Miller McEntire Periodontal Prognostic Index (i.e., “The Perio Report Card”) Usage in Practice

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© Springer Nature Switzerland AG 2020

S. Nares (ed.)Advances in Periodontal

1. The Miller McEntire Periodontal Prognostic Index (i.e., “The Perio Report Card”) Usage in Practice

Robert A. Levine1, 2, 3, 4   and Preston Dallas (PD) Miller5

Pennsylvania Center for Dental Implants and Periodontics, Philadelphia, PA, USA

Kornberg School of Dentistry at Temple University, Philadelphia, PA, USA

University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

University of Illinois at Chicago, Chicago, IL, USA

New York University School of Dentistry, New York, NY, USA
Robert A. Levine (Corresponding author)

Periodontal prognosisSmoking cessationCompliance to periodontal therapyPatient motivationPatient valueMMPPI

1.1 Introduction

The Miller McEntire Periodontal Prognostic Index (MMPPI), which the authors like to term “the Perio Report Card,” is a simple, powerful, evidenced-based, statistically validated, and accurate motivational tool [1] which can be used daily in clinical practice with all patients (Fig. 1.1). The current score sheet has undergone multiple modifications, and individual clinicians can make further modifications to suit their practice needs. Its usage is not limited to patients presenting with periodontitis but is routinely used with periodontally healthy patients which is reviewed below in Case #1. The benefits to the patient are that they better understand their long-term periodontal prognosis of 15 and 30 years. Accurate prognosis can be determined by scoring the most periodontally involved molar that you plan to keep. The strength of the MMPPI is that it translates clinical outcomes into patient value [2].

Fig. 1.1

MMPPI (Miller, Levine, Fava 2017)

1.2 Objectives and Application

The objectives of using this index include:
  • Motivating the patient to accept treatment, complete treatment, and make the patient aware of the importance of complying with periodontal maintenance [35] defined as the “Keys to Success.”

  • To simplify scoring so that the score can not only be determined by the dentist but also by trained auxiliaries. If performed by auxiliaries, it takes no chair time from the dentist. To help to train staff easily to score patients, it is recommended to review in a scheduled team meeting on the MMPPI (Parts 1 and 2).

  • To encourage patients to make lifestyle changes to improve their overall health. This would include smoking cessation and blood sugar control [6, 7].

  • To empower the whole “team” (dentists, dental assistants, dental hygienists, and case presenters) in its use in helping patients to attain better periodontal and systemic health as we are the “physicians of the mouth.”

  • To encourage the patients to refer family and friends.

For a better understanding of clinical scoring, the reader is referred to online videos and resources (see Footnote 1). Since smoking was the most significant factor, there is a video on smoking cessation on this site. Smokers should also be referred to support services for in-depth counseling and assistance.

For patients with diabetes mellitus or who are suspected of having diabetes mellitus, HbA1c values need to be evaluated. An in-office HbA1c testing kit should be readily available. If the patient has not been diagnosed with diabetes mellitus and the in-office HbA1c score is elevated, the patient should be referred to a physician for the diagnosis, as this is a medical diagnosis and not a dental diagnosis. By following these objectives, we can become more of a physician of the mouth rather than just simply performing traditional dental procedures [810].

Based on the study by Miller et al. [1], seven patient factors are highlighted to be scored that include (Fig. 1.1):

  1. 1.
    Furcation involvement of the molar to be scored:

    • none = 0,

    • 1 total furcation = 1 (does not matter if it is a Class 1, 2, or 3)

    • 2 total furcations = 2

    • T-T (through and through) furcation = 3

    (Note: Typically when furcations are charted, the severity is noted, i.e., Class 1, Class 2, and Class 3. This index only scores the number of furcations present, not the class or severity).

  2. 2.
    HbA1c levels:

    • <6% =0

    • 6.1–7.0% = 1

    • 7.1–8.0% = 2

    • 8.1–9.0% = 3

    • >9.1% = 4

    (Important note on scoring HbA1c: If the patient does not know their recent score, score the patient as a “2” until the patient’s blood work is received. Using the MMPPI thus motivates the patient to better understand their HbA1c score and control their diabetes by lowering their blood sugar.)

  3. 3.
    Mobility of the molar to be scored:

    • none = 0,

    • 1 = 1

    • 2 = 2

    • 3 = 3 (tooth is depressible)

  4. 4.
    Deepest probing depth in millimeters (mm) of the molar to be scored:

    • <5 mm = 0

    • 5–7 mm = 1

    • 8–10 mm = 2

    • >10 mm = 3

  5. 5.
    Molar type: 0–2:

    • Mandibular molar = 0 (either a mandibular first or second molar is not significant)

    • Maxillary first molar = 1

    • Maxillary second molar = 2

  6. 6.
    Smoking: either you smoke or do not smoke:

    • non-smoker = 0,

    • smoker = 4,

    (Note: Of all categories scored, smoking was by far the most significant negative factor in determining periodontal prognosis. Using the Cox Hazard Ratio, statistically a score of 4 was assigned for smoking. The overall objective is to keep the MMPPI score below a 5. When the score is 5 or less, statistically patients never lose teeth to periodontal disease [1]. For example, if a smoker has a score of 9, they have a 75% chance of keeping their teeth for 15 years (Fig. 1.1). If the patient stops smoking, the score becomes a 5, and they will have a 93% chance of keeping their teeth for 15 years (Fig. 1.1). While immediate cessation is desired, many patients will only stop smoking over a period of time (see online video on smoking cessation)) (see Footnote 1).

  7. 7.
    Age has a minimal and limited factor on periodontal long-term prognosis:

    • 1–39 years of age = 0

    • 40 or > years of age = 1

Scoring and prognosis: our clinical posttreatment “target” goal is an MMPPI score of < 5:
  • Score of 1 to 4 has an “excellent” prognosis

  • Score of 5 to 8 has a “good” prognosis

  • Score of 9 to 11 or greater has a “guarded” prognosis.

1.2.1 Keys to Success (Bottom Right of Fig. 1.1)

It is important to realize that the keys to success are not a promise of success but a guideline that allows the patient to succeed. All of these keys are the responsibility of the patient and if followed will produce a long-term favorable outcome. Until recently, the importance of cleaning the tongue has not been emphasized. Ninety-five percent of the bacteria left after brushing and interdental cleaning are on the posterior third of the tongue. It is impossible to remove these bacteria with a toothbrush without causing the patient to gag. To achieve this, a metal tongue scraper is required. For proper technique, view the online video on the importance of cleaning your tongue (see Footnote 1). For more information on how to further disinfect the mouth, an online video is available on the most effective, least expensive mouthwash (see Footnote 1).

Emphasizing the keys to success is an integral part of the initial examination. The goal/objective of getting to an MMPPI score of <5 does not happen without complying with all 5 of the keys to success (Fig. 1.1). If at periodontal maintenance the MMPPI score is elevated, the keys to success need to be reviewed to see in what area the patient is not compliant. For example, has the patient started smoking again?

Important Note on “Keys to Success”: As indicated in the title, this index is a periodontal report card. To further motivate the patient at the initial exam, taking a moment to give the patient a posttreatment target score has been found to be particularly motivational. The mnemonic phrase “If you want to keep your teeth alive, keep your MMPPI score below a 5” summarizes in lay-terms the objective of the target score. The patient should be scored at each maintenance appointment. Scoring even healthy patients demonstrates to the patient your concern for their overall oral health and reinforces the importance of periodontal maintenance in keeping their MMPPI stable. Thus the patient is more likely to accept aesthetically enhancing procedures such as veneers or periodontal plastic surgery. Although periodontal disease is a major cause of tooth loss, caries remains a significant factor, especially with the rising incidence of root caries. Today patients are on many more medications than in the past. Many of these medications cause dry mouth (i.e., medication-induced xerostomia, MIX), which is a major cause of root caries.

1.3 Case Examples

1.3.1 Clinical Case Example #1: Using the MMPPI in a Periodontally Healthy Patient (Amy: MMPPI Score at Initial Exam = 1): See Figs. 1.2, 1.3, 1.4 and 1.5

Amy presents to our periodontal practice (RAL) as a healthy (HbA1c <6% = 0) non-smoking (non-smoker = 0) 32-year-old female (age < 39 = 0) and a history of good compliance to preventative periodontal care at every 6 months frequency with her restorative dentist. She was referred for periodontal plastic surgery for root coverage #24 (Miller Class 2) and #25 (Miller Class 1) [1116] (Figs. 1.2 and 1.3). A complete periodontal charting was completed as part of the initial periodontal examination including probing depths, mobility of teeth, gingival recession, and occlusion. The summary of this visit is noted in her MMPPI that was reviewed “knee-to-knee and eye-to-eye” with her (Fig. 1.4). Her deepest periodontal probing depth was 4 mm on the distal of #3 (see Fig. 1.1: probing mm <5 mm = 0) with light bleeding upon probing. The scored tooth #3 had no mobility (zero mobility = 0), and a total MMPPI score was recorded as 1 (15-year periodontal prognosis of 98% and 30-year periodontal prognosis of 94%). As noted prior, the 15- and 30-year periodontal prognosis advised the patient of an excellent long- term prognosis of not losing her teeth due to periodontal disease. However, there is still the possibility of losing these two teeth due to continued attachment loss, root caries, and its sequela. The use of the MMPPI in Amy’s case is highly motivational for four reasons: she leaves the initial visit with our office with positive news on her overall case prognosis from a periodontal perspective (MMPPI = 1); it reinforces her restorative dentist’s referral for the recommended root coverage procedure; it motivates her to complete our combined recommendation of periodontal plastic surgical procedure for root coverage for teeth #24 and 25; and lastly it stresses the importance of continued periodontal maintenance visits with her dentist at his/her recommended frequency to keep her MMPPI below a 5. After discussing her MMPPI score of 1 and her excellent prognosis for 15 and 30 years, Amy shared with us that initially she thought that her “gum recession was the beginning of a cascading downhill course for herself from a dental standpoint.” After presenting her an excellent case prognosis, we then gave her the solution to her site-specific periodontal problem with the benefits of thickening the gingival tissues, widening the zone of keratinized gingiva with attempts at partial to 100% root coverage, thus improving the long-term prognosis of #24 and #25 [11, 16]. The clinical goal of 100% root coverage in a Miller Class 1 or 2 is protecting these two teeth from future root caries and additional periodontal attachment loss while thickening the soft tissue which creates a more favorable barrier in preventing future gingival recession. Amy scheduled and completed the recommended treatment (Fig. 1.5). As part of discussion with Amy, we also shared the concerns that we see daily with medication-induced xerostomia (MIX) in our aging patient population. MIX relates to clinical concerns for recurrent caries or what we see frequently in the non-compliant patient of multiple areas of deep interproximal or buccal root caries. As our healthy patients age, many will be given medications for systemic diseases such as HTN, diabetes, anxiety, depression, asthma, etc. which will have significant detrimental effects on exposed root surfaces such as seen in Amy’s case. Thus, this needs to be shared with a patient like Amy as their medical status may change as they grow older along with their systemic health and medications. These medications will significantly increase their susceptibility to MIX and subsequent root caries. This concern is illustrated in Case #2. Sadly, many in the medical profession are unaware of the harmful oral side effects caused by numerous medications they routinely prescribe. In all patients we recommend and stress the importance of the “Keys to Success” (bottom right of the MMPPI form) with good compliance to plaque control and their recommended periodontal maintenance frequency which in Amy’s case is twice a year with her general dentist [1720].

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Aug 28, 2021 | Posted by in Periodontics | Comments Off on Miller McEntire Periodontal Prognostic Index (i.e., “The Perio Report Card”) Usage in Practice
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