QUESTION?

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QUESTION?
Is my disease fatal?Will I lose my teeth?Will
your treatment help me?What can you do to help
me?
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? 11 ? PROGNOSTIC JUDGMENT TREATMENT PLANNING
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PROGNOSIS
Prognosis??Forecast??????
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OVERTHANKS
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INFECTION)?????????
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Prognosis has different connotations and nuances.
Treatment can alter prognosis.

• The patient has every right to know the answers
  to these questions.

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Question?
Is my disease fatal?Will I lose my teeth?Will
your treatment help me?What can you do to help
me?
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What are the therapeutic "odds"?What are the
financial risks? What are the chances that the
treatment will be of benefit?
44
Prognosis has three meanings
in dentistry.
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Diagnostic prognosis.

• What are evaluations of the course of the disease
  without treatment?
• What is the status of the teeth now
• What is the anticipated future of these teeth?

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Therapeutic prognosis.

• Given the state of the art and science of
  periodontics and the knowledge and skill of the
  practitioner, what effect will periodontal
  treatment have on the course of the disease?

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Prosthetic prognosis.

• What is the forecast for the success of the
  prosthetic restoration?
• Will the prosthesis be therapeutic or
  detrimental?
• What specific needs dictate that it be
  prescribed?

48
Judgement of the severity depends on

• 1. pocket depth,
• 2. degree of bone loss,
• 3. tooth mobility,
• 4. crown-root ratio.

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generalized or localized
The distribution of disease Inflammatory factors
Traumatic factors
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Individual tooth therapeutic prognosis
includes such factors as Percentage of bone
loss Probing depth
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Distribution and type of bone lossPresence and
severity of furcation involvementsMobility
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Crown-root ratioPulpal involvementTooth
position and occlusalStrategic value
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Following are factors included in overall
prognosis

• Age
• Medical status

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Individual tooth prognoses (distribution and
severity)Degree of involvement, duration, and
history of the disease (rate of progression)
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Patient cooperationEconomic considerationsKnowle
dge and ability of the dentistEtiologic factors
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Accuracy and completeness of the information
gathered at the examinationDentist's ability to
recognize and eliminate or control the factors
causing the disease
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the patient's ability and determination in
maintaining the health of the periodontium and
teeth.
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The overall prognosis depends on the prognoses of
the individual teeth.
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PAST HISTORY (RATE OF DESTRUCTION)
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Probably the most important factor in forecasting
the future health status of a dentition is
knowledge of its past health status.
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Speed of breakdown under controls or uncontrols
The location, shape and depths of the pockets
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Tooth mobility can be controlled or eliminated,
the prognosis is better.The greater the bone
loss, the poorer the prognosis.
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As bone loss exceeds 50, the prognosis worsens
rapidly.The more irregular the bone loss, the
poorer the prognosis.
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the pattern of bone loss horizontal, vertical or
infrabony defects.the age of the patient and the
etiologic factors involved in the patient's
disease.
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poorer prognosis tilted, drifted, or rotated,
hygiene difficult, elimination of pockets impaired
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periodontal disease is complicated by active
systemic factors and traumatism
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morphologic in nature and include the number and
distribution of teeth, tooth morphology,
furcation involvement.
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Extent of involvement. Is the furcation
partially or totally involved?Status of bone
support. If the bone levels are relatively
sound, the effort to save may be justifiable.
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Root length and crown-root ratio must be
considered
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Angulation of root spread. Health of neighboring
teeth.
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The number and distribution of teeth
presentcrown-root ratio,shape and number of the
root
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the height of the alveolar crestpersonal
psychologic and sociologic, financial
considerations.
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OTHER CONSIDERATIONS IN ESTABLISHING PROGNOSIS
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The performance of home care is acceptable and
the caries incidence is low,the prognosis is
better
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The prime consideration is the preservation of
the dentition as a functioning unit.
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In some instancesthe extraction of a single
tooth will make the whole situation untenable.In
other situations isolated extractions will
simplify the problem.
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what is considered to be a hopeless tooth. This
will make treatment planning simpler.
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the characteristics of hopeless periodontally
involved teeth
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Associated with intractable pain relieved,
massive infection reduced by extractionMobility
beyond 3 degrees
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Furcation involvement with little or no
interradicularboneBone loss beyond the apexBone
loss to the apex on one side of the tooth
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Generalized circumferential bone loss to within 3
mm of the apexPocket depth to the apex without
pulpal involvementVertical cracks or fractures
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Inaccessible perforations or accessory
canalsNumber and position of remaining teeth
precluding prostheticExtreme caries
susceptibility
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Objectivesof treatment
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Treatment goals should be evaluated in every case.
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Can treatment objectives of a firm
non-retractable gingiva that does not bleed be
reached? Can the pocket be eliminated? Will the
bone regenerate? Can the tooth be stabilized?
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Can tooth be restored?Can the patient tolerate
the treatment?
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If you believe the answers to these questions to
be "yes," then plan and proceed with the
treatment. If no, alternative treatment,
compromise, or extraction is advisable.
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As definitive laboratory tests are developed to
make diagnosis more accurate, and as further
knowledge concerning the etiology and
pathogenesis of periodontal diseases is
developed, prognosis will change from a
qualitative to a quantitative judgment.
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TREATMENT PLAN
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PresentationPatient consentOrder of
treatmentPhase IPhases Il and IIIMaintenance
therapyProsthetic prescription
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Alternative treatment plansTreatment
criteriaQuality of carePhilosophy of
treatmentRecord keepingReferral
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PresentationPatient consentAfter hearing the
presentation, the patient must decide whether to
undergo treatment.
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PHASE I
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First steps (The initial effort) should be
directed toward the elimination of inflammation
and the institution of a program of plaque
control.
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To reduce pocket depthTo minimize periodontal
traumatismOrthodontics(may precede or follow
any surgical interventions)
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Extractions(Teeth with hopeless
prognoses)RestorationsUsually periodontal
therapy should precede restorative interventions.
the restorations should be temporary
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The provisional splinting during the treatment
period should be evaluated.
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Scheduling of restorative treatment should be
done according to the following general rules
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Normal patients. (Restorative treatment starts
immediately.)Class I (ADA periodontal disease
classification)
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Without occlusal treatment needCaries control
and scaling and root planning. including plaque
control, may be simultaneous. Definitive
restorative treatment should follow completion of
scaling and plaque control.
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With occlusal treatment need Definitive
restorative treatment may immediately follow
completion of scaling, plaque control, and
occlusal adjustment.
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With surgical treatment need Definitive
restorative treatment should not be instituted
for at least 4 to 6 weeks after the patient has
healed.
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Splinting(Wire ligation and composite acid-etch
splinting)Emergency (pain, swelling, infection,
and discomfort)The emergencies all take priority
over other treatment scheduling.
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Medical status a systemic condition that would
complicate treatment, a medical consultation is
necessary.
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PHASES II AND III
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Phase II surgery permits pocket elimination /
reduction The restoration of normal osseous form
ostectomy-osteoplastyosseous surgery combined
with grafting procedures
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root resectionsmucogingival and
gingivectomyperiodontal-endodontic restorative
treatmentprovisional splinting.
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Maintenance therapyThe specialist may see the
patient once a year or every other year for the
less involved cases, whereas the generalist
maintains the patient in the recall system.
Advanced cases may be seen alternately at 2- to
4-month intervals.
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PROSTHETIC PRESCRIPTIONWaiting for a period of
at least 2 months after periodontal
surgery.Partial dentures or a fixed prosthesis
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ALTERNATIVE TREATMENT PLANS
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Alternative treatment plans should be prepared
for the patient who elects to forego splinting
and surgery when these are indicated.
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In this case the patient may be treated through
phase I therapy and be placed on a maintenance
schedule. The establishment of an alternative
plan generally calls for a rigorous maintenance
schedule with scaling and planing performed more
frequently than is otherwise usual.
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Treatment criteria
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Quality of careIn general, periodontal care
seeks the followingRemoval of known etiologic
factorsReduction of all pockets to a minimal
depth to facilitate maintenance by the patient
and the dental hygienistCreation of a
maintainable gingival and osseous architecture
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Restoration of a functional and esthetic
dentitionMaintenance of the resulting health by
the patient, doctor, and hygienist
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PHILOSOPHY OF TREATMENT
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periodontal diseases can be treated successfully
the health of the diseased periodontium can be
restored and the teeth maintained.
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The therapeutic concept of today includes all
forms of therapy, conservative and complex
selected and blended for the successful
management of the individual patient.
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Therapy must be tailored to the needs, both
physical and psychologic, of the patient.
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RECORD KEEPINGThe treatment performed should be
recorded carefully at each visit.
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ReferralThere are three basic reasons for
referral(1) professional, (2) moral an
ethical, and (3) legal.
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Professional Professional referrals are
classified as follows1. MedicalReferral/consul
tation is indicated when a patient's medical
history discloses significant information that
may contribute to or influence the course and
outcome of the treatment or when the dentist
suspects illness.
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2.Dental Referral/consultation is indicated
when the dentist cannot provide the entire
dental therapy the patient needs. When the
examination reveals periodontal disease that the
generalist cannot or does not wish to treat,
referral to a periodontist is in order. Equally
the periodontist is obligated to refer patients
for treatment to the general practitioner or
other specialists.
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3.Moral and ethical

• The specialists or consulting dentists upon
  completion of their care shall return the
  patient, unless the patient expressly reveals a
  different preference, to the referring dentist,
  or if none, to the dentist of record for future
  care.

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The specialists shall be obligated when there is
no referring dentist and upon a completion of
their treatment to inform patients when there is
a need for further dental care.
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Other reasons for referral includepatient
relocation, dentist-patient personality
conflict, and dentist's preference.Some
dentists do not use specialty, do not use
specialty service
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CommunicationInforming the patient about the
disease conditiona recall-maintenance schedule
should be made.
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DocumentationAll communication, written or
verbal, must be properly documented on the
patients chart.Patients have the right of
access to their records and may acquire copies of
the original documents, not original documents.
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Summary
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It is difficult for the dentist or specialist to
possess expert knowledge and skill in all areas
of dentistry because of the ever-expanding scope
and complexity of dental therapy.
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Today's dentist is confronted with a wide range
of treatment procedures and available
alternatives. At all times during the course of
treatment, the primary focus is the patient's
welfare.
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Effective communication and interaction among the
dentist, the patient, and the specialist are
vital elements of proper treatment.