1 Prognosis

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PROGNOSIS

In this lecture we'll Talk about PROGNOSIS and factors that affect prognosis :.

Definition of Prognosis:

Prognosis Is the PREDICTION of the:

course of a disease{ stage of the disease and how fast is this stage going on}.

duration of a disease{and how long does it take for the treatment to be finished }.

outcomes of a disease{the results if this case is left untreated or if we treat it }.

Of course prognosis is made after thorough examination of the case and good understanding of the

underlying pathologyof the disease; because knowing the pathogenesis let you know what's going onand what's gonna happen . SUPPOSE :

You have two pts at the same age, both have severe form of periodontal disease ,one is diagnosed tohave aggressive periodontitis and the other has chronic periodontitis , which one you'd expect to have

worse prognosis ??!!!

Certainly; the one with aggressive periodontitis ,so, put in your mind that diagnosisitself is a main

factor of prognosis .

Another example: if you have 40 year-old patient has (x) amount of bone loss and another patient

who is 20 years old having the same amount of bone loss , which one has better prognosis ????

The old patient (who is 40 yr old) has better prognosis ,because the same amount of bone loss takes

longer time in the old pt compared to the younger one who seems to have more destructive disease in

nature


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Prognosis is established AFTER the diagnosis is made and BEFORE the

treatment plan is established

Prognosis should be established before treatment is started ,and based on this prognosis your

treatment plan should be done

So, the clinical steps are :

- Taking History & Examination

- FurtherInvestigationsif needed-.

- Define the Diagnosis

- Determine the Prognosisof the disease .

- Plan the Treatment.

NOW , the difference between PROGNOSIS and RISK .

Prognosisis the prediction of a presentdisease ..(done after the disease is there ).

Riskis the likelihood to get the disease (the possibility to get the disease ).

So ,the Prognostic factors: are the factors that affect the prognosis ..

While theRisk factors: are the factors which make the patient at risk to get the disease..

TYPES OF PROGNOSIS:Basically prognosis of periodontal diseases is classified into 5 main classes:

Good

Fair

Poor

Questionable

Hopeless


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GOOD PROGNOSIS:

We could classify the pt as having good prognosis if he has One or more of the following:

Adequate remaining bone support(to make the tooth savable .. the more loss of the alveolarbone ,the worse prognosis you have to expect ).

Adequate possibilities to control etiologic factors..(correctable etiologic factors , like havinggingivitis because of over-hanging restoration ).

Adequate patient cooperation

No systemic/environmental modifying factorsor well-controlled systemic factors.

FAIR PROGNOSIS:

We could classify the pt as having fair prognosis if he has One or more of the following:

Less-than-adequate remaining bone support (this is examined based on the radiographes)

Some(initial) tooth mobility.

Grade I furcation involvement.

Adequate maintenance possible.

Acceptable patient cooperation.

Presence of limited systemic/environmental factors. (like controlled diabetic pt , mildsmokers)

POOR PROGNOSIS:

We could classify the pt as having poor prognosis if he has One or more of the following:

Moderate-to-advanced bone loss.


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detectable Tooth mobility .

Grade Iand II Furcation involvements.

presence of areas the are difficult to maintain by the pt.

Doubtful patient cooperation (mentally or physically disable pts).

Presence of systemic/environmental factors .

QUESTIONABLE PROGNOSIS:

We could classify the pt as having questionable prognosis if he has One or more of the following:

Advanced bone loss.

Grade II and III furcation involvements.

Tooth mobility.

Inaccessible areas.

Presence of systemic/environmental factors.

HOPLESS PROGNOSIS:

We could classify the pt as having hopless prognosis if he has One or more of the following:

Advanced bone loss.

Non maintainable areas .

Extractions indicated .

Presence of uncontrolled systemic/environmental factors.


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PROVISIONAL PROGNOSIS:

"Initial prognosis of the case "

When your case is doubtfully not good and you cant determine the diagnosis , what you do is putting aprovisional diagnosis and start treating your pt and the final prognosis will be established after

evaluating phase therapy

So you initiate treatment of teeth that have a doubtful outlook in the hope that a favorable response

may tip the balance and allow teeth to be retained ..

OVERALLVS INDIVIDUALTOOTHPROGNOSIS:

OVERALL PROGNOSIS:

General factors (not related to a single tooth ) that influence the prognosis.

Concerned with patient and dentition as a whole:

- Pts Age(with age pts manual dexterity reduces).

-

Severity of disease..(mild forms of the disease are more likely to respond to the treatment compared to the severe

forms ).

- Systemic factors..(like Parkinson disease , diabetes)

- Smoking..

- Presence of plaque, calculus and other local factors.

-

Patient compliance.

- Prosthetic possibilities . ( if you want to extract teeth to construct a complete denturealthough these teeth could be preserved so the prosthesis of the choice could change the

prognosis in a way or another)


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Plaque control :

pts who perform plaque control measures better have better prognosis.

Patient Compliance and Cooperation:

Pt Compliance is essential in the success of perio treatment, so you need to determine :

Patient's attitude.

Desire to retain the natural teeth.

Willingness and ability to maintain good oral hygiene .And you need to check the current times and way of brushing because this reflects the

patients future compliance.

Systemic and Environmental Factors

Smoking : Smoking is a risk factor (makes the periodontal tissue at more risk to develop the disease) and a

prognostic factors ( smokers with perio diseases have worse prognosis if compared to non-smokers ) as

well .

SMOKING :


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increase the severity of periodontal destruction .

decrease the capacity of periodontal tissues in term of healing

See the table below :

Systemic Diseases and Conditions:

Type I and type II DM.

Conditions that limit the patient's performance of oral procedures (e.g., Parkinson's disease) also

adversely affect the prognosis.

Genetic Factors:

Determines the nature of the host response.

GENETIC FACTORS play a major role in aggressive periodontitis.

in chronic periodontitis its found that the patients tend to have specific genetic

polymorphismRelated basically to interleukin-1 (IL-1) genes and sometimes (IL-6),this

polymorphism resulting in an increase in the production of IL-1 and have beenassociated significantly with the increase of chronic periodontitis risk.

periodontitis prognosis

SMOKER SLIGHT TO MODERATE FAIR TO POOR

SEVER POOR TO HOPELESS

NON-

SMOKER

SLIGHT TO MODERATE GOOD

SEVER FAIR


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Local factors: (for individual tooth prognosis)

Anatomic Factors:Its better in term of prognosis to have:

long wide roots over short narrow one.

multi-rooted over single rooted tooth.

Short, tapered roots with large crowns adversely affect the prognosis.

Cervical enamel projections:

- Ectopic extensions of enamel that extend to the root surface ; which means therell be

no attachment there and that makes the tooth at more risk to have perio diseases and

worsen the prognosis if the tooth already has the disease .

?if you have two teeth with grade 2 furcation involvement one has short root trunkand the other has long trunk which is better in term of prognosis??

If we have furcation involvement Root with short trunks has better prognosis because this

means that the amount of bone destruction is less ..

So, tooth with long trunk has better prognosis if there is no furcation involvement while if we

there's furcation involvement it'll have poor prognosis because this indicates large amount of

bone loss .

Enamel pearls:

Large, round deposits of enamel that can be located in furcations or other areas on theroot surface.


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Bifurcation ridge:Its an enamel extension between two roots in multi-rooted teeth..

In 73% of mandibular first molars.

Crossing from the mesial to the distal root at the midpoint of the furcation.

Interfereswith the attachment apparatus and regenerative procedures.

Anatomic factors decrease the efficiency of SCALING and Root PLANINGso they can have a negative impact on the prognosis.

the smallest instrument we use for root planning and treatment subgingivally is the curette and

the diameter of the curette is even more than the opening of the furcation in more than 80% of the

cases so this make the accessibility much more difficult thus worsen the prognosis..

Other anatomic considerations that present accessibility problems are:

Developmental grooves.

Root proximity..(as the divergence of the root increases the prognosis becomes betterbecause the amount of supporting bone increases)

Furcation involvements.

Root Concavities ; Maxillary first premolars, first molars.

Tooth mobility:The more mobility you have the worse prognosis you'd expect


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Treatment plan:

the DR wants us to read this topic from the textbook focusing on the different phases of

perio treatment ..its just of two pages and there will be questions in the exam about this.

Its not sequential and should be customized for each patient.

Should be done after careful examination and diagnosing the case.

No treatment (except emergency) should be initiated before establishing a treatment plan.

Done by : Shorooq Alalmeh

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