Patient stratification for preventive care in dentistry

Abstract

Prevention reduces tooth loss, but little evidence supports biannual preventive care for all adults. We used risk-based approaches to test tooth loss association with 1 vs. 2 annual preventive visits in high-risk (HiR) and low-risk (LoR) patients. Insurance claims for 16 years for 5,117 adults were evaluated retrospectively for tooth extraction events. Patients were classified as HiR for progressive periodontitis if they had ≥ 1 of the risk factors (RFs) smoking, diabetes, interleukin-1 genotype; or as LoR if no RFs. LoR event rates were 13.8% and 16.4% for 2 or 1 annual preventive visits (absolute risk reduction, 2.6%; 95%CI, 0.5% to 5.8%; p = .092). HiR event rates were 16.9% and 22.1% for 2 and 1 preventive visits (absolute risk reduction, 5.2%; 95%CI, 1.8% to 8.4%; p = .002). Increasing RFs increased events (p < .001). Oral health care costs were not increased by any single RF, regardless of prevention frequency (p > .41), but multiple RFs increased costs vs. no (p < .001) or 1 RF (p = .001). For LoR individuals, the association between preventive dental visits and tooth loss was not significantly different whether the frequency was once or twice annually. A personalized medicine approach combining gene biomarkers with conventional risk factors to stratify populations may be useful in resource allocation for preventive dentistry (ClinicalTrials.gov, NCT01584479).

Keywords: comparative effectiveness research; health care delivery; interleukin polymorphisms; oral health; periodontal disease; personalized medicine.

Conflict of interest statement

Conflicts of Interest:All authors provided disclosure according to ICJME guidelines for the following: WVG has institutional grant support or consulted with the following organizations: National Institutes of Health, Colgate-Palmolive Co., Amgen, Inc., OraPharma, Inc., Organogenesis, Inc. Sunstar Corp., Geistlich Pharma, and Medtronic. KSK is a full-time employee, shareholder, and officer of Interleukin Genetics; and LDS is a full-time employee and shareholder of Interleukin Genetics. GWD is a consultant for Interleukin Genetics and is a member of their Scientific Advisory Board. TMB and AKC have no disclosures to declare.

Figures

Figure 1.

Patient enrollment. Of a total of 25,452 individuals to whom letters were mailed, 12,212 responses were returned, of which 9,927 were from those consenting to participate in the study. From these individuals, 9,872 were mailed enrollment kits, and 5,578 individuals returned enrollment kits for the study. After exclusion of individuals for specific issues noted above, 5,291 individuals were genotyped. In total, 5,117 individuals had complete questionnaires and genetic information for analysis.

Figure 2.

The influence of risk status and frequency of preventive visits on tooth loss events. Panel A demonstrates a 13.8% cumulative event rate for low-risk patients with 2 preventive visits annually (LoR-P2), in contrast to 22.1% in high-risk patients with 1 visit annually (HiR-P1). In low-risk (LoR) patients, 2 preventive visits per yr (LoR-P2) were no better than 1 preventive visit per yr (LoRP1) in reducing the percentage of patients with tooth loss events over 16 yrs. In high-risk patients, 2 preventive visits per yr (HiR-P2) significantly reduced the number of patients who had events, in contrast to 1 visit per yr (HiR-P1; p = .002). The ‘irregular care’ patients are individuals with limited numbers of visits during the indexing period (Table), while the patients considered to have periodontitis during the indexing period were identified according to high-frequency visits of > 14 during the six-year time frame. Panel B shows that the slope of the absolute difference between 1 and 2 preventive visits annually for HiR patients over time differed from 0a (HiR P1-P2 diff; p = .005). At 16 yrs, an additional 2.6/100 LoR patients experienced events as a result of 1 preventive visit per yr in contrast to 2, and the slope of the absolute difference between 1 and 2 preventive visits annually for low-risk patients over time was not different from 0b (LoR P1-P2 diff; p = .36). At 16 yrs, an additional 5.2/100 HiR patients had events as a result of 1 preventive visit per yr, in contrast to 2. In the first 11 yrs of monitoring, HiR patients displayed no difference in the event rate based on the frequency of preventive visits (p = .261). The trends between the 2 slopes were not different (p = .76).c

Figure 3.

Frequency of tooth loss events in patients relative to the number of risk factors. Panel A shows that the increasing numbers of risk factors at 5 yrs were not significant (trend p = .168), while from years 11 to 16 the trend was significant with increasing numbers of risk factors (p < .001). In Panel B, event rates were not different by preventive visit frequency for patients with diabetes alone or smoking alone (p = .296 and p = .179, respectively), whereas event rates for patients with the IL-1 genotype alone differed by frequency of preventive visits (p = .029). In patients with any 1 risk factor, 1 annual preventive visit increased the event rate in contrast to 2 (p = .007). Among all patients with 1 preventive visit annually, having any 1 risk factor in contrast to 0 did not increase event rate (p = .077), but having 2 or 3 risk factors increased the event rate in contrast to 0 (p < .001) and 1 risk factor (p = .005). Findings were similar among patients with 2 preventive visits annually, for 1 risk factor in contrast to 0 (p = .207), and for 2 or 3 risk factors in contrast to 0 (p < .001) and 1 risk factor (p < .001).