Prognosis

The prognosis is a prediction of the probable course,
duration, and outcome of a disease based on a general
knowledge of the pathogenesis of the disease and the
presence of risk factors for the disease.

1. PROGNOSIS DR.OINAM MONICA DEVI

2. Contents Definition Types of Prognosis Factors in Determination of Prognosis Prognosis of Specific Periodontal Diseases Determination and Reassessment of Prognosis Conclusion

3. Definition A prognosis is a prediction of the probable course, duration, and outcome of a disease based on a general knowledge of the pathogenesis of the disease and the presence of risk factors for the disease ( Carranza, 13 th e d). The provisional prognosis allows the clinician to 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.

4. PROGNOSIS After the diagnosis Before the treatment plan In some cases, risk factors and prognostic factors are the same. For example, patients with diabetes or patients who smoke are more at risk for acquiring periodontal disease, and once they have it, they generally have a worse prognosis. Prognosis initially assigned should be reevaluated after completion of all phases of therapy, including periodontal maintenance.

5. Classification of Prognosis (McGuire MK ,1996;Kwok V, 2007) Good prognosis : Control of etiologic factors and adequate periodontal support ensure the tooth will be easy to maintain by the patient and clinician. Fair prognosis : Approximately 25% attachment loss or grade I furcation invasion. Poor prognosis : 50% attachment loss, grade II furcation invasion. Questionable prognosis : >50% attachment loss, poor crown-to root ratio, poor root form, grade II furcation invasion or grade III furcation invasion; mobility no. 2 or no. 3; root proximity. Hopeless prognosis : Inadequate attachment to maintain health, comfort, and function.

6. Kwok and Caton (2007) proposed a scheme based on “the probability of obtaining stability of the periodontal supporting apparatus.” Favorable prognosis : Comprehensive periodontal treatment and maintenance will stabilize the status of the tooth. Future loss of periodontal support is unlikely. Questionable prognosis : Local or systemic factors influencing the periodontal status of the tooth may or may not be controllable. If controlled, the periodontal status can be stabilized with comprehensive periodontal treatment. If not, future periodontal breakdown may occur. Unfavorable prognosis : Local or systemic factors influencing the periodontal status cannot be controlled. Comprehensive periodontal treatment and maintenance are unlikely to prevent future periodontal breakdown. Hopeless prognosis : The tooth must be extracted.

7. Overall Prognosis The overall prognosis is concerned with the dentition as a whole. Factors that may influence the overall prognosis include Patient age Current severity of disease Systemic factors The presence of biofilm or calculus Patient compliance Prosthetic possibilities

8. The overall prognosis answers the following questions: Should treatment be undertaken? Is treatment likely to succeed? When prosthetic replacements are needed, are the remaining teeth able to support the added burden of the prosthesis?

9. Individual Prognosis The individual tooth prognosis is determined after the overall prognosis and is affected by it. For example, in a patient with a poor overall prognosis, the dentist likely would not attempt to retain a tooth that has a questionable prognosis because of local conditions.

10. Factors to Consider When Determining a Prognosis Overall Clinical Factors Patient age Disease severity Biofilm control Patient compliance Systemic and Environmental Factors Smoking Systemic disease or condition Genetic factors Stress Local Factors Biofilm and calculus Subgingival restorations Anatomic Factors Short, tapered roots Cervical enamel projections Enamel pearls Bifurcation ridges Root concavities Developmental grooves Root proximity Furcation invasion Tooth mobility Caries Tooth vitality Root resorption Prosthetic and Restorative Factors Abutment selection

11. Factors in Determination of Prognosis Overall Clinical Factors Patient Age For two patients with comparable levels of remaining connective tissue attachment and alveolar bone, the prognosis is generally better for the older of the two. For the younger patient, the prognosis is not as good because of the shorter time frame in which the periodontal destruction has occurred. In younger patient, the occurrence of so much destruction in a relatively short period would exceed any naturally occurring periodontal repair.

12. Disease Severity A patient's history of previous periodontal disease may be indicative of their susceptibility to future periodontal breakdown. Variables determining the patient's past history of periodontal disease: probing pocket depth, level of attachment, amount of bone loss, and type of bony defect must be assessed properly.

13. Clinical attachment loss reveals the approximate extent of root surface that is devoid of periodontal ligament; the radiographic examination shows the amount of root surface still invested in bone. Probing pocket depth is less important than level of attachment because it is not necessarily related to bone loss. In general, a tooth with deep probing depths and little attachment and bone loss has a better prognosis than one with shallow pockets and severe attachment and bone loss.

14. Prognosis is adversely affected if the base of the pocket is close to the root apex. The presence of apical disease as a result of endodontic involvement also worsens the prognosis. The prognosis also can be related to the height of remaining bone but bone level assessment alone insufficient for determining the overall prognosis

15. Generalized mild chronic periodontitis in a healthy, nonsmoking 67-year-old female. Overall prognosis is favourable Generalized moderate-to-severe chronic periodontitis in a healthy, nonsmoking 49-year-old female. Overall prognosis is questionable/unfavorable. Carranza, 13 th ed

16. The prognosis for horizontal bone loss depends on the height of the existing bone because it is unlikely that clinically significant bone height regeneration will be induced by therapy. In the case of angular, intrabony defects, if the contour of the existing bone and the number of osseous walls are favorable, there is an excellent chance that therapy could regenerate bone to approximately the level of the alveolar crest.

17. When greater bone loss has occurred on one surface of a tooth, the bone height on the less involved surfaces should be taken into consideration when determining the prognosis. Carranza, 13 th ed

18. The practitioner should weigh the potential success of one treatment option (extraction and implant placement) versus the other (periodontal therapy and maintenance) carefully when assigning a questionable prognosis to teeth. Strategic extraction of teeth with unfavorable or questionable prognoses may improve the prognosis of adjacent teeth, enhance the prosthetic treatment, and increase the success rate of implants replacing the strategically extracted teeth. Carranza, 13 th ed

19. Biofilm Control Bacterial biofilm is the primary etiologic factor associated with periodontal disease. Effective removal of biofilm on a daily basis by the patient is critical to the success of periodontal therapy and the prognosis.

20. Patient Compliance and Cooperation The prognosis for patients with gingival and periodontal disease is critically dependent on the patient's attitude, desire to retain the natural teeth, and willingness and ability to effectively control biofilm . The dentist should make it clear to the patient and in the patient record that further treatment is needed but will not be performed because of a lack of patient cooperation.

21. Systemic and Environmental Factors Smoking Patients should be informed that smoking affects not only the severity of periodontal destruction but also the healing potential of the periodontal tissues. The prognosis in patients who smoke and have slight to moderate chronic periodontitis is generally questionable. Patients who stop smoking, the prognosis can improve to favorable in those with slight to moderate chronic periodontitis and to questionable in those with severe chronic periodontitis .

22. Systemic Disease or Condition Evidence from epidemiologic studies clearly demonstrates that the prevalence and severity of chronic periodontitis are significantly higher in patients with poorly controlled diabetes than in those whose diabetes is well controlled or those who do not have diabetes. Similarly, in patients with other systemic disorders that could affect disease progression, prognosis improves with correction of the systemic problem. Incapacitating conditions that limit the patient's performance of oral procedures (e.g., Parkinson disease) also adversely affect the prognosis. Newer “automated” oral hygiene devices, such as electric toothbrushes, may be helpful for these patients and may improve their prognosis.

23. Genetic Factors Evidence indicates that genetic factors may play an important role in determining the nature of the host response. Genetic polymorphisms in the interleukin-1 (IL-1) genes, resulting in increased production of IL-1β, have been associated with a significant increase in risk for severe, generalized, and chronic periodontitis . It has been demonstrated that knowledge of the patient's IL-1 genotype and smoking status can aid the clinician in assigning a prognosis.

24. Detection of genetic variations linked to periodontal disease can potentially influence the prognosis in several ways. 1. Early detection of patients at risk because of genetic factors can lead to early implementation of preventive and treatment measures for these patients. 2. Identification of genetic risk factors later in the disease or during the course of treatment can influence treatment recommendations, such as the use of adjunctive antibiotic therapy or increased frequency of maintenance visits. 3. Identification of young individuals who have not been evaluated for periodontitis but who are recognized as being at risk because of the familial aggregation seen in aggressive periodontitis can lead to the development of early intervention strategies. In each of these cases, early diagnosis, intervention, and alterations in the treatment regimen may lead to an improved prognosis for the patient.

25. Stress Physical and emotional stress, as well as substance abuse, may alter the patient's ability to respond to the periodontal treatment performed. These factors must be realistically faced when attempting to establish a prognosis.

26. Local Factors Biofilm and Calculus The microbial challenge presented by bacterial biofilm and calculus is the most important local factor in periodontal diseases. Having a favorable prognosis depends on the ability of the patient and the clinician to remove these etiologic factors.

27. Subgingival Restorations Subgingival margins may contribute to increased biofilm accumulation, increased inflammation, and increased bone loss when compared with supragingival margins. Discrepancies in these margins (e.g., overhangs) and duration of their presence are important factors in the amount of destruction that occurs. A tooth with a discrepancy in its subgingival margins has a worse prognosis than a tooth with well-contoured supragingival margins.

28. Anatomic Factors Anatomic factors that may affect the prognosis include short, tapered roots with large crowns, cervical enamel projections and enamel pearls, intermediate bifurcation ridges, root concavities, and developmental grooves. The clinician must also consider root proximity and the location and anatomy of furcations when assigning a prognosis. Prognosis is less favorable for teeth with short, tapered roots and relatively large crowns.

29. Cervical enamel projections (CEPs) on the root surface interferes with the attachment apparatus and may prevent regenerative procedures from achieving their maximum potential. The morphology of the tooth root is an important consideration when discussing prognosis . Root concavities increase the attachment area and produce a root shape that may be more resistant to torquing forces, they also create areas that can be difficult for both the dentist and the patient to clean. Developmental grooves, which sometimes appear in the maxillary lateral incisors or in the lower incisors, create an accessibility problem. Root proximity can result in interproximal areas that are difficult for the clinician and patient to access.

30. Tooth Mobility The principal causes of tooth mobility are loss of alveolar bone, inflammatory changes in the periodontium , and trauma from occlusion. Tooth mobility caused by inflammation and trauma from occlusion may be correctable. The likelihood of restoring tooth stability is inversely proportional to the extent to which mobility is caused by the loss of supporting alveolar bone. A longitudinal study of the response to treatment of teeth with different degrees of mobility revealed that pockets on clinically mobile teeth do not respond as well to periodontal therapy as pockets on nonmobile teeth exhibiting the same initial disease severity. The stabilization of tooth mobility through the use of splinting may have a beneficial impact on the overall and individual tooth prognosis.

31. Caries, Tooth Vitality, and Root Resorption For teeth mutilated by extensive caries, the feasibility of adequate restoration and endodontic therapy should be considered before undertaking periodontal treatment. Extensive idiopathic root resorption or root resorption resulting from orthodontic therapy jeopardizes the stability of teeth and adversely affects the response to periodontal treatment. The periodontal prognosis of treated nonvital teeth does not differ from that of vital teeth. New attachment can occur to the cementum of both nonvital and vital teeth.

32. Prosthetic and Restorative Factors The overall prognosis and individual tooth prognosis overlap because the prognosis for key individual teeth may affect the overall prognosis for prosthetic rehabilitation. When few teeth remain, the prosthodontic needs become more important, and sometimes periodontally treatable teeth may have to be extracted if they are not compatible with the design of the prosthesis. Teeth that serve as abutments are subjected to increased functional demands. More rigid standards are required when evaluating the prognosis of teeth adjacent to edentulous areas. A tooth with a post that has undergone endodontic treatment is more likely to fracture when serving as a distal abutment supporting a distal removable partial denture.

33. Prognosis for Patients With Gingival Disease Biofilm -Induced Gingival Diseases Gingivitis Associated With Dental Plaque Only Biofilm -induced gingivitis is a reversible disease that occurs when bacterial biofilm accumulates at the gingival margin. The prognosis is good for patients with gingivitis associated with bacterial biofilm only favorable, provided All local irritants are eliminated Other local factors contributing to biofilm retention are eliminated Gingival contours conducive to the preservation of health are attained The patient cooperates by maintaining good oral hygiene

34. Biofilm -Induced Gingival Diseases Modified by Systemic Factors The frank signs of gingival inflammation that occur in patients having systemic disorders are seen in the presence of relatively small amounts of bacterial biofilm . The long-term prognosis for these patients depends not only on control of bacterial biofilm but also on control or correction of the systemic factors.

35. Biofilm -Induced Gingival Diseases Modified by Medications Gingival diseases associated with medications include drug influenced gingival enlargement, often seen with phenytoin , cyclosporine, and nifedipine and in oral contraceptive–associated gingivitis. In drug-influenced gingival enlargement, the severity of the lesions is associated with inflammation, which is usually induced by bacterial biofilm . Gingival overgrowth in a 5-year-old male patient who was taking cyclosporine for the management of aplastic anemia. Carranza, 13 th ed

36. Eliminating the source of inflammation, either trauma or biofilm , can limit the severity of the gingival overgrowth. Surgical intervention is usually necessary to correct the alterations in gingival contour. The long-term prognosis depends on whether the etiology of the inflammation can be completely eliminated or the patient‘s systemic problem can be treated with an alternative medication that does not have gingival enlargement as a side effect. The gingival overgrowth was resected surgically Carranza, 13 th ed

37. In oral contraceptive–associated gingivitis, frank signs of gingival inflammation can be seen in the presence of relatively little biofilm . The long-term prognosis in these patients depends not only on the control of bacterial biofilm but also on the likelihood of continued use of oral contraceptives.

38. Gingival Diseases Modified by Malnutrition The prognosis in vitamin C deficiency patients may depend on the severity and duration of the deficiency and on the likelihood of reversing the deficiency through dietary supplementation.

39. Non- Biofilm -Induced Gingival Lesions Non- biofilm -induced gingivitis in patients is not usually attributed to biofilm accumulation, prognosis depends on elimination of the source of the infectious agent. Prognosis for patients suffering from dermatologic disorders like lichen planus , pemphigoid , etc manifesting in the oral cavity as atypical gingivitis is linked to management of the associated dermatologic disorder. Prognosis for patients presenting with gingival lesions as a result of allergic, toxic, foreign-body reactions, mechanical and thermal trauma depends on the elimination of the causative agent.

40. Prognosis for Patients With Periodontitis In patients with more severe disease, as evidenced by furcation invasion and tooth mobility, or in patients who are noncompliant with oral hygiene practices, the prognosis may be questionable or unfavorable, and even hopeless.

41. Periodontitis as a Manifestation of Systemic Diseases Periodontitis as a manifestation of systemic diseases can be divided into the following two categories : 1. Periodontitis associated with hematologic disorders such as leukemia and acquired neutropenias 2. Periodontitis associated with genetic disorders such as familial and cyclic neutropenia , Down syndrome, Papillon - Lefèvre syndrome, and hypophosphatasia The prognosis in these cases will be questionable or unfavorable.

42. Other genetic disorders do not affect the host's ability to combat infections but still affect the development of periodontitis . (1) Hypophosphatasia , in which patients have decreased levels of circulating alkaline phosphatase , severe alveolar bone loss, and premature loss of deciduous and permanent teeth. (2) Ehlers- Danlos syndrome, a connective tissue disorder, in which patients may present with clinical characteristics of aggressive periodontitis . In both examples the prognosis is questionable or unfavorable.

43. Necrotizing Periodontal Disease In Necrotizing ulcerative gingivitis (NUG), the primary predisposing factor is bacterial plaque, usually complicated by the presence of secondary factors such as acute psychologic stress, tobacco smoking, and poor nutrition, all of which can contribute to immunosuppression . With control of both the bacterial plaque and the secondary factors, the prognosis for a patient with necrotizing ulcerative gingivitis (NUG) is favorable. The tissue destruction in NUG cases is not reversible, and poor control of the secondary factors may make these patients susceptible to recurrence of the disease. With repeated episodes of NUG, the prognosis may worsen to questionable.

44. The clinical presentation of Necrotizing Ulcerative Periodontitis (NUP) is similar to that of NUG, except the necrosis extends from the gingiva into the periodontal ligament and alveolar bone. In systemically healthy patients, this progression may have resulted from multiple episodes of NUG, or the necrotizing disease may occur at a site previously affected with periodontitis . In these patients, the prognosis depends on alleviating the biofilm and secondary factors associated with NUG.

45. Determination and Reassessment of Prognosis Determination of prognosis of a tooth or teeth requires a careful and thorough assessment of the presence of disease and its severity and extent. An accurate prognosis cannot be made without an accurate diagnosis. Once disease has been properly and accurately diagnosed, determining the prognosis can still be difficult, particularly for teeth with disease. Many factors can influence disease progression and the response to therapy, and the specific influence of any one factor is unknown and likely different from one patient to another.

46. The outcome of therapy significantly depends on the treatment to be rendered, the quality of the treatment, the skills and knowledge of the treating clinician, and patient home care. Prognosis of teeth with minimal disease is favorable and by far the easiest to assign with accuracy and precision. Once disease progresses to a point that teeth are no longer functional or treatable, the prognosis is again easy to determine.

47. It is not always possible to accurately determine the prognosis prior to initiating periodontal treatment. During the periodontal examination, due to the lack of anesthesia, it may not be possible to accurately and carefully probe a tooth to determine the true extent of bone loss and severity of disease. The prognosis may change as more specific diagnostic information is discovered and improve with periodontal treatment or disease progression. An inability to enhance the host response will negatively influence the prognosis.

48. A frank reduction in probing depth and inflammation after therapy indicates a favorable response to treatment and may suggest a better prognosis than previously assumed. If the inflammatory changes cannot be controlled or reduced by therapy, the overall prognosis may be unfavorable. Given two patients with comparable bone destruction, the prognosis may be better for the patient with the greater degree of inflammation because a larger component of that patient's bone destruction may be attributable to local etiologic factors.

49. Prognosis changes with treatment. The maxillary left first and second molars were initially assigned an unfavorable prognosis due to advanced bone loss and deep grade II furcation invasion (A, B). Both teeth were vital, stable, and did not require any restorative treatment. Both teeth were treated with periodontal surgery. After 5 years, they remain healthy and functional, and the prognosis improved to favorable (C, D). Carranza, 13 th ed

50. The progression of periodontitis generally occurs in an episodic manner, with alternating periods of quiescence and shorter destructive stages. No methods are available at present to accurately determine whether a given lesion is in a stage of remission or exacerbation. Advanced lesions, if active, may progress rapidly to a hopeless stage, whereas similar lesions in a quiescent stage may be maintainable for long periods. Stable lesions in a patient in periodontal maintenance may also break down and advance due to changes in biofilm control, stress level, or systemic health. Prognosis along with diagnosis must be carefully evaluated and reassessed throughout the course of treatment and over time during supportive maintenance therapy. Conclusion

51. References Newman, Takei, Klokkevold , Carranza. Carranza’s, clinical periodontology , 10th ed ; 632-34. Newman, Takei, Klokkevold , Carranza. Carranza’s, clinical periodontology , 13th ed ; 1880-1916. Kwok V, Caton J. Prognosis revisited: a system for assigning periodontal prognosis. J Periodontol . 2007;78:2063. McGuire MK, Nunn ME. Prognosis versus actual outcome.II . The effectiveness of clinical parameters in developing an accurate prognosis. J Periodontol. 1996;67:658.

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