Mays Mohmd Nasser
Murad Shaqman
16
16/2/2015
Periodontics
Lecture No.
Date:
Doctor:
Done by:
Sheet
Slide
s
Hand Out
University of Jordan
Faculty of Dentistry
Fourth year –2nd semester 2014-2015
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
Periodontal Treatment Planning and Prognosis
Three things must be present in a certain case to be diagnosed as periodontitis; attachment
loss, inflammation and local factors (plaque and or calculus). In another word plaque induced
inflammatory attachment loss is the main characteristic of periodontitis.
Inflammation can be caused by several factors such as trauma but in the case of
periodontitis we are looking for plaque induced inflammation.
I.e. a patient with gingival recession on the buccal surfaces of anterior teeth is not
diagnosed as a periodontitis case.
It’s very important to know if a periodontitis patient was previously treated or not. This is
to determine whether the attachment loss the dentist is observing is due to the history of
periodontal disease or due to an active periodontal disease.
Note that the primary difference between gingivitis and periodontitis is bone loss (clinical
attachment loss).
In addition to clinical examination, radiographic examination plays an important role in the
diagnosis of periodontal diseases.
A good radiographic technique is important to end up with diagnostic quality radiographs.
Full mouth series, periapical radiographs and vertical bitewings are needed to diagnose
periodontal diseases.
Bone loss is the main feature to observe in a radiograph.
Recall that bone loss is of two types; vertical bone loss and horizontal bone loss.
To differentiate radio graphically between vertical and horizontal bone loss draw an
imaginary line passing through the cemento-enamel junction of adjacent teeth. If the bone
level and the cemento-enamel junction line were parallel then it’s considered as horizontal
bone loss.
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
Note that the distance between the two lines should be more than 2mm to be considered as
bone loss. Refer to slide 7, the 2nd radiograph; this is not considered as bone loss since the
distance is less than 2mm. So you have to know the normal to identify the abnormal.
On the following picture notice the parallelism of the bone level and the cemento-enamel
junction line.
Slide 7, the first radiograph shows vertical bone loss and a component of horizontal bone
loss. Vertical and horizontal bone loss can’t be isolated, there’s always a combination of them.
The short arrow represents an infrabony defect. The radio opacity; the long arrow is
pointing at represents an intact buccal or lingual wall.
An infrabony defect is a defect inside bone and can be classified according to the number of
remaining bony walls into zero walls bony defect ,one wall bony defect, two walls bony defect
and three walls bony defect.
T wo wa l l s bo n y d e f e c t s ur r o u nd e d
b y t wo wa l l s ( b ucc a l o r l i n g u a l a n d
i n t er pr o x i m a l )
Three walls infrabony defect surrounded
By three walls (buccal,lingual, and interproximal)
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
Keep in mind that horizontal bone defects are zero walls bony defects.
Vertical Bitewings have better projection than periapical radiographs.
Slide 8, the 2ndperiapical radiograph shows a normal bone level but obviously its projection is
not accurate; the cusps are not superimposed. The other bitewing radiograph is for the same
patient and showing bone loss. Thus bitewings depict the height of crestal alveolar bone more
accurately than periapical radiographs.
Slide 8 shows Vertical bitewings which are used in cases where the periodontal bone
resorption is severe condition.
Slide 9, the first radiograph shows horizontal bone loss while the second one shows vertical
bone loss.
In slide 9, the 2nd radiograph, notice the arch shaped defect which is a characteristic of
localized aggressive periodontitis. In addition this infrabony defect (with no radioopacity) is
considered a one wall bony defect.
In the past, they believed that the absence of Crestal lamina dura is a sign of inflammation
which was wrong; the presence of lamina dura is a sign of health while its absence is not a
sign of inflammation.
Crestal lamina dura appears as a white line at the level of the crestal bone.
Keep in mind that lamina dura is a radiographic phenomenon and there is no histological
difference between it and the surrounding areas.
Radiographic changes in periodontitis involve vertical or horizontal bone loss, sub gingival
calculus on the roots and periodontal ligament widening especially in cases of teeth mobility.
Sometimes conventional radiographs don’t show the whole picture due to two main reasons;
1st, they are two dimensional radiographs, 2nd anatomical consideration.
Slide 14, a radiolucent lesion on a radiograph might appear different from another
projection.
Slide 15, lingual and buccal aspects are not visible on radiographs, observe the normal bone
level in the first radiograph, but when putting gutta-percha inside the pocket a very deep
pocket was discovered.
Slide 18, cone beam CT scan reveals a three wall defect that is otherwise obscure on
conventional radiographs.
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
Risk assessment
Risk factor: may been environmental, behavioral or biologic factor that when present
increases the likelihood that an individual will develop the disease, and can be modified such
as diabetes.
Risk determinants are risk factors that can’t be controlled such as age and gender
Risk indicators are probable or putative risk factors; we don’t have enough evidence to show
that it’s associated with the disease.
Risk marker: associated with increased risk for the disease but do not cause the disease.
Keep in mind that the presence of risk factors affects the response to therapy.
factors includeRisk
1) Tobacco smoking
2) Diabetes
3) The type of pathogenic bacteria present
4) The extent of microbial tooth deposits (plaque)
include d characteristic/backgrounRisk determinants
1) Genetic factors
2) Age
3) Gender
4) Socioeconomic status, studies show that periodontal diseases are more prevalent in
people with low socioeconomic status.
5) Stress is not really a risk determinant because you can modify it; it’s more like a
background characteristic.
include:indicators are not 100% proven and Risk
1) HIV/AIDS
2) Osteoporosis
3) Infrequent dental visits
Risk markers
1) Previous history of periodontal disease is not an etiological factor of periodontal
disease but it’s a marker that this patient with previous history of periodontitis is
susceptible to have periodontal disease in the future.
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
2) Bleeding on probing is a marker for inflammation but it’s not an indicator; you can’t
predict attachment loss depending on bleeding on probing.
3) Gingivitis; a patient with minimal plaque and brushes his teeth regularly but
complaining of gingivitis have higher risk than a patient that never brushes his teeth
and don’t have any sign of inflammation.
You have to observe risk factors and determinants in a patient to assess risks associated
with his/her case. The more risk factors and determinants the patient have the more the
risk to have the disease and the worse the prognosis, check slide 29.
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.
Prognosis is usually assigned after phase one; a tooth that have poor prognosis may have good
prognosis after performing phase one. Thus prognosis is a dynamic process.
Prognosis is about tooth mortality not about the complete subsidence of the disease in other
words all we care about in prognosis is the probability of tooth loss.
Prognosis of gingivitis is always good because there is no bone loss accordingly there is no
probability to lose the tooth.
Classification systems (based on tooth mortality)
Good prognosis:
-Good control of etiological factors; removal of sub gingival calculus, improved plaque control,
better compliance.
-adequate periodontal support ensures that the tooth will be easily maintained by the patient
and clinician. (No or minimal bone loss)
Fair prognosis:
Approximately 25% bone loss (attachment loss) and/or class 1 invasion (location and depth
allow proper maintenance with good patient compliance)
Poor prognosis:
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
-Approximately 50% bone loss
-class II furcation involvement (accessible location and depth make maintenance possible but
difficult) such as class II furcation invasion in the mandibular molars (buccal or lingual)
which is accessible, while class II furcation invasion in the maxillary molars ( interproximal)
is not accessible for maintenance .
Questionable prognosis:
- More than 50% attachment loss
- Poor crown to root ratio
- Poor root form such as fused roots while divergent roots give good support
- Not accessible Class II furcation involvement (location and depth make access
difficult) or class III furcation involvement.
- More than grade 2 mobility
Keep in mind that grade 3 mobility doesn’t always mean tooth extraction; you have to
diagnose the cause of mobility, if the cause was severe bone loss then you have to take it
out. On the other hand if the mobility was due to occlusal problem you have to correct the
occlusion.
- Root proximity
Hopeless prognosis:
-severe attachment loss; when there is inadequate attachment to maintain health, comfort
and function.
- J shaped bone loss extending to the apex
- Extensive carious tooth
Classification systems (based on periodontal stability)
Is the case going to be stable or not?
This is a long term prognosis; 5-10 years prediction 35:02
We don’t use this classification in university
Favorable prognosis:
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
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.
Unfavorable prognosis:
Local and/or systemic factors influencing the periodontal status can’t be controlled.
Comprehensive periodontal treatment and maintenance are unlikely to prevent future
periodontal breakdown.
Hopeless prognosis:
The tooth must be extracted
Overall prognostic factors
1) Age
An old patient have better prognosis than a young patient
2) Disease severity
A patient with 25% bone loss have better prognosis than a patient with 50% bone loss.
3) Patient’s compliance
4) Plaque control
5) Finances
A patient that can afford treatment has better prognosis than a patient that can’t
afford it.
)(systemic and environmentalOverall prognostic factors
1) Smoking
2) Systemic diseases such as diabetes
3) Genetic factors – polymorphism
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
4) Stress levels
Tooth local prognostic factors
-The most important tooth local prognostic factor is attachment loss.
-probing depth; the more residual pocketing the patient have the worse the prognosis will be.
-percentage of bone loss
-Type of bone loss; vertical bone loss can be treated by regeneration thus a patient with
vertical bone loss have better prognosis than a patient with horizontal bone loss.
Note that horizontal bone loss can’t be regenerated.
-furcation invasion
-Crown-root ratio
-Subgingival restorations
-Anatomic factors; root form, concavities and grooves.
- Mobility
-position in the arch; posterior teeth have multiple roots accordingly having worse prognoses
than single rooted anterior teeth.
- Caries and restorability
- Endodontic status
- Prosthetic treatment plan
- Tooth malposition
Prognosis of gingival diseases
Gingival diseases induced by plaque only
Good with the control of local factors
Example: plaque control, removal of calculus and removal of overhanging restorations.
Gingival diseases associated with systemic modifiers
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
It depends heavily on the control of systemic condition or disease; if there is good
control there will be good prognosis
Example: diabetes mellitus, pregnancy, medication, malnutrition.
Chronic periodontitis
Ranges from good to poor/questionable
It depends on many prognostic factors.
Aggressive periodontitis
- Localized aggressive periodontitis prognosis ranges from good to poor/questionable
and itdepends on many factors such as attachment loss, probing depth, furcation
invasion, type of bone loss and mobility.
- Generalized aggressive periodontitis prognosis ranges from good to poor/questionable
but it’s more challenging.
Periodontitis as a manifestation of systemic disease
Its prognosis is usually poor
Necrotizing ulcerative diseases
Its prognosis varies depending on the involvement of bone and the extent of destruction.
Short term goals of treatment planning
- Control inflammation
- Eliminate local factors
- Eliminate pocketing
- Correct restorations
Long term goal of treatment planning
- Establish healthy , functional and esthetic dentition
Except for emergencies, no treatment should be initiated until a treatment plan has been
established.
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
To extract or not to extract?
It was a much easier question to answer in the past due to the limited alternatives of teeth
(there was no implant dentistry) accordingly the answer was always to restore the tooth and
never to extract it.
With the advent of implant dentistry, careful consideration of options is necessary.
f extraction:oications Ind
-A mobile tooth that its function becomes painful and it can cause dental abscesses during
therapy and there is no use for it in the overall treatment plan.
Phases of periodontal therapy
Phase 1
- Diet control ( in patients with rampant caries )
- Removal of calculus and root planing
- Correction of restorative and prosthetic irritational factors
- Excavation of caries and restoration placement ( temporary or final depending on
whether a definitive prognosis for the tooth has been determined
- Antimicrobial therapy (local such as mouth washes or systemic such as antibiotics)
- Occlusal therapy
- Minor orthodontic movement
- Provisional splinting
- Prosthesis
Re-evaluation
Re-evaluation is done 6-8 weeks after phase one; we wait for the connective tissue to heal.
We evaluate probing depth, gingival inflammation, plaque control, calculus and caries.
Phase 2
We perform periodontal, implant or endodontic surgery.
Phase 3
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
-Placement of final restorations
-placement of fixed or removable prosthesis
Phase 4
Phase 4 is all about periodontal maintenance.
We check plaque, calculus, probing depth, inflammation, and occlusion.
Keep in mind that maintenance phase is an ongoing phase; once you finished phase 1
maintenance must be checked every 3 months even if the patient is still undergoing
restorative therapy.
Prepared by Mays Mohmd Nasser
Mays Mohmd Nasser Periodontics Sheet No 16 16/2/2015
