Prognosis In Periodontics

Determination Of Prognosis

Define prognosis. Discuss the various factors in determination of prognosis in detail.
Answer. “Prognosis is the prediction of probable course, duration and outcome of a disease-based on general knowledge of pathogenesis of disease and presence of risk factors for the disease and the likelihood of its response to treatment”.

Prognosis must be determined after the diagnosis is made and before treatment is planned. In most cases, careful analysis of these factors allows the clinician to establish one of the following prognosis.

Factors Determining the Overall Prognosis

Factors determining the overall prognosis are clinical factors and systemic/environmental factors. These are as follows:

• Overall clinical factors:
  • Patient’s age
  • Disease severity
  • Plaque control
  • Patient compliance and co-operation
• Systemic/environmental factors:
  • Patient habits: Smoking
  • Systemic disease/condition
  • Genetic factors
  • Stress

Read And Learn More: Periodontics Question And Answers

Prognosis Overall Clinical Factors

 

• Patient age: In the two patients of comparable connective tissue attachment and alveolar bone, prognosis is better in older individual. When compared to older patient reparative process in younger patient is more, amount of bone loss in a span of few years is also more than the bone formed. Younger patient can have aggressive type of periodontitis or increased disease progression because of systemic disease or smoking. In young patient, reparative capacity is greater as compared to older individual but the occurrence of so much destruction in short period would exceed any natural occurring periodontal repair.
• Disease severity: It is determined by recording the patients past history of periodontal disease for this the following variables should be carefully recorded.
  • Pocket depth.
  • Level of attachment.
  • Degree of bone loss.
  • Type of bony defect.
    These can be determined by clinical and radiographic evaluation.
    • Pocket depth: A tooth with deep pockets and little attachment and bone loss has a better prognosis than one with shallow pockets and severe attachment and bone loss.
    • Level of attachment: Prognosis is adversely affected if the base of the pocket is close to the root apex.
    • Degree of bone loss: The prognosis can also be related to the height of the remaining bone. Prognosis is poor in case of teeth with severe bone loss where there is no sufficient bone to support the tooth.
    • Type of bony defect: The prognosis for horizontal bone loss depends upon the height of the existing bone. The prognosis for angular, intrabony defects depends upon the contour of the existing bone and the number of osseous walls. The chance to regenerate bone in vertical bony defect is excellent as compared to horizontal bony defects. When there is greater bone loss on one tooth surface, the bone height on less involved surfaces should be considered when determining the prognosis.
• Plaque control: Effective removal of plaque is important for the success of periodontal therapy and to the prognosis.
• Patient compliance and cooperation: Dependent on patients attritude; desire to retain the natural teeth, willingness and ability to maintain good oral hygiene. If the patient is unwilling or unable to perform adequate plaque control and receive periodic maintenance check-ups, the treatments to be considered are:

Refuse to accept the patient for treatment.

Extract teeth that have a hopeless or poor prognosis and perform scaling and root planing on the remaining teeth.

Prognosis Systemic/Environmental Factors 

• Smoking: It is the most important environmental risk factor affecting the development and progression of periodontal disease. Systemic effects of smoking are inhibition of peripheral blood and oral neutrophil function, reduced antibody production and alteration of peripheral immunoregulatory T cells. Response of smokers to periodontal treatment is less as well. Smokers do not respond to both conventional and surgical periodontal treatment. But cessation of smoking can affect the treatment outcome and also prognosis.
• Systemic disease/condition: Studies have shown that patients with type I and type II diabetes have increased severity of periodontitis than in those without diabetes. In patients with uncontrolled diabetes the prognosis is questionable when surgical periodontal treatment is required. In well-controlled diabetic patients with mild-tomoderate periodontitis who comply well to recommended instructions respond well and hence have good prognosis. Diseases affecting patient’s motor functions such as Parkinson’s disease limits their oral hygiene performances which adversely affect the prognosis.
• Genetic factors: Periodontitis is a multifactorial disease of which genetic factors are one of the causes, e.g. genetic polymorphisms in the interleukin -1 (IL-1) genes, resulting in increased production in IL-1, have been associated with a significant increase in risk for severe, generalized, chronic periodontitis. Detection of genetic factors can influence prognosis in following ways, i.e.
• Early implementation of preventive and treatment measures for these patients.
• During the course of treatment, it can influence treatment recommendations.
• Identification of young individuals at risk can lead to the development of interventional strategies.
  • Stress: Physical and emotional stress as well as substance abuse alter the patient’s ability to respond to periodontal treatment.

Factors Considered in Determining Individual Prognosis of Tooth

Factors considered or affecting the individual tooth prognosis are:

• Local factors
• Prosthetic and restorative factors

Local Factors

The local factors which are considered in determining individual prognosis of tooth are:

• Plaque and calculus
• Subgingival restorations
• Anatomic factors

Following are the anatomic factors

• Short, tapered roots
• Cervical enamel projections
• Enamel pearls
• Bifurcation ridges
• Root concavities
• Developmental grooves
• Tooth mobility
• Furcation involvement.

Plaque and Calculus

It is the most important local factor in periodontal diseases. In most of the cases, having good prognosis depends on the ability of the patient and the clinician to remove these etiologic factors. However, when teeth are drifted or rotated, oral hygiene may be more difficult, in such cases prognosis is poor.

Subgingival Restorations

Tooth with overhang subgingival margin discrepancies exhibit poor prognosis compared to the tooth with well contoured supragingival margins. This causes inflammation and bone loss. So a tooth with any discrepancy at its subgingival margin leads to increased plaque accumulation and has poor prognosis.

Anatomic Factors

Following are the anatomic factors:

• Short, tapered roots: Teeth with short and tapered roots have poor prognosis as compared to long and broad roots. More favorable is crown root ratio, better is the prognosis. A maxillary molar with widespread roots and large root base exhibit good prognosis compared to conical rooted premolar or incisor with equal amount of bone loss.
• Cervical enamel projections: They are ectopic enamel projections which extend beyond the normal contour of CEJ. They are seen on mandibular molars and maxillary premolars. They impart negative effect on prognosis.
• Enamel pearls: They are large round enamel deposits which are seen in the furcation areas. Seen commonly on maxillary third molars. They impart negative effect on prognosis.
• Bifurcation ridges: These are the projections on the root surfaces which interfere with attachment apparatus and prevent regenerative procedures from getting their maximum potential. Mandibular first molars commonly show bifurcation ridge which crosses from mesial to distal root at midpoint of furcation. They impart negative effect on prognosis.
• Root concavities: These are the areas which are difficult for the dentist and patient to clean and so worsen the prognosis.
• Developmental grooves: These are the invaginations resulting from incorrect formation of the root. Grooves often begin at the cingulum and extend at the variable distance apically on root surface between midpalatal line and line angle. These grooves act as plaque retentive areas which are very difficult to clean. These grooves are seen commonly in maxillary lateral incisors and maxillary central incisors.
• Tooth mobility: If cause of tooth mobility is eliminated and the mobility is controlled, prognosis is better. Prognosis of tooth mobility is poor in cases with advanced bone loss. A tooth that can be rotated or depressed has poor prognosis than a tooth having horizontal mobility. Tooth mobility is correlated with other clinical and radiographic findings in determining the prognosis.
• Furcation involvement: Multirooted teeth having short root trunks with furcation involvement has less favorable prognosis than long root trunks. Maxillary first premolars exhibit more difficulties and hence unfavorable prognosis when lesion reaches mesial or distal furcation. Maxillary molars also impose some difficulty so require resection of one of the buccal roots to improve access to the area. Resection procedure improves the prognosis.

Prosthetic and Restorative Factors

Following are the prosthetic and restorative factors:

• Abutment selection
• Caries
• Nonvital teeth
• Root resorption.

Abutment Selection

The overall prognosis considers the level of bone as well as attachment level for establishing that whether the remaining teeth act as abutment for prosthesis.

Caries, Non-vital Teeth and Root Resorption

• Teeth having extensive caries should be adequately restored and endodontic therapy should be considered before going for periodontal treatment.
• Extensive idiopathic root resorption as a result of orthodontic therapy jeopardizes stability of teeth and adversely affects the response to periodontal treatment.
• Periodontal prognosis of treated nonvital tooth is not different from that of vital teeth.