Anda di halaman 1dari 13

1

2

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 pathology of the disease; because knowing the pathogenesis let you know what's going on
and what's gonna happen . SUPPOSE :
You have two pts at the same age, both have severe form of periodontal disease ,one is diagnosed to
have 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 diagnosis itself 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





3


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
- Further Investigations if needed-.
- Define the Diagnosis
- Determine the Prognosis of the disease .
- Plan the Treatment.

NOW , the difference between PROGNOSIS and RISK .

Prognosis is the prediction of a present disease ..(done after the disease is there ).
Risk is the likelihood to get the disease (the possibility to get the disease ).

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

4


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 alveolar
bone ,the worse prognosis you have to expect ).
Adequate possibilities to control etiologic factors..(correctable etiologic factors , like having
gingivitis because of over-hanging restoration ).
Adequate patient cooperation
No systemic/environmental modifying factors or 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 , mild
smokers)


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.

5

detectable Tooth mobility .
Grade I and 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.






6


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 a
provisional diagnosis and start treating your pt and the final prognosis will be established after
evaluating phase 1therapy

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 ..




OVERALL VS INDIVIDUAL TOOTH PROGNOSIS:
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 denture
although these teeth could be preserved so the prosthesis of the choice could change the
prognosis in a way or another)

7


INDIVIDUAL TOOTH PROGNOSIS
--Concerned with a tooth conditions and local factors..
--Determined after the overall prognosis and is affected by it.



Overall
Clinical
Factors

Systemic/
Environmental
Factors


Local factors

Prosthetic/
restorative
factors


-Patient
age

-Disease
severity

-Plaque
control

-Patient
complianc
e




-Smoking

-Systemic
disease/
condition

-Genetic
factors(which
play major role in
aggressive
periodontitis)

-Stress
(adversely affect the
periodontium, so
people under stress
are more susceptible
to perio diseases
compared to healthy
individual)


-plaque / calculus (they are
risk factor as well).

- subgingival restoration

- anatomic factors:

short tapered roots
cervical enamel
projections
enamel pearls
bifurcation ridges
root concavities
developmental grooves
root proximity
furcation involvement

-tooth mobility


-abutment
selection

-caries

-non-vital
teeth

-root
resorption

this table shows the factors that affect the prognosis "prognostic factors" : ..


8

? what are the main diagnostic( characteristic) factors of aggressive periodontitis .
1. Rapid bone destruction and attachment loss compared to chronic periodontitis
2. Familial aggregation (genetic factors)..


Overall Clinical Factors
Patients Age
as we explained above its better in the older patients. ( because its occurred over
longer duration)
despite Younger patient has greater reparative capacity
Disease severity:
We could assess the severity of the disese by the assessment of:

Height of remaining bone..
Type of the bony defect (horizontal-Angular)
? NOW ,which do you think has better clinical outcome (prognosis) angular or horizontal bone loss???
ANGULAR (VERTICAL) bone loss has better prognosis , because :
in vertical bone loss ; the remaining bone that is facing the root is amenable for the procedure that
help in regeneration of bone while Its unlikely for the bone to regenerate in horizontal bone loss
secondly; (have a look on the pic below ) : you know that the axis of rotation of the the teeth
related to the level of the bone so if you have vertical bone loss the axis of rotation will be
more coronally thus the distribution of the force on the tooth will be more uniform and the
stress will be less .
<<< but keep in mind that angular bone loss reflects active disease or active bonw
distruction>>>


9




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 :

11

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
polymorphism Related 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 been
associated 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

11


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 trunk
and 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 the
root surface.

12


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.
Interferes with the attachment apparatus and regenerative procedures.


Anatomic factors decrease the efficiency of SCALING and Root PLANING
so 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 better
because 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



13

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