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Prognosis
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- 2. CONTENTS • Definition • Classification •Prognosis and Risk • Relationship between diagnosis and prognosis • Prognostic factors • Treatment plan and prognosis • Prognosis for patients with gingival disease • Prognosis of patients with periodontitis • Prognosis of patients with Necrotizing diseases • Reevaluation of prognosis after phase I therapy
- 3. Definition The prognosis isa 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.
- 4. Prognosis and Risk •Risk generally deals with the likelihood that an individual will develop a disease in a specified period. • Risk factors are those characteristics of an individual that put the person at increased risk for developing a disease. • Prognostic factors are characteristics that predict the outcome of disease once the disease is present. In some cases, risk factors and prognostic factors are the same.
- 5. CLASSIFICATION • Excellent prognosis:No bone loss, excellent gingival condition, good patient co-operation, no systemic or environmental factors. • Good prognosis: Adequate remaining bone support, adequate possibilities to control etiologic factors and establish a maintainable dentition, adequate patient co-operation, no systemic or environmental factors, or if systemic factors are present, they are well controlled. • Fair prognosis: Less-than adequate remaining bone support, some tooth mobility, grade I furcation involvement, adequate maintenance possible, acceptable patient co-operation, presence of limited systemic or environmental factors. • Poor prognosis: Moderate to advanced bone loss, tooth mobility, grade I and II furcation involvements, difficult to maintain areas or doubtful patient cooperation, presence of systemic or environmental factors. • Questionable prognosis: Advanced bone loss, grade II and III furcation involvements, tooth mobility, inaccessible areas, presence of systemic or environmental factors. • Hopeless prognosis: Advanced bone loss, non maintainable areas, extractions indicated, presence of uncontrolled systemic or environmental factors.
- 6. • Kwok andCaton, 2007: • Favorable prognosis: • Comprehensive periodontal treatment and maintenance will stabilize the status of the tooth. • Future loss of periodontal support is unlikely. • Questionable prognosis: • Local and/or systemic factors influencing the periodontalstatus of the tooth may or may not be controllable. • If controlled, the periodontal status can be stabilized with comprehensive periodontal treatment. • If not, future periodontal breakdown may occur. • Unfavorable prognosis: • Local and/or systemic factors influencing the periodontal status cannot be controlled. • Comprehensive periodontal treatment and maintenance are unlikely to prevent future periodontal breakdown. • Hopeless prognosis: • The tooth must be extracted.
- 8. INDIVIDUAL TOOTH PROGNOSISOVERALL TOOTH PROGNOSIS Percentage of bone loss Age Deepest probing depth Medical History Horizontal/vertical bone loss Family History Deepest furcation involvement Oral Hygiene: Good/Fair/Poor Mobility Compliance: Y/N Crown to Root ratio: F/UF Maintenance interval: 2 months, 2months alternate Root form F/UF 3months, 3months alternate Caries or Pulpal Involvement :Y/N Parafunctional habit with night guard Tooth malposition: Y/N Parafunctional habit without night guard. Fixed or Removable prosthesis:Y/N
- 9. Overall Clinical Factors Systemic/Envi ronmental Factors Age Smoking Disease severity Systemic diseases Plaque controlGenetic factors Patient compliance Stress Local Factors Plaque/ Calculus Subgingival Restorations Anatomic factors Tooth mobility Prosthetic/Res torative factors Abutment selection Caries Non-vital teeth Root resorption
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- 11. Patient Age • Youngerpatient – shorter time – more periodontal destruction- poor or fair prognosis • May have aggressive type of periodontitis, or associated systemic disease or smoking • occurrence of so much destruction in a relatively short period • Older patient – longer time – better prognosis
- 12. Disease Severity Previous periodontaldisease of periodontal disease: • pocket depth, • level of attachment, • degree of bone loss, • type of bony defect
- 13. Pocket depth andCAL • The determination of the level of clinical attachment (CAL) reveals the approximate extent of root surface • Deep pockets with little attachment and bone loss has a better prognosis than one with shallow pockets and severe attachment and bone loss • If CAL is less good to fair prognosis
- 14. Bone loss • Relatedto the height of remaining bone. • Prognosis for horizontal bone loss depends on the height of the existing bone. • Angular defects - if the contour of the existing bone & the number of osseous walls are favorable, there is an excellent chance that therapy could regenerate bone to approximately the level of the alveolar crest = good prognosis • 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 • Less boneloss = better prognosis
- 15. Plaque Control • Bacterialplaque - primary etiologic factor associated with periodontal disease. • Effective removal of plaque on a daily basis by patient Increased Success of periodontal therapy Good prognosis
- 16. Patient Compliance/ Cooperation •Depends on • the patient's attitude, • desire to retain the natural teeth, • willingness and ability to maintain good oral hygiene, • timely periodic maintenance checkups
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- 18. Smoking • Risk factor •Direct relationship - smoking and the prevalence and incidence of periodontitis • ▶ Affects severity • ▶ Affects healing • ▶ Slight to moderate periodontitis - fair to poor • ▶ Severe periodontitis - poor to hopeless
- 19. SYSTEMIC DISEASE/ CONDITION •▶ Prevalence and severity of periodontitis - significantly higher - type I and II diabetes • ▶ Prognosis dependent on patient compliance, dental and medical status • ▶ Well controlled patients – slight to moderate periodontitis - good prognosis
- 20. GENETIC FACTOR • Geneticpolymorphism in IL-1 genes resulting in overproduction of IL-1b - severe, generalized, chronic periodontitis. • Genetic factors also influence serum IgG2 antibody titers and the expression of Fc-gRII receptors on the neutrophil - aggressive periodontitis. • Genetic factors cannot be altered. • Early diagnosis, intervention, and alterations in the treatment regimen may lead to an improved prognosis
- 21. Plaque / Calculus •The microbial challenge in bacterial plaque and calculus is the most important local factor in periodontal diseases. Subgingival Restorations • Subgingival margins may contribute to • increased plaque accumulation, • increased inflammation • increased bone loss • Subgingival margins has a poor prognosis than a tooth with well-contoured, supragingival margins
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- 23. ANATOMIC FACTORS • short,tapered roots with large crowns, • cervical enamel projections (CEPs) • enamel pearls, • intermediate bifurcation ridges, • root concavities, • developmental grooves. Scaling with root planing is a fundamental procedure in periodontal therapy. Anatomic factors that decrease the efficiency of this procedure can have a negative impact on the prognosis
- 24. Short tapered roots •Disproportionate crown-to-root ratio and the reduced root surface available for periodontal support, the periodontium may be more susceptible to injury by occlusal forces. • Teeth with short, tapered roots and relatively large crown – Poor prognosis
- 25. Cervical enamel projectionsCEPs • Ectopic extensions of enamel that extend beyond the normal contours of the cementoenamel junction. Extend into the furcation. Found on buccal surfaces of maxillary molars.
- 26. Enamel pearls • Theyare larger, round deposits of enamel that can be located in furcations or other areas on the root surface.
- 27. Root concavities • Theyappear more marked on maxillary first premolars, the mesiobuccal root of the maxillary first molar. • These concavities increase the attachment area and produce a root shape that may be more resistant to torquing forces.
- 28. • Other anatomicconsiderations that present accessibility problems are developmental grooves, root proximity and • furcation involvements.
- 29. Tooth Mobility Principal causes- •▶ Loss of alveolar bone • ▶ Inflammatory changes in the periodontal ligament • ▶ Trauma from occlusion. • ▶ stabilization by use of splinting • Grade I to II – good to fair • Grade III – Hopeless
- 30. Caries, Non-vital Teeth& Root Resorption • For teeth mutilated by extensive caries endodontic therapy should be considered before undertaking periodontal treatment. • ▶ Extensive idiopathic root resorption or root resorption that has occurred as a result of orthodontic therapy, risks the stability of teeth and adversely affects the response to periodontal treatment = poor prognosis
- 31. RELATIONSHIP BETWEEN DIAGNOSIS ANDPROGNOSIS • Factors such as • patient age, • severity of disease, • genetic susceptibility, • Presence of systemic disease are important in developing both diagnosis as well as prognosis
- 32. PROGNOSIS FOR PATIENTSWITH GINGIVAL DISEASE • DENTAL PLAQUE INDUCED GINGIVAL DISEASES • Gingivitis Associated with Dental Plaque Only: • Reversible • provided all local irritants are eliminated • patient cooperates by maintaining good oral hygeine. • Prognosis - good • Plaque induced gingival diseases modified by systemic factors: • Long term prognosis depends - control of bacterial plaque along with correction of the systemic factors • Prognosis - fair
- 33. Plaque induced gingivaldisease modified by medications: • The long-term prognosis depends on whether the patient's systemic problem can be treated with an alternative medication Gingival diseases modified by malnutrition: • Prognosis of these patients depend upon the severity and duration of the deficiency and on the likelihood of reversing the deficiency through dietary supplements.
- 34. Non plaque inducedgingival lesions ▶ Seen in patients with a variety of bacterial, fungal and viral infections, Allergic, toxic, and foreign body reactions, as well as mechanical and thermal trauma Treatment of the etiology=better prognosis
- 35. PROGNOSIS OF PATIENTSWITH PERIODONTITIS Chronic periodontitis • In cases where clinical attachment loss and bone loss are not very advanced • Slight to moderate periodontitis - prognosis - good.
- 36. Aggressive periodontitis • Localizedaggressive periodontitis • Diagnosed early - can be treated conservatively with oral hygiene instruction and systemic antibiotic therapy - good prognosis. • Advanced diseases, prognosis can be good if the lesions are treated with debridement, local and systemic antibiotics, and regenerative therapy • Generalized form – fair, poor or questionable prognosis due to generalized interproximal loss, poor antibody response and thus poor response to conventional periodontal therapy
- 37. Periodontitis As AManifestation 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 fair prognosis.
- 38. Necrotizing Periodontal Diseases • Withcontrol of both bacterial plaque and secondary factors prognosis (NUG) – good • The necrosis extends from the gingiva into the periodontal ligament and alveolar bone- poor
- 39. PROGNOSIS FOR PERIODONTALDISEASES: No: DISEASES PROGNOSIS 1. Gingivitis Good 2. Gingival disease modified by systemic factors and medications Depends on the systemic factors. 2. Localised Chronic Periodontitis Good to Fair 3. Generalised Chronic Periodontitis Fair to Poor 4. Localised Aggressive Periodontitis Good 5. Generalised Aggressive Periodontitis Fair to Poor or Hopeless 6 NUG Good 7 NUP Poor
- 40. REEVALUATION OF PROGNOSIS AFTERPHASE I THERAPY • Reduction in pocket depth and inflammation after Phase I therapy indicates a favorable response to treatment and may suggest a better prognosis. • If the inflammatory changes not controlled or reduced by phase I therapy- overall prognosis - unfavorable.