Please refer to Fable .CM during the following discussion. Overall Clinical Factors
Patient Age. For two patients with comparable levels of remaining connective tissue attachment and alveolar bone, the prognosis is generally better in the older of the two. lor the younger patient, the prognosis is not as good because of the shorter time frame in which the periodontal destruction has occurred. In some cases this may be because the younger patient suffers from an aggressive type of periodontitis or disease progression may have increased due to systemic disease or smoking. In addition, although the younger patient would ordinarily be expected to have a greater reparative capacity, the occurrence of so much destruction in a relatively short
Ih'U'rmiiuition of Prognosis ■ ( HAITI R 33 477
period would exceed any naturally occurring periodontal repair.
Disease Severity. Studies have demonstrated that a patient's history ot previous periodontal disease may he indicative of their susceptibility lor future periodontal breakdown (see Chapter 5). I herefore I lie following variables should be carefully recorded because they are important for determining the patient's past history ol periodontal disease: pocket depth, level ot attachment, degree of bone loss, and type of bony defect. They are determined by clinical and radiographic evaluation (see Chapters 30 and 31).
The determination of the level ot clinical attachment reveals the approximate extent of root surface that is devoid ol periodontal ligament; the radiographic examination shows the amount ot root surface still invested in bone. Pocket depth is less important than level of attachment, because it is not necessarily related to bone loss. In general, 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. However, deep pockets are a source ot infection and may contribute to progressive disease.
Prognosis is adversely affected if the base of the pocket (level of attachment) is close to the root apex. The presence of apical disease as a result of endodontic involvement also worsen the prognosis. However, surprisingly good apical and lateral bone repair can sometimes be obtained by combining endodontic and periodontal therapy (see ( hapter 65).
The prognosis also can be related to the height of remaining bone. Assuming bone destruction can be arrested, is there enough bone remaining to support the teeth? I he answer is readily apparent in extreme c ases, that is. when there is so little bone loss that tooth support is not in jeopardy (Tig. 33-1) or when bone loss is so severe that the remaining bone is obviously insufficient for proper tooth support d ig 33-2). Most patients, however, do not fil into these extreme categories. I he height of remaining bone is usually somewhere in between, making bone level assessment alone insufficient for determining the overall prognosis.
The type of defect also must be determined. T he 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.1,1
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. Because of the greater height of bone in relation to other surfaces, the center of rotation of the tooth will be nearer the crown d ig. 33-3). This results in a more favorable distribution of forces to the periodontium and less tooth mobility.44
In dealing with a tooth with a questionable prognosis, the chances of successful treatment should be weighed against any benefits that would accrue to the adjacent teeth it the tooth under consideration were extracted. Heroic attempts to retain a hopelessly involved tooth may jeopardize the adjacent teeth. Extraction of the questionable tooth may be followed by partial restoration of the bone support of the adjacent teeth d ig. 33-4).
Plaque Control. Bacterial plaque is the primary eti-ologic factor associated with periodontal disease (see Chapter 6). Therefore effective removal of plaque on a daily basis by the patient is critical to the success of periodontal therapy and to the prognosis.
Patient Compliance/Cooperation. I lie progno sis 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 maintain good oral hygiene. Without these, treatment cannot succeed. Patients should be clearly informed ot the important role they must play tor treatment to succeed. If patients are unwilling or unable to perform adequate plaque control and to receive the timely periodic maintenance checkups and treatments deemed necessary by the dentist, then the dentist can (1) refuse to accept the patient for treatment or (2) extract teeth that have a hopeless or poor prognosis and perform scaling and root planing on the remaining teeth, fhe 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.
Smoking. Epidemiologic evidence suggests that smoking may be the most important environmental risk factor impacting the development and progression ot periodontal disease (see Chapter 5). Therefore it should be made clear to the patient that a direct relationship exists between smoking and the prevalence and incidence ot periodontitis. In addition, patients should be informed that smoking affects not only the severity of periodontal destruction, but also the healing potential of the periodontal tissues. As a result, patients who smoke do not respond as well to conventional periodontal therapy as patients who have never smoked.Therefore the prognosis in patients who smoke and have slight-to-moderatc periodontitis is generally fair to poor. In patients with severe periodontitis, the prognosis may be poor to hopeless.
However, it should be emphasized that smoking cessation can affect the treatment outcome and therefore the prognosis.1,4 Patients with slight to moderate periodontitis who stop smoking can often be upgraded to a good prognosis, whereas those with severe periodontitis who stop smoking may be upgraded to a lair prognosis.
Systemic Disease/Condition. I he patient's svs temic background affects overall prognosis in several ways, lor example, evidence from epidemiologic studies clearly demonstrates that the prevalence and severity ot periodontitis is significantly higher in patients with type 1 and type II diabetes than in those without diabetes and that the level of control ot the diabetes is an important
Ficj. $3-1 Chronic periodontitis, overall prognosis good. A, Gingival inflammation, poor oral hygiene, and pionounced anterior overbite in a systemically healthy, nonsmoking 42-year-old man B, Although local lac tors are present, the patient presents with adequate remaining bone support and a good prognosis, provided local factors can be controlled.
/ ht en il il mt h m of! *n»xnos is • C!H APÏÏ.K t.* 479
variable in this relationship (see t hapter S) Therefore patients at risk for diabetes should be identified as early as possible and informed ol the relationship between periodontitis and diabetes. Similarly, patients diagnosed with diabetes must be informed ol the impact ol diabetic control on the development and progression of periodontitis. It follows that the prognosis in these cases is dependent on patient compliance relative to both their medical and dental status. Well-controlled patients with diabetes with slight-to-moderate periodontitis who comply with their recommended periodontal treatment
should have a good prognosis. Similarly, in patients with other systemic disorders that could affect disease progression, 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 (see < hapter W). Incapacitating conditions that limit the patient's performance ol oral procedures (e.g., Parkinson's disease) also adversely affec t the prognosis. Newer "automated" oral hygiene devices such as electric toothbrushes may be helpful for these patients and improve their prognosis (see ( hapter 49).
Genetic Factors. Periodontal diseases represent a complex interaction between a microbial challenge and the host's response to that challenge, both ol which may be influenced by environmental factors such as smoking. In addition to these external factors, there also is evidence that genetic factors may play an important role in determining the nature ol the host response.1 Kvidence for this type of genetic influence exists for patients with both chronic and aggressive periodontitis. (îenetic polymorphisms in the interleukin-l (II-I) genes, resulting in increased production of II. 1 -p, have been associated with a significant increase in risk for severe, generalized, chronic periodontitis.'" It has been demonstrated that knowledge of the patient's II -1 genotype and smoking status can aid the clinician in assigning a prognosis/1 (ienetic factors also appear to influence serum Ig(i2 antibody titers and the expression of 1-c-yKII receptors on the neutrophil, both of which may be significant in aggressive periodontitis.1, Other genetic disorders such as leukocyte adhesion deficiency type I can influence neutrophil function, creating an additional risk factor for aggressive periodontitis. Finally, the familial aggregation that is characteristic ot aggressive periodontitis indicates that additional, as yet unidentified, genetic lac tors may be important in susceptibility to this form of disease (see i hapter 2S).
480 PAR I 5 ■ Treatment of Temnton tat Disease
Tig. 33-4 Extraction of severely involved tooth to preserve bono on adjacent teeth. A, Extensive bone destruction around the mandibular first molar B, Radiograph made 8.5 years after extraction of the first molar and replacement by a prosthesis. Note the excellent bone support.
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