Care or Scare Pathways?

Posted 27/03/2014

seminar
Juliette Reeves reports from Iain Chapple’s presentation at the Up To Date Scientific Exchange Seminar in London

The Up To Date Scienti!c Exchange Seminars from Oral-B are back again this year with the first took place on 7 November at the Pullman London St Pancras Hotel. Hosted by Dr Stephen Hancocks, Professors Iain Chapple and Avijit Banerjee brought us all up to date with the latest concepts in periodontal risk and oral health assessment and advances in technologies that complement minimally invasive dentistry.


A changing world

This year, Professor Iain Chapple presented a critical appraisal of 21st century dentistry by discussing care pathways, risk and oral health assessment and addressing the taxing issue of ‘over-regulation’. He started by discussing the importance of measuring risk and how, unless it is done in a proportionate manner, can waste time, money and create stasis in healthcare provision. He also discussed wellness models of care and described a risk-based approach to oral health assessment that has received excellent feedback from primary care pilot practices outwith the NHS. Finally, Iain discussed risk factors for periodontitis, peri-implantitis and periodontitis as a risk factor for systemic diseases.


The global population demographic is changing, falling fertility rates and fewer children per female mean that the number of those above the age of 65 is signi!cantly increasing. For the !rst time in history, people aged 65 and over will outnumber children under the age of five. This trend is emerging around the globe. Today, almost 500 million people are aged 65 and over, accounting for 8% of the world’s population. This is set to double over the next 40 years. This demographic accounts for 70-75% of the spend in the public healthcare system. The UK Adult Dental Health Survey shows 45% of the population have periodontal disease, with those aged over 65 showing a prevalence rate of up to 60%.


With this in mind, Iain went on to review the various models the NHS has used to deliver dentistry. These include fee per item, units of dental activity (UDAs) and capitation pilots, all of which created problems; ranging from over-prescription through to under-prescription and supervised neglect. He then asked the question: ‘What if we measure it?’
If we cannot measure disease we cannot control, manage or improve the system. Measurement however, needs to be proportionate otherwise, instead of being able to treat our patients, we can become engulfed in red tape and paperwork. Over-regulation is time consuming and can be costly; as illustrated by the Care Quality Commission (CQC) and the revisions made to HTM 01-05 over the years.

Shift
Iain then went on to look at the core principles of the new contract being piloted in the UK. These pilots are playing a vital role in overhauling the dental contract, by shifing the emphasis in dental care to a more preventive approach, paying dentists for good oral health rather than number of procedures they do. The core tenets of the new contract include comprehensive oral health assessment, and care pathways driven by RAG scores (red, amber, green risk assessment). This will encompass a review of the patients’ biological and behavioural response. As patient scores improve, advanced care options will be implemented where required. Three pathways of care will be introduced: emergency care, single course of treatment and continuing care pathways.
The question of the need for risk assessment was then discussed. The concept of risk assessment has been used in medicine for years, for example the American Heart Association introduced risk assessment in 1999 and the WHO stated: 'The reliable and comparable analysis of risks to health is key to the prevention of disease'. In other words we can’t practice prevention without risk assessment. Iain then went on to observe that risk screening will underpin care pathways in dentistry, in addition to being needed for legal protection.
While the new contract has had favourable acceptance rates from both patients and clinicians in the pilots, the collection of data and providing a comprehensive oral health assessment within the time restraints of a busy practice, has been a challenge for many practitioners. Iain then went on to demonstrate a risk and disease scoring programme that has recently been incorporated in the Denplan Excel model. The Denplan Excel Previser Patient Assessment (DEPPA) uses Previser’s online risk calculator and the oral health assessment to provide a risk and disease score with treatment recommendations for the clinician and visual representation of current health and improvement scores for the patient.


Risk factors

Iain then went on to highlight that key risk factors for the development of periodontal diseases are now known to include genetics, age, nutrition, smoking, the presence of diabetes and stress. Rosling et al demonstrated that by evaluating disease progression in normal and high susceptibility patients and providing an SPT (supportive periodontal therapy) programme over 12 years, bone and attachment levels remained stable in the high risk group and bone loss or attachment loss was prevented in the normal group. He explained that this demonstrates the concept of risk as the third dimension in prevention and treatment strategies. Where increased risk is present, a more proactive system of review and early treatment is required. Conversely, when decreased risk is present less treatment is required.

Iain reminded us that the strongest risk factors for peri-implantits include: poor oral hygiene, a history of periodontitis and cigarette smoking. He suggested that implant failure needs to be rede!ned as the presence of progressive bone loss. Studies show failure rates of 16% at best and 55% at worst. Once peri-implantitis is established, response to treatment is unpredictable, unlike periodontal disease. Renvert et al observed that: 'The progression of peri-implantitis is more akin to that seen for deep furcations than other periodontal lesions. This may be due to accessibility di$culties in both situations’.

Finally, Iain addressed periodontitis as a risk factor for systemic diseases. The Joint EFP and AAP Workshop on Periodontal and Systemic Diseases concluded that there is signifcant evidence of the effect of periodontal disease on systemic health. This workshop in November 2012 concluded that there is strong evidence for an increased risk of atherosclerotic CVD, diabetes complications and poor glycaemic control in patients with periodontitis, mediated via oxidative stress and systemic in&ammation.

Iain concluded that an integrated wellness approach to oral and systemic health is the future for dental profession and that risk assessment will be at the centre of our practice.