Prognosis 6 th seminar

prognosis in perio

1. PROGNOSIS D.Hema Pg -ii Dept. of periodontics PMVIDS

2. CONTENTS Introduction Definitions Prognosis & Risk Prognosis & Causality Types of Prognosis Factors in Determination of Prognosis Relationship Between Diagnosis and Prognosis Reevaluation of Prognosis After Phase I Therapy Conclusion References

3. INTRODUCTION If I have this treatment done how long can I expect to keep my teeth? Pathogenesis Risk factors Treatment options

4. T he ability to predict with some accuracy just what will be the fate of the teeth and their supporting tissues, that are affected by the disease and the outcomes of the treatment done to treat these diseases is one of basic requirements while treating a patient. Such prediction depends upon a careful scientific evaluation of the sum total of factors which comprise known and unknown etiology, which determine the probability of eliminating the disease by means available to the periodontist , and which enhance the possibility of maintaining the status of a functionally dynamic reparation.

5. DEFINITIONS G reek word , pro  before gignoskein  to fore know or to know. The Merriam-Webster Dictionary: “ the prospect of recovery as anticipated from the usual course of disease or peculiarities of the case .” The American Heritage Medical Dictionary: “a prediction of the probable course and outcome of a disease, and the likelihood of recovery from a disease .” Boston : Houghton Mifflin, 2007 .

6. 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. It is established after the diagnosis is made and before the treatment plan is established . Carranza, 12 th ed. 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. it is advisable to establish a provisional prognosis until phase I therapy is completed and evaluated . Carranza, 12 th ed.

7. Short term prognosis: Where estimation is made for the next 3-5 years. Long term prognosis: Where the teeth are expected to remain in health and function beyond 5 years. Therapeutic prognosis: Deals with the response of tissues to treatment and successful arrest of disease process. Prosthetic prognosis: Indicate the ability of remaining teeth to support the prosthesis. Carranza, SOUTH ASIA 2 ND ED

8. Prognosis and Causality C ausality involves identification of the agents that are responsible for causing a target disorder. It is related to prognosis in a most direct way. Treatment of many diseases involves removal of the true offending or causal agent (or at least reducing its impact). To the extent that this can be done , the treatment will be effective and the prognosis good . To the extent that the actual agent is not identified or cannot be reduced or eliminated, suboptimal outcomes may be expected and the prognosis will be less favorable.

9. Risk generally deals with the likelihood that an individual will develop a disease in a specified period. Risk factors are those characteristics of an individual that put the person at increased risk for developing a disease. Prognostic factors are characteristics that predict the outcome of disease once the disease is present. In some cases, risk factors and prognostic factors are the same. Ex: Diabetes & Smoking. Prognosis and Risk

10. Prognostic factors can be categorized into those that can be : controlled by the patient (daily plaque removal, smoking cessation, compliance with wearing occlusal guards, compliance with the recommended preventive maintenance schedule); those impacted by periodontal treatment (probing depth, mobility, furcation involvement, trauma from occlusion, bruxism, other parafunctional habits); those associated with systemic disease (diabetes mellitus, immunological disorders, hypothyroidism); and those that are uncontrollable (poor root form, poor crown-root ratio, tooth type, age, genetics).

11. TYPES OF PROGNOSIS McGuire MK, Nunn ME, 1996, based on studies evaluating tooth mortality, the following classification has been proposed: Good prognosis: Control of etiologic factors adequate periodontal support easy to maintain by the patient and clinician. Fair prognosis: Approximately 25% attachment loss and/or Class I furcation involvement location and depth allow proper maintenance with good patient compliance.

12. Poor prognosis: 50% attachment loss, Class II furcation involvement location and depth make maintenance possible but difficult . Questionable prognosis: >50% attachment loss, poor crown-to root ratio, poor root form, Class II furcations (location and depth make access difficult) or Class III furcation involvements; >2+ mobility; root proximity . Hopeless prognosis: Inadequate attachment to maintain health, comfort, and function .

13. good , fair , hopeless prognoses Poor, questionable prognoses McGuire MK, Nunn ME: Prognosis versus actual outcome. II. The effectiveness of clinical parameters in developing an accurate prognosis. J Periodontol 67:658, 1996. established with a reasonable degree of accuracy. likely to change to other categories as they depend on a large number of factors that can interact in unpredictable number of ways

14. Kwok and Caton , 2007: have 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 and/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 .

15. Unfavorable prognosis: Local and/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.

16. Kwok V, Caton J: Prognosis revisited: a system for assigning periodontal prognosis. J Periodontol 78:2063, 2007.

17. Overall Vs Individual Tooth Prognosis Overall prognosis: concerned with the dentition as a whole. 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?

18. Individual tooth prognosis: 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.

19. Individual tooth prognosis Overall tooth prognosis Percentage of bone loss Age Deepest probing depth Medical History Horizontal/vertical bone loss Family History Deepest furcation involvement Oral Hygiene: Good/Fair/Poor Mobility Compliance: Y/N Crown to Root ratio: F/UF Maintenance interval: 2 mnths, 2mnths alternate Root form F/UF 3mnths, 3mnths alternate Caries or Pulpal Involvement : Y/N Parafunctional habit with night guard Tooth malposition: Y/N Parafunctional habit without night guard. Fixed or Removable prosthesis: Y/N Adapted from McGuire and Newman(1996)

20. FACTORS IN DETERMINATION OF PROGNOSIS Overall Clinical Factors Local Factors Systemic/Environmental Factors Prosthetic/Restorative factors Age Plaque/ Calculus Smoking Abutment selection Disease severity Subgingival Restorations Systemic diseases Caries Plaque control Anatomic factors Genetic factors Non-vital teeth Patient compliance Tooth mobility Stress Root resorption

21. Overall Clinical Factors Patient Age: the younger patient, the prognosis is not as good as for the older  shorter time frame  periodontal destruction has occurred; may have aggressive type of periodontitis, or associated systemic disease or smoking. occurrence of so much destruction in a relatively short period would exceed any naturally occurring periodontal repair .

22. Disease Severity H/O previous periodontal disease  susceptibility for future periodontal breakdown. Variables to be recorded for determining the patient’s past history of periodontal disease: pocket depth, level of attachment, degree of bone loss, and type of bony defect .

23. Pocket depth and CAL: Pocket depth less imp. than CAL  not necessarily related to bone loss. > prognosis Deep pockets with little bone loss shallow pockets with severe bone loss source of infection  contribute to disease progression.

24. Bone loss: The prognosis also can be related to the height of remaining bone . so little bone loss that tooth support is not in jeopardy bone loss is so severe that the remaining bone is obviously insufficient for proper tooth support

25. Type of defect: H orizontal 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. A ngular , 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

26. “ Watch and wait” approach: teeth with questionable prognosis are extracted to enhance: Likelihood of partial restoration of the bone support of adjacent teeth or successful implant placement. “watch and wait” approach may allow an area to deteriorate to the point that placing an implant is no longer a viable option. practitioner should weigh the potential success of when assigning a prognosis to questionable teeth. extraction and implant placement Periodontal therapy and maintenance vs

27. Plaque Control: Bacterial plaque is the primary etiologic factor associated with periodontal disease. Therefore effective removal of plaque on a daily basis by the patient is critical to the success of periodontal therapy and to the prognosis .

28. Patient Compliance and Cooperation: Prognosis depends on: patient’s attitude, desire to retain the natural teeth, and willingness and ability to maintain good oral hygiene . Without these , treatment cannot succeed. If patients are unwilling or unable to perform adequate plaque control and to receive the timely periodic maintenance checkups and treatments, the dentist can: refuse to accept the patient for treatment or extract teeth that have a hopeless or poor prognosis and perform scaling and root planing on the remaining teeth.

29. Systemic and Environmental Factors Smoking: important environmental risk factor impacting the development and progression of periodontal disease. patients who smoke do not respond as well to periodontal therapy as patients who have never smoked. slight - moderate periodontitis smoke fair to poor prognosis severe periodontitis poor to hopeless prognosis good prognosis Stop smoke smoke Stop smoke Fair prognosis smoking cessation can affect treatment outcome and the prognosis .

30. Systemic Disease or Condition: P atient’s systemic background affects overall prognosis in several ways. Diabetes: the prevalence and severity of periodontitis are significantly higher in patients with diabetes than in those without it. the level of control of the diabetes is an important variable in this relationship. patients diagnosed with diabetes must be informed of the impact of diabetic control on the development and progression of disease. Well-controlled diabetic patients with slight-to-moderate periodontitis who comply with their recommended periodontal treatment should have a good prognosis.

31. prognosis improves with correction of the systemic problem . The prognosis is questionable when surgical periodontal treatment is required but cannot be provided because of the patient’s health. 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

32. Genetic Factors: genetic factors may play an important role in determining the nature of the host response. Kornman et al,1998: Genetic polymorphisms in interleukin-1 genes , resulting in increased production of IL-1β , Risk-severe generalized chronic periodontitis. Hart et al, 1997: Genetic factors also appear to influence serum IgG2 antibody titers and the expression of FcγRII receptors on the neutrophil , both of which may be significant in aggressive periodontitis. Other genetic disorders, such as LAD type 1, can influence neutrophil function, creating an additional risk factor for aggressive periodontitis.

33. Detection of genetic variations linked to periodontal disease can potentially influence the prognosis in several ways. early detection can lead to early implementation of preventive and treatment measures for these patients. Identification 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. identification of young individuals with risk of familial aggregation seen in aggressive periodontitis, can lead to the development of early intervention strategies & may lead to an improved prognosis for the patient.

34. 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.

35. Local Factors Plaque and Calculus: The microbial challenge presented by bacterial plaque and calculus is the most important local factor in periodontal diseases. Therefore , in most cases, having a good prognosis depends on the ability of the patient and the clinician to remove these etiologic factors

36. Anatomic Factors: Anatomic factors that may predispose the periodontium to disease and therefore affect the prognosis include: short , tapered roots with large crowns; cervical enamel projections and enamel pearls; intermediate bifurcation ridges; root concavities; and developmental grooves. root proximity location and anatomy of furcations D ecrease the efficiency of periodontal procedures  - ve impact on the prognosis.

37. Poor prognosis: reduced root surface available for periodontal support, the periodontium may be more susceptible to injury by occlusal forces. Short, tapered roots with large crowns

38. Cervical enamel projections (CEPs): flat , ectopic extensions of enamel that extend beyond the normal contours of the CEJ. 28.6 % of mandibular molars and 17% of maxillary molars. Mostly found on buccal surfaces of maxillary second molars affect plaque removal , can complicate scaling and root planing. should be removed to facilitate maintenance.

39. Enamel pearls & bifurcation ridges: larger , round deposits of enamel that can be located in furcations or other areas on the root surface. 75 % appearing in maxillary third molars An intermediate bifurcation ridge has been described in 73% of mandibular first molars. They may prevent regenerative procedures from achieving their maximum potential. have a negative effect on the prognosis for an individual tooth .

40. Root concavities: exposed through loss of attachment can vary from shallow flutings to deep depressions. difficult to clean . They appear more marked on maxillary first premolars, the MB root of the maxillary first molar, both roots of mandibular first molars, and the mandibular incisors.

41. Developmental grooves: Maxillary lateral incisors ( palatogingival groove ) or in the lower incisors, create an accessibility problem. plaque-retentive area that is difficult to instrument .

42. Root proximity: can result in interproximal areas that are difficult for the clinician and patient to access.

43. Furcation area : may be difficult or impossible to debride by routine periodontal instrumentation. Routine home care methods may not keep it free of plaque presence of furcation involvement is one clinical finding that can lead to a diagnosis of advanced periodontitis and Potentially to a less-favorable prognosis for the affected tooth or teeth. Prognosis can be improved by: Making the furcation area accessible for oral hygiene maintenance Resecting one of the roots

44. Plunger cusps & open contacts: Wedge the food forcefully onto the interdental spaces of the opposing arch resulting in food impaction. Prognosis can be improved by rounding and shortening of the plunger cusps.

45. Tooth Mobility: caused by inflammation and trauma from occlusion  correctable. resulting from loss of alveolar bone  not likely to be corrected . restoring tooth stability is inversely proportional to the extent of bone loss. Flezar et al, 1988: pockets on clinically mobile teeth do not respond as well to periodontal therapy as pockets on nonmobile teeth exhibiting the same initial disease severity. Rosling et al,1976: if ideal plaque control was attained , similar healing can be attained in both hypermobile and firm teeth. The stabilization of tooth mobility through the use of splinting may have a beneficial impact on the overall and individual tooth prognosis.

46. Prosthetic and Restorative Factors: 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. To provide a functional and aesthetic dentition or for a tooth to serve as abutment  assess bone and attachment levels. At this point, the overall prognosis and the individual tooth prognosis overlap because the prognosis of a key individual teeth may affect the overall prognosis for prosthetic rehabilitation.

47. For example, saving or losing a key tooth may determine whether other teeth are saved or extracted or whether the prosthesis used is fixed or removable. When few teeth remain, the prosthodontics 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.

48. Subgingival Restorations: Subgingival margins and over hanging restorations may contribute to increased plaque accumulation, increased inflammation, and increased bone loss. The size of these discrepancies and duration of their presence are important factors in the amount of destruction that occurs. tooth with a discrepancy in its subgingival margins has a poorer prognosis than a tooth with well-contoured supragingival margins

49. Pontic design: Prosthesis with non-mucosal contact pontics tend to allow for oral hygiene maintenance than the mucosal contact pontics . This plays a key role in maintaining the periodontal health and thereby affecting the prognosis. Mucosal contact: Ridge lap/saddle Modified ridge lap Ovate Conical No mucosal contact: Sanitary/hygienic Modified sanitary

50. Caries, Nonvital Teeth, 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.

51. RELATIONSHIP BETWEEN DIAGNOSIS AND PROGNOSIS Many of the criteria used in the diagnosis and classification of the different forms of periodontal disease are also used in developing a prognosis. Factors such as patient age, severity of disease, genetic susceptibility, and presence of systemic disease are important criteria in the diagnosis of the condition , as well as important in developing a prognosis. These common factors suggest that for any given diagnosis, there should be an expected prognosis under ideal conditions.

52. Prognosis for Patients with Gingival Disease Gingivitis Associated with Dental Plaque Only: the prognosis for patients with gingivitis associated with dental plaque only is good, provided: all local irritants are eliminated , factors contributing to plaque retention are eliminated , gingival contours conducive to preservation of health are attained, patient cooperates by maintaining good oral hygiene. Dental Plaque–Induced Gingival Diseases

53. Plaque-Induced Gingival Diseases Modified by Systemic Factors: The inflammatory response to bacterial plaque at the gingival margin can be influenced by systemic factors, such as endocrine-related changes associated with puberty, menstruation, pregnancy , and diabetes, and the presence of blood dyscrasias. frank signs of gingival inflammation that occur in these patients are seen in the presence of relatively small amounts of bacterial plaque. long-term prognosis for these patients depends on: control of bacterial plaque control or correction of the systemic factor(s).

54. Plaque-Induced Gingival Diseases Modified by Medications: In drug-influenced gingival enlargement, reductions in dental plaque can limit the severity of the lesions. Sometimes require surgical intervention. Continued use of the drug usually results in recurrence. long-term prognosis depends on: whether the patient’s systemic problem can be treated with an alternative medication without gingival enlargement as a side effect. control of bacterial plaque likelihood of continued use of medication.

55. Gingival Diseases Modified by Malnutrition: Although malnutrition has been suspected to play a role in the development of gingival diseases, most clinical studies have not shown a relationship between the two. One possible exception is severe vitamin C deficiency. In early experimental vitamin C deficiency, gingival inflammation and bleeding on probing were independent of plaque levels present. prognosis depends on: severity and duration of the deficiency likelihood of reversing the deficiency through dietary supplementation.

56. Non–Plaque-Induced Gingival Lesions: seen in patients with a variety of bacterial, fungal , and viral infections. prognosis depends on elimination of the source of the infectious agent. Dermatologic disorders , such as lichen planus , pemphigoid , pemphigus vulgaris, erythema multiforme , and lupus erythematosus , also can manifest in the oral cavity as atypical gingivitis. Prognosis for these patients is linked to management of the associated dermatologic disorder . allergic , toxic, and foreign body reactions, as well as mechanical and thermal trauma, can result in gingival lesions. Prognosis for these patients depends on elimination of the causative agent.

57. Prognosis for Patients with Periodontitis Chronic Periodontitis: slowly progressive disease associated with well-known local environmental factors. slight-to-moderate periodontitis: prognosis is generally good, provided the inflammation can be controlled through good oral hygiene and the removal of local plaque-retentive factors. severe disease: as evidenced by furcation involvement and increasing clinical mobility, or in patients who are noncompliant with oral hygiene practices, the prognosis may be downgraded to fair to poor.

58. Aggressive Periodontitis: These patients often present with limited microbial deposits that seem inconsistent with the severity of tissue destruction. However, the deposits that are present often have elevated levels of Aggregatibacter actinomycetemcomitans or Porphyromonas gingivalis . These patients also may present with phagocyte abnormalities and a hyper-responsive monocyte/macrophage phenotype. These clinical, microbiologic, and immunologic features would suggest that patients diagnosed with aggressive periodontitis would have a poor prognosis.

59. Localized aggressive periodontitis: occurs around the age of puberty and is localized to first molars and incisors. patient often exhibits a strong serum antibody response to the infecting agents, contributing to localization of the lesions. When diagnosed early, these cases can be treated conservatively with oral hygiene instruction and systemic antibiotic therapy, resulting in an excellent prognosis. When more advanced disease occurs, the prognosis can still be good if the lesions are treated with debridement, local and systemic antibiotics , and regenerative therapy

60. Generalized aggressive periodontitis: they present with generalized interproximal attachment loss poor antibody response to infecting agents. Secondary contributing factors , such as cigarette smoking, are often present. These factors, coupled with the alterations in host defense seen in many of these patients , may result in a case that does not respond well to conventional periodontal therapy. Therefore these patients often have a fair, poor, or questionable prognosis, and the use of systemic antibiotics should be considered to help control the disease

61. Periodontitis as Manifestation of Systemic Diseases: Can be divided into the following two categories: Periodontitis associated with hematologic disorders such as leukemia and acquired neutropenias . Periodontitis associated with genetic disorders such as familial and cyclic neutropenia, Down syndrome, Papillon - Lefèvre syndrome, and hypophosphatasia . Although the primary etiologic factor in periodontal diseases is bacterial plaque, systemic diseases that alter the ability of the host to respond to the microbial challenge presented may affect the progression of disease and therefore the prognosis for the case.

62. These disorders generally manifest early in life, the impact on the periodontium may be clinically similar to generalized aggressive periodontitis . The prognosis in these cases will be fair to poor. Other genetic disorders do not affect the host’s ability to combat infections but still affect the development of periodontitis. Examples include: hypophosphatasia , in which patients have decreased levels of circulating alkaline phosphatase, severe alveolar bone loss , and premature loss of deciduous and permanent teeth, Ehlers- Danlos syndrome , in which patients may present with the clinical characteristics of aggressive periodontitis . In both examples the prognosis is fair to poor.

63. Necrotizing Periodontal Diseases: N ecrotizing ulcerative gingivitis [NUG] Necrotizing ulcerative periodontitis [NUP ].

64. NUG: primary predisposing factor is bacterial plaque. complicated by the presence of secondary factors: acute psychologic stress, tobacco smoking, and poor nutrition, all of which can contribute to immunosuppression. superimposition of these secondary factors on a preexisting gingivitis can result in the painful, necrotic lesions characteristic of NUG.

65. prognosis for a patient with NUG is good  With control of both the bacterial plaque and the secondary factors . tissue destruction in these 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 be downgraded to fair.

66. NUP: necrosis extends from gingiva into the pdl and alveolar bone. In systemically healthy patients, it may have resulted from multiple episodes of NUG, or it may occur at a site previously affected with periodontitis . In these patients, the prognosis depends on alleviating the plaque and secondary factors associated with NUG .

67. However, many patients presenting with NUP are immunocompromised through systemic conditions, such as HIV infection. In these patients the prognosis depends on not only reducing local and secondary factors, but also on dealing with the systemic problem. In advanced cases, prognosis may be better established after reviewing the effectiveness of phase I therapy

68. Prognosis of Endo- Perio lesions The prognosis and treatment of each endodontic–periodontal disease type varies . Primary endodontic: endodontic therapy & has good prognosis. Primary periodontal: periodontal therapy & prognosis depends on severity of the periodontal disease and patient response . Primary endodontic with secondary periodontal involvement: first treated with endodontic therapy. periodontal treatment should be considered after 2-3 months as it allows sufficient time for initial tissue healing and better assessment of the periodontal condition. Prognosis depends primarily on severity of periodontal involvement, periodontal treatment and patient response.

69. Primary periodontal with secondary endodontic involvement: require both endodontic and periodontal therapies. Prognosis depends primarily upon the severity of the periodontal disease and the response to periodontal treatment. True combined endodontic–periodontal diseases : Treated with both endo and perio treatments. Have a more guarded prognosis than the other types. A ssuming the endodontic therapy is adequate, what is of endodontic origin will heal. Thus the prognosis of combined diseases rests with the efficacy of periodontal therapy . Rotstein I, Simon J. Diagnosis, prognosis and decision-making in the treatment of combined periodontal endodontic lesions. Periodontology 2000, Vol. 34, 2004, 165–203.

70. Prognosis in Implant Dentistry Factors that could determine the prognosis of implants are: Periodontal status, age , bone density, occlusion , smoking , genetics , systemic diseases, microorganisms , antibiotics , and type of implants. Abullais SS, AlQahtani NA, Kudyar N, Priyanka N. Success of dental implants: Must-know prognostic factors. J Dent Implant 2016;6:44-8

71. Out of all, factors related to the patient seem to be more critical than those related to the implant in determining the success and survival of implant. Several of these prognostic factors can be modified according to the need of situation. For example, the patient can modify smoking habits, plaque control, systemic health and clinician can modify implant selection, site preparation, and loading strategy. Both the patient and clinician are equally important for long term management and maintenance, which will enhance dental implant success rates for better oral function, esthetics, and patient welfare

72. Algorithm for determining prognosis and treatment for dental implants with peri-implant mucosal inflammation- Noguiera et al ,2011 PIMI Prognosis system No PIMI (healthy) No bleeding/no bone loss Mild PIMI ( mucositis ) Bleeding, no bone loss Moderate/Severe PIMI (peri-implantitis) Bleeding, bone loss Systemic PIMI (peri-implantitis) Bleeding, bone loss, systemic condition Advanced PIMI (peri-implantitis) Infection and/or occlusal trauma, mobility Diagnosis Favourable Unfavourable Hopeless OHI OHI+ISD OHI+ISD or GBR OHI+ISD or Implant removal New implant Implant removal New implant SIT Favourable Unfavourable Prognosis Treatment

73. Lets Compare The Prognosis On Teeth With The Prognosis On Implants By Defining What Is Success And What Is failure

74. 1. Systemic phase (evaluation of overall patient health, consultation as indicated)  provisional prognosis. 2 . Initial therapy ( antiinfective therapy) a. Emergency treatment b. Extraction of hopeless teeth c. Restorative and endodontic therapy d. Oral hygiene assessment and instruction e. Debridement (scaling/root planing) f. Adjunctive treatment Reevaluation of phase I therapy  prognosis re-evaluation. Surgical therapy (if indicated) Postsurgical reevaluation and assessment of revised prognosis Definitive restorative therapy Maintenance therapy Prognosis evaluation in Periodontal Therapy

75. Based on the results of the comprehensive examination, including assessments of periodontitis, caries, tooth sensitivity , & the resulting diagnosis, as well as considering the patient’s needs regarding esthetics and function, a pre-therapeutic prognosis for each individual tooth (root) is made. Three major questions are addressed: 1. Which tooth/root has a “ good ” (secure) prognosis? 2. Which tooth/root is “ irrational-to-treat ”? 3. Which tooth/root has a “ doubtful ” ( unsecure) prognosis ? Pre-therapeutic single tooth prognosis good prognosis  simple therapy and act as secure abutments for function. Lindhe J, Lang NP, Karring T. Treatment planning protocols . Clinical Periodontology and Implant Dentistry. 5 th ed.

76. “irrational-to-treat ”  extracted. Such teeth may be identified on the basis of the following criteria: Periodontal : Recurrent periodontal abscesses Combined periodontal–endodontic lesions Attachment loss to the apex Endodontal : Root perforation in the apical half of the root Dental : Vertical fracture of the root Oblique fracture in the middle third of the root Caries lesions that extend into the root canal Functional : Third molars without antagonists and with periodontitis/caries.

77. doubtful prognosis: needs comprehensive therapy and must be brought into the category of good prognosis by means of additional therapy. Such teeth may be identified on the basis of the following criteria: Periodontal : Furcation involvement Angular (i.e. vertical) bony defects “ Horizontal” bone loss involving > two thirds of the root Endodontal : Incomplete root canal therapy Periapical pathology Presence of voluminous posts/screws Dental : Extensive root caries.

78. REEVALUATION OF PROGNOSIS AFTER PHASE I THERAPY A frank reduction in pocket depth and inflammation after phase I therapy better prognosis than previously assumed. Inflammatory changes present cannot be controlled or reduced by phase I therapy overall prognosis may be unfavorable 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 irritants

79. In addition, phase I therapy allows the clinician an opportunity to work with the patient and the patient’s physician to control systemic and environmental factors such as diabetes and smoking, which may have a positive effect on prognosis if adequately controlled . Phase I therapy will , at least temporarily, transform the prognosis of the patient with an active advanced lesion, and the lesion should be reanalyzed after completion of phase I therapy.

80. The Miller– McEntire Prognosis Scoring System Used to determine t he long term Prognosis on periodontally i nvolved molars. It is evidence based, statistically derived & accurate Data were collected from a complete periodontal examination and patient history from 102 patients and were used to develop a quantitative approach for determining prognosis. Factors Scored: Age 5. Furcations Probing depth 6. M olar type Mobility 7. Diabetes Smoking

81. Molars with a score of 4.32 or better, have an excellent long term prognosis

82. Miller- McEntire Score can be used: For determining an accurate prognosis on periodontally involved molars As an aid in treatment planning and communicating with patients As a basis for referral Miller PD Jr, McEntire ML, Marlow NM, Gellin RG. An evidenced-based scoring index to determine the periodontal prognosis on molars. J Periodontol . 2014 Feb;85(2):214-25.

83. CONCLUSION Patients almost always ask for reassurance on the chances of retaining natural teeth and express their doubt on the advisability of proceeding with therapy. There are no reliable algorithms for prognosis, so clinicians must use their clinical judgement . Constant reviewing of the results of treatment coupled with detailed documentation of the periodontal status will sharpen the clinicians acumen for accurate assessment of prognosis. Needless to say, the determination of prognosis is a vital and essential step in periodontal treatment planning .

84. REFERENCES Newman Takei, Klokkevold Carranza . Determination of Prognosis. Carranza’s Clinical Periodontology. 12th ed. Lindhe J, Lang NP, Karring T. Treatment planning protocols . Clinical Periodontology and Implant Dentistry. 5 th ed . Rose LF, Mealey BL, Genco RJ, Cohen DW . Formulating a periodontal diagnosis and prognosis. Periodontics Medicine, Surgery, and Implants. Rotstein I, Simon J. Diagnosis , prognosis and decision-making in the treatment of combined periodontal endodontic lesions . Periodontology 2000, Vol. 34, 2004, 165–203.

85. 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 1998 67:658. Nogueira-Filho G, Iacopino AM, Tenenbaum HC. Prognosis in implant  dentistry:a  system for classifying the degree of peri-implant  mucosal inflammation. J Can Dent Assoc. 2011;77:b8 Abullais SS, AlQahtani NA, Kudyar N, Priyanka N. Success of dental implants: Must-know prognostic factors . J Dent Implant 2016;6:44-8

86. Sameth N, Jotkowitz A. Classification and prognosis evaluation of individual teeth—A comprehensive approach. Quintessence Int. 2009 May;40(5):377-87 . Miller PD Jr, McEntire ML, Marlow NM, Gellin RG. An evidenced-based scoring index to determine the periodontal prognosis on molars . J Periodontol . 2014 Feb;85(2):214-25.