Exam 3 Tx & Prognosis Flashcards
Except for _________ no dental TX should be initiated until a TX plan is established and accepted by patient
Emergencies
After a diagnosis and prognosis have been determined the __________ and ___________ is planed
- treatment
- sequence
Treatment plan may require the following types of decisions
1) Extract/retain teeth
2) Pocket therapy techniques that will be used (surgical or non-surgical)
3) Need for occlusal therapy- before, during or after pocket therapy
4) Use of dental implants
5) Temp restorations/provisional crowns
6) Final restorations that will be needed after therapy, teeth serve as abutments for prosthesis.
7) Ortho consult
8) endo therapy
9) esthetic considerations
10) sequence of therapy
11) medical consult
The urgent phase of care begins with a through review of the patients ________ condition and history.
This initial emergency appointment is to establish patient comfort, it includes:
1______________
2______________
-Medical
1) Eliminate pain and /or abscess
2) Address emergency concern
Control phase includes what ? (6)
1) Control of active pathological lesions (apical, perio abscess, primary occlusal trauma)
2) Control caries an dinital tooth prep and provisonal (operative dentistry)
3) Provisional restoration for esthetic and/or functional reason
4) Control plaque & intial perio therapy
5) Oral surgery procedures
6) Initiation of endodontic treatment
Re-evaluation phase is to determine what?
The response to our initial therapy BEFORE our definitive phase.
What may the Re-evaluation phase include?
1) Completion of endo TX (post and core)
2) Reeval of occlusal adj
3) reveal of provisional restoration
4) reevaluation of response after initial perio therapy and plaque control
5) definitive perio surgery (osseous re-contour/mucogingival defect)
6) Re-prep of teeth after perio surgery
7) Healing time after oral/perio surgery
8) Establishing design for fixed and removable pros
9) Final eval of esthetics
Anything that needs a lab slip is __________ phase
Definitive
After reassessing the initial TX, the patient entrees the ____________ or __________ phase of TX.
This phase includes all therapies that _______ function after the patients disease has been __________
- Corrective
- Definitive
- Restore
- Controlled
Examples of the definitive phase include ?
1) Fixed and removable prosthodontics
2) Implant restoration
3) ortho
What are the regular re-care examinations for the maintenance phase?
1) Reassessment of occlusion
2) Reassessment of maintenance for any completed treatment
3) Reassessment of patient’s home care
What is gingivitis?
1) Inflammation soft tissue (superficial)
2) Bleeding on provocation
3) PD 1-4 mm and present as psuedopocket
4) No loss of attachment or radiographic evidence of bone loss
5) No tooth mobility
6) No furcation involvement
What is the initial therapy Phase I of gingivitis?
1) Medical consult
2) OHI
3) Full-mouth scale and polish
4) Re-evaliation 4-6 weeks
5) Prophylaxis every 6 months if disease resolved
What is the clinical presentation of Mild Chronic Perio?
1) Inflammation extending to bone
2) Bleeding on provocation
3) Attachment loss of 1-2 mm from CEJ
4) Probing depths of 3-4 mm
5) Radiographic bone loss of LESS than 20%
What is the initial therapy- Phase I for Mild Chronic Perio?
1) Medical consult
2) OHI
3) Quadrant or half-mouth scaling and root planning w/ anesthesia
4) Requires 2-4 appointments
5) Re-evaluation (4-6 weeks)
6) 3-4 month maintain interval
What is the clinical presentation of MODERATE Chronic Perio?
1) Inflammation extending to bone
2) Bleeding on provocation
3) CAL of 3-4 mm from CEJ
4) PD 5-6 mm
5) Radiographic bone loss of 20%-40%
6) Class I and II furcation involvement
7) Class I and II tooth mobility
What is the initial therapy- Phase I for MODERATE Chronic Perio?
1) Medical consult
2) OHI
3) Quadrant or half-mouth scaling and root planing w/ anesthesia
4) Requires 2-4 appointments
5) Re-eval (4-6 wks)
6) Locally delivered antimicrobials in 5-6 mm residual pockets
7) Referral to periodontist
What is the clinical presentation of ADVANCED Chronic Perio?
1) Inflammation extending to bone
2) bleeding on provocation
3) CAL of greater than 5 mm from CEJ
4) PD of greater than 7 mm
5) Radiographic bone loss greater than 40%
6) Class I, II , or III furcation involvement
7) Class I, II, or III tooth mobility
What is the initial therapy- Phase I for ADVANCED Chronic Perio?
1) Medical consult
2) OHI
3) Quadrant or half-mouth scaling and root planing w/ anesthesia
4) Requires 2-4 appointments
5) Re-eval (4-6 wks)
* *6) Locally delivered antimicrobials in 5-6 mm residual pockets
* *7) Referral to periodontist
What are the sequence of thought when determine prognosis?
1) Diagnostic
2) Therapeutic
3) Prosthetic
4) Provisional
What is diagnostic prognosis?
Prognosis without treatment
What is therapeutic prognosis?
What effect will periodontal TX have on course of disease?
What is prosthetic prognosis?
Given the anticipated result of perio TX, what is the forces for the success of the prosthetic restoration?
What is provisional prognosis?
The prognosis given prior initial phase of TX. It may change according to the patient/tooth response
Prognosis is divided into what 2 groups?
1) Overall prognosis
2) Individual tooth
Systemic Background (overall prognosis):
Sometimes the patient life expectancy is _________ than the tooth life expectancy. Seen in _________________ and _________________
- SHORTER
- AIDS
- Terminal stages of cancer
Systemic habits that affect prognosis ______________, _____________, and ______________.
1) Smoking
2) High refined sugar intake
3) Methamphetamine abuse
Overall prognosis is affected by what factors?
1) Systemic background ( smoking, AIDS (not HIV), Diabetes)
2) Pt attitude toward TX (compliance)
3) Availably of maintenance care
4) Vertical or horizontal bone loss
5) Furcation involvements (access for OH)
6) Pt history (Perio destruction, rate of disease, caries history (root especially)
7) Skill and interest of operator
8) Finances
____________ is the single most important risk factor
Smoking
Cigarette smokers are ___________ more likely than non-smokers to develop severe periodontitis.
5-8 times
- Smoking affects _______ and ______ in cross-section studies.
- Smoking has a ___________ incidence in longitudinal studies.
- Statistically there is significant association even after _________ for other risk factors
- prevalent
- severity
- HIGHER
- controlling
_______ inhibits ___________ healing following perio therapy.
- Smoking
- wound
Smoking ________ the quality of ___________ in shallow and deep pockets.
- Alters
- microbiota
Smoking _____________ NEUTS, Chemotaxis, Phagocytosis and oxidative burst.
DECREASES
Smoking:
____________ collagenase production.
______________ gingival venules, arterials, and capillaries
______________ GCF flow
INCREASES
Constricts
DECREASES
What are the 20 min positive benefits related to smoking cessation??
1) BP drops to normal
2) Pulse rate drops to normal
3) Peripheral body temp INCREASE to normal
What are the 8 hr positive benefits related to smoking cessation??
CO in blood drops to normal
What are the 24 hr positive benefits related to smoking cessation??
Chance of heart attack decreases
What are the 2 weeks- 3months positive benefits related to smoking cessation??
1) circulation improves
2) lung function increases up to 30%
What are the 1- 9 Months positive benefits related to smoking cessation??
1) Coughing, sinus congestion, shortness of breath DECREASES
2) Cilia re-grow in lungs thereby enhancing host defense against respiratory infections
What are the 1 year positive benefits related to smoking cessation??
1) Risk of coronary heart disease is 50 % less than that of a smoker
What are the 5 year positive benefits related to smoking cessation??
1) Lung cancer death rate for average smoker (1 pack a day) DECREASES by almost 50%
2) Stroke risk is rescued to that of non-smoker in 5-15 year quit range
3) Risk of oral, pharynx and esophageal cancer is 50% less than that of smoker’s
What are the 10-15 Year positive benefits related to smoking cessation??
1) Lung cancer death similar to nonsmokers
2) Risk of coronary heart disease is that of nonsmokers
In Type I and II Diabetes what is altered (INCREASES) in oral microbial flora ?
1) Type I diabetes (IDDM): Captocytophaga sp
2) Type II diabetes: Porphyromonas gingivalis
In Diabetes what is altered HOST DEFENSE MECHANISM ?
1) DECREASED PMN function (decrease chemotaxis and phagocytosis)
2) INCREASE glucose in GCF
(May allow growth of different subginigval bacteria)
What are the Vascular changes in Diabetes?
1) INCREASED thickness of Basement membrane and vessel walls
2) (Decreased O2 diffusion and elimination of wastes)
In Diabetes what is the collagen breakdown changes seen?
1) Stimulation of collagenase activity
2) Altered collagen metabolism
3) Limited production of growth factors
4) Impaired wound healing and increased severity of periodontitis
In UNTREATED moderate to advanced periodontitis ___________ teeth are lost per patient per year.
0.36
In TREATED moderate to advanced periodontitis with NO maintenance ___________ teeth are lost per patient per year.
0.22
In TREATED moderate to advanced periodontitis with REGULAR maintenance ___________ teeth are lost per patient per year.
0.11
- In multiple studies, The aggregate data from 6 studies show that untreated patients with chronic periodontitis lose __________ teeth pt/yr where as TREATED patients lose ___________ teeth pt/yr, a difference of x ________.
- Over a 10 year period UNTREATED patients can expect to lose __________ and treat patient ______ teeth.
- 0.28 (untreated)
- 0.08 (treated)
- 3.5
- 3-4 (untreated)
- 0-1 (treated)
In Longitudinal studies:
Average tooth loss can be misleading as all patients do not ____________ the same
Respond
Well maintained: 83.2% of patients lost ______ teeth
Downhill: 12.6% pf patients lost ________ teeth
Extreme Downhill: 4.2% lost ______ teeth
- 0-3 teeth
- 4-9 teeth
- 10-23 teeth
Compliance:
The level of OH at the 1st treatment appointment is not as important as the ________ of OH at the completion of the _____________ treatment.
- Level
- Initial phase of treatment (phase I)
Which type of periodontitis is the worst and better prognosis?
Worst: Agressive
Better: Chronic “adult”
In the worst prognosis Inflammation is __________ despite the severity of disease
NOT PRESENT
In the better prognosis inflammation is ___________
Present
What is the worst and better prognosis regarding plaque and calculus?
Worst: Almost absent
Better: Abundant
Which prognosis(worst or better) in regards to bone loss associated with acute or chronic injury, leads to chronic infection?
Worst
Which prognosis(worst or better) in regards to bone loss associated with acute or chronic injury, leads to Periodontal abscess?
Better
What is the individual tooth prognosis for Shallow PD _________, Moderate PD _______, and Severe PD_____
Shallow = 1-3 mm Moderate= 4-6 mm Severe = greater than 7
SRP:
Following SRP at PD greater than 5 mm residual calculus will remain __________ of the time .
Curette efficiency = _______mm
Instrumentation limit= _______mm
-85%
- 3.73 mm
- 5.52 mm
In the individual tooth prognosis, PD are _________ important than _____________
- Less
- CAL/ bone loss
PD GREATER than 6 mm will be _________ to maintain without _________, but prognosis should be based on _________ not by PD.
- difficult
- surgery
- CAL
Regarding individual tooth prognosis/Bone loss how many walls is the better prognosis?
3 walls > 2 walls> 1 wall > horizontal bone loss
Regarding individual tooth prognosis, what are the factors of root morphology?
1) length (MORE LENGTH = BETTER)
2) shape
3) root proximity
4) root topography
5) crown to root ratio
Ratio for a tooth with average root length is _______
(13 mm) 1: 2
What is the average loss of teeth with furcation involvement following treatment?
35.7 % (20.5 years)
Ross & Thompson study in 5-24 years ______ % teeth lost/
12 %
Hirschfeld & Wasserman study in 22 years ______ % teeth lost?
31%
McFall study in 19 years ______ % teeth lost?
56%
Goldman study in 22 years ______ % teeth lost?
44%
What is Class I prognosis in furcation involvement?
Fair prognosis
What is Class II prognosis in furcation involvement?
Questionable
-Mandibular furcations and buccal maxillary furcations have the BEST predictability for regenerative procedures
Class III/IV prognosis in furcation involvement?
Poor/Hopeless
What are the reasons for mobility beyond physiologic range?
1) Loss of support
2) Inflammation
3) Trauma
What is the prognosis based on degree of tooth mobility?
1) Class 1 : fair (slight mobility)
2) Class 2: questionable (moderate more than normal)
3) hopeless (severe mobility + depressive)
What is the classification of prognosis?
1) Good
2) Fair
3) Poor
4) Questionable
5) Hopeless
With GOOD prognosis:
Bone loss= Cooperation= Systemic disease= Mobility= Furcation involvement=
Bone loss= adequate Cooperation= adequate Systemic disease= no Mobility= physiologic Furcation involvement= none
With FAIR prognosis:
Bone loss= Cooperation= Systemic disease= Mobility= Furcation involvement=
Bone loss= Less than adequate Cooperation= Acceptable Systemic disease= limited Mobility= grade 1 Furcation involvement= Class I maintain
With POOR prognosis:
Bone loss= Cooperation= Systemic disease= Mobility= Furcation involvement=
Bone loss= Moderate/advanced Cooperation= doubtful Systemic disease= present and controlled Mobility= Grade 1 or 2 Furcation involvement= Class I or II
With QUESTION prognosis:
Bone loss= Cooperation= Systemic disease= Mobility= Furcation involvement=
Bone loss= advanced Cooperation= doubtful Systemic disease= Present and controlled Mobility= Grade 2 Furcation involvement= Class II
With HOPELESS prognosis:
Bone loss= Cooperation= Systemic disease= Mobility= Furcation involvement=
Bone loss= Advanced Cooperation= doubtful Systemic disease= uncontrolled Mobility= Grade 3 Furcation involvement= Class III
In more hopeless situations what happens?
1) PD to apex without pulpal involvement
2) Vertical cracks or fractures
3) Inaccessible perforations or accessory canals
4) Extreme caries susceptibility
5) Number and position of teeth impossible for restoration
6) Bone loss beyond the apex
It is extremely difficult to predict the prognosis of a tooth if the initial prognosis is other than _______
good
What are key questions a patient may ask?
1) Cost?
2) will it hurt?
3) How long will last?
4) How long it will take?
5) How it will look?
6) What if I don’t do anything?
7) What are the alternatives?
What are some considerations in determining prognosis?
1) Big picture
2) key teeth
3) key arch
4) strategic retreat
5) patients do fine with bicuspid occlusion
6) which teeth are hopeless teeth?
7) Overall, MAX molars are lost MORE frequent than MAND molars
