Numbers Don't Lie Trisha O’Hehir, RDH, BS, Editorial Director, Hygienetown Magazine

What do you do when a patient says, “I just want my teeth cleaned?” How do you respond when you know the dentist doesn’t want you to “upset” the patient by telling the whole story about what you see. You’ll hear, “It’s not that bad, just do the best you can and don’t scare them with talk about periodontal disease.”

Of course, not all dentists overlook the importance of early intervention for periodontal disease. Some may actually be more anxious to treat than you are. You see a few 4 mm areas and bleeding and suddenly the patient is scheduled for four quadrants of scaling and root planning and you feel as though you’re overcharging and over treating.

How do you communicate with the dentist about periodontal disease and then agree about the best course of treatment for the patient? Most of the time it seems dentists and hygienists are speaking different languages. That’s not so unusual since dentists spend their day in a repair mode and hygienists spend it in more of a preventive mode, both looking at the same things but from different perspectives.

If you’re faced with periodontal disease when a patient is scheduled for a “cleaning,” you need an objective way to evaluate the data you collect. It needs to be as easy as checking for blood pressure or cholesterol levels.

Wouldn’t it be nice to have an easy way to determine each patient’s periodontal score? To know their disease severity and also their risk level for further disease? If you’re dreaming, why not throw in a treatment plan based on the findings? Is it possible that such a product exists?

You’re not dreaming. You now have an easy-to-use, inexpensive tool available to do all of the above and more. If you have access to the Internet, you have access to a new product that will help you solve these problems. It’s the PreViser Oral Health Information Suite™. This “suite” of software programs allows you to determine two periodontal scores for your patients – their risk score and their disease severity score. Ranging from 1 to 5, the risk scores tell the clinician and patient how hard they have to work to control this disease. Disease severity scores are between 1 and 100 and reflect the continuum from gingivitis to advanced periodontitis. Using a quantitative number (1 to 100) in addition to a Case Type will allow improvements to be realized with a number change, which provides encouraging feedback to patients and clinicians.

The best part is the price of PreViser––$6 per patient for as many evaluations as you want during one year for that patient! That’s not a typo, it’s only $6 per patient for his/her risk score, disease severity score, treatment plan and patient online tutorials. This has been in research, development and testing by a team of periodontists for over 10 years, and now it’s available online at PreViser.com.

One of the founders of this new technology is Periodontist, Roy Page. Some of you will recognize his name from the textbook he authored on periodontal disease and his many research publications. Roy Page, DDS, PhD is Professor Emeritus in both Periodontics and Pathology at the University of Washington, and director of the Regional Clinical Dental Research Center at UW.

HT: Dr. Page, the PreViser technology is very exciting. Do you think it will change the practice of dental hygiene?

RP: PreViser will definitely change the practice of dental hygiene – for the better. Hygienists using this tool will have a far greater role in management of periodontal disease. They will become the central focus of the periodontal care in the general practice. The dentist, as the team leader, must be supportive, but it will be hygienist’s role to incorporate this new software technology into the practice.

Hygienists are excited about this product because it provides a single language to discuss periodontal issues and treatment with the dentist. It will also make discussions with the patients easier. The PreViser tool provides an objective evaluation and therefore patients readily accept the risk number and the disease severity number. People relate to numbers. Knowing their numbers gets them involved. They know their blood pressure; they know their cholesterol. Now they’ll know their periodontal disease scores and look for improvement in the numbers. They’ll know whether they’re on the right or wrong path depending on how the numbers change over time.

HT: How did you get involved with this project?

RP: In the mid-1999s, as the Washington Dental Service Distinguished Professor of Dentistry at UW, I was responsible for organizing and presenting a scientific meeting for dental clinicians in the Northwest. The focus of the meeting was caries and periodontal disease, dealing especially with diagnosis, risk and susceptibility. Periodontists Drs. Randy Nolf and Carole Hildebrand had traveled across country to participate in the meeting, talked to me about their endeavor to develop a disease management model of periodontal care as an alternative to the traditional repair model. After extensive discussion, they invited me to join their think-tank of periodontists, who had been working on the project for about a year, I was happy to do so. The 10 periodontists involved in this project used both research and their extensive clinical experience to develop and fine-tune this product. It’s exciting to see such efforts lead to a product that will so favorably impact oral health.

HT: Are there any technology folks involved?

RP: Many of the periodontists involved are whizzes with technology and developed the technology needed to get the project off the ground. Dr. John Martin is a mathematician as well as a periodontist and his expertise with numbers and algorithms was invaluable in the development of both the risk score and the disease severity score. Of course, now there are other technology experts involved who understand what we’ve done and what we want to do and they are making it happen.

HT: How does the PreViser actually work?

RP: It’s very simple and uses the information clinicians already gather about their patients. Either at the time of examination or afterwards, select information is entered into the form online. Nine areas are covered: patient’s age, smoking history, diabetes, history of periodontal surgery, pocket depths, furcation involvement, restorations or calculus below the gingival margin, radiographic bone height, and vertical bone loss. We will soon be interfacing with existing practice management software systems, so entering the necessary information will be even easier.

After the “Enter” button is pushed, it only takes about a minute to get the results of the Risk Score, Disease Severity Score and treatment recommendations. Two different reports are available; one for the dentist and the patient’s chart, and the other, written in layman’s terms, for the patient to take home.

HT: Do you feel that PreViser’s risk scores are accurate and, if so, why?

RP: Yes, we believe the scores accurately predict what will happen. We used records of more than 500 people upon whom comprehensive oral examinations with radiographs had been conducted every three years over a period of 15 years. We used the baseline examination records to calculate a PreViser risk score for each person, and we compared the risk prediction with the actual periodontal status at years 6, 9 and 15. We used mean radiographic alveolar bone loss and tooth loss as measures of periodontal disease. The risk scores were right on target in predicting the presence and progress of periodontitis. This study was published in the May 2002 issue of the Journal of the American Dental Association.

HT: Why was the decision made to house this technology online rather than simply selling a software package to dental offices?

RP: If we sell the product as it is today, updates will be difficult and costly to share with users. With the online format, improvements are integrated immediately and users benefit from it right away. Of more importance, the online format allows us to collect and utilize treatment outcomes information. Each dental office has its own incredible database of information, but that information is not in a form that can be used to determine which treatments work best and which do not. With a worldwide database, we will soon have enough treatment outcomes information to advise clinicians with precision what outcomes can be expected from use of any specific treatment for any given set of clinical conditions.

This information will provide quantitative evidence upon which clinicians can base diagnostic and treatment decisions. Clinicians will truly have a way to manage disease rather than reacting with only repair-type treatments.

HT: Don’t dentists and hygienists feel that a computer can’t replace their expertise and ability to assess their patients’ risk and periodontal disease state?

RP: Oh, yes, that is true for some, but the research proves otherwise. We tested the validity of the risk scores determined by expert clinician judgment for over 100 patients. Clinically calibrated hygienists gathered the data on these patients so expert dentists and periodontists would be able to objectively look at each case and assign a risk score. These scores were then compared with scores determined with PreViser’s validated risk assessment tool. Expert clinicians included the group of 10 periodontists who developed the system, a panel of six distinguished and well-known periodontists and a group of 36 general dentists. The results showed that the expert clinician scores agreed with the PreViser-assigned scores only 20% of the time and that expert clinicians greatly under estimated the level of risk, especially for high-risk patients. PreViser’s risk and disease scores provide, for the first time, quantitative evidence upon which clinicians can base their decisions.

HT: How many offices are already using this new technology?

RP: Just as Hygienetown.com started with hundreds of members and is now counting members by the thousands, PreViser is being used by hundreds of offices and we look forward to the day we can say thousands of offices are using it. This technology requires a paradigm shift in thinking. As more hygienists and dentists see the value of PreViser, they will provide this service for their patients.

Another influence will be the insurance companies. Rather than sending radiographs and letters to insurance companies to request authorization for treatment, it may be as easy as submitting PreViser scores online to receive instant authorization. A change of this magnitude would impact thousands of offices.

HT: I understand the price of PreViser is just $6 per patient, per year for unlimited evaluations. Do you have a fee range that dentists are charging for this service?

RP: We have made an effort to keep our fee so low that money wouldn’t keep people from using this service to manage the periodontal care of their patients. It is my understanding that some offices include the $6 cost in the exam fee while others may charge a fee from $15 to $30.

HT: I understand that PreViser also provides caries and oral cancer risk assessment. This technology could be used with so many chronic infectious diseases. Are there plans to expand beyond dentistry?

RP: Yes, PreViser can also calculate a caries risk score and an oral cancer risk score. These are included free for all patients enrolled in the PreViser system. This technology is patented and we do have plans to expand to other areas, but right now our focus is dentistry. Maybe one day Oprah will be doing this interview about all her medical and periodontal PreViser scores and how valuable they are for managing oral health and general health. These scores will enable clinicians to provide targeted therapy for those who are at greatest risk and provide a disease severity score to monitor treatment success. This technology will result in better management of periodontal disease and ultimately, better oral health.

HT: PreViser will definitely make a difference for hygienists as they strive to provide the best possible care for their patients who sometime only want a “cleaning” when disease is present. The PreViser Risk Score, Disease Severity Score and treatment suggestions will provide a framework for discussions with patients and employers about periodontal disease and the best course of treatment. Dr. Page, the PreViser is making hygienist’s dreams come true.