L7 Prognosis of Periodontally Involved Teeth

Prognosis of Periodontally Involved Teeth¹

Dr Emma Perry | BDSc, AssocDeg DH, GradCert HPEd

Content courtesy of: Associate Professor Leticia A Miranda | DDS, Specialist (Perio), MSc (Perio), PhD (Perio, Medicine) Dr Anna Hughes | BDS, MSc, FDSRCPS, MRACDS (Perio) Dr Pradeep Koppolu | BDs, MDS (Perio), PhD, FICOI, FPFA, PDCR

Learning Outcomes and Lecture Outline²

• Define prognosis.
• Explain the importance of assigning periodontal prognosis before treatment and after each examination.
• Discuss the factors which affect periodontal prognosis.
• Compare different periodontal prognosis systems.

Learning Outcomes³

• Define prognosis.
• Explain the importance of assigning periodontal prognosis before treatment and after each examination.
• Discuss the factors which affect periodontal prognosis.
• Compare different periodontal prognosis systems.

Lecture Outline

• Define prognosis.
• Explain the importance of assigning periodontal prognosis before treatment and after each examination.
  • Aims of prognosis
  • Prognosis in context
• Prognosis systems
  • Challenges and complexity
  • Factors to consider
  • Previous systems
  • Future of prognosis
  • Prognosis at OHCWA
• Case examples
• Implants

Introduction to Periodontal Prognosis

Definition and Clinical Importance⁴⁵

Prognosis

• Greek
  • Pro = before
  • Gno = “to know”
  • Foreknowledge
• The likely outcome or course of a disease; the chance of recovery or recurrence

Historically based on Experience

Aetiopathogenesis and Risk Factors

Statistics / Validated models or systems

• Prognosis is the prediction of the probable outcome of an individual’s current medical condition. A prognosis is made on the basis of the normal course of a disease, the individual’s physical and psychological condition, and additional factors such as therapeutic approach.

.

Prognosis

Aim: To predict the outcome of periodontally involved teeth, leading to better decision-making, treatment planning, and long-term predictable results

Prognosis is an essential part of periodontal care, together with diagnosis/treatment/maintenance

It directly influences treatment planning

Involves the analysis of all contributing factors to periodontitis - hence a good history, examination, and accurate diagnosis are essential prerequisites

Prognosis is a complex process and requires a multidisciplinary approach involving the patient

Prognosis is affected by the experience and skill of the clinician

McGowan et al 2017

Prognosis provides guidance

Questions from dentist to periodontist (Or dental student to tutor)

• Can I go ahead and restore this periodontally involved tooth?

Questions from patient to dentist

• How long will my teeth last?
• How successful will this treatment be?
• Should I have the tooth extracted and replaced with an implant?
• Should I have the tooth extracted and added to my denture? Will I then need a new denture in a few years?

Time and value for money

Prognosis in the Context of Therapy⁶

Challenges in Determining Prognosis

Multifactorial Nature and Provisional Prognosis⁷⁸

Challenges of determining prognosis

Current consensus is periodontitis is a multifactorial disease influenced by many risk factors which individually impinge on disease progression, treatment management, and response.

• Prognosis may change for better or worse.
• Constant reassessment of prognosis necessary.

Provisional Prognosis

For periodontal prognosis, the McGuire & Nunn 1996 classification as modified by Kwok and Caton 2007 prognosis can be utilised as this is very familiar to the current prognosis system used for restorative treatment plans. The determination of prognosis is an evolving and dynamic process. Prognosis can change after treatment as well as after recurrent disease activity. Therefore, prognostication occurs after each examination of the patient (Kwok & Caton 2007).

Challenges of determining prognosis Current aetiopathogenesis model

Behavioural risk factors absent Behavioural risk factors present Environmental risk factors absent Environmental risk factors evident

Clinical Health

Health Promoting biofilm = Symbiosis Complement PMNs Proportionate Host response Antigens Bact’l DNA fMLP Low biomass Acute Resolution of inflammation

Gingivitis

Incipient Dysbiosis (Quorum Sensing Bacteria) Antibody PMNs ++ T & B cells High biomass Chronic Resolution of inflammation

Antigens Virulence Factors LPS

Periodontitis

Frank Dysbiosis (Pathogenic Biofilm) Antibody PMNs +++ Plasma cells DAMPs Haem ↑ GCF Cytokines Prostanoids MMPs Oxidative Stress High biomass Failed Resolution of inflammation Connective Tissue & Bone Damage Chronic non-Resolving inflammation

Antigens Gingipains LPS

Genetic risk factors absent Genetic risk factors present Epigenetic effects not evident Epigenetic effects evident

Chappelle 2015

Challenges of determining prognosis

Left Column: How accurate are we at determining the prognosis of periodontally compromised teeth? [Dental Radiograph showing periodontal bone loss]

Right Column: The University of Western Australia | Are we too hasty in making the decision to extract? [Dental Radiograph showing healthy periodontal bone levels]

Prognosis Versus Actual Clinical Outcomes⁹¹⁰

Prognosis vs actual outcome

Prognosis versus actual outcome. II. The effectiveness of clinical parameters in developing an accurate prognosis McGuire & Nunn 1996

• Assigned 5 categories
• Good, fair, poor, questionable hopeless
• Treated and maintained over 8 years
• Good prognosis stayed relatively stable
• Fair prognosis category mostly improved
• Poor/questionable categories generally improved
• 25% of hopeless teeth were retained after 8 years
• Overall accuracy 35 %

Prognosis vs actual outcome THE UNIVERSITY OF WESTERN AUSTRALIA

Periodontal attachment levels of extractions presumably performed for periodontal reasons Splieth et al 2002

• Looked at what were dentists “forceps level” • 500 teeth extracted for periodontal reasons • A considerable number of teeth were extracted at an attachment level of 50-70% • Concluded that the threshold for periodontal extractions was too low • Called for an improvement in the knowledge of periodontal diagnosis and treatment

Factors Determining Prognosis

Overview of Prognostic Factors¹¹

Table 1 Factors affecting tooth prognosis

Systemic factors	Periodontal factors	Prosthodontic factors	Endodontic factors
Patient compliance	Symptoms	Caries	Loss of vitality
Plaque control	Plaque	Functional or non-functional tooth	Combined endodontic-periodontic infection
Smoking	Calculus	Over-eruption	Root resorption
Disease severity	Periodontal probing depths	Abutment tooth or not
Patient age	Bleeding/suppuration on probing	Occlusal trauma
Systemic disease	Tooth mobility	Aesthetics
Stress	Furcation involvement	Tooth surface loss
Mouth breathing/xerostomia	Bony defects
Alcohol intake	Subgingival/defective restorations
Diet	Root length, size and divergence
	Root concavities
	Root proximity
	Developmental grooves
	Bifurcation ridges
	Cervical enamel projections
	Enamel pearls
	Access
	Disease severity

Prognostic Factors:

Factors which are associated with a particular outcome among diseased individuals. i.e. likelihood of survival vs likelihood of improvement.

One essential element of prognosis is the definition of the intended outcome.

• Patient level factors
• Local/Tooth level factors
• TIME
• Defined outcome

Individual Tooth Versus Overall Prognosis¹²

Prognosis for individual teeth vs overall

Periodontitis does not progress uniformly in the dentition, and has general/systemic factors as well as local/tooth-related factors.

INDIVIDUAL

• Considers each individual tooth as periodontitis does not occur uniformly and has an episodic nature
• Considers other aspects: endo, restorative…

OVERALL

• Considers dentition as a whole.
• Should include general factors that affect the dentition as a whole too
• Should treatment be undertaken?
• Is treatment likely to succeed?
• When restorative treatments are needed, are the teeth able to support them?

Patient Level Factors¹³¹⁴

• Age
• Patients’ expectations
• Risk factors (smoking, diabetes, stress)
• Compliance to biofilm control
• Compliance to maintenance care

The University of Western Australia

Patient Age

For two patients with comparable levels of remaining connective tissue attachment and alveolar bone, the prognosis is generally better for the older of the two. For the younger patient, the prognosis is not as good because of the shorter time frame in which the periodontal destruction has occurred; the younger patient may also have an aggressive pattern of disease progression because of systemic disease, smoking, or other factors. 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 period would exceed any naturally occurring periodontal repair.

Local and Tooth Level Factors¹⁵¹⁶¹⁷

Local/Tooth level factors

Anatomic factors • Short tapered roots • Cervical enamel projections • Enamel pearls • Root concavities • Developmental grooves • Root proximity

Tooth position and occlusion • Furcation involvement • Crown-root ratio • Abutment tooth • Traumatic occlusion

Disease severity • BOP • PPD • CAL • Bone loss for age

Distribution and type of bone loss • Localised • Generalised • Horizontal • Infrabony

Tooth mobility

Other involvements • Caries • Endodontic

The University of Western Australia

Local/Tooth level factors

A

B

C

Fig. 41.7 Palatogingival groove. (A) Probe in place to indicate a deep pocket along the palatogingival groove. (B) Radiograph with a gutta-percha point placed in the pocket. (C) The area is surgically opened. Note the palatogingival groove along the entire palatal portion of the root. (Courtesy Dr. Nadia Chugal, University of California, Los Angeles.)

Local/Tooth level factors

A B

Prognosis of A is better than B Centre of rotation for A is nearer to the crown

Clinical Decision Making for Extraction Versus Conservation¹⁸

Retain or extract - it’s complex

EXTRACTION VERSUS CONSERVATION

DECISION CHART

1st Level	2nd Level	3rd Level	4th Level	5th Level	6th Level
INITIAL ASSESSMENT	PERIODONTAL DISEASE SEVERITY	FURCATION INVOLVEMENT	ETIOLOGIC FACTORS	RESTORATIVE FACTORS	OTHER DETERMINANTS
PATIENT EXPECTATIONS	PD	FURCATION Hamp et al. 197551	PRESENCE OF CALCULUS	FAULTY RESTORATIONS AND FRACTURES	SMOKING
- Willing to save (Green, Favorable)	- <5 mm (Green, Favorable)	- Class I (White, Favorable)	YES (Green, Favorable)	- Restorable (Green, Favorable)	- Non-smoker (Green, Favorable)
- Willing to extract* (Red, Unfavorable)	- 5-7 mm (Yellow, Caution)	- Class II (Yellow, Caution)	NO (White, Favorable)	- Non-restorable* (Red, Unfavorable)	- Smoker (Red, Unfavorable)
TREアTMENT EXPECTATIONS			SURGERY COMPROMISES BONE DIMENSION	EXTENSIVE CARIES	SYSTEMIC CONDITIONS
- Short-term (Green, Favorable)			NO (Green, Favorable)	- NO (Green, Favorable)	- Uncontrolled (Red, Unfavorable)
- Long-term (White, Caution)			YES (Yellow, Caution)	- YES (Yellow, Caution)	- Controlld (Yellow, Caution)
ESTHETICS	RECURRENТ PERIODONTАL ABSCESS	INTERPROXIMAL BONE LEVEL TO FURCATION ENTRANCE	PERIODONTAL RETREATMENT
- Not involved (Green, Favorable)	- NO (Green, Favorable)	ABOVE (Green, Favorable)	NO (White, Favorable)	CROWN:ROOT	USE OF BISPHOSPHONATES
- Involved (Yellow, Caution)	- YES (Red, Unfavorable)	AT (Yellow, Caution)	- NO (White, Favorable)	- Favorable (Green, Favorable)	- IV (Green, Favorable)
FINANCES	- 2 (Yellow, Caution)	REMAINING ROOTS INTO FURCATION?	- Recurrent (Red, Unfavorable)	- Favorable (Green, Favorable)	- Oral (Yellow, Caution)
- Limited (Yellow, Caution)	- 1 (Yellow, Caution)	REMAINING ROOTS INTO FURCATION?		- 1:1 (Yellow, Caution)	- Minimal (Yellow, Caution)
PATIENT’S COMPLIANCE	BONE LOSS	ROOT ANOMALIES	ROOT PROXIMAITY		CLINICIAN’S SKILL
- Adequate (Green, Favorable)	- <30% (Green, Favorable)	- NO (White, Favorable)	NO (White, Favorable)	- Post/Core AND Crown REQUIRED (Red, Unfavorable)
- Inadequate (Yellow, Caution)	- 30%-65% (Yellow, Caution)		YES (Red, Unfavorable)	- YES (Yellow, Caution)
	- >65% (Red, Unfavorable)	FINANCIAL CONCERNS?	ROOT CANAL THERAPY		CLINICAN’S SKILL
		YES (Green, Favorable)	- Treatment successful or not necessary (White, Favorable)		- Experienced (Green, Favorable)
	BONE DEFECT MORPHOLOGY	YES (White, Favorable)	- Treatment failed (Red, Unfavorable)
	- Deep, narrow (Green, Favorable)		NO (White, Favorable)
	- Superficial, wide (Yellow, Caution)

4th Level:

PRESENCE OF CALCULUS		SURGERY COMPROMISES BONE DIMENSION
YES (Green, Favorable)	NO (White, Favorable)	YES (Yellow, Caution)
NO (Yellow, Caution)		NO (Green, Favorable)

Figures/Legend:

1 or 2	Extraction is recommended
>3 or 2 + 1 + >2	Consider extraction
1 + >2	Attempt to treat; if fails, then extraction advisable
2	Tooth maintenance may be compromised but feasible
3	All + or 3: Tooth conservation is recommended

Legend Meaning:

• Red Box: Long-term survival unfavorable. Strongly suggests extraction.
• White Box: Prosceed with caution recommended.
• Green Box: Long-term maintenance favorable.

Evolution of Prognosis Systems

Limitations of Previous Systems¹⁹

Previous prognosis systems

Several proposed since the 1970s

Main limitations

• Based exclusively on tooth level factors
• Patient level modifiers/factors generally not considered
• Subjective measures instead of objective and quantifiable, (“extensive”, “marked”, “poor”…)
• Complex systems

Often inaccurate due to input data and complexity of use

Previous prognosis systems

Output from a model is only as good as the input and interpretation

Criteria for an Ideal Prognosis System^{20212223242526}

An ideal prognosis system McGowan et al 2017

• Include objective, quantifiable measures of clinical parameters
  • % bone loss
  • Grade of furcation involvement
  • Grade of mobility
  • …
• Include patient level modifiers
• Include only factors reported in the literature shown to influence tooth loss
• Provide short–term (< 5 year) and long–term (> 5 year) prognosis
• Define expected outcome in a way that is relevant to other treating practitioners
• As simple as possible
• Validated prospectively

L (AvY), length of study in average years; N (P), number of patients; N (T), number of teeth; WM, well maintained; DG, downhill group; EDG, extreme downhill group; PLM, patient level modifiers; APT, active periodontal treatment; PRA, periodontial risk assessment; PRC, periodontial risk calculator.

Study	L (AvY)	N (P)	N (T)	Classification System	Limiteditions & Strengths
Hirschfeld & Wasserman 1978	22	600	15,666	Favorable Questionable	+ Simple - Subjective measures - Relatively accurate in WM group, but inaccurate in DG and irrelevant in EDG - No PLM considered
Becker et al. 1984a, b	a: 6.5 b: 5.25	a: 95 b: 44	a: 2,414 b: 1,117	Good Questionable Hopeless	+ Accurate in WM group - Qualitative measures - Complex - All patients had ≥1 quadrant of pocket reduction Surgery - No PLM considered - Hopeless teeth extracted during APT
McGuire & Nunn 1996	9.97	100	2509	Good Fair Poor Questionable Hopeless	+ 81% accurate at 5-8 years - When teeth with a good prognosis excluded, accuracy drops to ~50% - Hopeless category determined by subjective criteria only - PLM considered but not included in determination of individual tooth prognosis - Complex - Hopeless teeth extracted during APT
Checchi et al. 2002	6.7	92	2310	Good Questionable Hopeless	+ Straightforward - Radiographic evaluation only - Removed 126 teeth during APT and no information is available on prognosis of these teeth - PLM considered but not included in determination of individual tooth prognosis
Kwok & Caton 2007	N/A	N/A	N/A	Favorable Questionable Unfavorable Hopeless	+ PLM can be factored into individual tooth prognosis + Considers the stability of the periodontium - Not validated - Subjective measures
Faggion et al. 2008	11.8	198	4559	Provides probability of tooth survival in 10% increments	+ PLM (diabetes) can be factored into individual tooth prognosis, but does not consider smoking - Does not stratify diabetic patients according to level of diabetic control - Complex
Miller et al. 2014	24	102	816	Provides a score between 1-11	+ PLM considered (smoking) + Simple - Molar teeth only - Subjective measures
Nibali et al. 2016	6.6	100	2494	Good Fair Questionable Unfavorable	+ Includes quantitative measure of periapical status - Do not appear to validate the model in the study, instead uses PRA & PRC - Complex - PLM considered (used PRA) but not included in determination of individual tooth prognosis

Proposed New Classification Categories²⁷²⁸

Proposed new prognosis system

	Secure	Doubtful	Poor	Irrational to treat
Prognosis	Future loss of periodontal supporting tissues is unlikely over 10 years (long term)	The periodontal tissues are expected to remain stable over 5 years (short term); IF patient-, tooth- and site-level factors are able to be managed	Breakdown of the periodontal supporting tissues is likely over the next 5 years (short term)	No periodontal support remaining
Tooth-level assessment ≥1 of the following:	BL/Age <0.5 PD ≤ 5 mm	BL/Age 0.5-1 PD 6-7 mm Degree II furcation Untreated infrabony defect Anatomic factors Tooth mobile >1 mm in transverse direction	BL/Age >1 PD ≥ 8 mm Degree III furcation Progressive tooth mobility	Circumferential bone loss to the apex Tooth mobile in axial direction
Patient-level assessment	The tooth-level assessment is downgraded by 1 level to a maximum of poora if ≥ 1 of the following factors are present: Smoking: ≥1/d Poorly controlled diabetes: HbA1c ≥ 9 BOP at ≥30% of sites at review appointment
Treatment recommendations	Tooth is suitable for prosthodontic, endodontic, and restorative therapy	Tooth may be suitable for prosthodontic, endodontic, and restorative therapy, but definitive treatment is best delayed until SPT	Tooth is not suitable for prosthodontic work. Endodontic and restorative therapy can be considered but tooth is not expected to survive over 5 years	Most appropriate course of clinical care is extraction
Compliance is mandatory: accuracy of prognosis cannot be relied upon for poorly compliant patients (as determined by attendance at SPT)

BL, bone loss; BOP, bleeding on probing; HbA1c, glycated hemoglobin; PAI, periapical index; PD, pocket depth; SPT, supportive periodontal therapy. ^a A secure prognosis is downgraded to doubtful, and doubtful to poor, but poor cannot be made irrational to treat.

An ideal prognosis system

• Include objective, quantifiable measures of clinical parameters
  • % bone loss
  • Grade of furcation involvement
  • Grade of mobility
  • Probing depths
• Include patient level modifiers
• Include factors reported in the literature shown to influence tooth loss
• Provide short-term (< 5 year) and long-term (> 5 year) prognosis
• Define expected outcome in a way that is relevant to other treating practitioners
• As simple as possible
• Validated prospectively

McGowan et al 2017

Criteria for Teeth Irrational to Treat²⁹

Irrational to treat

• “Hopeless”
• Insufficient remaining tooth structure to support a restoration
• Vertical root fracture
• Concurrent endo-perio disease with communication and Grade III mobility, 100% bone loss
• Inaccessible, non-functional third molars

THE UNIVERSITY OF WESTERN AUSTRALIA

Future Directions in Periodontal Prognosis³⁰

Future of prognosis

• Advances in periodontal therapy
  • Diagnostics (volumetric analysis)
  • Surgical approaches, lasers, regeneration
  • Longer term reviews
  • Understanding the value of long term maintenance (SPT)
• Advances in endodontic therapy
  • Improved diagnostics
  • Use of microscopes
  • New instrumentation and disinfection techniques
• Risk assessment and understanding the risk factors in implant therapy
  • Redefining success
    • Absence of persistent signs/symptoms,
    • No radiolucency/progressive bone loss
    • Patient satisfaction with restoration… rather than survival

Clinical Application at OHCWA

Comparison of Kwok and Caton vs McGuire and Nunn³¹³²³³

Prognosis at OHCWA

<table border="1">
  <tr>
    <th>Kwok & Caton</th>
    <th>Mcguire & Nunn</th>
    <th>Description</th>
  </tr>
  <tr>
    <td rowspan="2">Favourable/Certain</td>
    <td>Good</td>
    <td>Control of the etiologic factors and adequate periodontal support as measured clinically and radiographically to ensure the tooth would be relatively easy to maintain by the patient and clinician assuming proper maintenance</td>
  </tr>
  <tr>
    <td>Fair</td>
    <td>Approximately 25% attachment loss as measured clinically and radiographically and/or Class I furcation involvement. The location and depth of the furcation would allow proper maintenance with good patient compliance</td>
  </tr>
  <tr>
    <td>Uncertain</td>
    <td>Poor</td>
    <td>50% attachment loss and Class II furcations. The location and depth of the furcations would allow proper maintenance, but with difficulty</td>
  </tr>
  <tr>
    <td>Unfavourable</td>
    <td>Questionable</td>
    <td>>50% attachment loss resulting in a poor crown/root ratio. Poor root form. Class II furcations not easily accessible to maintenance care, or Class III furcations. #2+ mobility. Significant root proximity</td>
  </tr>
  <tr>
    <td>Hopeless</td>
    <td>Hopeless</td>
    <td>Inadequate attachment to maintain the tooth in health, comfort, and function. Extraction was performed or suggested. i.e., Grade III mobility or vertical mobility with extensive attachment loss</td>
  </tr>
</table>

Prognosis at OHCWA

Kwok & Caton 2007	McGuire & Nunn 1996	Description
Favourable/Certain	Good	Control of the etiologic factors and adequate periodontal support as measured clinically and radiographically to ensure the tooth would be relatively easy to maintain by the patient and clinician assuming proper maintenance.
	Fair	Approximately 25% attachment loss as measured clinically and radiographically and/or Class I furcation involvement. The location sea depth of the furcation would allow proper maintenance with good patient compliance.
Uncertain	Poor	50% attachment loss and Class II furcations. The location and depth of the furcations would allow proper maintenance, but with difficulty.
Unfavourable	Questionable	>50% attachment loss resulting in a poor crown-root ratio. Poor root form. Class II furcations not easily accessible to maintenance care, or Class III furcations. Gr 2+ mobility. Significant root proximity.
Hopeless	Hopeless	Inadequate attachment to maintain the tooth in health, comfort, and function. Extraction was performed or suggested. Gr 3 mobility or extensive attachment loss.

Recording Prognosis in Electronic Forms³⁴³⁵³⁶

Prognosis at OHCWA

Prognosis Prognosis scores are recorded on the upper palatal and lower lingual charts in the corresponding ‘Prog’ rows

Palatal

Lingual

Left click, using the mouse, above the first tooth, then using the digits on the keyboard record the prognosis, as you type the cursor will automatically move along the chart. Any teeth, which are charted as missing, will be omitted when recording the scores.

To record:	Use the following on the keyboard:
Prognosis score	Enter the required letter using the keyboard. As each letter is entered the cursor will automatically move to the next measurement.
G- Good
F- fair
P- Poor
H- Hopeless

Palatal

Lingual

OHCWA Perio eForm

Page 7

EVIDENCE OF BONE LOSS	% BONE LOSS / AGE	CASE PHENOTYPE	SMOKING	DIABETES
Grade A	NO LOSS	< 0.25	HEAVY FILM DEPOSITS	NON SMOKING	NORMO GLYCEMIC
Grade B	< 2 mm 5 YEARS	0.25 TO 1.0	FILM DEPOSITS CORRESPOND TO DESTRUCTION	< 10 CIGARETTES DAY	HbA1c < 7.0 %
Grade C	>= 2 mm 5 YEARS	> 1.0	LOW FILM DEPOSITS HIGH DESTRUCTION	>= 10 CIGARETTES DAY	HbA1c > 7.0 %
CURRENTLY STABLE PERIODONTITIS :(REDUCED PERIODONTIUM: BOP < 10% POCKETS 4 mm OR LESS)
CURRENTLY REMISSION PERIODONTITIS (GINGIVAL INFLAMMATION ON A REDUCED PERIODONTIUM: BOP > 10% ON A TREATED PERIO CASE POCKETS 4 mm )
CURRENTLY UNSTABLE PERIODONTITIS (BOP > 10 % AND POCKETS 4-5 mm OR MORE)
OTHER FORMS OF PERIODONTITI
PERI-IMPLANT HEALTH
PERI-IMPLANT MUCOSITIS
PERI-IMPLANTITIS
PERI-IMPLANT ANOMALIES

OVERALL PERIODONTAL PROGNOSIS

• Good
• Fair
• Poor
• Questionable
• Hopeless

REFERRAL REQUIRED describe unit and needs

Student Signature

Tutor Signature

Control of the etiologic factors and adequate periodontal support as measured clinically and radiographically to ensure the tooth would be relatively easy to maintain by the patient and clinician assuming proper maintenance.

Approximately 25% attachment loss as measured clinically and radiographically and/or Class I furcation involvement. The location sea depth of the furcation would allow proper maintenance with good patient compliance.

50% attachment loss and Class II furcations. The location and depth of the furcations would allow proper maintenance, but with difficulty.

>50% attachment loss resulting in a poor crown-root ratio. Poor root form. Class II furcations not easily accessible to maintenance care, or Class III furcations. Gr 2+ mobility. Significant root proximity.

Inadequate attachment to maintain the tooth in health, comfort, and function. Extraction was performed or suggested. Gr 3 mobility or extensive attachment loss.

McGuire & Nunn 1996 Kwok & Caton 2007

OHCWA Perio eForm Page 6

PERIODONTAL DIAGNOSIS & PROGNOSIS

• CLINICAL GINGIVAL HEALTH BOP < 10% PROBING < 3mm
• CLINICAL GINGIVAL HEALTH ON A REDUCED PERIODONTIUM BOP < 10% ON TREATED PERIODONTITIS PATIENT PROBING < 3mm
• GINGIVITIS BOP MORE 10% NO POCKETS
  • LOCALISED
  • GENERALISED
• GINGIVAL INFLAMMATION ON A PERIODONTITIS PATIENT BOP > 10% TREATED PERIODONTITIS PATIENT RECESSON PROBING < 3mm
• OTHER FORMS OF GINGIVITIS: _________________________________________________

---

• PERIODONTITIS:

STAGE	INTERDENTAL CAL	RADIOGRAPHIC BONE LOSS	TOOTH LOSS	COMPLEXITY
STAGE I	[ ] 1-2 mm	[ ] < 15% HORIZONTAL BONE LOSS	[ ] NO TOOTH LOSS	[ ] MAX PROBING DEPTH < 4 mm
STAGE II	[ ] 3-4 mm	[ ] 15 - 33% HORIZONTAL BONE LOSS	[ ] NO TOOTH LOSS	[ ] MAX PROBING DEPTH < 5 mm
STAGE III	[ ] >= 5 mm	[ ] MIDDLE ROOT THIRD AND MORE [ ] ANGULAR	[ ] =< 4 TEETH	[ ] MAX PROBING DEPTH > 6 mm [ ] FURCATION GRADE II [ ] GRADE III [ ] MODERATE RIDGE DEFECT
STAGE IV	[ ] >= 5 mm	[ ] MIDDLE ROOT THIRD AND MORE [ ] ANGULAR	[ ] >= 5 TEETH [ ] LESS THAN 20 TEETH REMAINING	[ ] MAX PROBING DEPTH > 6 mm [ ] FURCATION GRADE II [ ] GRADE III [ ] SEVERE RIDGE DEFECTS [ ] MASTICATORY DYSFUNCTION [ ] 2ry OCCLUSAL TRAUMA [ ] BITE COLLAPSE

---

DISTRIBUTION:

• LOCALISED 30% AND LESS TEETH
• GENERALISED MORE THAN 30 % TEETH
• INCISIVE MOLAR

OHCWA Perio eForm

Page 1

Relevant Medical History

Presenting complaint [Blank Text Box]

Diabetic

• No
• Type I
• Type II
• Prediabetes
• Gestational HbA1c % level [Blank Text Box]

Smoker

• No
• Yes, Current
• Ex Smoker
  • Number a day: [Blank Text Box]
  • Years: [Blank Text Box]
  • Quit date: [Blank Text Box]

Stress

• Yes
• No

Other medical conditions [Blank Text Box]

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Page 2

Relevant Dental History

Signs of Gingival bleeding [Empty Checkbox] Bad Breath / Taste [Empty Checkbox] Teeth Migration [Empty Checkbox] Tooth Loss: Caries [Empty Checkbox] Perio [Empty Checkbox]

Brush Type: Manual [Empty Checkbox] Electric [Empty Checkbox] Interdental Clean: Floss [Empty Checkbox] Brushes [Empty Checkbox] Other [Empty Checkbox]

Plaque: [Placeholder for table or graphic itemizing plaque]

Biofilm Amount

• min
• max
• mod amount
• abundant

Biofilm Distribution %

Chart in Perio Tab and input result here

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Page 3

CALCULUS DISTRIBUTION

• Mild
• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• Abundant

---

An ideal prognosis system

The University of Western Australia logo

• Include objective, quantifiable measures of clinical parameters Gold star icon
  • % bone loss
  • Grade of furcation involvement
  • Grade of mobility
  • Probing depths
• Include patient level modifiers Blue star icon
• Include factors reported in the literature shown to influence tooth loss Pink star icon
• Provide short-term (< 5 year) and long-term (> 5 year) prognosis
• Define expected outcome in a way that is relevant to other treating practitioners
• As simple as possible
• Validated prospectively McGowan et al 2017

Validity^37383940

• The system must accurately predict the outcome of the tooth.

Reliability

• The system must produce consistent results when used by different clinicians or by the same clinician at different times.

Clarity

• The criteria must be clearly defined and easy to understand.

Simplicity

• The system should be easy to use in a clinical setting.

Comprehensiveness

• The system should consider all relevant factors that may affect the prognosis.

OHCWA Perio eForm

Received: 2 June 2020 | Revised: 18 August 2020 | Accepted: 28 August 2020 DOI: 10.1002/PERD.20-001

ORIGINAL ARTICLE

Analyzing the predictability of the Kwok and Caton periodontal prognosis system: A retrospective study

Lincoln Nguyen1,* | Goutam Krish1,* | Ahmed Alsaleh1 | James Mailoa2 | Yvonne Kapila1 | Richard T. Kao1,3 | Guo-Hao Lin1

1 Department of Oral and Maxillofacial Sciences, School of Dentistry, University of California San Francisco, San Francisco, CA, USA 2 Private practices, Makassar, Indonesia 3 Private practice, Cupertino, CA, USA

Correspondence Dr. Guo-Hao Lin, Department of Oral and Maxillofacial Sciences, University of California, San Francisco, 707 Parnassus Avenue, San Francisco, CA 94143, USA. Email: guo-hao.lin@ucsf.edu

*Lincoln Nguyen and Goutam Krish are co-first authors and equally contributed to this study

Abstract

Background: The aim of this study was to analyze the predictability of the Kwok and Caton periodontal prognosis system by investigating tooth survival within a 64-month period and to compare this to other well-established prognosis systems.

Methods: This retrospective study included the records of patients who had a minimum of two dental exams at least 12 months apart at a single University-affiliated Dental Center. Data including patient’s age, sex, length of follow-up period, initial tooth prognosis, revised tooth prognosis, tooth type, and number of teeth lost at the latest exam were recorded. Descriptive analysis was used for data interpretation.

Results: A total of 4,046 teeth from 174 patients qualified for the study. Teeth with initial poorer prognosis had a higher chance of being extracted compared to those with a better initial prognosis. Tooth survival rate at the latest follow-up for those with an initial favorable, questionable, unfavorable, and hopeless prognosis was 97.9%, 90.7%, 62.5%, and 17.7%, respectively. Teeth initially assigned to a poorer prognosis category had a higher proportion that changed to a worse prognosis at the latest periodontal exam.

Conclusions: The Kwok and Caton prognosis system can predictably determine tooth survivability within a 5-year period. The defined categories of this prognosis system are more reliable than that of other systems in the short-term. However, long-term (>5 years) prediction accuracy of this prognosis system needs further investigation.

KEYWORDS dentistry, diagnosis, periodontitis, prognosis, risk factor(s)

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5 | CONCLUSIONS

Our study investigated the predictability of the Kwok and Caton prognosis system and found that this system can accurately determine tooth survivability within a 5-year period. The defined categories of this prognosis system are more reliable than other previously published systems for short-term predictions. However, the long-term (≥ 5 years) prediction accuracy of this prognosis system has to be further investigated.

• Include objective, quantifiable measures of clinical parameters
  • % bone loss
  • Grade of furcation involvement
  • Grade of mobility
  • Probing depths
• Include patient level modifiers
• Include factors reported in the literature shown to influence tooth loss
• Provide short-term (< 5 year) and long-term (> 5 year) prognosis
• Define expected outcome in a way that is relevant to other treating practitioners
• As simple as possible
• Validated prospectively

McGowan et al 2017

Clinical Description	Maintenance Status
Control of the etiologic factors and adequate periodontal support as measured clinically and radiographically to ensure the tooth would be relatively easy to maintain by the patient and clinician assuming proper maintenance.	relatively easy to maintain
Approximately 25% attachment loss as measured clinically and radiographically and/or Class I furcation involvement. The location and depth of the furcation would allow proper maintenance with good patient compliance.	proper maintenance with good patient compliance
50% attachment loss and Class II furcations. The location and depth of the furcations would allow proper maintenance, but with difficulty.	maintenance, but with difficulty
>50% attachment loss resulting in a poor crown-root ratio. Poor root form. Class II furcations not easily accessible to maintenance care, or Class III furcations. Gr 2+ mobility. Significant root proximity.	not easily accessible to maintenance care
Inadequate attachment to maintain the tooth in health, comfort, and function. Extraction was performed or suggested. Gr 3 mobility or extensive attachment loss.	Inadequate attachment to maintain the tooth

An ideal prognosis system should:

• Include objective, quantifiable measures of clinical parameters
  • % bone loss
  • Grade of furcation involvement
  • Grade of mobility
  • Probing depths
• Include patient level modifiers
• Include factors reported in the literature shown to influence tooth loss
• Provide short-term (< 5 year) and long-term (> 5 year) prognosis
• Define expected outcome in a way that is relevant to other treating practitioners
• As simple as possible
• Validated prospectively

The University of Western Australia

McGowan et al 2017

Case Studies and Clinical Examples⁴¹⁴²⁴³

Case examples

Fig. 41.10 Clinical photos (A and B) and full mouth radiographic series (C) of a patient who had molar-incisor pattern of periodontitis (used to be called “localized aggressive periodontitis”). The overall prognosis is favorable except for the maxillary right first molar (unfavorable), maxillary left first molar (questionable), and mandibular right first molar (questionable).

Case examples

Fig. 41. Generalized, stage III, grade C periodontitis in a healthy, nonsmoking 49-year-old female. (A and B), Moderate clinical biofilm, calculus, and gingival inflammation. (C) Moderate to severe radiographic bone loss. Overall prognosis is questionable/unfavorable. (Copyright Jonathan H. Do, DDS. All rights reserved.)

Implants Versus Natural Tooth Retention⁴⁴⁴⁵

Irrational to treat - now implants?

“In no way does the longevity of oral implants surpass that of natural teeth even of those that are compromised for either periodontal or endodontic reasons.” Holm-Pedersen et al 2007

“However, other colleagues have started to realize that there sometimes is an over-confidence in implant therapy and that expensive treatments with uncertain prognosis are provided when other solutions, saving a greater number of natural teeth, would have been a comparable, or even a better, choice long-term.” Lundgren et al 2008

“There is no evidence available to support an aggressive approach in early extraction of teeth, to preserve bone for later implant placement.” Chandki & Kala 2012

“Periodontal regeneration can change the prognosis of hopeless teeth and is a less costly alternative to tooth extraction and replacement.” Cortellini et al 2020

Irrational to treat - now implants?

• Implants do not survive more than treated periodontally compromised teeth
• Implants have common complications
• Management of implant complications is challenging
• Implants are not cheaper than periodontal therapy
• Tooth complication? Extract and replace with implant
• Implant complication? …

Footnotes

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