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Defining Periodontitis for “Person-Centered Care”
The concept of “total patient care” in dentistry has evolved from describing an academic block curriculum of isolated techniques and courses to an integrated curriculum with the goal of improving treatment outcomes, to being considered part of the medical record for federal and third-party reimbursement. The systemic link for dentistry to be part of the medical record is primarily through inflammation, the first manifestation of a periodontal condition with the initiation of a subsequent inflammatory cascade involving functional mediators that have the potential to go beyond the original site of concern. This connection of the original inflammatory site and its mediators permeating local tissues to distant sites may link the medical aspects of the encounter.
The link between oral and systemic disease may warrant the amalgamation of the healthcare record to include all conditions being diagnosed, treated, and maintained. This mandates that the condition be accurately diagnosed and appropriately treated, including long-term periodontal maintenance, and properly documented in the patient’s record. The oral health of the patient should be integrated into the medical record to reflect the “total patient care” concept so that patients can be a meaningful component of their own health. The patient’s record or source document can be termed a dental, health, and/or medical record, and if all combined and electronic, termed the “patient’s medical/healthcare home.”
In terms of the Affordable Care Act1 and its cornerstone philosophy of patient-centered care, patients need to be informed of and are entitled to the information in their medical home. Furthermore, a means to educate patients should be provided to them whereby they become a part of the process to improve their own health. The terms and descriptors used in the medical home should be transparent to the patient and other providers as well as those involved in reimbursement to maximize the information transfer. The effect of an engaged person/patient is reflected in the term “person-centric care” where it is “the person” who is vigilant and responsible for his/her health. This approach describes the transformation of healthcare to “health maintenance” and away from disease management.
In practice, this approach includes prevention, early diagnosis, and continued maintenance of health, and, for the topic discussed in the following article (p.432), the periodontium. These aspects along with risk management comprise directives of the new health reform act that leads toward the patient spending the majority of time overseeing his/her health by minimizing risks, utilizing preventative techniques, and having appropriate professional consultations/examinations to detect early signs of (periodontal) breakdown. Prescriptions for care would be entered into the patient’s record and uploaded for visual assessment by his/her dentist, primary care physicians, and other healthcare providers. A periodontal diagnosis should be precisely, clearly, and unambiguously defined for all who are involved in the patient’s progress, including the patient. This is what is now defined as “total care,” where the process of healthcare to health is both dynamic and inclusive of all the stakeholders involved in maintaining and optimizing the health of the “person.”
A Transformative View
Incorporating risk assessments into the dental paradigm of the clinical encounter requires a transformative view of how dentists assess, diagnose, manage, and treat a condition. Risk assessment, in the context of “total person/patient care,” takes the long view of the person’s health as opposed to the acute, surgical approach that has historically defined dentistry.
The National Health and Nutrition Examination Surveys (NHANES) underestimated the prevalence of periodontitis by 50% or more, and furthermore, the findings suggest that NHANES protocols produced high levels of misclassification of periodontitis cases and, thus, have low validity for surveillance and research.2 The need for consistency in definitions of terms is further stated in a position paper commissioned by the European Association of Dental Public Health in which a systematic review of the literature revealed that only 15 of 3,472 studies gave a definition of periodontitis and indicated how it was measured.2,3 The literature further documents the lack of agreement on periodontal terminology, which is the basis for the treatment phase of the study that follows on p.432.3-6
The Practitioners Engaged in Applied Research & Learning (PEARL) Network was the first practice-based research network (PBRN) to conduct a study directed at periodontics, and the Network reported on the diagnosis phase of the study while funded under the National Institute of Dental and Craniofacial Research/National Institutes of Health (NIDCR/NIH).7 In the following article the PEARL Network demonstrates how a lack of consensus for periodontal terms can affect the outcome of treatment. The study topic was initiated by general practitioners as part of the PBRN design, where practitioners are more likely to accept the findings, since they themselves generate the data and can further disseminate the findings to practitioners at large.
The study reports findings generated by general dentists with the outcome of over-diagnosis in health (43%); gingivitis (35.9%); mild periodontitis (15%); and moderate periodontitis (5.2%).7 Misclassification of severe periodontitis was minimal as the clinical descriptions of the condition are more distinct and noted. The authors’ findings are somewhat in line with recent data on breast cancer where “analysis of data on mammography screening over the past 30 years suggests that of all breast cancers diagnosed, 22% to 31% are over-diagnosed.”8,9
The importance of well-defined and agreed upon terms for describing degrees of periodontitis severity and extent cannot be understated if the information is to be used by healthcare providers as well as the patient. An essential component of “total care” is “the ability of person/patient information to be utilized by a broad number of healthcare professionals so that treatment is considered in its totality making it a true confluence of health information for the benefit of the patient and their providers.” This information defines the medical home concept in terms of meaningful use as described in the Affordable Care Act.1 The authors’ study indicates that the clinical interpretation of periodontal conditions is constrained by definition and/or procedural codes or both. The study’s general dentist findings was the basis for a recent study and supports the literature, which has documented the need for improvement in the classification of periodontitis.10
The PEARL clinical findings along with what has been described in the literature supports the need for a consensus meeting with all involved stakeholders to produce periodontal definitions that are meaningful to healthcare providers when viewing a patient's medical home record. Definitions should assist in leading to diagnosis coding, which would allow for a more seamless integration into the medical home. It may also require a two-tier system, one more global for healthcare providers and one more specific for dental referrals. However defined, periodontal definitions should convey to the patient the diagnosis, treatment, and risks and be interpretable to healthcare providers. Dentistry lends itself to “person-centric care” in that the burden for improvement and maintenance is on the person to be compliant in maintaining his/her oral health between dental visits. Compliance will be the primary outcome of health apps in the future, which may be constantly monitoring our health data, predict disease, and warn us when we are about to get sick. They will advise us on what medications to take and to improve our lifestyle and habits. The “person” will have the pivotal role of managing his/her own health outcomes.
The PEARL Network provides an infrastructure for meaningful change through its structure based upon Good Clinical Practice (GCP), which ensures data integrity for generalizability of its clinical findings. Data is derived from conducting person-centric clinical trials consisting of comparative effectiveness studies to be incorporated in best practice, expanding label indications, and pharmacovigilance studies.11,12 PEARL can provide a venue for knowledge transfer within the network and beyond and function as a catalyst to initiate change in practice and healthcare policy.13 Traditionally, dentistry follows medicine in healthcare reform, however, defining periodontitis may prove to be an opportunity for dentistry to establish a new pathway in healthcare policy. The following manuscript presents comments toward this goal.
About the Authors
Frederick A. Curro, DMD, PhD
Practitioners Engaged in Applied Research and Learning (PEARL) Network
New York, New York
John Martin, DDS
Private Practitioner in Periodontics and PEARL Practitioner-Investigator
State College, Pennsylvania
Chief Science Officer
Mount Vernon, Washington
Frederick Naftolin, MD, PhD
Professor of Obstetrics and Gynecology
Environmental Medicine Director
Reproductive Biology Research Co-Director
New York University Interdisciplinary Program in Menopause Medicine
New York, New York
Ashley C. Grill, RDH, MPH
New York, New York
Clinical Assistant Professor
Dental Hygiene Programs
New York University College of Dentistry
New York, New York
Van P. Thompson, DDS, PhD
Tissue Engineering and Biophotonics
King’s College London Dental Institute
1. Public Law 111–148. 111th United States Congress. Washington, DC: United States Government Printing Office. March 23, 2010. Retrieved 2013-12-22.
2. Leroy R, Eaton KA, Savage A. Methodological issues in epidemiological studies of periodontitis–how can it be improved? BMC Oral Health. 2010;10:8. doi:10.1186/1472-6831-10-8.
3. Savage A, Eaton KA, Moles DR, Needleman I. A systematic review of definitions of periodontitis and methods that have been used to identify this disease. J Clin Periodontol. 2009;36(6):458-467.
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7. Martin JA, Grill AC, Matthews AG, et al. Periodontal diagnosis affected by variation in terminology. J Periodontol. 2013;84(5):606-613.
8. Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med. 2012;367(21):1998-2005.
9. Rosenbaum L. Invisible risks, emotional choices–mammography and medical decision making. N Engl J Med. 2014;371(16):1549-1552.
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11. Curro FA, Robbins DA, Naftolin F, et al. Person-centric clinical trials: defining the N-of-1 clinical trial utilizing a practice-based translational network. Clinical Investigation. 2015;5(2):145-159.
12. Karl EH, Curro FA. Medical histories: a case report of pharmacovigilance for dentists to participate in a drug safety program.” Clinical Advances in Periodontics. 2013;3(1):40-43.
13. Institute of Medicine. Sharing Clinical Trial Data: Maximizing Benefits, Minimizing Risk. Washington, DC: The National Academies Press; January 2015.