Prognosis Re-evaluation Maintenance Flashcards
Prognosis
“A prediction of the course, duration and
outcome of a disease based on a general
knowledge of the risk factors for the disease.”
Deliver a predictable and long term stable comprehensive tx plan
Prognosis
(4)
Comprehensive examinations
(Clinical findings, Radiographic findings)
Diagnosis
Prognosis
Treatment plan
- Diagnostic Prognosis:
an evaluation of the course
of the disease without treatment
- Therapeutic Prognosis:
an evaluation of the course
of the disease with treatment
- Prosthetic Prognosis :
the anticipated result of the
periodontal therapy with anticipated prosthetic treatment
Comprehensive Treatment Plan
(3) Prognosis
Diagnostic
Therapeutic
Prosthetic
Diagnostic Prognosis
Evaluated 30 patients with moderate to advanced periodontitis with
no treatment at an average of 3.72 years after initial examination
The average tooth loss was
0.36 teeth/patient/year
Therapeutic Prognosis
Evaluated 44 patients with moderate to advanced periodontitis with
treatment BUT NO MAINTENANCE over a 5-year period
The average tooth loss was
0.22 teeth/patient/year
Therapeutic Prognosis
Evaluated 95 patients with moderate to advanced periodontitis with
treatment AND REGULAR MAINTENANCE at an average of 6.5 years
The average tooth loss was
0.11 teeth/patient/year
Prosthetic Prognosis
251 patients with advanced periodontitis needs prosthetic therapy.
They were periodontally treated, restored with bridges and placed
in a maintenance program with a follow-up of 5-8 years
Only –% of bridgework fulfilled the requirements of Ante’s Law.
The periodontium is well — (probing depth of 2-3mm,
unchanged bone level) between 5-8 years after active treatment.
8
maintained
Prosthetic Prognosis
8% bridges failed due to loss of retention, fracture of bridgework or
abutment teeth.
(2) did not influence periodontal status
Severe reduction of periodontal support around the abutment teeth
and difference in bridgework
Factors to consider
Individual tooth prognosis
(8)
Percentage of bone loss
Deepest probing depth
Horizontal or vertical bone loss
Anatomical factors
(furcation involvement, root form, mobility, etc.)
Crow-to-root ratio
Caries or pulpal involvement
Tooth malposition
Fixed or removable abutment
Factors to consider
Overall prognosis
(9)
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
Overall prognosis
Concerned with the
dentition as a whole
Individual tooth prognosis
Modified and affected
by overall prognosis
Individual Tooth Prognosis
(6)
- Amount or percentage of attachment loss
- Bony defect topography
- Pocket depth
- Rate of attachment loss
- System/environmental factors
- Pt’s compliance and OH control
- Amount or percentage of attachment loss
- The most important determinant, influences mobility and C/R ratio
- Pocket depth
- need to relate to
attachment loss
- System/environmental factors
(6)
- Smoking, diabetes, stress, genetics, medications inducing gingival
enlargements, systemic disease effecting periodontitis etc.
Individual Tooth Prognosis
* Anatomical factors
(10)
- Excessive occlusal forces
- Defective overhang or subgingival restorations
- Cervical Enamel Projections (CEPs)/enamel pearls
- Developmental/palatogingival grooves
- Root concavities
- Root forms and lengths
- Furcation and intermediate bifurcation ridge
- Accessary canals
- Root proximity
- Tooth mobility
Anatomical factors
- Defective overhang or subgingival restorations
Cervical Enamel Projections (CEPs)
Cervical Enamel Projections (CEPs)
When present, it extends into furcation areas of ~—% of molars.
The most common location:
20-30
buccal surface of 2nd mandibular molar
Enamel pearls
In the …
Incidence of —%
molar furcation areas, especially maxillary 2nd and 3rd molars.
1.1% to 9.7%
Palatogingival groove
Found in
4% to 6% of maxillary lateral incisors.
Root concavity
Radiographs — the defects.
UNDERESTIMATE
Root form and length
Long, divergent and multi-roots are less prone to have —.
The longer the root trunk, the — likely it is to become periodontally
involved. When it’s involved, the more — the furcation the more
difficult it is to access and treat
mobility
less
apical
Furcation involvement
* — molars are lost more often
than — molars
Maxillary
mandibular
Furcation ridge
* —% of mandibular molars
* Cementum extending from the
* Hamper plaque control
73
mesial
to the distal of a furcation opening
Accessary canals
—% molars have accessory canals in the furcation
* —% of mandibular molars
* —% of maxillary molars
28.4
29.4
27.4
Root proximity
Definition: the distance between
the roots of adjacent teeth on
radiographs is ≤– mm.
Distance <— mm is a significant local risk factor for alveolar
bone loss in mandibular anterior teeth.
Amount of bone loss is about — times higher than normal
1.0
0.8
3.6
Tooth position
Within the …
Pathologic tooth migration
alveolus envelope and
bone support
McGuire and Nunn 1996
* This system is based on —
* The coefficients from this model were able to predict accurately the
5-year and 8-year prognoses —% of the time.
* When teeth with “good” prognoses were excluded, the predictive
accuracy dropped approximately —%
tooth loss
81
50
McGuire and Nunn 1996
Good
(4)
- Etiologic
factors can be
controlled - Adequate
periodontal
support - Controlled
systemic
factors - Teeth can be
relatively easy
to maintain by
patients and
professionals
McGuire and Nunn 1996
Fair
(5)
- Up to 25%
attachment
loss - Grade I
furcation - Limited
systemic
factors - Teeth can be
maintained
with proper - home care and
professionals
McGuire and Nunn 1996
Poor
(5)
- Up to 50%
attachment
loss - Grade II
furcation - Presence of
systems
factors - > Miller class I
mobility - The furcation
situation
allows proper
maintenance
but with
difficulty
McGuire and Nunn 1996
Questionable
(5)
- > 50%
attachment
loss - Grade II or III
furcation - Poor crown-
root ratio, poor
root form,
significant root
proximity - ≥ Miller class II
mobility - Teeth not
easily
maintained by
patients and/or
professionals
McGuire and Nunn 1996
Hopeless
(5)
- Inadequate
attachment to
support the
tooth - Grade III or IV
furcation - Miller class III
mobility - Teeth can’t be
maintained by
patients and/or
professionals - Extraction is
suggested or
performed
Kwok and Caton 2007
* This system is based on
* Periodontal prognostication is dynamic and should be
reevaluated throughout
periodontal stability
treatment and maintenance.
Kwok and Caton 2007
Favorable
(2)
- The periodontal status of the tooth can be stabilized with
comprehensive periodontal treatment and periodontal maintenance. - Future loss of the periodontal supporting tissues is unlikely if these
conditions are met
Kwok and Caton 2007
Questionable
(2)
- The periodontal status of the tooth is influenced by local and/or
systemic factors that may or may not be able to be controlled. - The periodontium can be stabilized with comprehensive periodontal
treatment and periodontal maintenance if these factors are controlled;
otherwise, future periodontal breakdown may occur
Kwok and Caton 2007
Unfavorable
(2)
- The periodontal status of the tooth is influenced by local and/or
systemic factors that cannot be controlled. - Periodontal breakdown is likely to occur even with comprehensive
periodontal treatment and maintenance.
Kwok and Caton 2007
Hopeless
(1)
- The tooth must be extracted
Does Endo Treatment Affect
Perio Prognosis?
NO
All the following factors need to
be considered when assigning
the prognosis EXCEPT
A. Rate of attachment loss
B. Parafunctional habit
C. Furcation anatomy
D. Endodontic treatment
Re-evaluation
The evaluation or assessment of treatment. It’s
used to determine the effectiveness of SRP and
to review the proficiency of plaque control
Objectives of Treatment
(3)
- Arrest the disease
- Regenerate lost periodontium
- Maintain periodontal health
- Maintain periodontal health
(2)
- Reduce “critical mass” of plaque
- Allow host to control the bacteria
Expectation
Healing after SRP
* Formation of long —
* It appears — weeks after therapy
* Clinical presentation with less (3)
* Gradual reductions in (3)
junctional epithelium
1-2
inflammation, redness and swelling
inflammatory cell population, crevicular fluid flow, and repair of connective tissue
Expectation
Healing after SRP
* Transient root hypersentitivy and recession
of the gingival margins will frequently be
seen during —
* Important to warn patients about these
potential results
* If unexpected, may result in (3)
healing
distrust, lack
of motivation, and unwillingness to
continue therapy
Expectation
The decrease in the probing depth consists of two
components:
clinical attachment gain and recession
Timing
— after completion of SRP
4-6 weeks
Timing
4-6 weeks after completion of SRP
* Allows time for healing of (2)
* Allows patient sufficient time to (2)
* Gingival inflammation is usually reduced or
eliminated within – weeks after removal of
calculus and local irritants
epithelium and CT
practice and improve OH
3-4
Timing
4-6 weeks after completion of SRP
* The time to …
* The time to decide whether the patient needs to
be …
re-motivate the patient and go over
further instructions if the patient has NOT
improved OH.
referred for advanced periodontal treatment.
Timing
Why not wait longer?
* Initial improvement of clinical attachment was
found at – weeks following SRP, and no additional
gain of clinical attachment occurred in the
succeeding 3 months.
* Longer than – months, pathogenic bacteria have
already repopulated periodontal pockets.
3
2
Re-evaluation Elements
Evaluate clinical parameters and
compare to baseline
(7)
- OH & Pt’s compliance
- Resolution of the inflammation
(BOP, Plaque control) - Progression of attachment loss
- Mucogingival defects and
gingival recession
(progressing? the same?) - Resolution of occlusal trauma
- Hypersensentitivy
- Furcation, mobility
Re-evaluation Elements
Criteria for success
No pockets =/> 5 mm and none >4 mm with BOP
* It is vital to chart
diligently before and
after.
* It drives the customized
treatment plan.
Updated Treatment Plan
Determination of additional treatment/referral
* 172 well-maintained patients
* Association of risk factors with tooth loss and periodontitis progression
* Compared with PD≤3 mm, PD=5 mm represented a risk factor for tooth loss
* PD≥6 mm was a risk factor for disease progression
* Residual PD – mm represent an incomplete treatment and require
further therapy
≥6
Referral
Decision to refer to a periodontist
* The PD > – mm is proposed as current guideline for referral
* REFER, If the pt has grade – progression
* Early referral of advanced case is critical to provide the best outcome
* PD of –mm, treatment by a periodontist is usually successful
* PD > – mm: limited success
5
C
5-8
9
What to expect at re-
evaluation?
A. Long junctional epithelium formation was found at 1-2
weeks following the treatment.
B. B. Gingival inflammation is usually reduced or eliminated
within 6-8 weeks after removal of calculus and local irritants
C. Initial improvement of clinical attachment was found at 3
weeks following SRP and additional gain of clinical
attachment occurred in the succeeding 3 months
D. The decrease in the probing depth results from the gingival
recession.
Maintenance
Supportive Periodontal Treatment (SPT)
Introduction
Supportive Periodontal Treatment (SPT)
Periodontal Maintenance
Preventive Maintenance
Recall Maintenance
* SPT includes all the procedures performed at selected intervals to
assist the periodontal patient in …
* These usually consist of (5)
maintaining oral health.
examination, an evaluation of oral hygiene
and nutrition, scaling, root curettage, and polish of teeth.
TO-DO List at SPT Appointment
(7) steps
- Review and update of medical and dental history
- Clinical examination (to be compared with previous data)
* Extraoral examination
* Intraoral examination
* Dental examination
* Periodontal examination: probing depths, bleeding on probing,
general levels of plaque and calculus, evaluation of furcations,
exudate, gingival recession, attachment levels
* Examination of dental implants and peri-implant tissues - Radiographic examination as needed
- Assessment of disease status or changes by comparing clinical
and radiographic information with baseline - Assessment of personal oral hygiene
- Treatment:
* Removal of subgingival and supragingival plaque and calculus.
* Behavioral modification:
* Oral hygiene reinstruction
* Adherence to suggested PM intervals
* Counseling on control of risk factors
* Selective scaling or root planing, if indicated.
* Occlusal adjustment, if indicated
* Use of local antimicrobial agents, or irrigation procedures, as
needed.
* Root desensitization, if indicated
* Return to Phase II active therapy if indicated - Communication
* Informing the patient of current status and need for additional
treatment if indicated
* Consultation with other health care practitioners who may be
providing additional therapy. - Planning future SPT intervals according to individual Periodontal
Risk Assessment.
Absence of SPT
* 25 patients received OHI, initial therapy, then assigned to 5 different
surgical approach in pockets more than 5mm.
* No SPT follows active treatment
* Recall at 6, 12, 24 months for assessment
* Significant further attachment loss (1.2mm-1.9mm) in all groups.
All treatment approaches are equally ineffective in
preventing recurrence of destructive periodontitis
in the absence of SPT
Absence of SPT
* 90 patients with advance periodontal disease received OHI, initial therapy and
surgical treatment.
* 2/3 were in a well-organized maintenance program (q2-3m)
* 1/3 were referred back to GP for maintenance (not supervised)
* Re-examined at 3 and 6 years
* GP group had obvious signs of recurrent periodontitis (increased PI and 45%
loss of attachment); strict maintenance group had unaltered attachment levels.
The treatment is bound to fail with
sloppy or no SPT
Effectiveness
* 78 patients had periodontal therapy and every 3-month maintenance over 8 years
* Plaque score (PI) affects variations in pocket depth (PD) and attachment levels (AL)
* Compared the 25% sample having the lowest PI with the 25% having the highest PI
* The initial post-treatment reductions in PD and AL were more favorable in patients
with good OH, but the differences were not significant after 3-4 years of maintenance.
(2) could be maintained irrespective of
personal oral hygiene
Post-treatment pocket depth and attachment
levels
Effectiveness
* 61 patients with advanced periodontal disease undergone osseous surgery
* 14 year period of effective SPT every 3-6 months including subgingival scaling
* Minimal progression of periodontits as attachment loss, recurrent deep pockets
or extracted teeth.
The state of “periodontal health” could be maintained
in both young and older patients over –
10 years
Frequency
* For patients with a history of periodontal disease, periodontal — should be provided on a regular and recurrent basis,
generally at intervals of – months
* Patients without additional attachment loss can have maintenance
visits once every – months.
* Most studies supported maintenance visits at least once every – months for patients with history of periodontal disease.
* The shorter the recall interval for maintenance visits following
periodontal surgery, the better the surgical outcomes
maintenance
2– 6
6
3
Periodontal Risk
Assessment (PRA)
* Six parameters are used to
evaluate the risk for
recurrence of periodontitis at
a – level.
* Each patient is assigned to a
— and maintenance
frequency is established
accordingly.
patient
risk group (low, moderate or
high)
PRA Parameters
(6)
- BOP (%)
- <10% Low; 10-25% Moderate; >25% High
- # of pockets ≥5 mm
- ≤4 pockets: Low; 5-8: pockets Moderate; >8: pockets High
- # of missing teeth (excludes 3rd molars)
- ≤4 teeth: Low; 5-8 teeth: Moderate; >8 teeth: High
- Loss of periodontal support/patient’s age
- ≤0.5: Low; 0.5-1.0: Moderate; >1.0: High
- Diabetes
- Yes: High; No: Low
- Cigarette smoking
- Yes: High; No: Low
- BOP (%)
- <10% Low; 10-25% Moderate; >25% High
- # of pockets ≥5 mm
- ≤4 pockets: Low; 5-8: pockets Moderate; >8: pockets High
- # of missing teeth (excludes 3rd molars)
- ≤4 teeth: Low; 5-8 teeth: Moderate; >8 teeth: High
- Loss of periodontal support/patient’s age
- ≤0.5: Low; 0.5-1.0: Moderate; >1.0: High
- Diabetes
- Cigarette smoking
- Yes: High; No: Low
- Yes: High; No: Low
Clinical Parameters at SPT
Appointment
(3)
- Clinical examination (to be compared with previous data)
* Periodontal examination - Treatment
- Planning future SPT intervals according to individual Periodontal
Risk Assessment
Probing depths stable, no bleeding
(2)
- Routine treatment, review OHI
- Same recall interval
Probing depths stable, bleeding
(4)
- Review OHI
- Re-scale and root plane bleeding sites (if
needed/etiological factor still present) - Consider local delivery of antimicrobials
- Consider shortening recall interval
Clinical Parameters at SPT
Appointment
* Maintenance is usually every – months initially
- Clinical studies support this regiment to keep the clinical
parameters stable
* If referred and treated, then determine what maintenance
schedule is needed
- Alternate between referral dentist and periodontist is an option
* Maintenance versus compromised maintenance
3
Pts displaying a low risk profile for periodontitis recurrence yield all risk factors in the low risk category or, at most, one risk factor in the moderate risk category
for such pts, an sPT interval of at least once a year was recommended
Pts presenting with at least two risk factors in the moderate risk category and at most one risk factor in the high risk category were classified as displaying a moderate risk profile
SPT twice a year
Pts showing at least two risk factors in the high risk category are defined to belong to a high risk profile for disease recurrence
SPT at intervals of 3-4 mo per year
- Loss of periodontal support/patient’s age
- ≤0.5: Low; 0.5-1.0: Moderate; >1.0: High
