Prognosis

=Discuss the concept of prognosis including how its determine and its relevance. = 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. It is the forecast of disease outcome to treatment. It is established after diagnosis and before treatment plan by using all the clinical and radiographic findings. Clinicians can have an overall prognosis of the dentition and an individual tooth prognois. Prognosis can be confused with the term risk factors. Risk factors are those characteristics of an individual that put the person at increased risk for developing a disease.


 * Factors in Determination of Prognosis**


 * Overall Clinical Factors:**
 * Patient age
 * Disease Activity such as type of bone loss and how it is affecting the adjacent teeth
 * Plaque Control
 * Patient Compliance
 * Systemic and Environmental Factors:**
 * Smoking
 * Systemic Disease or Condition
 * Genetic Factors
 * Stress
 * Local Factors:**
 * Plaque and Calculus
 * Subgingival Restorations
 * Anatomical Factors
 * Short, Tapered Roots
 * Cervical Enamel Projections
 * Enamel Pearls
 * Bifurcation Ridges
 * Root Concavities
 * Developmental Grooves
 * Root Proximity
 * Furcation Involvement
 * Tooth Mobility
 * Prosthetic and Restorative Factors:**
 * Abutment Selection
 * Caries
 * Nonvital Teeth
 * Root Resorption


 * Overall Clinical Factors**
 * Patient Age- For the younger patient, the prognosis is not as good because of the short time frame in which the periodontal destruction has occurred; the younger the patient may be an aggressive type of periodontitis.
 * Plaque Control: Primary etiologic factor and effective daily removal of plaque is essential for success of periodontal therapy and prognosis.
 * Patient Compliance: The prognosis for patients with gingival and periodontal disease is dependent on patient’s attitude, desire to retain their natural teeth, willingness and ability to maintain good oral hygiene.
 * Smoking- Smoking may be the most important environmental risk factor impacting the development and progression of periodontal disease.
 * Discuss with patient the direct relationship between smoking and prevalence and incidence of periodontal disease. Patient who smokes does not respond as well to periodontal therapy. Patients with slight to moderate periodontitis who stop smoking can upgrade to a good prognosis. Severe periodontitis who stop smoking may be upgraded to a fair prognosis.
 * Systemic Disease- prevalence and severity of periodontitis are significantly higher in patients with type 1 and type 2 diabetes than in those without diabetes, and the level of control of the diabetes is an important variable in this relationship. Therefore, patients at risk for diabetes should be identified as early as possible and informed of the relationship between periodontitis and diabetes.
 * Genetic Factors-May play an important role in determining the nature of the host response.Genetic disorders, such as leukocyte adhesion deficiency type 1, can influence nuetrophil function, creating an additional risk factor for aggressive periodontitis.
 * Stress- Physical, emotional stress, and substance abuse, may alter the patients ability to respond to periodontal treatment performed.


 * Local Factors:**
 * Plaque and Calculus-The most important local factor in periodontal diseases. Having a good prognosis depends on the ability of the patient and the clinician to remove these etiologic factors.
 * Subgingival Restorations- Subgingival margins may contribute to increase plaque accumulation, increased inflammation, and increased bone loss when compared to with supragingival margins. A tooth with a discrepency in its subgingival margins has a poorer prognosis than a tooth with well-contoured supragingival margins.
 * Anatomic Factors- Anatomic factors that may predispose the periodontium to disease and therefore affect the prognosis include short, tapered roots with large crowns, cervical enamel projections and enamel pearls, bifurcations ridges, root concavities, and developmental grooves. The clinician must also consider root proximity and location and anatomy of furcations. The prognosis is poor for teeth with short, tapered roots and large crowns. Because of the disproportionate crown-to-root ratio and reduced root surface for periodontal support, the periodontium is at greater risk for injury caused by occlusal forces. The presence of enamel projections (CEPs, enamel pearls) on the root surface intereferes with the attachment apparatus and may prevent regenerative procedures from achieving their maximum potential. Root proximity can result in interproximal areas that are difficult for the clinicaina and patient to maintain.
 * Tooth Mobility- The principal causes of tooth mobility are loss of alveolar bone, inflammatory changes in the periodontal ligament, and trauma from occlusion. Mobility caused by inflammation and trauma from occlusion may be correctable. Mobility as a result of loss of alveolar bone is not likely to be corrected. The stabilization of tooth mobility through the use of a splint may have beneficial impact on the overall as well as the individual prognosis.
 * Probing Depths- persistent deep pockets can harbor plaque increasing inflammation. The determination of the level of clinical attachment reveals the approximate extent of root surface that is devoid of periodontal ligament. Pocket depths are less important than level of attachment because it is not necessarily related to bone loss. A tooth with a deep pocket and little attachment or bone loss has a better prognosis than a tooth with shallow pockets and severe attachment and bone loss. The presence of apical disease at the base of the pocket as a result of endodontic invlovemnet also worsens the prognosis.
 * Furcations- furcations have a negative impact on prognosis. When a furcation is present it is difficult to scale these areas making them the perfect environment to harbor bacteria. Furcations are more difficult to access because the entrance is usually narrower than a traditional curette.


 * Prosthetic and Restorative Factors**
 * Abutment Selection- abutments are prone to more stresses from functional demands. Therefore the prognosis for teeth serving a abutments should be considered because they may become damaged (Carranza, Klokkevold, Newman, & Takei, 2006).
 * Caries- for teeth with extensive decay the ability to place a restoration and endodontic therapy should be considered before periodontal therapy begins.
 * Nonvital Teeth- nonvital tooth prognosis does not differ from vital tooth prognosis. New attachment can occur to the cementum of both nonvital and vital teeth.
 * Root Resorption- root resorption jeopardizes the tooth's stability thus declining the prognosis and adversely affects the response to periodontal therapy.


 * Prognosis is determined overall and in some cases individual teeth may have a different prognosis.**

No bone loss, excellent gingival condition, good patient cooperation, no systemic or environmental factors.
 * TYPES OF PROGNOSIS**
 * Excellent prognosis:**

Can be classified as a good prognosis if one or more of the following is/are present: Adequate remaining bone support, adequate possibilities to control etiologic factors such as plaque and establish a maintainable dentition, adequate patient cooperation, no systemic or environmental factors, and/or if systemic factors are present that are well controlled (Carranza,p. 614)
 * Good prognosis:**

Can be classified as a fair prognosis if one or more of the following is/are present: Less than adequate remaining bone support, some tooth mobility, Grade I furcation involvement, adequate maintenance possible, acceptable patient cooperation, and/or presence of limited systemic or environmental factors.
 * Fair prognosis:**

Can be classified as poor prognosis if on or more of the following is/are present: Moderate to advance bone loss, Grade I or II furcations, tooth mobility, difficult to maintain areas, doubtful patient cooperation, and/or presence of systemic or environmental factors.
 * Poor prognosis:**

Can be classified as qustionable prognosisi if one or more of the following is/are present: Advanced bone loss, Grade II or III furcations, tooth mobility, inaccessible areas, and/or presence of systemic or environmental factors.
 * Questionable prognosis:**

Can be classified as hopeless prognossi if one or more of the following is/are present: Advanced bone loss, non maintainable areas, extractions indicated and/or presence of uncontrolled systemic or environmental factors.
 * Hopeless prognosis:**

Excellent, good, and hopeless prognosis can be established with a degree of accuracy; however, fair, questionable, and poor prognosis have large number of factors that need to considered and examined. Fair, questionable, poor prognosis are unpredictable. **Examples:**

The radiograph on the left (A): The trabecular bone pattern is consistent. The lamina dura is present and intact. The alveolar crest is approximately 2mm away from the CEJ. The periodontal ligament has slight widening on #24 and #25. The crown to root ratio is 1:2. There appears to be adequate bone between the roots. Assuming there are no systemic conditions, and based on the radiographs alone, this patient would have an excellent prognosis (TL 8).

The radiograph on the right (B): The trabecular bone pattern appears to be inconsistent, especially near the apices of #24 and #25. The lamina dura is not present. The alveolar crest is approximately 6mm away from the CEJ. The PDL has widening on #24 and #25. The crown to root ratio is 2:1. There is adequate bone between the roots. Based on the radiographs, this patient would have a questionable prognosis due to the advanced bone loss (TL 8).

__Gingivitis associated with dental plaque only__- This occurs when the plaue is present along the gingival margins. At this stage the plaque can be removed. Gingivitis associated with plaque only can occur in periodontium that has no attachment loss or in peridontium with nonprogressing attachment loss. At this stage the prognosis of the disease is good as long as all irritants are removed and proper oral hygiene is implemented daily. __Plaque-induced gingival disease modified by systemic factors__- This gingival disease will have an inflammatory response due to the plaque along the gingival margins that is present because of systemic factors, such as puberty, menstration, pregnancy, and diabetes. The future prognosis of this disease is based on each individuals oral hygiene. __Plaque-induced gingival disease modified by medications__-This disease is present by an enlargement of gingiva due to the patients medication, such as phenytoin, cyclosporine, and oral contraceptives. Proper oral hygiene may not be enough to control the overgrowth, is this occurs the patient will need surgical intervention. The prognosis is based on the implementation of an alternative medication that does not cause the gingival enlargment. __Gingival Disease modified by malnutrition__- This disease is thought to be related to vitamin C deficiency. The prognosis of this disease is dependant on the period of time the patient has the deficiency and the severity. __Non-plaque-induced gingival lesions__- This disease can present in patients with bacterial, fungal, and viral infections. Prognosis is related to the elimination of the sorce. (Carranza 622)
 * Prognosis for patients with gingival disease-** dental plaque-induced gingival disease

__Chronic Periodontitis__ The prognosis depends on the severity of the disease. Generally, the prognosis is good if the patient has slight to moderate periodontitis (in which bone loss and clinical attachment loss is not advanced) and the inflammation can be controlled. The prognosis, however can reach fair to poor in severe cases with extensive bone loss, furcation involvement, an increase in mobility and those who are noncompliant with oral hygiene habits at home. __Aggressive Periodontitis__ The prognosis can range from excellent to questionable, depending on the factors involved. If localized, and diagnosed early and treated with systemic antibiotics and if oral hygiene instructions are followed though, the prognosis can be excellent. On the other hand, if the disease is generalized with contributing factors present such as smoking, these cases may not respond well to treatment (OHI, scaling and root planing, or surgical intervention) and therefore have a lower prognosis). __Periodontitis as a manifestation of systemic diseases__ The prognosis is dependent on the ability of the host to respond to the bacteria. Disorders that affect the way the host responds such as neutropenia and leukocyte adhesion deficiency syndrome, contribute to the development of periodontal disease, resulting in a fair to poor prognosis. __Necrotizing periodontal diseases__ The prognosis of an individual with necrotizing ulcerative gingivitis is good if the plaque as well as secondary factors (such as poor nutrition, stress and smoking) are controlled. Once the necrosis advances into the periodontium, NUP (necrotizing ulcerative periodontitis) results. Many individuals with NUP are immunocompromised so the prognosis is dependent on better controlling the systemic issue and reducing contributing factors.
 * Prognosis for patients with periodontitis**

After phase I therapy pocket depths and inflammation are assessed at the re-care appointment. If there is reduction this indicates that there has been a favorable prognosis. If upon re-evaluation there is no progress than it is considered unfavorable prognosis. Phase I therapy allows the clinician to help control systemic and environmental factors, which can have a positive effect on the prognosis. (Carranza, 624). Prognosis allow the clinicians to decide on a treatment plan. The prognosis should be discussed with the patient, and the possible outcomes without and with treatment (TL 8). This is important in order to ensure that the patient understands that they have an influence on the prognosis as well.
 * Reevaluation of Prognosis after Phase I Therapy**

References Carranza, F. A., Klokkevold, P. R., Newman, M. G., & Takei, H. H. (2006). //Carranza's clinical periodontology 10th edition//. St. Louis, MO: Saunders Elevier.