prognosis in periodontics

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Page 1: Prognosis in periodontics
Page 2: Prognosis in periodontics

PROGNOSIS

Page 3: Prognosis in periodontics

CONTENTS

Defination

Determination of prognosis

Type of prognosis

Factors affecting prognosis

Relationship between diagnosis and prognosis

Reevaluation of prognosis after phase I

therapy

Conclusion

References

Page 4: Prognosis in periodontics

Prognosis is the prediction of the probable

course, duration, and outcome of a disease

based on a general knowledge of the

pathogenesis of the disease and the presence of

risk factors for the disease.

Goodman et al

Page 5: Prognosis in periodontics

Made before treatment plan is established

Based on:

Specific information about disease

Previous experience

Confused with risk

Risk : Likelihood that an individual will get a

disease in a specified period

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DETERMINATION OF PROGNOSIS:

1> Excellent

2> Good

3> Fair

4> Poor

5> Questionable

6> Hopeless

(Mc Guire et al 1991)

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EXCELLENT

No bone loss

Excellent gingival condition

Good patient cooperation

No systemic / environmental factors

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GOOD

Adequate remaining bone support

Adequate possibilities to control etiologic

factors and establish a maintainable dentition

Adequate patient cooperation

No systemic / environmental factors or if

present well controlled

Page 9: Prognosis in periodontics

FAIR

Less than adequate remaining bone support

Some tooth mobility

Grade I furcation involvement

Adequate maintenance possible

Acceptable patient cooperation

Limited systemic / environmental factors

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POOR

Moderate to advanced bone loss

Tooth mobility

Grade I and II furcation involvement

Difficult to maintain areas

Doubtful patient cooperation

Presence of systemic / environmental factors

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QUESTIONABLE

Advanced bone loss

Grade II and III furcation involvements

Tooth mobility

Inaccessible areas

Presence of systemic / environmental factors

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HOPELESS

Advanced bone loss

Non-maintainable areas

Extractions indicated

Uncontrolled systemic / environmental

conditions

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OVERALL VERSUS INDIVIDUAL TOOTH PROGNOSIS

Factors that may influence the overall prognosis include

Patient age

Current severity of disease

Systemic factors

Smoking

Presence of plaque & calculus

Patient compliance

Prosthetic possibilities.

Determined after the overall prognosis and is affected by it.

INDIVIDUAL TOOTH

PROGNOSISOVERALL PROGNOSIS

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Should treatment be undertaken?

Is it likely to succeed?.

When prosthetic replacements are needed, are the

remaining teeth able to support the added burden

of the prosthesis?

Page 15: Prognosis in periodontics

Prosthetic/ Restorative

Factors

Local FactorsSystemic/ Environmental

Factors

Overall Clinical Factors

Abutment selection

CariesNonvital teethRoot resorption

- Plaque/calculus- Subgingival restorations- Anatomic factors:

Short, tapered rootsCervical enamel projectionsEnamel pearlsBifurcation ridgesRoot concavitiesDevelopmental groovesRoot proximityFurcation involvement

- Tooth mobility

SmokingSystemic

disease/conditionGenetic factorsStress

Patient ageDisease severityPlaque controlPatient compliance

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OVERALL CLINICAL

FACTORS

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1.PATIENT AGE

Comparable CT attachment and alveolar bone –

prognosis better for older

Younger patient – shorter time – more periodontal

destruction

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2. DISEASE SEVERITY

Determination of :

Pocket depth

Level of attachment

Degree of bone loss

Type of bony defect

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Prognosis for horizontal bone loss dependson the height of the existing bone.

Angular defects - if the contour of theexisting bone & the number of osseouswalls are favorable, there is an excellentchance that therapy could regeneratebone to approximately the level of thealveolar crest.

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When greater bone loss has occurred on one surface

of a tooth, the bone height on the less involved

surfaces should be taken into consideration when

determining the prognosis.

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3. PLAQUE CONTROL

Bacterial plaque - primary etiologic factor

associated with periodontal disease.

Effective removal of plaque on a daily basis by

patient.

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4. PATIENT COMPLIANCE &

COOPERATION

Refuse to accept the patient for treatment

Extract teeth with hopeless or poor prognosis and

perform scaling and root planing on remaining

teeth

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SYSTEMIC/

ENVIRONMENTAL

FACTORS

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1.SMOKING

Direct relationship - smoking and theprevalence and incidence of periodontitis

Affects severity

Affects healing

Slight to moderate periodontitis - fair topoor

Severe periodontitis - poor to hopeless

Page 25: Prognosis in periodontics

2. SYSTEMIC DISEASE/

CONDITION

Prevalence and severity of periodontitis -

significantly higher - type I and II diabetes

Prognosis dependent on patient compliance

relative to both dental and medical status

Well controlled patients - slight to moderate

periodontitis - good prognosis

Page 26: Prognosis in periodontics

4. GENETIC FACTORS

Genetic polymorphism in IL-1 genes resulting in

overproduction of IL-1 - associated with significant

increase in risk for severe, generalized, chronic

periodontitis.

Genetic factors also influence serum IgG2 antibody

titers and the expression of Fc-RII receptors on the

neutrophil - significant in aggressive periodontitis.

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Identification of genetic factors can lead to

treatment alterations – adjunctive antibiotic

therapy & frequent maintenance visits.

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LOCAL FACTORS

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1.PLAQUE AND CALCULUS

Bacterial plaque and calculus - most

important local factor in periodontal

diseases.

Good prognosis- depends on ability of

patient and clinician to remove etiological

factor.

Page 30: Prognosis in periodontics

2. SUBGINGIVAL RESTORATIONS

Contribute to

Increased plaque accumulation

Increased inflammation

Increased bone loss

Subgingival margins - poor prognosis.

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3.ANATOMIC FACTORS

Short, tapered roots with large crowns, cervical

enamel projections (ceps) and enamel pearls,

intermediate bifurcation ridges, root concavities,

and developmental grooves - predispose

periodontium to disease

Teeth with short, tapered roots and relativelylarge crown – Poor prognosis

Page 32: Prognosis in periodontics

CEPs are flat, ectopic extensions of enamel extending

beyond the normal contours of the cementoenamel

junction.

Enamel pearls are larger, round deposits of enamel

that can be located in furcations or other areas on the

root surface

Developmental grooves – create accessibility problems

plaque-retentive area - difficult to instrument

Page 33: Prognosis in periodontics

Root concavities exposed through loss ofattachment can vary from shallow flutings to deepdepressions. They appear more marked on maxillaryfirst premolars, the mesiobuccal root of the maxillaryfirst molar.

Although these concavities increase the attachmentarea and produce a root shape that may be moreresistant to torquing forces but they are inaccessibleto clean.

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4.TOOTH MOBILITY

Principal causes-

Loss of alveolar bone

Inflammatory changes in the

periodontal ligament

Trauma from occlusion.

stabilization by use of splinting

- beneficial impact on the

overall and individual tooth

prognosis.

Correctable

Non correctable

Page 35: Prognosis in periodontics

Prosthetic/Restorative

Factors

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The overall prognosis requires a general consideration ofbone levels and attachment levels to establish whetherenough teeth can be saved either to provide a functional andaesthetic dentition or to serve as abutments for a usefulprosthetic replacement of the missing teeth.

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The overall prognosis and the prognosis for individual

teeth overlap because the prognosis for key individual

teeth may affect the overall prognosis for prosthetic

rehabilitation.

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When few teeth remain, the prosthodontic needs becomemore important, and sometimes periodontally treatableteeth may have to be extracted if they are not compatiblewith the design of the prosthesis.

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Caries, Non-vital Teeth & Root Resorption.

For teeth mutilated by extensive caries, the feasibilityof adequate restoration and endodontic therapy shouldbe considered before undertaking periodontaltreatment.

Extensive idiopathic root resorption or root resorptionthat has occurred as a result of orthodontic therapy,risks the stability of teeth and adversely affects theresponse to periodontal treatment.

Page 40: Prognosis in periodontics

RELATIONSHIP BETWEEN

DIAGNOSIS AND PROGNOSIS

Factors such as patient age, severity of

disease, genetic susceptibility, and presence of

systemic disease are important in developing

both diagnosis as well as prognosis.

Page 41: Prognosis in periodontics

PROGNOSIS FOR PATIENTS WITH GINGIVAL

DISEASE

Reversible

Prognosis - good provided all local irritants areeliminated & patient cooperates by maintaininggood oral hygeine.

I. DENTAL PLAQUE INDUCED GINGIVAL DISEASES

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The inflammatory response to bacterial plaque can be

influenced by systemic factors, such as endocrine

related changes associated with puberty, pregnancy

and diabetes.

Long term prognosis depends - control of bacterial

plaque along with correction of the systemic factors.

b) Plaque induced gingival diseases modified

by systemic factors

Page 43: Prognosis in periodontics

• Drug induced gingival enlargement often seen

with phenytoin, cyclosporin, nifedipine and in oral

contraceptive associated gingivitis.

• Plaque control alone does not prevent the

development of lesions, and surgical intervention is

usually necessary to correct the alteration of gingival

contours.

c) Plaque induced gingival disease

modified by medications

Page 44: Prognosis in periodontics

d) Gingival diseases modified by

malnutrition

Exception - vitamin C deficiency (gingival

inflammation and bleeding on probing independent

of plaque levels present)

Prognosis of these patients depend upon the

severity and duration of the deficiency and on the

likelihood of reversing the deficiency through dietary

supplements.

Page 45: Prognosis in periodontics

II. Non plaque induced

gingival lesions

Seen in patients with a variety of bacterial, fungal

and viral infections.

Dermatologic disorders such as lichen planus,

pemphigoid, pemphigus vulgaris, erythema

multiforme, and lupus erythematosus can also

manifest in oral cavity as atypical gingivitis.

Allergic, toxic, and foreign body reactions, as well as

mechanical and thermal trauma, can result in

gingival lesions.

Page 46: Prognosis in periodontics

PROGNOSIS OF PATIENTS WITH

PERIODONTITIS

Chronic periodontitis

In cases where clinical attachment loss and bone

loss are not very advanced (slight to moderate

periodontitis) - prognosis - good.

The inflammation - controlled through good oral

hygiene and the removal of local plaque retentive

factors.

Page 47: Prognosis in periodontics

AGGRESSIVE PERIODONTITIS

Poor prognosis

Localized aggressive periodontitis –

Occurs around puberty

Localized to first molars and incisors

Patient exhibits strong serum antibody response to

the infecting agent contributing to localization of

lesions.

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Diagnosed early - can be treated conservatively with

oral hygiene instruction and systemic antibiotic

therapy - excellent prognosis.

Advanced diseases, prognosis can be good if the

lesions are treated with debridement, local and

systemic antibiotics, and regenerative therapy

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Generalized form – fair, poor or questionable

prognosis due to generalized interproximal loss, poor

antibody response and thus poor response to

conventional periodontal therapy.

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PERIODONTITIS AS A MANIFESTATION

OF SYSTEMIC DISEASES

It can be divided into two categories:

- periodontitis associated with hematologic

disorders such as leukemia and acquired

neutropenia.

- periodontitis associated with genetic disorders

such as familial and cyclic neutropenia, down

syndrome and hypophosphatasia.

Primary etiologic factor - bacterial plaque

Systemic diseases affect the progression of disease

and thus prognosis.

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NECROTIZING PERIODONTAL

DISEASES

Necrotizing ulcerative gingivitis (NUG)

Necrotizing ulcerative periodontitis (NUP).

In NUG - primary predisposing factor - bacterial plaque.

Disease - complicated by presence of secondary

factors such as acute psychological stress, tobacco

smoking, poor nutrition leading to immunosuppression.

Page 52: Prognosis in periodontics

With control of both bacterial plaque and secondaryfactors prognosis (NUG) - good although tissuedestruction is not reversible.

NUP is similar to that of NUG, except the necrosis extends from the gingiva into the periodontal ligament and alveolar bone.

Many patients presenting with NUP are immunocompromised through systemic conditions, such as HIV infection.

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REEVALUATION OF PROGNOSIS

AFTER PHASE I THERAPY

If the inflammatory changes not controlled or

reduced by phase I therapy- overall prognosis -

unfavorable.

In these patients the prognosis can be directly

related to the severity of inflammation.

Reduction in pocket depth and inflammation after

Phase I therapy indicates a favorable response to

treatment and may suggest a better prognosis than

previously assumed.

Page 54: Prognosis in periodontics

CONCLUSION

Prognosis help us in planning the customized

treatment for each patient thus help in

providing overall care to patient. So it should

be given due importance in general clinical

practice

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REFERENCES

Carranza’s Clinical Periodontology 10th Edition.

Lindhe- 5th edition

Hart TC,Kornman KS. Genetic factors in pathogenesis of

periodontitis. Periodontol 2000 1997;14:202

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THANK YOU