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Periodontics > Prognosis Re-evaluation Maintenance > Flashcards

Prognosis Re-evaluation Maintenance Flashcards

1
Q

Prognosis

A

“A prediction of the course, duration and
outcome of a disease based on a general
knowledge of the risk factors for the disease.”

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2
Q

Deliver a predictable and long term stable comprehensive tx plan
Prognosis
(4)

A

Comprehensive examinations
(Clinical findings, Radiographic findings)
Diagnosis
Prognosis
Treatment plan

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3
Q
  • Diagnostic Prognosis:
A

an evaluation of the course
of the disease without treatment

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4
Q
  • Therapeutic Prognosis:
A

an evaluation of the course
of the disease with treatment

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5
Q
  • Prosthetic Prognosis :
A

the anticipated result of the
periodontal therapy with anticipated prosthetic treatment

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6
Q

Comprehensive Treatment Plan
(3) Prognosis

A

Diagnostic
Therapeutic
Prosthetic

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7
Q

Diagnostic Prognosis
Evaluated 30 patients with moderate to advanced periodontitis with
no treatment at an average of 3.72 years after initial examination
The average tooth loss was

A

0.36 teeth/patient/year

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8
Q

Therapeutic Prognosis
Evaluated 44 patients with moderate to advanced periodontitis with
treatment BUT NO MAINTENANCE over a 5-year period
The average tooth loss was

A

0.22 teeth/patient/year

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9
Q

Therapeutic Prognosis
Evaluated 95 patients with moderate to advanced periodontitis with
treatment AND REGULAR MAINTENANCE at an average of 6.5 years
The average tooth loss was

A

0.11 teeth/patient/year

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10
Q

Prosthetic Prognosis
251 patients with advanced periodontitis needs prosthetic therapy.
They were periodontally treated, restored with bridges and placed
in a maintenance program with a follow-up of 5-8 years

Only –% of bridgework fulfilled the requirements of Ante’s Law.
The periodontium is well — (probing depth of 2-3mm,
unchanged bone level) between 5-8 years after active treatment.

A

8
maintained

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11
Q

Prosthetic Prognosis
8% bridges failed due to loss of retention, fracture of bridgework or
abutment teeth.
(2) did not influence periodontal status

A

Severe reduction of periodontal support around the abutment teeth
and difference in bridgework

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12
Q

Factors to consider
Individual tooth prognosis
(8)

A

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

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13
Q

Factors to consider
Overall prognosis
(9)

A

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

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14
Q

Overall prognosis

A

Concerned with the
dentition as a whole

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15
Q

Individual tooth prognosis

A

Modified and affected
by overall prognosis

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16
Q

Individual Tooth Prognosis
(6)

A
  • Amount or percentage of attachment loss
  • Bony defect topography
  • Pocket depth
  • Rate of attachment loss
  • System/environmental factors
  • Pt’s compliance and OH control
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17
Q
  • Amount or percentage of attachment loss
A
  • The most important determinant, influences mobility and C/R ratio
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18
Q
  • Pocket depth
  • need to relate to
A

attachment loss

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19
Q
  • System/environmental factors
    (6)
A
  • Smoking, diabetes, stress, genetics, medications inducing gingival
    enlargements, systemic disease effecting periodontitis etc.
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20
Q

Individual Tooth Prognosis
* Anatomical factors
(10)

A
  • 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
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21
Q

Anatomical factors

A
  • Defective overhang or subgingival restorations
    Cervical Enamel Projections (CEPs)
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22
Q

Cervical Enamel Projections (CEPs)
When present, it extends into furcation areas of ~—% of molars.
The most common location:

A

20-30
buccal surface of 2nd mandibular molar

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23
Q

Enamel pearls
In the …
Incidence of —%

A

molar furcation areas, especially maxillary 2nd and 3rd molars.
1.1% to 9.7%

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24
Q

Palatogingival groove
Found in

A

4% to 6% of maxillary lateral incisors.

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25
Q

Root concavity
Radiographs — the defects.

A

UNDERESTIMATE

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26
Q

Root form and length
Long, divergent and multi-roots are less prone to have —.
The longer the root trunk, the — likely it is to become periodontally
involved. When it’s involved, the more — the furcation the more
difficult it is to access and treat

A

mobility
less
apical

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27
Q

Furcation involvement
* — molars are lost more often
than — molars

A

Maxillary
mandibular

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28
Q

Furcation ridge
* —% of mandibular molars
* Cementum extending from the
* Hamper plaque control

A

73
mesial
to the distal of a furcation opening

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29
Q

Accessary canals
—% molars have accessory canals in the furcation
* —% of mandibular molars
* —% of maxillary molars

A

28.4
29.4
27.4

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30
Q

Root proximity
Definition: the distance between
the roots of adjacent teeth on
radiographs is ≤– mm.

Distance <— mm is a significant local risk factor for alveolar
bone loss in mandibular anterior teeth.
Amount of bone loss is about — times higher than normal

A

1.0
0.8
3.6

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31
Q

Tooth position
Within the …
Pathologic tooth migration

A

alveolus envelope and
bone support

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32
Q

McGuire and Nunn 1996
* This system is based on —
* The coefficients from this model were able to predict accurately the
5-year and 8-year prognoses —% of the time.
* When teeth with “good” prognoses were excluded, the predictive
accuracy dropped approximately —%

A

tooth loss
81
50

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33
Q

McGuire and Nunn 1996
Good
(4)

A
  • Etiologic
    factors can be
    controlled
  • Adequate
    periodontal
    support
  • Controlled
    systemic
    factors
  • Teeth can be
    relatively easy
    to maintain by
    patients and
    professionals
34
Q

McGuire and Nunn 1996
Fair
(5)

A
  • Up to 25%
    attachment
    loss
  • Grade I
    furcation
  • Limited
    systemic
    factors
  • Teeth can be
    maintained
    with proper
  • home care and
    professionals
35
Q

McGuire and Nunn 1996
Poor
(5)

A
  • Up to 50%
    attachment
    loss
  • Grade II
    furcation
  • Presence of
    systems
    factors
  • > Miller class I
    mobility
  • The furcation
    situation
    allows proper
    maintenance
    but with
    difficulty
36
Q

McGuire and Nunn 1996
Questionable
(5)

A
  • > 50%
    attachment
    loss
  • Grade II or III
    furcation
  • Poor crown-
    root ratio, poor
    root form,
    significant root
    proximity
  • ≥ Miller class II
    mobility
  • Teeth not
    easily
    maintained by
    patients and/or
    professionals
37
Q

McGuire and Nunn 1996
Hopeless
(5)

A
  • Inadequate
    attachment to
    support the
    tooth
  • Grade III or IV
    furcation
  • Miller class III
    mobility
  • Teeth can’t be
    maintained by
    patients and/or
    professionals
  • Extraction is
    suggested or
    performed
38
Q

Kwok and Caton 2007
* This system is based on
* Periodontal prognostication is dynamic and should be
reevaluated throughout

A

periodontal stability
treatment and maintenance.

39
Q

Kwok and Caton 2007
Favorable
(2)

A
  • 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
40
Q

Kwok and Caton 2007
Questionable
(2)

A
  • 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
41
Q

Kwok and Caton 2007
Unfavorable
(2)

A
  • 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.
42
Q

Kwok and Caton 2007
Hopeless
(1)

A
  • The tooth must be extracted
43
Q

Does Endo Treatment Affect
Perio Prognosis?

A

NO

44
Q

All the following factors need to
be considered when assigning
the prognosis EXCEPT
A. Rate of attachment loss
B. Parafunctional habit
C. Furcation anatomy
D. Endodontic treatment

A
45
Q

Re-evaluation

A

The evaluation or assessment of treatment. It’s
used to determine the effectiveness of SRP and
to review the proficiency of plaque control

46
Q

Objectives of Treatment
(3)

A
  • Arrest the disease
  • Regenerate lost periodontium
  • Maintain periodontal health
47
Q
  • Maintain periodontal health
    (2)
A
  • Reduce “critical mass” of plaque
  • Allow host to control the bacteria
48
Q

Expectation
Healing after SRP
* Formation of long —
* It appears — weeks after therapy
* Clinical presentation with less (3)
* Gradual reductions in (3)

A

junctional epithelium
1-2
inflammation, redness and swelling
inflammatory cell population, crevicular fluid flow, and repair of connective tissue

49
Q

Expectation
Healing after SRP
* Transient root hypersentitivy and recession
of the gingival margins will frequently be
seen during —
* Important to warn patients about these
potential results
* If unexpected, may result in (3)

A

healing
distrust, lack
of motivation, and unwillingness to
continue therapy

50
Q

Expectation
The decrease in the probing depth consists of two
components:

A

clinical attachment gain and recession

51
Q

Timing
— after completion of SRP

A

4-6 weeks

52
Q

Timing
4-6 weeks after completion of SRP
* Allows time for healing of (2)
* Allows patient sufficient time to (2)
* Gingival inflammation is usually reduced or
eliminated within – weeks after removal of
calculus and local irritants

A

epithelium and CT
practice and improve OH
3-4

53
Q

Timing
4-6 weeks after completion of SRP
* The time to …
* The time to decide whether the patient needs to
be …

A

re-motivate the patient and go over
further instructions if the patient has NOT
improved OH.
referred for advanced periodontal treatment.

54
Q

Timing
Why not wait longer?
* Initial improvement of clinical attachment was
found at – weeks following SRP, and no additional
gain of clinical attachment occurred in the
succeeding 3 months.
* Longer than – months, pathogenic bacteria have
already repopulated periodontal pockets.

A

3
2

55
Q

Re-evaluation Elements
Evaluate clinical parameters and
compare to baseline
(7)

A
  • 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
56
Q

Re-evaluation Elements
Criteria for success

A

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.

57
Q

Updated Treatment Plan
Determination of additional treatment/referral
* 172 well-maintained patients
* Association of risk factors with tooth loss and periodontitis progression
* Compared with PD≤3 mm, PD=5 mm represented a risk factor for tooth loss
* PD≥6 mm was a risk factor for disease progression
* Residual PD – mm represent an incomplete treatment and require
further therapy

A

≥6

58
Q

Referral
Decision to refer to a periodontist
* The PD > – mm is proposed as current guideline for referral
* REFER, If the pt has grade – progression
* Early referral of advanced case is critical to provide the best outcome
* PD of –mm, treatment by a periodontist is usually successful
* PD > – mm: limited success

A

5
C
5-8
9

59
Q

What to expect at re-
evaluation?
A. Long junctional epithelium formation was found at 1-2
weeks following the treatment.
B. B. Gingival inflammation is usually reduced or eliminated
within 6-8 weeks after removal of calculus and local irritants
C. Initial improvement of clinical attachment was found at 3
weeks following SRP and additional gain of clinical
attachment occurred in the succeeding 3 months
D. The decrease in the probing depth results from the gingival
recession.

A
60
Q

Maintenance

A

Supportive Periodontal Treatment (SPT)

61
Q

Introduction
Supportive Periodontal Treatment (SPT)
Periodontal Maintenance
Preventive Maintenance
Recall Maintenance
* SPT includes all the procedures performed at selected intervals to
assist the periodontal patient in …
* These usually consist of (5)

A

maintaining oral health.
examination, an evaluation of oral hygiene
and nutrition, scaling, root curettage, and polish of teeth.

62
Q

TO-DO List at SPT Appointment
(7) steps

A
  1. Review and update of medical and dental history
  2. 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
  3. Radiographic examination as needed
  4. Assessment of disease status or changes by comparing clinical
    and radiographic information with baseline
  5. Assessment of personal oral hygiene
  6. 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
  7. 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.
  8. Planning future SPT intervals according to individual Periodontal
    Risk Assessment.
63
Q

Absence of SPT
* 25 patients received OHI, initial therapy, then assigned to 5 different
surgical approach in pockets more than 5mm.
* No SPT follows active treatment
* Recall at 6, 12, 24 months for assessment
* Significant further attachment loss (1.2mm-1.9mm) in all groups.
All treatment approaches are equally ineffective in

A

preventing recurrence of destructive periodontitis
in the absence of SPT

64
Q

Absence of SPT
* 90 patients with advance periodontal disease received OHI, initial therapy and
surgical treatment.
* 2/3 were in a well-organized maintenance program (q2-3m)
* 1/3 were referred back to GP for maintenance (not supervised)
* Re-examined at 3 and 6 years
* GP group had obvious signs of recurrent periodontitis (increased PI and 45%
loss of attachment); strict maintenance group had unaltered attachment levels.
The treatment is bound to fail with

A

sloppy or no SPT

65
Q

Effectiveness
* 78 patients had periodontal therapy and every 3-month maintenance over 8 years
* Plaque score (PI) affects variations in pocket depth (PD) and attachment levels (AL)
* Compared the 25% sample having the lowest PI with the 25% having the highest PI
* The initial post-treatment reductions in PD and AL were more favorable in patients
with good OH, but the differences were not significant after 3-4 years of maintenance.

(2) could be maintained irrespective of
personal oral hygiene

A

Post-treatment pocket depth and attachment
levels

66
Q

Effectiveness
* 61 patients with advanced periodontal disease undergone osseous surgery
* 14 year period of effective SPT every 3-6 months including subgingival scaling
* Minimal progression of periodontits as attachment loss, recurrent deep pockets
or extracted teeth.
The state of “periodontal health” could be maintained
in both young and older patients over –

A

10 years

67
Q

Frequency
* For patients with a history of periodontal disease, periodontal — should be provided on a regular and recurrent basis,
generally at intervals of – months
* Patients without additional attachment loss can have maintenance
visits once every – months.
* Most studies supported maintenance visits at least once every – months for patients with history of periodontal disease.
* The shorter the recall interval for maintenance visits following
periodontal surgery, the better the surgical outcomes

A

maintenance
2– 6
6
3

68
Q

Periodontal Risk
Assessment (PRA)
* Six parameters are used to
evaluate the risk for
recurrence of periodontitis at
a – level.
* Each patient is assigned to a
— and maintenance
frequency is established
accordingly.

A

patient
risk group (low, moderate or
high)

69
Q

PRA Parameters
(6)

A
  • 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
70
Q
  • BOP (%)
A
  • <10% Low; 10-25% Moderate; >25% High
71
Q
  • # of pockets ≥5 mm
A
  • ≤4 pockets: Low; 5-8: pockets Moderate; >8: pockets High
72
Q
  • # of missing teeth (excludes 3rd molars)
A
  • ≤4 teeth: Low; 5-8 teeth: Moderate; >8 teeth: High
73
Q
  • Loss of periodontal support/patient’s age
A
  • ≤0.5: Low; 0.5-1.0: Moderate; >1.0: High
74
Q
  • Diabetes
  • Cigarette smoking
A
  • Yes: High; No: Low
  • Yes: High; No: Low
75
Q

Clinical Parameters at SPT
Appointment
(3)

A
  1. Clinical examination (to be compared with previous data)
    * Periodontal examination
  2. Treatment
  3. Planning future SPT intervals according to individual Periodontal
    Risk Assessment
76
Q

Probing depths stable, no bleeding
(2)

A
  • Routine treatment, review OHI
  • Same recall interval
77
Q

Probing depths stable, bleeding
(4)

A
  • Review OHI
  • Re-scale and root plane bleeding sites (if
    needed/etiological factor still present)
  • Consider local delivery of antimicrobials
  • Consider shortening recall interval
78
Q

Clinical Parameters at SPT
Appointment
* Maintenance is usually every – 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

A

3

79
Q

Pts displaying a low risk profile for periodontitis recurrence yield all risk factors in the low risk category or, at most, one risk factor in the moderate risk category

A

for such pts, an sPT interval of at least once a year was recommended

80
Q

Pts presenting with at least two risk factors in the moderate risk category and at most one risk factor in the high risk category were classified as displaying a moderate risk profile

A

SPT twice a year

81
Q

Pts showing at least two risk factors in the high risk category are defined to belong to a high risk profile for disease recurrence

A

SPT at intervals of 3-4 mo per year

82
Q
  • Loss of periodontal support/patient’s age
A
  • ≤0.5: Low; 0.5-1.0: Moderate; >1.0: High

Periodontics (13 decks)

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