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.”
process of getting a prognosis
Diagnostic Prognosis
an evaluation of the course
of the disease without treatment
Therapeutic Prognosis:
an evaluation of the course
of the disease with treatmen
Prosthetic Prognosis :
the anticipated result of the periodontal therapy with anticipated prosthetic treatment
avg tooth loss with perio pts with no tx or maintenance
The average tooth loss was 0.36 teeth/patient/year
avg tooth loss of perio pts with tx and no maintenance
0.22 teeth/patient/year
avg tooth loss in perio pts with tx and maintenance
about 0.1 teeth/year
prothestic prognosis with good perio tx and maintenance
relatively good, teeth will fail to support but perio status can be maintained
factors to consider for prognosis
Individual tooth prognosis and Overall prognosis
Individual tooth prognosis factors
- 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
Overall prognosis factors
- 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:
Individual tooth prognosis
Modified and affected
by overall prognosis
Individual Tooth Prognosis
* Amount or percentage of?
* The most important determinant?
* Bony defect?
* Pocket? need to relate to?
* Rate of?
* System/environmental? examples?
* Pt’s?
Individual Tooth Prognosis
* Amount or percentage of attachment loss=The most important determinant, influences mobility and C/R ratio
* Bony defect topography
* Pocket depth
* need to relate to attachment loss
* Rate of attachment loss
* System/environmental factors
* Smoking, diabetes, stress, genetics, medications inducing gingival enlargements, systemic disease effecting periodontitis etc.
* Pt’s compliance and OH control
Individual Tooth Prognosis
* Anatomical factors
- 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
defective restoration overhang
overhang or subgingival restorations can cause inflammation and loss of support
Cervical Enamel Projections (CEPs)
When present, it extends into furcation areas of ~20-30% of molars.
The most common location: buccal surface of 2nd mandibular molar.
PDL cannot attatch
Classification:
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. (Not enter yet)
Grade III: The enamel projection extends horizontally into the furcation.
Enamel pearls
In the molar furcation areas, especially maxillary 2nd and 3rd molars.
Incidence of 1.1% to 9.7%. 21
cause lack of PDL attatchment
Palatogingival groove
Found in 4% to 6% of maxillary lateral incisors
root concavities
Radiographs UNDERESTIMATE the defects.
req surgical tx
Root form and length
Long, divergent and multi-roots are less prone to have mobility.
The longer the root trunk, the less likely it is to become periodontally involved. When it’s involved, the more apical the furcation the more difficult it is to access and treat
Furcation root trunk length
Maxillary molars:
Mandibular molars:
Maxillary 1st premolar:
Furcation root trunk length
Maxillary molars:
mesial 3mm, buccal 4mm, distal 5mm
Mandibular molars:
buccal 3mm, lingual 4mm
Maxillary 1st premolar:
mesial 7mm
Furcation and intermediate bifurcation ridge
Furcation involvement
* Maxillary molars are lost more often than mandibular molars
Furcation ridge
* 73% of mandibular molars
* Cementum extending from the mesial to the distal of a furcation opening
* Hamper plaque control/ collect plaque
Accessary canals
28.4% molars have accessory canals in the furcation
* 29.4% of mandibular molars
* 27.4% of maxillary molars
perio tx unsuccessful with accessory canals
Root proximity
Definition: the distance between the roots of adjacent teeth on radiographs is ≤1.0 mm.
Distance <0.8 mm is a significant local risk factor for alveolar bone loss in mandibular anterior teeth.
Amount of bone loss is about 3.6 times higher than normal.
classes 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 are
Tooth position
Within the alveolus envelope and bone support, can be outside of this= too far B or L
Pathologic tooth migration
Kwok and Caton 2007
- This system is based on periodontal stability
- Periodontal prognostication is dynamic and should be
reevaluated throughout treatment and maintenance
kwok and caton favorable
- 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 questionable
- 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 unfavorable
- 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 hopeless
extract
Does Endo Treatment Affect
Perio Prognosis?
no
All the following factors need to
be considered when assigning
the prognosis EXCEPT
endo tx
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
- Arrest the disease
- Regenerate lost periodontium
- Maintain periodontal health: Reduce “critical mass” of plaque and Allow host to control the bacteria
Healing after SRP
* Formation of? when?
* Clinical presentation?
* inflam cell pop? GCF? CT?
- Formation of long junctional epithelium, It 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
Healing after SRP
Transient root hypersentitivy/recession?
* Important to warn?
* If unexpected?
Transient root hypersentitivy and recession of the gingival margins will frequently be seen during healing
* Important to warn patients about these potential results
* If unexpected, may result in distrust, lack of motivation, and unwillingness to continue therapy
decreased probing depths with tx
4-6mm PD vs >7mm
The decrease in the probing depth consists of two
components: clinical attachment gain and recession
4-6mm PD: 1mm PD reduction and 0.5mm attachment gain
>7mm PD: 2mm PD reduction and 1mm attachment gain
re-evaluation timing after SRP
* Allows healing time for?
* Allows patient sufficient time to?
* Gingival inflammation reduced in what time frame?
4-6 weeks after completion of SRP
* Allows time for healing of epithelium and CT
* Allows patient 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
re-eval
* The time to?
* The time to decide?
- The time to re-motivate the patient and go over
further instructions if the patient has NOT
improved OH. - The time to decide whether the patient needs to
be referred for advanced periodontal treatment.
why not wait longer for re-eval:
* Initial improvement of clinical attachment was found at ? following SRP, and?
* Longer than 2 months?
- 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
Re-evaluation Elements:
Evaluate clinical parameters and compare to baseline
- 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
Residual PD≥6 mm represent?
Residual PD≥6 mm represent an incomplete treatment and require further therapy
Referral
Decision to refer to a periodontist
* The PD > 5 mm is proposed as current guideline for referral
* REFER, If the pt has grade C progression
* Early referral of advanced case is critical to provide the best outcome
* PD of 5-8mm, treatment by a periodontist is usually successful
* PD > 9mm: limited success
What to expect at re-evaluation?
quiz question
A. Long junctional epithelium formation was found at 1-2 weeks following the treatment
maintenance/SPT
- SPT includes all the procedures performed at selected intervals to assist the periodontal patient in maintaining oral health.
- These usually consist of examination, an evaluation of oral hygiene and nutrition, scaling, root curettage, and polish of teeth
TO-DO List at SPT Appointment
- 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
All treatment approaches
in the absence of SPT
All treatment approaches are equally ineffective in
preventing recurrence of destructive periodontitis
in the absence of SPT
The treatment with no SPT
The treatment is bound to fail with sloppy or no SPT
Effectiveness of SPT
Post-treatment pocket depth and attachment
levels could be maintained irrespective of personal oral hygiene
The state of “periodontal health” could be maintained
in both young and older patients over 10 years
Frequency SPT
* For patients with a history of periodontal disease?
* Patients without additional attachment loss?
* Most studies supported maintenance visits when?
* The shorter the recall interval for maintenance visits following periodontal surgery?
- 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 once every 6 months.
- Most studies supported maintenance visits at least once every 3 months for patients with history of periodontal disease.
- The shorter the recall interval for maintenance visits following periodontal surgery, the better the surgical outcomes.
Periodontal Risk
Assessment (PRA)
- Six parameters are used to evaluate the risk for
recurrence of periodontitis at a patient level. - Each patient is assigned to a risk group (low, moderate or high) and maintenance frequency is established accordingly.
PRA Parameters and their values
- 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
low, moderate, high recall intervals for PRA
Probing depths stable, no bleeding at recall procedure
- Routine treatment, review OHI
- Same recall interval
Probing depths stable, bleeding recall procedure
- 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 time frame initally?
* Clinical studies support ?
* If referred and treated, then?
* Alternate between ?
* Maintenance versus?
- Maintenance is usually every 3 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
