The document discusses the history and evolution of periodontal prognosis systems. Traditional systems assigned prognosis based on anatomical factors like bone loss and mobility, but did not consider systemic factors. More recent systems provide more detailed classifications of individual tooth prognosis as favorable, questionable, unfavorable or hopeless based on probability of maintaining periodontal stability. Prognosis is influenced by local factors like attachment loss and furcation involvement as well as patient compliance with maintenance and systemic factors like smoking and diabetes.

1. October 21, 2011 Thomas J. Kepic DDS, MSD

2. Determining periodontal prognosis Integral part of periodontal practice Directly influences treatment planning

3. Prognosis (Latin) Foreknowledge. Prediction of the future. The prospect of recovery anticipated from the usual course of disease.

4. “Prognostic factors” - those characteristics that may predict the outcome once the disease is actually present but do not actually cause it.

5. Traditional list of clinical factors used in assigning prognosis Individual tooth prognosis: Horizontal or vertical bone loss Percentage of bone loss Deepest probing depth Deepest furcation involvement Mobility Crown to root ratio Root form Caries or pulpal involvement Tooth malposition Fixed or removable abutment

14. Traditional Periodontal Prognostication Systems are based on tooth loss (mortality)

15. Hirschfeld and Wasserman (1978) Retro study, 600 “maint” patients, average 22 years Most patients had advanced perio Two prognostic categories: favorable or questionable Questionable prognosis: extensive bone loss, deep pockets, furcations, mobility. Compared prognosis assignment with actual tooth loss Grouped patients by # teeth lost: well-maintained group lost 0-3 teeth, downhill group lost 4-9 teeth, extreme down hill group lost 10-23 teeth

16. Higher percentages (~80%) of teeth with a questionable prognosis were lost in the well-maintained group compared to a lower percentage (~25%) in downhill and extreme downhill (~50%) groups. This means that a questionable prognosis was most accurate in the well-maintained group, and many originally favorable teeth were lost in the downhill groups. Therefore, patients who lose more teeth (downhill and extreme downhill groups) were less predictable in this system. Lack of consideration for systemic factors and local factors.

18. Becker et al. (1984) Followed two groups of post-treatment patients with and without maintenance therapy Three prognostic categories: good, questionable, hopeless This system used more detailed criteria for classification than Hirschfeld: bone level, probing, furcation, palatal grooves, caries, abscesses This system correctly predicted for well-maintained patients In 6.5 years, 1.7% of good teeth were lost; 25% of questionable teeth were lost; and 80% of hopeless teeth were lost.

19. This system did not predict as well in poor maintained patients. In poorly maintained patients after 5 years, 3% of good teeth were lost compared to 37% of questionable teeth and 33% of hopeless teeth. These results showed several important points: -the more detailed classification showed improved predictability in well-maintained patients. -prognosis can be determined effectively for 5-6 years -poorly maintained patients were not as predictable -poor pt compliance influences long-term prognosis

27. McGuire and Nunn (1996) Evaluated 100 treated periodontal patients (2,484 teeth) under maintenance care for 5 years, with 38 of these patients followed for 8 years.

29. Good Prognosis (one or more): Etiologic factors controlled and adequate periodontal support. Tooth easy to maintain by patient / clinician assuming proper maint.

30. Fair Prognosis (one or more): ~ 25% attachment loss, and/or Class I furcation. Location / depth of furcation allows for proper maint with good patient compliance.

31. Poor Prognosis (one or more): 50% attachment loss with Class II furcations. Location / depth of furcations allow for proper maint, but with difficulty.

32. Questionable Prognosis (one or more): > 50% attach loss, poor C/R ratio, poor root form. Class II furcations not easily accessible or Class III furcations. 2+ mobility. Root proximity.

34. Except for teeth with hopeless prognoses, teeth with worse prognoses initially are more likely to improve Smoking ↓ likelihood of improvement by 60% Good OH ↑ chances to improve by 2 ½x teeth that had fair / poor OH Teeth used as abutments for fixed prostheses had worse prognoses

35. Decision to retain compromised teeth is complex. Depends on the practitioner’s: Treatment philosophy Quality of therapy

36. Tooth loss usually does not occur naturally: decision of Practitioner Patient

37. The traditional process for the assignment of prognosis is based on an outdated model of disease progression which assumes that all plaque is the same and everyone is equally susceptible. The influence of the host is largely ignored and environmental factors are believed to be very important in the initiation and progression of the disease. Under this paradigm, clinical factors, primarily anatomical in nature, are used to develop a prognosis and eventual outcome dependent upon environmental factors that limit care.

38. New paradigm suggests that periodontal disease depends on the microbial insult, the body’s reaction to the insult, and the control of the level of pathogens. Does our traditional concept for the assignment of prognosis fit our new concept of periodontal diseases as site-specific infections that depend much more on pathogens, protective species, and host resistance than they do on the traditional list of factors used in prognosis determination?

43. Prognosis Revisited: A System for Assigning Periodontal Prognosis Vivien Kwok and Jack Caton -J. Periodontol Nov 2007

44. Prognosis outcome determined by periodontal stability. Based on probability of obtaining stability of the periodontal supporting apparatus Using evidence-based factors

45. Important concepts of prognosis: Periodontal status is variable and should be continually evaluated. Timing of the projection. “Short term” and “long term” are arbitrary definitions. Individual teeth vs. overall dentition. Consider prognosis at both levels.

46. Define prognosis in terms of stability of the periodontium: Chronic periodontitis is often episodic (periods of exacerbation and remission) Etiology is multifactorial Patients not equally at risk Tooth surfaces are variably affected within the mouth

47. Two levels of prognosis Overall dentition– simplifies communication between DDS / patient Individual teeth – affected by local factors (disease doesn’t progress uniformly)

49. Questionable: The periodontal status of the tooth is influenced by local and/or systemic factors that may or may not be able to be controlled.

50. Unfavorable: The periodontal status of the tooth is influenced by local and/or systemic factors that cannot be controlled. Breakdown likely even with tx and maintenance.

52. General Factors: Patient compliance in an effective maintenance program. Lack of maintenance can result in disease recurrence. (Many studies support this.) Smoking. Greater prevalence of perio disease; increased levels of microbial pathogens; affects host response; impairs immune defense; decreased collage metabolism; nicotine binds to root surfaces affecting collagen attachment; negative effects on regenerative procedures; > than 11 years of cessation to return to non smokers odds. Diabetes. Higher prevalence of periodontal disease. More severe disease with poor compliance. Decreases PMN function. Increases collagenase activity. Compromised wound healing. Results of treatment in controlled diabetics comparable to those of healthy patients.

53. General Factors(continued): Other Systemic Factors. Chediak-Higashi syndrome (neutrophil dysfunction); HIV; leukemia. Medications. Phenytoin, nifedipine, cyclosporine. Gingival overgrowth. Stress Nutrition Hormones Obesity Osteoporosis Alcohol

54. Local Factors: Deep probing depth and attachment loss. Associated with future periodontal breakdown. Probing depths >5mm difficult to maintain. Deep pockets associated with virulent periodontal pathogens. Other anatomic plaque-retentive factors. Furcation involvement Enamel pearls CEPs Palato-gingival and other root grooves Crowding Root proximity Open contacts Overhanging restorations

55. Local Factors (continued): Mobility. Many studies showed that mobility had a huge influence on prognosis. Ghiani and Bissada Wheeler et al. Wang 1994 Mobility is such an important clinical parameter because this one indicator provides a good overview of many other parameters such as: Attachment loss Occlusal stability Parafunctional habits.

56. Local Factors (continued): Trauma from occlusion and parafunctional habits. Mobility Wear facets Enlarged PDL space Traumatic forces combined with inflammation can cause increased bone loss and attachment loss.

58. 10/18/79 Pretreatment

59. 10/18/79 Pretreatment

84. 10/18/79 Pretreatment 7/23/81 Post Treatment

85. 10/18/79 Pretreatment 7/23/81 Post Treatment

86. 10/18/79 Pretreatment 7/23/81 Post Treatment

87. 10/18/79 Pretreatment 7/23/81 Post Treatment

89. 2/25/86 Post Orthodontic Therapy

90. 2/25/86 Post Orthodontic Therapy

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101. 12/14/93

103. 11/15/99