Prognosis Re-evaluation and Maintenance Flashcards
what is prognosis
a prediction of the course, duration and outcome of a disease based on a general knowledge of the risk factors for the disease
what are the steps in delivering a predictable and long term stable comprehensive treatment plan
- comprehensive exam -> dx -> prognosis -> tx plan
what is a diagnostic prognosis
an evaluation of the course of the disease without treatmentw
what is a therapeutic diagnosis
an evaluation of the course of the disease with treatment
what is the prosthetic prognosis
the anticipated result of the periodontal therapy with anticipated prosthetic treatment
what are the two main factors to consider in prognosis assignment
- individual tooth prognosis
- overall prognosis
what are the factors that make up the individual tooth prognosis
- percentage of bone loss
- deepest probing depth
- horizontal or vertical bone loss
- anatomical factors- furcation involvement, root form, mobility
- crown to root ratio
- caries or pulpal involvement
- tooth malposition
- fixed or removable abutment
what are the factors in overall prognosis
- age
- medical status
- smoker and/or diabetic
- family history of periodontal disease
- oral hygiene
- compliance
- maintenance interval
- parafunctional habits with/without guard
- individual tooth prognosis
what do we examine in the individual tooth prognosis
- amount or percentage of attachment loss
- bony defect topography
- pocket depth
- rate of attachment loss
- systemic/enivronmental factors
- patients compliance and OH control
what is the most important determinant in the individual tooth prognosis
amount or percentage of attachment loss
what are the anatomical factors considered in individual tooth prognosis
- excessive occlusal forces
- overhang or defective subgingival restorations
- cervical enamel projections/enamel pearls
- developmental/palatogingival grooves
- root concavities
- root forms and lengths
- furcation and intermediate bifurcation ridges
- accessory canals
- root proximity
- tooth proximity
what are the 3 grades of CEPs
- grade I: the enamel projection extends from the CEJ of the tooth toward the furcation entrance
- grade II: the enamel projection approaches the entrance to the furcation
- grade III: the enamel projection extends horizontally into the furcation
when present, CEPs extends into furcation areas of _____ of molars
20-30%
the most common location for CEPs is:
the buccal surface of 2nd mandibular molars
enamel pearls are found in _____ especially ______
molar furcation areas, maxillary 2nd and 3rd molars
what is the incidence of enamel pearls
1.1-1.9%
what is the incidence of the palatogingival groove
4-6% of maxillary lateral incisors
when looking at the furcal aspects of maxillary first molar teeth, root concavities were found in:
- 94% of mesiobuccal roots
- 31% of distobuccal roots
- 17% of palatal roots
radiographs ____ the root concavity defects
underestimate
what is the furcation root trunk length in maxillary molars
- mesial 3mm
- buccal 4mm
- distal 5mm
what is the furcation root trunk length of mandibular molars
- buccal 3mm
- lingual 4mm
what is the furcation root trunk length of maxillary 1st premolars
- mesial 7-8mm
what teeth are less prone to having mobility
long- divergent and multi rooted teeth
the longer the root trunk the ____ likely it is to become periodontally involved
less
when it is involved the more apical the furcation the more _____ it is to access and treat
difficult
with furcation involvement are maxillary molars or mandibular molars lost more
maxillary molars
what are furcation ridges
- cementum extending from the mesial to the distal of a furcation opening
- impede plaque control
what is the incidence of accessory canals in molars
- 28.4% of molars have accessory canals in the furcation
- 29.4% in mandibular molars
- 27.4% in maxillary molars
the distance between roots of adjacnet teeth on radiographs is:
less than or equal to 1mm
the distance of _____ is a significant local risk factor for alveolar bone loss in mandibular anterior teeth
less than 0.8mm
the amount of bone loss when teeth are less than .8mm apart is ____ higher than normal
3.6 times
what are the 3 levels of root proximity
- class I: about 0.3mm. no bone just PDL between teeth
- class II: 0.3-0.5mm, just cortical bone present
- class III: 0.5mm. some cancellous bone in the area
what is the ideal tooth position
within the alveolus envelope and has full bone support
describe pathologic tooth migration
- when the balance among the factors that maintain physiologic tooth position is disturbed by periodontal disease
- occurs most frequently in the anterior region
what are the classification systems
- McGuire and Nunn - 1996
- Kwok and Caton (2007)
describe the McGuire and Nunn system
-system is based on tooth loss
- the coefficients from this model were able to predict accurately the 5 year and 8 year prognosis 81% of the time
- when the teeth with a good prognosis were excluded the predictvie accuracy dropped approximately 50%
what are the classes in the Mcquire system
- good
- fair
-poor - questionable
- hopeless
describe the Kwok and Caton system
- system is based on periodontal stability
- periodontal prognostication is dynamic and should be re evaluated throughout treatment and maintenance
does endo treatment affect periodontal prognosis
- early inflammatory changes in the pulp exert very little effect on the periodontium
- even a pulp that is significantly inflamed may have little or no effect on the surrounding periodontal tissues
the initial pulpal inflammatory response is an attempt to:
prevent the spread of infection to the apical tissues
what is the re-evaluation used to determine
the effectiveness of SRP and to review the proficiency of plaque control
what are the objectives of treatment
- arrest the disease
- regenerate lost periodontium
- maintain periodontal health
- reduce critical mass of plaque
- allow host to control the bacteria
what is the expectation of healing after SRP
- formation of a long junctional epithelium
- appears 1-2 weeks after therapy
- clinical presentation with less inflammation, redness, and swelling
- gradual reductions in inflammatory cell population, crevicular fluid flow and repair of connective tissue
- transient root hypersensitivity and recession of the gingival margins can be seen during healing
the decrease in the probing depths consists of two components:
clinical attachment gain and recession
when is re evaluation done
4-6 weeks after completion of SRP
why wait 4-6 weeks to do re-eval
- allows time for healing of epithelium and CT
- allows pt sufficient time to practice and improve OH
- gingival inflammation is usually reduced or eliminated within 3-4 weeks after removal of calculus and local irritants
- the time to remotivate the pt and go over further instructions if the pt has not improved OH
- the time to decide whether the patient needs to be referred for advanced periodontal tx
why NOT wait longer than 4-6 weeks for re-eval
- initial improvement of clinical attachment was found at 3 weeks following SRP and no additional gain of clinical attachment occurred in the succeeding 3 months
- longer than 2 months, pathogenic bacteria have already repopulated periodontal pockets
what clinical parameters do you evaluate and compare to baseline
-OH and patients compliance
- resolution of the inflammation (BOP, plaque control)
- progression of attachment loss
- mucogingival defects and gingival recession
- resolution of occlusal trauma
- hypersensitivity
- furcation, mobility
what are the criteria for success in re-eval
- no pockets greater than 5mm and non greater than 4mm with BOP
the decision to refer to periodontist is based on the following:
- PD greater than 5mm is proposed as the current guideline
- grade C progression
- early referral of advanced cases is crticial to provide the best outcome
- PD of 5-8mm- usually successful
- PD greater than 9mm- limited success
supportive periodontal treatment includes:
all the procedures performed at selected intervals to assist the periodontal patient in maintaining oral health
supportive periodontal treatment usually consists of:
- examination
- evaluation of OH
- evaluation of nutrition
- scaling
- root currettage
- polishing of teethw
what is another name for maintenance
supportive periodontal treatment
what are the 3 types of maintenance
- periodontal maintenance
- preventative maintenance
- recall maintenance
what is the checklist for SPT appointment
- review and update medical and dental hx
- clinical exam: extra oral exam, intra oral exam, dental exam, periodontal exam
- radiographic exam
- assessment of disease status or changes by comparing clinical and radiographic information with baseline
- assessment of OH
- treatment
what is involved in treatment in the checklist for SPT appointment
- removal of subgingival and supragingival plaque and calculus
- behavioral modification: OH re-instruction, adherence to maintenance intervals, control of risk factors
- selective scaling or root planing
- occlusal adjustment
- use of local antimicrobial agents or irrigation procedures
- root desensitization
- return to phase II active therapy if needed
if you dont have maintenance, the treatment will _____
fail
for patients with a history of periodontal disease, periodontal maintenance should be provided on a regular and recurrent basis, generally at intervals of _____
2-6 months
patients without additional attachment loss can have maintenance visits every:
6 months
most studies support maintenance visits at least _____ for patients with a history of periodontal disease
once every 3 months
the shorter the recall interval for maintenance visits following periodontal surgery, the _____ the surgical outcomes
better
what places patients in low risk category
- BOP less than 10%
- 4 pockets greater than 5mm
- 4 missing teeth
- less than 0.5 loss of periodontal support
- no systemic conditions
- non or former smoker
what places patient in moderate risk category
- BOP 10%-25%
- 4-8 pockets greater than 5mm
- 5-8 missing teeth
- 0.5-1.0 loss of periodontal support
- no systemic conditions
- less than 20 cigarettes per day
what places patients in the high risk category
- BOP greater than 25%
- greater than 8 pockets greater than 5mm
- more than 8 missing teeth
- greater than 1.0 loss of periodontal support
-diabetes - more than one pack of cigs per day
patients with low risk profile or at most one risk factor in the moderate category how often are intervals
once a year at least
patients with at least two risk factors in moderate category and at most one factor in high risk how often SPT
twice a year
patients with at least 2 risk factors in high risk category how often SPT
3-4 months
what are the clinical parameters at SPT appointment
- clinical exam
- periodontal exam
- treatment
- planning future SPT intervals according to individual periodontal risk assessment
what do you do if probing depths are stable and no bleeding at SPT
- routine tx
- review OHI
- same recall interval
what do you do if probing depths are stable but there is bleeding at SPT
- re-scale and root plane bleeding sites
- consider local delivery of antimicrobials
- review OHI
- consider shortening recall interval
maintenance is usually at ______ initially
every 3 months
if referred to a periodontist and treatment then:
determine what maintenance schedule is needed
what is perio maintenance versus compromised perio maintenance
in compromised perio maintenance the disease process is still active, but the pateints oral hygiene is not adequate enough to proceed to surgical therapy
- this is a temporary solution until OH has improved
