefully, at some point in the future, there will be genetic, cellular, and microbial biomarkers that we will have at our disposal to better monitor the disease process. The use of genetic testing is becoming more acceptable to both patients and practitioners since these types of tests are being used to customize care in other aspects of medicine. Periodontists can focus resources towards Those patients who are considered high risk, while reducing “over-treatment” of individuals who are not very susceptible to disease.

What do these findings mean for periodontal practitioners?

Overall, these results should not come as a surprise to periodontal practitioners. Our clinical expertise over the years has reinforced that patients have differing propensities for risk of periodontal disease and subsequent tooth loss. This study solidifies that different disease susceptibilities are real and can be adapted for specific preventive strategies. The implications of the study may help identify a large set of patients who are at minimal risk of disease who can be safely managed in the general dentist’s office. Those patients with several risk factors can receive specialized preventive care and definitive disease management. The findings will help personalize our periodontal preventive regimens with our increasing knowledge of the risk factors.

Did any of the findings surprise you?

We were surprised to see how as the number of risk factors increased, the tooth loss rates increased. We knew smoking, diabetes, and genetics were important as individual risk factors, but were intrigued to see that when the risk factors were coupled together, increased rates of tooth loss occurred. For instance, to see a single gene like IL-1 have such an effect when paired with major risk factors such as smoking and diabetes was interesting.

What future research would you like to see in this area?

We know that periodontal disease is a multi-factorial disease controlled by multiple genes. Our study was more of a proof-of-principle examining the role of a single gene for personalized dentistry application. Periodontal disease pathogenesis is likely driven by dozens of genes in response to microbial infection and it will be interesting to look at multiple genes for the development of disease risk signatures, as well as biomarkers that can examine real-time assessment of disease activity. The results of such research can improve our ability as practitioners to identify risk and also examine how well our treatments are performing, especially in disease-susceptible individuals.

Dr. William V. Giannobile

Dr. William V. Giannobile is the lead author of “Patient Stratification for Preventive Care in Dentistry,” which was published recently in the Journal of Dental Research. He previously served as an Associate Editor of the Journal of Periodontology for 10 years, has published extensively in periodontology, and has won numerous prestigious honors and awards including the AAP’s Distinguished Scientist award in 2010. He is the immediate past president of the AAP Foundation. Dr. Giannobile is the Najjar Endowed Professor of Dentistry and Biomedical Engineering at the University of Michigan.

Read the full article at http://onlinedigeditions.com/article/Important+Study+Provides+Insight+On+Risk+Assessment+And+Preventive+Care+/1500286/174530/article.html.

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