Prognosis Lecture PDF

# Prognosis ## DR. HANADI ALZAHRANI ### 31-10-2022 ## Outline - Definitions - Determination and Reassessment of Prognosis - Importance - Factors in Determination of Prognosis - Types of Prognosis - Prognosis of Specific Periodontal Diseases ## Definitions - A prognosis is a prediction of the pr...

# Prognosis ## DR. HANADI ALZAHRANI ### 31-10-2022 ## Outline - Definitions - Determination and Reassessment of Prognosis - Importance - Factors in Determination of Prognosis - Types of Prognosis - Prognosis of Specific Periodontal Diseases ## Definitions - A prognosis is a 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. - Prognosis plays a pivotal role in therapy as treatment decisions are made based on prognosis. - A dynamic process. a provisional prognosis established after the diagnosis is made and before the treatment plan is established, should be reevaluated after completion of all phases of therapy, including periodontal maintenance. ## Importance ### Clinician: - To determine which treatment modalities will be most effective - To develop restorative recommendation and treatment plans ### Patient: - To determine whether treatment seems worthwhile ## Overall Versus Individual Tooth Prognosis ### Overall prognosis: Concerned with the dentition as a whole and answers the following: - Should treatment be undertaken? - Is it likely to succeed? - Are the remaining teeth able to support prosthetic replacement if needed. ### Individual tooth prognosis: - Is concerned with a tooth as a separate entity and determined after the overall prognosis and is affected by it. ## Types of Prognosis - Based on tooth mortality: - **Good prognosis:** Control of etiologic factors and adequate periodontal support ensure the tooth will be easy to maintain by the patient and clinician. - **Fair prognosis:** Approximately 25% attachment loss or grade I furcation invasion (location and depth allow proper maintenance with good patient compliance). - **Poor prognosis:** 50% attachment loss, grade II furcation invasion (location and depth make maintenance possible but difficult). - **Questionable prognosis:** >50% attachment loss, poor crown-to-root ratio, poor root form, grade II furcation invasion (location and depth make access difficult) or grade III furcation invasion; mobility no. 2 or no. 3; root proximity. - **Hopeless prognosis:** Inadequate attachment to maintain health, comfort, and function. - Based on "the probability of obtaining stability of the periodontal supporting apparatus": - **Favorable:** - Local and systemic factors can be controlled - Periodontal status can be stabilized - **Questionable:** - Local or systemic factors may or may not be controlled - Periodontium can be stabilized - But further periodontal breakdown may occur - **Unfavorable:** - Local or systemic factors cannot be controlled - Periodontium cannot be stabilized **Diagram:** | | Periodontal Treatment and Maintenance | Periodontal Stability | | :-------------------- | :-------------------------------------- | :------------------ | | **Favorable** | Likely | Likely | | **Questionable** | Maybe | Maybe | | **Unfavorable** | Unlikely | Unlikely | | **Hopeless** | | Extraction Needed | ## Prognostic factors Are characteristics that predict the outcome | | Overall Clinical Factors | Systemic/Environmental Factors | Local Factors | Prosthetic/Restorative Factors | | :-------------------------- | :-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | :--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | :----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | :-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | **Patient age** | ■ Patient age | ■ Smoking | ■ Plaque/calculus | ■ Abutment selection | | **Disease severity** | ■ Disease severity | ■ Systemic disease/condition | ■ Subgingival restorations | ■ Caries | | **Plaque control** | ■ Plaque control | ■ Genetic factors | ■ Anatomic factors: short, tapered roots | ■ Nonvital teeth | | **Patient compliance** | ■ Patient compliance | ■ Stress | ■ Cervical enamel projections<br> ■ Enamel pearls<br> ■ Bifurcation ridges<br> ■ Root concavities<br> ■ Developmental grooves<br> ■ Root proximity<br> ■ Furcation involvement<br> ■ Tooth mobility | ■ Root resorption | ## Factors in Determination of Prognosis ### Overall Clinical Factors: - **Patient age:** For two patients with comparable levels of remaining connective tissue attachment and alveolar bone, the prognosis is generally **better** for the older of the two. - **Disease severity:** - **Periodontal Pocket Depth Vs Attachment and Bone Loss:** - A tooth with deep pockets and little attachment and bone loss has a better prognosis than one with shallow pockets and severe attachment and bone loss. - **The height of the remaining bone:** - Assuming bone destruction can be arrested, is there enough bone remaining to support the teeth? - **Disease severity (Horizontal Vs Angular Bone Loss):** - The prognosis for horizontal bone loss depends on the height of the existing bone. - It is unlikely that clinically significant bone height regeneration will be induced by therapy. - More horizontal bone loss = increased mobility - In the case of angular, intrabony defects: - Excellent chance for regeneration to approximately the level of the alveolar crest (favorable number of osseous walls) - Less tooth mobility **(See image on page 13 for example)** - **Plaque Control:** - The primary etiologic factor - Prognosis depends on effective plaque removal by the pt on a daily basis - **Patient Compliance and Cooperation:** - Patient's attitude, desire to retain the natural teeth, and willingness and ability to maintain good oral hygiene. - Receive the timely periodic maintenance checkups and treatments ### Systemic and Environmental Factors: - **Smoking:** - Direct relationship exists between smoking and the prevalence and incidence of periodontitis (risk factor). - Smoking affects the severity of periodontal destruction and the healing potential of the periodontal tissues. - **Prognosis:** - Smoking + slight to moderate periodontitis...fair to poor. (good with smoking cessation) - Smoking + severe periodontitis/ aggressive periodontitis...poor to hopeless (fair with smoking cessation). - **Systemic disease or condition:** - The prevalence and severity of periodontitis are significantly higher in patients with type 1 and type 2 diabetes. - Well-controlled diabetic patients with slight-to-moderate periodontitis who comply with their recommended periodontal treatment should have a **good prognosis.** - Prognosis improves with correction of the systemic problem. - **Genetic factors:** - May play an important role in determining the nature of the host response. - Aggressive Periodontitis - Early diagnosis, intervention, and alterations in the treatment regimen may lead to an improved prognosis for the patient. - **Stress:** - Alter the patient's ability to respond to the periodontal treatment ### Local Factors: - Plaque and calculus - Subgingival margins and overhangs - Anatomic factors: short, tapered roots with large crowns; cervical enamel projections and enamel pearls; intermediate bifurcation ridges; root concavities; and developmental grooves, root proximity and the location and anatomy of furcations. Lead to more plaque accumulation and decrease the efficiency of SRP. - Tooth mobility - Causes: loss of alveolar bone, inflammatory changes in PDL,TFO - Tooth mobility resulting from loss of alveolar bone is not likely to be corrected ### Restorative and Prosthetic Factors: - Teeth that serve as abutments are subjected to increased functional demands. - Special oral hygiene measures must be instituted in these areas. - The feasibility of adequate restoration and endodontic therapy should be considered before undertaking periodontal treatment - Extensive root resorption jeopardises stability of teeth and adversely affects the response to periodontal treatment. - The periodontal prognosis of treated nonfatal teeth does not differ from that of vital teeth. ## Decisions about tooth retention - Often one of the most difficult decisions in dentistry is to decide whether a tooth should remain in the dentition or be removed. - The periodontal condition of a tooth is more important than the number of teeth in the dentition. - Teeth that are hopeless do not contribute to the usefulness of the dentition ## To be or not to be: extracted **A tooth should be extracted when:** - It is so mobile that function becomes painful. - It can cause acute abscesses during therapy. - There is no use for it in the overall treatment plan. **A tooth should be temporarily retained when it:** - Maintains a posterior stop. - Is an esthetic necessity. - Reduces the need to perform additional surgical therapy. ## Prognosis of Specific Periodontal Diseases ### Prognosis for patients with Gingival Diseases - **Gingivitis associated with dental plaque only:** - Prognosis: Good... Provided all local irritants and local factors contributing to plaque accumulation are eliminated and patient cooperates by maintaining good oral hygiene. - **Plaque-induced gingival diseases modified by systemic factors:** - Bacterial plaque (small amounts) initiates gingival inflammation, modified by endocrine changes (puberty, menstruation, pregnancy, diabetes) or blood dycrasias (leukemia,..) - Prognosis: depends on control of bacterial plaque + correction of the systemic factor. - **Plaque-induced gingival diseases modified by Medications:** - Drug-influenced gingival enlargement(phenytoin, cyclosporin, nifedipine) and oral contraceptives. - Prognosis: depends on control of bacterial plaque with surgical intervention to correct gingival contour in most cases + alteration of the medication - **Plaque-induced gingival diseases modified by Malnutrition:** - Severe vit. C deficiency (gingival inflammation and bleeding independent of plaque levels present) - Prognosis: depends on severity and duration of the deficiency and reversing it through dietary supplementation - **Non-Plaque-induced gingival lesions:** - Bacterial, fungal and viral. - Dermatological disorders. - Allergic, toxic and foreign body reactions. - Mechanical and thermal trauma. - Prognosis: depends on elimination of the causative agent ### Prognosis for patients with Periodontitis - **Chronic Periodontitis:** - Prognosis: - Good....in cases with AL and BL are not advanced, provided the inflammation can be controlled through good oral hygiene and removal of plaque-retentive factors. - Fair- poor...more severe disease, **furcation involvement**, increased mobility, noncompliant patient. - **Aggressive Periodontitis:** - Rapid AL and BL inconsistency with microbial deposits. - Familial aggregation. - Prognosis: - Localized AP: age of puberty, first molars and incisors. - (early diagnosed+ conservatively treated OHI+Systemic AB.....excellent P - (more advanced+ OHI+Systemic and local AB+ surgical regenerative therapy.....good P - Generalized AP: under 30 years, generalized interproximal AL. - (patients dont respond well to conventional, chemical and surgical therapy)....fair, poor or questionable P. - **Periodontitis as manifestation of systemic disease:** - Hematologic disorders (leukemia, acquired neutropenia) - Genetic disorders (familial and cyclic neutropenia, Down syndrome, Papillon-Lefevre syndrome) - Alter the ability of the host to respond to the microbial challenger. - Prognosis: Fair-Poor - **NUG:** - Prognosis: Good.. after removal of primary disposing factor (plaque) and secondary factors (acute psychologic stress, smoking and poor nutrition) - **NUP:** - If associated with HIV depends also on disease control.