Determination Of Prognosis PDF

Determination Of Prognosis Dr.Jafar Naghshbandini DDS, MS, D.D.S ; M.S , Diplomate Of The American Board Of Periodontology  Special thanks whoever taught me a word make me his servant Dr. Raul caffesse Dr. Jim Simon Part I  Definition Prognosis: It is a...

Determination Of Prognosis Dr.Jafar Naghshbandini DDS, MS, D.D.S ; M.S , Diplomate Of The American Board Of Periodontology  Special thanks whoever taught me a word make me his servant Dr. Raul caffesse Dr. Jim Simon Part I  Definition Prognosis: It 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. Your prognosis for each disease?!  Diagnosis Prognosis Treatment plan Differences Between Prognosis And Risk  Prognosis Risk I. Deals with the likelihood that an individual will It is the prediction of the duration, get a disease in a course and the termination of specified period. disease and its response to treatment II.Risk factors are those Prognostic factors are characteristics of an characteristics that predict the individual that put them outcome of disease once the disease at increased risk for is present. getting a disease.  It is based on the factors to be considered while determining the prognosis. Prognosis may be: Determination 1. Excellent prognosis Of 2. Good prognosis Prognosis 3. Fair prognosis 4. Poor prognosis 5. Questionable prognosis 6. Hopeless prognosis Excellent Prognosis 1. No bone loss 2. Excellent gingival condition 3. Good patient cooperation 4. No systemic/environmental factors  Good Prognosis 1. Adequate remaining bone support 2. Possibilities to control etiologic factors and establish a maintainable dentition 3. Adequate patient co-operation 4. No systemic/ environmental factors or if present are well-controlled.  1. Less than adequate remaining bone support 2. Some tooth mobility Fair 3. Grade I furcation involvement 4. Adequate maintenance Prognosis 5. Acceptable patient cooperation 6. Presence of limited systemic/ environmental factors  Poor Prognosis One or more of the following: : 1.Moderate to advanced bone loss 2.Tooth mobility 3.Grade I and II furcation involvements 4.Doubtful patient co-operation 5.Difficult to maintain areas 6.Presence of systemic/environmental factors. Questionable Prognosis One or more of the following: 1. Advanced bone loss 2. Grade II and III furcation involvements 3. Tooth mobility 4. Inaccessible areas 5. Systemic/environmental factors. Hopeless Prognosis One or more of the following: 1. Advanced bone loss 2. Non-maintainable areas 3. Extraction indicated 4. Presence of uncontrolled systemic/environmental factors. Phase I therapy: It is advisable to establish a provisional prognosis in this phase until it is completed and evaluated. The provisional prognosis allows initiating treatment of teeth having a doubtful outlook. Re-evaluation phase: allows to assess the tissue response to scaling, oral hygiene and root planning and also the use of chemotherapeutic agents where indicated.  1. Overall clinical factors. Factors For 2. Systemic/Environmental Determination factors. Of 3. Local factors. Prognosis 4. Prosthetic/restorative factors.  1. Overall Clinical Factors A. Patient age B. Disease severity C. Plaque control D.Patient compliance and co-operation  A. Patient Age In two patients with comparable levels of: 1. Remaining connective tissue attachment 2. Alveolar bone The prognosis is better in the older of the two?!.  B. Disease Severity It is determined by recording the patients past history of periodontal disease for this the following variables should be carefully recorded i. Pocket depth ii. Level of attachment. iii.Degree of bone loss. iv.Type of bony defect  A tooth with Deep pockets I. Pocket Little attachment and bone loss Depth Has a better prognosis than one with Shallow pockets Severe attachment and bone loss.  II. Level of attachment Reveals the The radiographic approximate extent of examination reveals root surface that is the amount of root devoid of periodontal surface still invested ligament in bone.  Prognosis is adversely affected if the base of the pocket is close to the root apex. The presence of apical disease as a result of endodontic involvement also worsens the prognosis.  III. Degree Of Bone Loss The height of the remaining bone is usually somewhere in between making bone level assessment alone insufficient for determining the overall prognosis.  IV. Type Of Bony Defect The prognosis for horizontal bone loss depends upon the height of the existing bone. The prognosis for angular, infrabony defects depends upon the contour of the existing bone and the number of osseous walls.  The chance to regenerate bone in vertical bony defect is excellent as compared to horizontal bony defects.  When greater bone loss has occurred on one surface of a tooth, the bone height on the less involved surfaces should be considered when determining the prognosis.  C. Plaque Control Plaque is the primary etiological factor for periodontal disease. Therefore effective removal of plaque is important for the success of periodontal therapy and to the prognosis D. Patient Compliance And Co-operation Dependent on patient’s 1. Attitude 2. Desire to retain the natural teeth 3. Willingness and ability to maintain good oral hygiene.  Ifthe patient is unwilling or unable to perform adequate plaque control and receive periodic maintenance checkups, the treatments to be considered are: 1. Refuse to accept the patient for treatment. 2. Extract teeth that have a hopeless or poor prognosis and perform scaling and root planning on the remaining teeth. Part II Systemic/Environmental Factors. Systemic Smoking disease/condition Genetic factors Stress  A. Smoking It is the most important environmental risk factor affecting The development and progression of periodontal disease. The healing potential of the periodontal tissues. There is a direct relationship between smoking and the prevalence and incidence of periodontitis. Therefore the prognosis in patients who 1. Smoke Fair To Poor 2.Have slight to moderate periodontitis But with the cessation of smoking a)The prognosis may be upgraded from fair to good in case of slight to moderate periodontitis b)Poor to fair in case of severe periodontitis.  B. Systemic disease/condition Prognosis in these cases is Patients with incapacitating dependent on patient compliance conditions and other systemic relative to both their medical and disorders can affect the dental status progression of disease  In patients with uncontrolled diabetics the prognosis is questionable when surgical periodontal treatment is required. Inwell-controlled diabetic patients with mild to moderate periodontitis, who comply well to recommended instructions respond well and hence have good prognosis.  C. Genetic factors Severe, Genetic polymorphisms in the interleukin –1 generalized, (IL-1) genes chronic periodontitis Genetic factors also appear to influence serum IgG2 antibody titers and the expression of Fc-yRII receptors on the neutrophil Aggressive periodontitis leukocyte adhesion deficiency type I Detection of genetic variations that are linked with periodontal disease can potentially influence the prognosis in several ways: 1. Early detection of patients at risk due to genetic factors (prevention and treatment measures). 2. Identification of genetic risk factors during the course of treatment (use of adjunctive antibiotic therapy). 3. The development of early intervention strategies in young individuals who are identified as being at risk. D. Stress 1. Physical stress 2.Emotional stress 3.Substance abuse Alter the patients ability to respond to periodontal treatment  Local Factors A. Plaque/calculus B. Subgingival restorations C. Anatomic variations/factors D. Tooth mobility  A. Plaque/calculus In most cases having a good prognosis is dependent on: 1. The ability of the patient to remove plaque/calculus. 2. The ability of the clinician to remove these etiologic factors.  Contribute to increased: Plaque accumulation B. Subgingival Increased inflammation restorations Increased bone loss A tooth with a discrepancy in its subgingival margins has a poorer prognosis than a tooth with well-contoured, supragingival margins.  Anatomic factor that predispose the periodontium to disease include: 1. Short, tapered roots with large crowns 2. Cervical enamel projections (CEP) C. Anatomic 3. Enamel pearls variations/ 4. Intermediate bifurcation ridges factors 5. Root concavities and developmental grooves 6. Root proximity 7. Furcation involvement 8. Tooth mobility.  The principal causes are: Mobility is not likely D. Tooth 1.Loss of alveolar bone to be corrected mobility 2.Inflammatory changes in the periodontal ligament Mobility may be 3.Trauma from occlusion correctable  Prosthetic/Restorative Factors The overall prognosis requires general consideration of bone levels attachment levels Teeth that serve as abutments are to establish whether teeth can be saved subjected to increased functional for functional and aesthetic purposes or demands. to serve as abutments for prosthesis. Relationship Between Diagnosis And Prognosis Factors such as patients age, severity of disease, genetic susceptibility and presence of systemic disease are all important criteria in the diagnosis of the condition. Distinction Between Condition And Prognosis  Condition Prognosis 1. It is linked to management of Dermatological disorders like lichen the associated planus, pemphigoid, pemphigus vulgaris, dermatologic erythema multiforme, lupus conditions. erythematosus Allergic, toxic and foreign body reactions, Mechanical and thermal trauma. Prognosis For Patients With Gingival Disease Dental Plaque-induced Gingival Disease Non-plaque-induced Gingival Lesion  Dental Plaque-induced Gingival Disease GINGIVITIS PLAQUE-INDUCED PLAQUE-INDUCED GINGIVAL DISEASES ASSOCIATED GINGIVAL DISEASES GINGIVAL MODIFIED BY WITH DENTAL MODIFIED BY DISEASES MALNUTRITION PLAQUE ONLY SYSTEMIC FACTORS MODIFIED BY MEDICATIONS Gingivitis Associated With Dental Plaque Only The prognosis for patients with gingivitis associated with only dental plaque is good Plaque-induced Gingival Diseases Modified By Systemic Factors Prognosis for these patients depends on not only control of bacterial plaque but also on control or correction of the systemic factors. Plaque-induced Gingival Diseases Modified By Medications Prognosis in these patients is dependent not only on the control of dental plaque, but also on the likelihood of continued use of the drug.  Gingival Diseases Modified By Malnutrition Prognosis in these cases may be dependant on the severity and duration of deficiency and on the likelihood of reversing the deficiency through dietary supplementation.  Non-plaque induced Gingival Lesion Itcan be seen in patients with a variety of bacterial, fungal and viral infections. Prognosis is dependant on elimination of the source of infectious agent.  Prognosis for Patients with Periodontitis I. Chronic SLOWLY PROGRESSIVE DISEASE CAN BE Periodontitis ASSOCIATED WITH LOCAL ENVIRONMENTAL FACTORS. LOCALIZED OR GENERALIZED. In case of not advanced attachment loss prognosis is generally good. But inflammation has to be controlled through good oral hygiene and removal of local plaque-retentive factors. In cases of severe disease with furcation's involvement and increasing clinical mobility/who are non-compliant with oral hygiene, prognosis is down graded from fair to poor.  II. Aggressive periodontitis Rapidly progressive disease with minimal/no local factors with increased level of Aa and P gingivitis. Can be localized or generalized Two common features are observed 1. Rapid attachment loss and bone destruction in an otherwise clinically healthy person. 2. A familial aggregation Localized type: Which occurs around the age of puberty Localized to first molars and incisors If diagnosed early can be treated conservatively with oral hygiene instructions and systemic antibiotic therapy, resulting in excellent prognosis. In advanced cases, the prognosis is still good if the lesions are treated with debridement, local and systemic antibiotics and regerative therapy. In generalized type: Seen in young patients with generalized interproximal attachment loss and poor antibody response. Secondarily aggravated by cigarette smoking does not respond well to conventional periodontal therapy therefore prognosis is often fair, poor or questionable and the use of systemic antibiotics should be considered. Periodontitis as a Manifestation of Systemic Disease It can be divided into two categories: I. Associated with hematological disorders such as leukemia and acquired neutropenias. II. Associated with genetic disorders such as familial and cyclic neutropenia, Down’s syndrome, hypophosphatasia, Papillon-Lefévre syndrome. In both these cases prognosis may be fair to poor and is mainly dependant on the treatment of systemic disease. Necrotizing Prognosis depends Periodontal on management of Disease disease. Re-evaluation Of Prognosis After Phase I Therapy A frank reduction in pocket depth and inflammation after phase I therapy indicates favorable response to treatment and is suggestive of a better prognosis and in vice versa cases the overall prognosis may be unfavorable.