**Prognosis of Periodontally Involved Teeth** 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** 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** The University of Western Australia institutional logo featuring the university shield and name. ## Learning Outcomes • 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. - 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. University logo for The University of Western Australia featuring a shield with a swan and open books. # Lecture Outline <p align="right"> <img src="https://upload.wikimedia.org/wikipedia/commons/thumb/4/44/The_University_of_Western_Australia_logo.svg/1024px-The_University_of_Western_Australia_logo.svg.png" height="50" alt="University Logo"/> </p> ## Learning Outcomes * **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 #### Learning Outcomes - **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 The University of Western Australia logo featuring a shield with an open book and the university name in blue text. # 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 * 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. A photograph showing hands hovering over a glowing crystal ball on a purple surface, illustrating the concept of 'Historically based on Experience'. . ### 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 **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 The University of Western Australia institutional logo located in the top right corner. 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 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** Photo of a male dentist or doctor wearing a white lab coat and blue medical gloves. He is holding his chin with one hand in a thoughtful pose against a yellow background. Photo of a female patient with short reddish-brown hair, wearing a light blue shirt. She is looking at the viewer while touching her teeth with her hand, appearing to be in pain or discomfort. Prognosis in context **Prognosis** Treatment planning Examination Diagnosis Therapy      Prognosis in context **Prognosis** Treatment planning Examination Diagnosis Therapy Flowchart node labeled 'Examination' with a magnifying glass icon on the left. Flowchart node labeled 'Diagnosis' with a medical cross symbol inside a circle on the left. Highlighted flowchart node labeled 'Prognosis' with a clock icon on the left. The background is highlighted in yellow/gold to indicate emphasis or selection. Flowchart node labeled 'Treatment planning' with a document/list icon on the left. Flowchart node labeled 'Therapy' with an icon of a tooth and a dental tool (likely a scaler or curette) on the left. ## 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 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). The University of Western Australia logo located in the top right corner. It features a shield with a blue and yellow design containing a swan, accompanied by the university's name in blue text. Challenges of determining prognosis Current aetiopathogenesis model Behavioural risk factors absent Behavioural risk factors present Environmental risk factors absent Environmental risk factors evident <a href="Fig96-14">Clinical Health</a> Health Promoting biofilm = Symbiosis Complement PMNs Proportionate Host response Antigens Bact'l DNA fMLP Low biomass Acute Resolution of inflammation <a href="Fig96-15">Gingivitis</a> Incipient Dysbiosis (Quorum Sensing Bacteria) Antibody PMNs ++ T & B cells High biomass Chronic Resolution of inflammation Antigens Virulence Factors LPS <a href="Fig96-16">Periodontitis</a> 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 Current aetiopathogenesis model Behavioural risk factors absent Behavioural risk factors present Environmental risk factors absent Environmental risk factors evident <a href="Fig96-14">Clinical Health</a> Health Promoting biofilm = Symbiosis Complement PMNs Proportionate Host response Antigens Bact'l DNA fMLP Low biomass Acute Resolution of inflammation <a href="Fig96-15">Gingivitis</a> Incipient Dysbiosis (Quorum Sensing Bacteria) Antibody PMNs ++ T & B cells High biomass Chronic Resolution of inflammation Antigens Virulence Factors LPS <a href="Fig96-16">Periodontitis</a> 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 A comparative diagram titled 'Current aetiopathogenesis model' illustrating the progression from Clinical Health to Periodontitis based on risk factors. The diagram is organized into three vertical columns: 'Clinical Health', 'Gingivitis', and 'Periodontitis'. Above these columns are horizontal axes indicating the presence or absence of Behavioural, Environmental, Genetic, and Epigenetic risk factors. The 'Clinical Health' column (green) depicts a 'Health Promoting biofilm = Symbiosis', low biomass, proportionate host response, and acute resolution of inflammation. The 'Gingivitis' column (orange) shows 'Incipient Dysbiosis', high biomass, T & B cells involvement, and chronic resolution of inflammation. The 'Periodontitis' column (red) details 'Frank Dysbiosis (Pathogenic Biofilm)', high biomass, plasma cells, DAMPs, Haem, GCF, Cytokines, Prostanoids, MMPs, Oxidative Stress, and connective tissue/bone damage with failed resolution of inflammation. Arrows indicate interactions between biofilm components (Antigens, LPS, Gingipains) and host responses. # **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]   **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] Dental radiograph showing periodontally compromised teeth with significant vertical bone loss and deep periodontal pockets. Dental radiograph showing healthy periodontal bone levels between adjacent teeth, likely for comparison purposes. # 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 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 %** A side-by-side photo comparison showing a cartoon monkey character with red fur and wide eyes. The left image shows the character facing forward while the right image shows the same character turned to the side profile. # 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 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 The University of Western Australia institutional logo. # Factors determining prognosis **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 | | |  Factors determining prognosis **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 | | | A table titled 'Factors affecting tooth prognosis' categorizing elements that determine the prognosis of a tooth. The table is divided into four columns: Systemic factors (including patient compliance, plaque control, smoking, disease severity, etc.), Periodontal factors (including symptoms, plaque, calculus, probing depths, mobility, etc.), Prosthodontic factors (including caries, functional status, over-eruption, aesthetics, etc.), and Endodontic factors (including loss of vitality, combined infection, root resorption). ## Factors determining prognosis ### 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  Factors determining prognosis ### 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 A large yellow arrow pointing right labeled 'TIME', illustrating the progression from factors to outcome in prognosis determination. 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? 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? The University of Western Australia logo featuring a shield with a swan and the university's name. Patient level factors - Age - Patients' expectations - **Risk factors** (smoking, diabetes, stress) - Compliance to biofilm control - Compliance to maintenance care The University of Western Australia Patient level factors - Age - Patients' expectations - **Risk factors** (smoking, diabetes, stress) - Compliance to biofilm control - Compliance to maintenance care The University of Western Australia University logo featuring a shield with an open book and a swan, accompanied by the text 'THE UNIVERSITY OF WESTERN AUSTRALIA'. **Patient level factors** **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. **Patient level factors** **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. The University of Western Australia logo featuring a shield with a swan and the university's motto 'Seek Wisdom'. # 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 **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 The official logo of The University of Western Australia, featuring a shield with a swan and the university name. **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 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.) Clinical photo showing an intraoral view of upper teeth with a periodontal probe inserted into a gingival sulcus on the palatal side, indicating a deep pocket. Clinical photo showing a surgically exposed area of gum tissue and bone with surgical instruments present, revealing the underlying anatomy. Dental radiograph showing the roots of upper teeth with a thin radiopaque gutta-percha point extending down between two adjacent tooth roots. **Local/Tooth level factors** A B Prognosis of A is better than B Centre of rotation for A is nearer to the crown  **Local/Tooth level factors** A B Prognosis of A is better than B Centre of rotation for A is nearer to the crown Labelled diagram comparing two tooth cross-sections labeled 'A' and 'B'. Diagram shows a tooth embedded in bone with a dark dot indicating the center of rotation. In panel A, the dot is located higher on the root (nearer to the crown). In panel B, the dot is located lower on the root (closer to the apex). The caption states that the prognosis for A is better because its center of rotation is nearer to the crown. **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<br>Hamp et al. 1975<sup>51</sup> | 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.  **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<br>Hamp et al. 1975<sup>51</sup> | 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. A complex decision tree diagram titled 'EXTRACTION VERSUS CONSERVATION DECISION CHART'. The chart is organized into six vertical columns representing levels of assessment: 1st Level (Initial Assessment), 2nd Level (Periodontal Disease Severity), 3rd Level (Furcation Involvement), 4th Level (Etiologic Factors), 5th Level (Restorative Factors), and 6th Level (Other Determinants). It visually maps clinical decision pathways using branching nodes. Decision outcomes are color-coded: Green boxes indicate favorable long-term maintenance, Yellow boxes indicate caution/proceed with caution, and Red boxes indicate unfavorable survival/strongly suggest extraction. Specific factors include Patient Expectations, PD depth, Mobility, Furcation Class, Presence of Calculus, Restorability, Smoking status, and Systemic Conditions. Below the main chart, there are three distinct legends explaining the scoring logic for extraction recommendation based on red, yellow, and green box counts. **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** 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 University of Western Australia logo located in the top right corner of the slide. The logo includes a shield with a swan and books, accompanied by the text 'THE UNIVERSITY OF WESTERN AUSTRALIA'. # Previous prognosis systems Output from a model is only as good as the input and interpretation  Previous prognosis systems Output from a model is only as good as the input and interpretation Clinical photo of two individuals in a grappling or combat sports match on a mat. The image demonstrates physical exertion and technique, with one person bent over the other. Visible text includes 'Previous prognosis systems' at the top left and 'Output from a model is only as good as the input and interpretation' below it. A logo for 'THE UNIVERSITY OF WESTERN AUSTRALIA' is visible in the top right corner. 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 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 The University of Western Australia institutional logo located in the top right corner. 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. <table> <tr> <th>Study</th> <th>L (AvY)</th> <th>N (P)</th> <th>N (T)</th> <th>Classification System</th> <th>Limiteditions & Strengths</th> </tr> <tr> <td>Hirschfeld & Wasserman 1978</td> <td>22</td> <td>600</td> <td>15,666</td> <td>Favorable Questionable</td> <td>+ Simple<br>- Subjective measures<br>- Relatively accurate in WM group, but inaccurate in DG and irrelevant in EDG<br>- No PLM considered</td> </tr> <tr> <td>Becker et al. 1984a, b</td> <td>a: 6.5<br>b: 5.25</td> <td>a: 95<br>b: 44</td> <td>a: 2,414<br>b: 1,117</td> <td>Good<br>Questionable<br>Hopeless</td> <td>+ Accurate in WM group<br>- Qualitative measures<br>- Complex<br>- All patients had ≥1 quadrant of pocket reduction Surgery<br>- No PLM considered<br>- Hopeless teeth extracted during APT</td> </tr> <tr> <td>McGuire & Nunn 1996</td> <td>9.97</td> <td>100</td> <td>2509</td> <td>Good<br>Fair<br>Poor<br>Questionable<br>Hopeless</td> <td>+ 81% accurate at 5-8 years<br>- When teeth with a good prognosis excluded, accuracy drops to ~50%<br>- Hopeless category determined by subjective criteria only<br>- PLM considered but not included in determination of individual tooth prognosis<br>- Complex<br>- Hopeless teeth extracted during APT</td> </tr> <tr> <td>Checchi et al. 2002</td> <td>6.7</td> <td>92</td> <td>2310</td> <td>Good<br>Questionable<br>Hopeless</td> <td>+ Straightforward<br>- Radiographic evaluation only<br>- Removed 126 teeth during APT and no information is available on prognosis of these teeth<br>- PLM considered but not included in determination of individual tooth prognosis</td> </tr> <tr> <td>Kwok & Caton 2007</td> <td>N/A</td> <td>N/A</td> <td>N/A</td> <td>Favorable Questionable Unfavorable Hopeless</td> <td>+ PLM can be factored into individual tooth prognosis<br>+ Considers the stability of the periodontium<br>- Not validated<br>- Subjective measures</td> </tr> <tr> <td>Faggion et al. 2008</td> <td>11.8</td> <td>198</td> <td>4559</td> <td>Provides probability of tooth survival in 10% increments</td> <td>+ PLM (diabetes) can be factored into individual tooth prognosis, but does not consider smoking<br>- Does not stratify diabetic patients according to level of diabetic control<br>- Complex</td> </tr> <tr> <td>Miller et al. 2014</td> <td>24</td> <td>102</td> <td>816</td> <td>Provides a score between 1-11</td> <td>+ PLM considered (smoking)<br>+ Simple<br>- Molar teeth only<br>- Subjective measures</td> </tr> <tr> <td>Nibali et al. 2016</td> <td>6.6</td> <td>100</td> <td>2494</td> <td>Good<br>Fair<br>Questionable<br>Unfavorable</td> <td>+ Includes quantitative measure of periapical status<br>- Do not appear to validate the model in the study, instead uses PRA & PRC<br>- Complex<br>- PLM considered (used PRA) but not included in determination of individual tooth prognosis</td> </tr> </table>  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. <table> <tr> <th>Study</th> <th>L (AvY)</th> <th>N (P)</th> <th>N (T)</th> <th>Classification System</th> <th>Limiteditions & Strengths</th> </tr> <tr> <td>Hirschfeld & Wasserman 1978</td> <td>22</td> <td>600</td> <td>15,666</td> <td>Favorable Questionable</td> <td>+ Simple<br>- Subjective measures<br>- Relatively accurate in WM group, but inaccurate in DG and irrelevant in EDG<br>- No PLM considered</td> </tr> <tr> <td>Becker et al. 1984a, b</td> <td>a: 6.5<br>b: 5.25</td> <td>a: 95<br>b: 44</td> <td>a: 2,414<br>b: 1,117</td> <td>Good<br>Questionable<br>Hopeless</td> <td>+ Accurate in WM group<br>- Qualitative measures<br>- Complex<br>- All patients had ≥1 quadrant of pocket reduction Surgery<br>- No PLM considered<br>- Hopeless teeth extracted during APT</td> </tr> <tr> <td>McGuire & Nunn 1996</td> <td>9.97</td> <td>100</td> <td>2509</td> <td>Good<br>Fair<br>Poor<br>Questionable<br>Hopeless</td> <td>+ 81% accurate at 5-8 years<br>- When teeth with a good prognosis excluded, accuracy drops to ~50%<br>- Hopeless category determined by subjective criteria only<br>- PLM considered but not included in determination of individual tooth prognosis<br>- Complex<br>- Hopeless teeth extracted during APT</td> </tr> <tr> <td>Checchi et al. 2002</td> <td>6.7</td> <td>92</td> <td>2310</td> <td>Good<br>Questionable<br>Hopeless</td> <td>+ Straightforward<br>- Radiographic evaluation only<br>- Removed 126 teeth during APT and no information is available on prognosis of these teeth<br>- PLM considered but not included in determination of individual tooth prognosis</td> </tr> <tr> <td>Kwok & Caton 2007</td> <td>N/A</td> <td>N/A</td> <td>N/A</td> <td>Favorable Questionable Unfavorable Hopeless</td> <td>+ PLM can be factored into individual tooth prognosis<br>+ Considers the stability of the periodontium<br>- Not validated<br>- Subjective measures</td> </tr> <tr> <td>Faggion et al. 2008</td> <td>11.8</td> <td>198</td> <td>4559</td> <td>Provides probability of tooth survival in 10% increments</td> <td>+ PLM (diabetes) can be factored into individual tooth prognosis, but does not consider smoking<br>- Does not stratify diabetic patients according to level of diabetic control<br>- Complex</td> </tr> <tr> <td>Miller et al. 2014</td> <td>24</td> <td>102</td> <td>816</td> <td>Provides a score between 1-11</td> <td>+ PLM considered (smoking)<br>+ Simple<br>- Molar teeth only<br>- Subjective measures</td> </tr> <tr> <td>Nibali et al. 2016</td> <td>6.6</td> <td>100</td> <td>2494</td> <td>Good<br>Fair<br>Questionable<br>Unfavorable</td> <td>+ Includes quantitative measure of periapical status<br>- Do not appear to validate the model in the study, instead uses PRA & PRC<br>- Complex<br>- PLM considered (used PRA) but not included in determination of individual tooth prognosis</td> </tr> </table> A comprehensive table titled 'Previous prognosis systems' summarizing various studies on periodontal prognosis. Columns include Study (e.g., Hirschfeld & Wasserman 1978), L (AvY) length of study in average years, N (P) number of patients, N (T) number of teeth, Classification System (e.g., Favorable/Questionable or Good/Fair/Poor/etc.), and Limitations & Strengths. The table lists multiple studies from 1978 to 2016 with detailed metrics and qualitative assessments. # Proposed new prognosis system <table> <thead> <tr> <th></th> <th>Secure</th> <th>Doubtful</th> <th>Poor</th> <th>Irrational to treat</th> </tr> </thead> <tbody> <tr> <td><strong>Prognosis</strong></td> <td>Future loss of periodontal supporting tissues is unlikely over 10 years (long term)</td> <td>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</td> <td>Breakdown of the periodontal supporting tissues is likely over the next 5 years (short term)</td> <td>No periodontal support remaining</td> </tr> <tr> <td><strong>Tooth-level assessment ≥1 of the following:</strong></td> <td>BL/Age <0.5<br>PD ≤ 5 mm</td> <td>BL/Age 0.5-1<br>PD 6-7 mm<br>Degree II furcation<br>Untreated infrabony defect<br>Anatomic factors<br>Tooth mobile >1 mm in transverse direction</td> <td>BL/Age >1<br>PD ≥ 8 mm<br>Degree III furcation<br>Progressive tooth mobility</td> <td>Circumferential bone loss to the apex<br>Tooth mobile in axial direction</td> </tr> <tr> <td><strong>Patient-level assessment</strong></td> <td colspan="4">The tooth-level assessment is downgraded by 1 level to a maximum of poor<sup>a</sup> if ≥ 1 of the following factors are present:<br>Smoking: ≥1/d<br>Poorly controlled diabetes: HbA1c ≥ 9<br>BOP at ≥30% of sites at review appointment</td> </tr> <tr> <td><strong>Treatment recommendations</strong></td> <td>Tooth is suitable for prosthodontic, endodontic, and restorative therapy</td> <td>Tooth may be suitable for prosthodontic, endodontic, and restorative therapy, but definitive treatment is best delayed until SPT</td> <td>Tooth is not suitable for prosthodontic work. Endodontic and restorative therapy can be considered but tooth is not expected to survive over 5 years</td> <td>Most appropriate course of clinical care is extraction</td> </tr> <tr> <td colspan="5">Compliance is mandatory: accuracy of prognosis cannot be relied upon for poorly compliant patients (as determined by attendance at SPT)</td> </tr> </tbody> </table> BL, bone loss; BOP, bleeding on probing; HbA1c, glycated hemoglobin; PAI, periapical index; PD, pocket depth; SPT, supportive periodontal therapy. <sup>a</sup> A secure prognosis is downgraded to doubtful, and doubtful to poor, but poor cannot be made irrational to treat.  Proposed new prognosis system <table> <thead> <tr> <th></th> <th>Secure</th> <th>Doubtful</th> <th>Poor</th> <th>Irrational to treat</th> </tr> </thead> <tbody> <tr> <td><strong>Prognosis</strong></td> <td>Future loss of periodontal supporting tissues is unlikely over 10 years (long term)</td> <td>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</td> <td>Breakdown of the periodontal supporting tissues is likely over the next 5 years (short term)</td> <td>No periodontal support remaining</td> </tr> <tr> <td><strong>Tooth-level assessment ≥1 of the following:</strong></td> <td>BL/Age <0.5<br>PD ≤ 5 mm</td> <td>BL/Age 0.5-1<br>PD 6-7 mm<br>Degree II furcation<br>Untreated infrabony defect<br>Anatomic factors<br>Tooth mobile >1 mm in transverse direction</td> <td>BL/Age >1<br>PD ≥ 8 mm<br>Degree III furcation<br>Progressive tooth mobility</td> <td>Circumferential bone loss to the apex<br>Tooth mobile in axial direction</td> </tr> <tr> <td><strong>Patient-level assessment</strong></td> <td colspan="4">The tooth-level assessment is downgraded by 1 level to a maximum of poor<sup>a</sup> if ≥ 1 of the following factors are present:<br>Smoking: ≥1/d<br>Poorly controlled diabetes: HbA1c ≥ 9<br>BOP at ≥30% of sites at review appointment</td> </tr> <tr> <td><strong>Treatment recommendations</strong></td> <td>Tooth is suitable for prosthodontic, endodontic, and restorative therapy</td> <td>Tooth may be suitable for prosthodontic, endodontic, and restorative therapy, but definitive treatment is best delayed until SPT</td> <td>Tooth is not suitable for prosthodontic work. Endodontic and restorative therapy can be considered but tooth is not expected to survive over 5 years</td> <td>Most appropriate course of clinical care is extraction</td> </tr> <tr> <td colspan="5">Compliance is mandatory: accuracy of prognosis cannot be relied upon for poorly compliant patients (as determined by attendance at SPT)</td> </tr> </tbody> </table> BL, bone loss; BOP, bleeding on probing; HbA1c, glycated hemoglobin; PAI, periapical index; PD, pocket depth; SPT, supportive periodontal therapy. <sup>a</sup> A secure prognosis is downgraded to doubtful, and doubtful to poor, but poor cannot be made irrational to treat. A table titled 'Proposed new prognosis system' detailing a classification for periodontal treatment. The columns are labeled Secure, Doubtful, Poor, and Irrational to treat. Rows include Prognosis, Tooth-level assessment, Patient-level assessment, and Treatment recommendations, along with specific clinical criteria and definitions. # 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 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 The University of Western Australia logo featuring the university's crest and name. # Proposed new prognosis system <table> <thead> <tr> <th></th> <th>Secure</th> <th>Doubtful</th> <th>Poor</th> <th>Irrational to treat</th> </tr> </thead> <tbody> <tr> <td><strong>Prognosis</strong></td> <td>Future loss of periodontal supporting tissues is unlikely over 10 years (long term)</td> <td>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</td> <td>Breakdown of the periodontal supporting tissues is likely over the next 5 years (short term)</td> <td>No periodontal support remaining</td> </tr> <tr> <td><strong>Tooth-level assessment ≥1 of the following:</strong></td> <td>BL/Age <0.5<br>PD ≤ 5 mm</td> <td>BL/Age 0.5-1<br>PD 6-7 mm<br>Degree II furcation<br>Untreated infrabony defect<br>Anatomic factors<br>Tooth mobile >1 mm in transverse direction</td> <td>BL/Age >1<br>PD ≥ 8 mm<br>Degree III furcation<br>Progressive tooth mobility</td> <td>Circumferential bone loss to the apex<br>Tooth mobile in axial direction</td> </tr> <tr> <td><strong>Patient-level assessment</strong></td> <td colspan="4">The tooth-level assessment is downgraded by 1 level to a maximum of poor<sup>a</sup> if ≥ 1 of the following factors are present:<br>Smoking: ≥1/d<br>Poorly controlled diabetes: HbA1c ≥ 9<br>BOP at ≥30% of sites at review appointment</td> </tr> <tr> <td><strong>Treatment recommendations</strong></td> <td>Tooth is suitable for prosthodontic, endodontic, and restorative therapy</td> <td>Tooth may be suitable for prosthodontic, endodontic, and restorative therapy, but definitive treatment is best delayed until SPT</td> <td>Tooth is not suitable for prosthodontic work. Endodontic and restorative therapy can be considered but tooth is not expected to survive over 5 years</td> <td>Most appropriate course of clinical care is extraction</td> </tr> <tr> <td colspan="5">Compliance is mandatory: accuracy of prognosis cannot be relied upon for poorly compliant patients (as determined by attendance at SPT)</td> </tr> </tbody> </table> **? Validated ?** BL, bone loss; BOP, bleeding on probing; HbA1C, glycated hemoglobin; PAI, periapical index; PD, pocket depth; SPT, supportive periodontal therapy. <sup>a</sup> A secure prognosis is downgraded to doubtful, and doubtful to poor, but poor cannot be made irrational to treat.   Proposed new prognosis system <table> <thead> <tr> <th></th> <th>Secure</th> <th>Doubtful</th> <th>Poor</th> <th>Irrational to treat</th> </tr> </thead> <tbody> <tr> <td><strong>Prognosis</strong></td> <td>Future loss of periodontal supporting tissues is unlikely over 10 years (long term)</td> <td>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</td> <td>Breakdown of the periodontal supporting tissues is likely over the next 5 years (short term)</td> <td>No periodontal support remaining</td> </tr> <tr> <td><strong>Tooth-level assessment ≥1 of the following:</strong></td> <td>BL/Age <0.5<br>PD ≤ 5 mm</td> <td>BL/Age 0.5-1<br>PD 6-7 mm<br>Degree II furcation<br>Untreated infrabony defect<br>Anatomic factors<br>Tooth mobile >1 mm in transverse direction</td> <td>BL/Age >1<br>PD ≥ 8 mm<br>Degree III furcation<br>Progressive tooth mobility</td> <td>Circumferential bone loss to the apex<br>Tooth mobile in axial direction</td> </tr> <tr> <td><strong>Patient-level assessment</strong></td> <td colspan="4">The tooth-level assessment is downgraded by 1 level to a maximum of poor<sup>a</sup> if ≥ 1 of the following factors are present:<br>Smoking: ≥1/d<br>Poorly controlled diabetes: HbA1c ≥ 9<br>BOP at ≥30% of sites at review appointment</td> </tr> <tr> <td><strong>Treatment recommendations</strong></td> <td>Tooth is suitable for prosthodontic, endodontic, and restorative therapy</td> <td>Tooth may be suitable for prosthodontic, endodontic, and restorative therapy, but definitive treatment is best delayed until SPT</td> <td>Tooth is not suitable for prosthodontic work. Endodontic and restorative therapy can be considered but tooth is not expected to survive over 5 years</td> <td>Most appropriate course of clinical care is extraction</td> </tr> <tr> <td colspan="5">Compliance is mandatory: accuracy of prognosis cannot be relied upon for poorly compliant patients (as determined by attendance at SPT)</td> </tr> </tbody> </table> **? Validated ?** BL, bone loss; BOP, bleeding on probing; HbA1C, glycated hemoglobin; PAI, periapical index; PD, pocket depth; SPT, supportive periodontal therapy. <sup>a</sup> A secure prognosis is downgraded to doubtful, and doubtful to poor, but poor cannot be made irrational to treat. Table presenting a 'Proposed new prognosis system' with columns for Prognosis, Tooth-level assessment, Patient-level assessment, and Treatment recommendations. Rows categorize outcomes into Secure, Doubtful, Poor, and Irrational to treat, providing specific clinical criteria and definitions for each category. Hand-drawn green box containing the text '? Validated ?', indicating a question regarding the validation status of the proposed system. # 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** 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** The University of Western Australia institutional logo featuring a shield with a swan and open books. # 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** 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** Prognosis at OHCWA ```html <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 ```html <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> ``` Table comparing prognostic criteria for tooth retention between Kwok & Caton and McGuire & Nunn systems. Columns include 'Kwok & Caton', 'Mcguire & Nunn', and 'Description'. Rows categorize prognosis from 'Favourable/Certain' to 'Hopeless', with detailed clinical descriptions including attachment loss percentages, furcation classes, mobility grades, and maintenance feasibility. **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.<br>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. |  **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.<br>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. | A structured table comparing dental prognosis classifications between two studies: Kwok & Caton (2007) and McGuire & Nunn (1996). The table is organized into three columns. The first column lists prognostic categories from 'Favourable/Certain' to 'Hopeless'. The second column maps these to McGuire & Nunn's categories ('Good', 'Fair', 'Poor', 'Questionable', 'Hopeless'). The third column provides detailed clinical descriptions for each category, including specific metrics like percentage of attachment loss, furcation involvement classes, root mobility grades, and maintenance difficulty. # 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**      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** A chart showing the upper palatal dental arch. It includes rows for 'Prog' (Prognosis), 'AL', 'Rec', and 'PD'. Below these rows are illustrations of teeth with measurements indicated by vertical lines. A blue circle highlights an empty slot in the 'Prog' row. A chart showing the lower lingual dental arch. It includes rows for 'PD', 'Rec', 'AL', and 'Prog'. Illustrations of teeth are shown above the rows. A blue circle highlights an empty slot in the 'Prog' row. A two-column table providing instructions on how to record prognosis scores. The left column lists the score categories ('G- Good', 'F- fair', 'P- Poor', 'H- Hopeless'), and the right column instructs the user to enter the required letter using the keyboard. An example filled-out chart for the upper palatal arch. The 'Prog' row contains entered scores: G, G, F, P, H, F, G. Other rows (AL, Rec, PD) contain numerical data corresponding to each tooth position. An example filled-out chart for the lower lingual arch. The 'Prog' row contains entered scores: G, F, F, P, P, H, H, F. Other rows (PD, Rec, AL) contain numerical data corresponding to each tooth position. OHCWA Perio eForm Page 7 <table> <tr> <th>EVIDENCE OF BONE LOSS</th> <th>% BONE LOSS / AGE</th> <th>CASE PHENOTYPE</th> <th>SMOKING</th> <th>DIABETES</th> </tr> <tr> <td><input type="checkbox"> Grade A</td> <td><input type="checkbox"> NO LOSS</td> <td><input type="checkbox"> < 0.25</td> <td><input type="checkbox"> HEAVY FILM DEPOSITS</td> <td><input type="checkbox"> NON SMOKING</td> <td><input type="checkbox"> NORMO GLYCEMIC</td> </tr> <tr> <td><input type="checkbox"> Grade B</td> <td><input type="checkbox"> < 2 mm 5 YEARS</td> <td><input type="checkbox"> 0.25 TO 1.0</td> <td><input type="checkbox"> FILM DEPOSITS CORRESPOND TO DESTRUCTION</td> <td><input type="checkbox"> < 10 CIGARETTES DAY</td> <td><input type="checkbox"> HbA1c < 7.0 %</td> </tr> <tr> <td><input type="checkbox"> Grade C</td> <td><input type="checkbox"> >= 2 mm 5 YEARS</td> <td><input type="checkbox"> > 1.0</td> <td><input type="checkbox"> LOW FILM DEPOSITS HIGH DESTRUCTION</td> <td><input type="checkbox"> >= 10 CIGARETTES DAY</td> <td><input type="checkbox"> HbA1c > 7.0 %</td> </tr> <tr> <td><input type="checkbox"> CURRENTLY STABLE PERIODONTITIS :(REDUCED PERIODONTIUM: BOP < 10% POCKETS 4 mm OR LESS)</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> CURRENTLY REMISSION PERIODONTITIS (GINGIVAL INFLAMMATION ON A REDUCED PERIODONTIUM: BOP > 10% ON A TREATED PERIO CASE POCKETS 4 mm )</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> CURRENTLY UNSTABLE PERIODONTITIS (BOP > 10 % AND POCKETS 4-5 mm OR MORE)</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> OTHER FORMS OF PERIODONTITI</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> PERI-IMPLANT HEALTH</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> PERI-IMPLANT MUCOSITIS</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> PERI-IMPLANTITIS</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> PERI-IMPLANT ANOMALIES</td> <td colspan="4"></td> </tr> </table> 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 7 <table> <tr> <th>EVIDENCE OF BONE LOSS</th> <th>% BONE LOSS / AGE</th> <th>CASE PHENOTYPE</th> <th>SMOKING</th> <th>DIABETES</th> </tr> <tr> <td><input type="checkbox"> Grade A</td> <td><input type="checkbox"> NO LOSS</td> <td><input type="checkbox"> < 0.25</td> <td><input type="checkbox"> HEAVY FILM DEPOSITS</td> <td><input type="checkbox"> NON SMOKING</td> <td><input type="checkbox"> NORMO GLYCEMIC</td> </tr> <tr> <td><input type="checkbox"> Grade B</td> <td><input type="checkbox"> < 2 mm 5 YEARS</td> <td><input type="checkbox"> 0.25 TO 1.0</td> <td><input type="checkbox"> FILM DEPOSITS CORRESPOND TO DESTRUCTION</td> <td><input type="checkbox"> < 10 CIGARETTES DAY</td> <td><input type="checkbox"> HbA1c < 7.0 %</td> </tr> <tr> <td><input type="checkbox"> Grade C</td> <td><input type="checkbox"> >= 2 mm 5 YEARS</td> <td><input type="checkbox"> > 1.0</td> <td><input type="checkbox"> LOW FILM DEPOSITS HIGH DESTRUCTION</td> <td><input type="checkbox"> >= 10 CIGARETTES DAY</td> <td><input type="checkbox"> HbA1c > 7.0 %</td> </tr> <tr> <td><input type="checkbox"> CURRENTLY STABLE PERIODONTITIS :(REDUCED PERIODONTIUM: BOP < 10% POCKETS 4 mm OR LESS)</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> CURRENTLY REMISSION PERIODONTITIS (GINGIVAL INFLAMMATION ON A REDUCED PERIODONTIUM: BOP > 10% ON A TREATED PERIO CASE POCKETS 4 mm )</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> CURRENTLY UNSTABLE PERIODONTITIS (BOP > 10 % AND POCKETS 4-5 mm OR MORE)</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> OTHER FORMS OF PERIODONTITI</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> PERI-IMPLANT HEALTH</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> PERI-IMPLANT MUCOSITIS</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> PERI-IMPLANTITIS</td> <td colspan="4"></td> </tr> <tr> <td><input type="checkbox"> PERI-IMPLANT ANOMALIES</td> <td colspan="4"></td> </tr> </table> 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** A clinical data entry table titled 'OHCWA Perio eForm Page 7'. The table contains columns for 'EVIDENCE OF BONE LOSS' (with checkboxes for Grade A, B, C), '% BONE LOSS / AGE', 'CASE PHENOTYPE', 'SMOKING', and 'DIABETES'. It includes rows for periodontitis stability status ('CURRENTLY STABLE PERIODONTITIS', etc.) and peri-implant health categories. Below the main grid is a section labeled 'OVERALL PERIODONTAL PROGNOSIS' with color-coded options: Good (green), Fair (yellow-green), Poor (yellow), Questionable (orange), Hopeless (red). A vertical stack of five colored text boxes explaining the definitions for the prognostic categories found in the adjacent table. From top to bottom: Green box defines 'Good' prognosis; Yellow-Green box defines 'Fair'; Yellow box defines 'Poor'; Orange box defines 'Questionable'; Red box defines 'Hopeless'. At the bottom are citations: McGuire & Nunn 1996, Kwok & Caton 2007. **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 **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 The official logo of The University of Western Australia. It features a shield with a yellow swan on a blue background, surrounded by text elements including 'THE UNIVERSITY OF WESTERN AUSTRALIA' and the motto 'UNDA VINCIT'. # 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:** <table> <tr> <th>STAGE</th> <th>INTERDENTAL CAL</th> <th>RADIOGRAPHIC BONE LOSS</th> <th>TOOTH LOSS</th> <th>COMPLEXITY</th> </tr> <tr> <td><b>STAGE I</b></td> <td>[ ] 1-2 mm</td> <td>[ ] < 15% HORIZONTAL BONE LOSS</td> <td>[ ] NO TOOTH LOSS</td> <td>[ ] MAX PROBING DEPTH < 4 mm</td> </tr> <tr> <td><b>STAGE II</b></td> <td>[ ] 3-4 mm</td> <td>[ ] 15 - 33% HORIZONTAL BONE LOSS</td> <td>[ ] NO TOOTH LOSS</td> <td>[ ] MAX PROBING DEPTH < 5 mm</td> </tr> <tr> <td><b>STAGE III</b></td> <td>[ ] >= 5 mm</td> <td>[ ] MIDDLE ROOT THIRD AND MORE<br>[ ] ANGULAR</td> <td>[ ] =< 4 TEETH</td> <td>[ ] MAX PROBING DEPTH > 6 mm<br>[ ] FURCATION GRADE II<br>[ ] GRADE III<br>[ ] MODERATE RIDGE DEFECT</td> </tr> <tr> <td><b>STAGE IV</b></td> <td>[ ] >= 5 mm</td> <td>[ ] MIDDLE ROOT THIRD AND MORE<br>[ ] ANGULAR</td> <td>[ ] >= 5 TEETH<br><br>[ ] LESS THAN 20 TEETH REMAINING</td> <td>[ ] MAX PROBING DEPTH > 6 mm<br>[ ] FURCATION GRADE II<br>[ ] GRADE III<br>[ ] SEVERE RIDGE DEFECTS<br>[ ] MASTICATORY DYSFUNCTION<br>[ ] 2ry OCCLUSAL TRAUMA<br>[ ] BITE COLLAPSE</td> </tr> </table> --- **DISTRIBUTION:** * [ ] LOCALISED 30% AND LESS TEETH * [ ] GENERALISED MORE THAN 30 % TEETH * [ ] INCISIVE MOLAR    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:** <table> <tr> <th>STAGE</th> <th>INTERDENTAL CAL</th> <th>RADIOGRAPHIC BONE LOSS</th> <th>TOOTH LOSS</th> <th>COMPLEXITY</th> </tr> <tr> <td><b>STAGE I</b></td> <td>[ ] 1-2 mm</td> <td>[ ] < 15% HORIZONTAL BONE LOSS</td> <td>[ ] NO TOOTH LOSS</td> <td>[ ] MAX PROBING DEPTH < 4 mm</td> </tr> <tr> <td><b>STAGE II</b></td> <td>[ ] 3-4 mm</td> <td>[ ] 15 - 33% HORIZONTAL BONE LOSS</td> <td>[ ] NO TOOTH LOSS</td> <td>[ ] MAX PROBING DEPTH < 5 mm</td> </tr> <tr> <td><b>STAGE III</b></td> <td>[ ] >= 5 mm</td> <td>[ ] MIDDLE ROOT THIRD AND MORE<br>[ ] ANGULAR</td> <td>[ ] =< 4 TEETH</td> <td>[ ] MAX PROBING DEPTH > 6 mm<br>[ ] FURCATION GRADE II<br>[ ] GRADE III<br>[ ] MODERATE RIDGE DEFECT</td> </tr> <tr> <td><b>STAGE IV</b></td> <td>[ ] >= 5 mm</td> <td>[ ] MIDDLE ROOT THIRD AND MORE<br>[ ] ANGULAR</td> <td>[ ] >= 5 TEETH<br><br>[ ] LESS THAN 20 TEETH REMAINING</td> <td>[ ] MAX PROBING DEPTH > 6 mm<br>[ ] FURCATION GRADE II<br>[ ] GRADE III<br>[ ] SEVERE RIDGE DEFECTS<br>[ ] MASTICATORY DYSFUNCTION<br>[ ] 2ry OCCLUSAL TRAUMA<br>[ ] BITE COLLAPSE</td> </tr> </table> --- **DISTRIBUTION:** * [ ] LOCALISED 30% AND LESS TEETH * [ ] GENERALISED MORE THAN 30 % TEETH * [ ] INCISIVE MOLAR Table titled 'PERIODONTITIS' detailing diagnostic criteria for Stages I through IV. Columns include Stage, Interdental Cal (Probing Depth), Radiographic Bone Loss, Tooth Loss, and Complexity factors like Furcation Grade and Ridge Defects. Composite of four data charts: Plaque Index (Buccal/Palatal), Marginal Bleeding Index (Buccal/Palatal), Probing Depth (PD) distribution, and Gingival Recession (Rec). Each chart displays a grid of tooth numbers with corresponding numeric values or graphical representations of site-specific measurements. Summary table showing calculated indices: Plaque Index (0 Sites, 0.00%), Marginal Bleeding Index (0 Sites, 0.00%), and Bleeding On Probing Index (0 Sites, 0.00%). **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 **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 The University of Western Australia logo located in the top right corner. It features a shield with a swan and the motto 'Seek Wisdom' alongside the university name. # OHCWA Perio eForm ## Page 1 ### Relevant Medical History **Presenting complaint** [Blank Text Box] **Diabetic** - [o] No - [o] Type I - [o] Type II - [o] Prediabetes - [o] Gestational **HbA1c % level** [Blank Text Box] **Smoker** - [o] No - [o] Yes, Current - [o] Ex Smoker - Number a day: [Blank Text Box] - Years: [Blank Text Box] - Quit date: [Blank Text Box] **Stress** - [o] Yes - [o] No **Other medical conditions** [Blank Text Box] --- ## 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 - [o] min - [o] max - [o] mod amount - [o] abundant #### Biofilm Distribution % *Chart in Perio Tab and input result here* <br> --- ## Page 3 ### CALCULUS DISTRIBUTION - Mild - [o] 0 - [o] 1 - [o] 2 - [o] 3 - [o] 4 - [o] 5 - [o] 6 - [o] 7 - [o] 8 - [o] 9 - [o] 10 - Abundant <br> ---  OHCWA Perio eForm Page 1 ### Relevant Medical History **Presenting complaint** [Blank Text Box] **Diabetic** - [o] No - [o] Type I - [o] Type II - [o] Prediabetes - [o] Gestational **HbA1c % level** [Blank Text Box] **Smoker** - [o] No - [o] Yes, Current - [o] Ex Smoker - Number a day: [Blank Text Box] - Years: [Blank Text Box] - Quit date: [Blank Text Box] **Stress** - [o] Yes - [o] No **Other medical conditions** [Blank Text Box] --- 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 - [o] min - [o] max - [o] mod amount - [o] abundant #### Biofilm Distribution % *Chart in Perio Tab and input result here* <br> --- Page 3 ### CALCULUS DISTRIBUTION - Mild - [o] 0 - [o] 1 - [o] 2 - [o] 3 - [o] 4 - [o] 5 - [o] 6 - [o] 7 - [o] 8 - [o] 9 - [o] 10 - Abundant <br> --- A visual scale for Plaque and Biofilm Amount assessment. It consists of two horizontal rows of small squares (representing teeth), with labels below indicating 'min', 'mod amount', and 'abundant' to guide scoring. # **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 **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 The University of Western Australia logo located in the top right corner.  Large pink star graphic overlaying the document. #### Validity - 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) --- **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. **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) --- **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. The University of Western Australia logo. The logo features a shield with a swan and the text 'SEEK WISDOM' below it, alongside the university name. # 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 THE UNIVERSITY OF WESTERN AUSTRALIA **McGowan et al 2017** - 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** The University of Western Australia institutional logo featuring the university crest and name. # Prognosis at OHCWA <table> <thead> <tr> <th>Clinical Description</th> <th>Maintenance Status</th> </tr> </thead> <tbody> <tr> <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> <td>relatively easy to maintain</td> </tr> <tr> <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> <td>proper maintenance with good patient compliance</td> </tr> <tr> <td>50% attachment loss and Class II furcations. The location and depth of the furcations would allow proper maintenance, but with difficulty.</td> <td>maintenance, but with difficulty</td> </tr> <tr> <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. Gr 2+ mobility. Significant root proximity.</td> <td>not easily accessible to maintenance care</td> </tr> <tr> <td>Inadequate attachment to maintain the tooth in health, comfort, and function. Extraction was performed or suggested. Gr 3 mobility or extensive attachment loss.</td> <td>Inadequate attachment to maintain the tooth</td> </tr> </tbody> </table>  | 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 | A comparison table titled 'Prognosis at OHCWA' showing clinical descriptions on the left and corresponding maintenance statuses on the right. The table uses color-coding (green to red) to indicate prognosis severity from easy maintenance to inadequate attachment for tooth retention. # **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 **The University of Western Australia** McGowan et al 2017 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 The University of Western Australia institutional logo. **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. 41.10** 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). Full mouth radiographic series labeled 'C' showing multiple dental X-rays arranged in rows and columns. The images display various angles including occlusal views and bitewings revealing tooth structures, roots, and bone levels. Clinical photo grid labeled 'B' showing intraoral photographs of teeth from different angles. Images reveal gum inflammation, tooth discoloration, and dental restorations. Clinical photo labeled 'A' showing frontal view of patient's dentition with visible teeth alignment and gingival tissue condition. 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.)    **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.) Composite figure showing dental radiographs labeled 'C' at the bottom left. The image consists of three rows of panoramic dental X-rays displaying multiple teeth with visible bone loss between roots. Grid of six clinical intraoral photographs showing various angles of teeth and gums, demonstrating moderate clinical biofilm, calculus, and gingival inflammation as described in the caption. Single clinical photograph showing a full view of upper and lower teeth with visible plaque and gum inflammation.     Radiographic panel showing multiple dental periapical X-rays of the maxillary and mandibular arches. The images display teeth with various restorations (fillings, crowns) and root canal treatments. Clinical intraoral photographs showing multiple views of the patient's dentition. The images reveal generalized gingival inflammation, plaque accumulation, and existing dental restorations including a gold crown on a posterior tooth. Frontal clinical photograph of the anterior dentition showing generalized gingival erythema and inflammation consistent with periodontitis. Composite figure illustrating generalized stage I, grade B periodontitis in a 67-year-old female. Panel A shows frontal view of inflamed anterior gingiva; Panel B displays multiple intraoral angles revealing inflammation and restorations; Panel C presents radiographs demonstrating radiographic bone loss. Caption states overall prognosis is favorable. 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? "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** The official logo of The University of Western Australia. It features the university's crest on the left and its name in blue text on the right. #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? ...  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? ... Purple graphic design element containing stylized white text reading 'Where to NEXT?' surrounded by directional arrows and mountain-like shapes. Questions? **emma.perry@uwa.edu.au** **pradeep.koppolu@uwa.edu.au** Images in presentation not otherwise credited are licence-free from https://www.freepik.com/   Portrait photo of a person with short hair and glasses, associated with email emma.perry@uwa.edu.au. Portrait photo of a man in a suit and tie, associated with email pradeep.koppolu@uwa.edu.au. [^1]: Original PDF page 1: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=1|L7 Prognosis of Periodontally Involved Teeth 2025, p.1]] [^2]: Original PDF page 2: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=2|L7 Prognosis of Periodontally Involved Teeth 2025, p.2]] [^3]: Original PDF page 3: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=3|L7 Prognosis of Periodontally Involved Teeth 2025, p.3]] [^4]: Original PDF page 4: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=4|L7 Prognosis of Periodontally Involved Teeth 2025, p.4]] [^5]: Original PDF page 5: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=5|L7 Prognosis of Periodontally Involved Teeth 2025, p.5]] [^6]: Original PDF page 6: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=6|L7 Prognosis of Periodontally Involved Teeth 2025, p.6]] [^7]: Original PDF page 7: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=7|L7 Prognosis of Periodontally Involved Teeth 2025, p.7]] [^8]: Original PDF page 8: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=8|L7 Prognosis of Periodontally Involved Teeth 2025, p.8]] [^9]: Original PDF page 9: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=9|L7 Prognosis of Periodontally Involved Teeth 2025, p.9]] [^10]: Original PDF page 10: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=10|L7 Prognosis of Periodontally Involved Teeth 2025, p.10]] [^11]: Original PDF page 11: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=11|L7 Prognosis of Periodontally Involved Teeth 2025, p.11]] [^12]: Original PDF page 12: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=12|L7 Prognosis of Periodontally Involved Teeth 2025, p.12]] [^13]: Original PDF page 13: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=13|L7 Prognosis of Periodontally Involved Teeth 2025, p.13]] [^14]: Original PDF page 14: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=14|L7 Prognosis of Periodontally Involved Teeth 2025, p.14]] [^15]: Original PDF page 15: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=15|L7 Prognosis of Periodontally Involved Teeth 2025, p.15]] [^16]: Original PDF page 16: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=16|L7 Prognosis of Periodontally Involved Teeth 2025, p.16]] [^17]: Original PDF page 17: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=17|L7 Prognosis of Periodontally Involved Teeth 2025, p.17]] [^18]: Original PDF page 18: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=18|L7 Prognosis of Periodontally Involved Teeth 2025, p.18]] [^19]: Original PDF page 19: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=19|L7 Prognosis of Periodontally Involved Teeth 2025, p.19]] [^20]: Original PDF page 20: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=20|L7 Prognosis of Periodontally Involved Teeth 2025, p.20]] [^21]: Original PDF page 21: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=21|L7 Prognosis of Periodontally Involved Teeth 2025, p.21]] [^22]: Original PDF page 22: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=22|L7 Prognosis of Periodontally Involved Teeth 2025, p.22]] [^23]: Original PDF page 23: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=23|L7 Prognosis of Periodontally Involved Teeth 2025, p.23]] [^24]: Original PDF page 24: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=24|L7 Prognosis of Periodontally Involved Teeth 2025, p.24]] [^25]: Original PDF page 25: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=25|L7 Prognosis of Periodontally Involved Teeth 2025, p.25]] [^26]: Original PDF page 26: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=26|L7 Prognosis of Periodontally Involved Teeth 2025, p.26]] [^27]: Original PDF page 27: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=27|L7 Prognosis of Periodontally Involved Teeth 2025, p.27]] [^28]: Original PDF page 28: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=28|L7 Prognosis of Periodontally Involved Teeth 2025, p.28]] [^29]: Original PDF page 29: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=29|L7 Prognosis of Periodontally Involved Teeth 2025, p.29]] [^30]: Original PDF page 30: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=30|L7 Prognosis of Periodontally Involved Teeth 2025, p.30]] [^31]: Original PDF page 31: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=31|L7 Prognosis of Periodontally Involved Teeth 2025, p.31]] [^32]: Original PDF page 32: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=32|L7 Prognosis of Periodontally Involved Teeth 2025, p.32]] [^33]: Original PDF page 33: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=33|L7 Prognosis of Periodontally Involved Teeth 2025, p.33]] [^34]: Original PDF page 34: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=34|L7 Prognosis of Periodontally Involved Teeth 2025, p.34]] [^35]: Original PDF page 35: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=35|L7 Prognosis of Periodontally Involved Teeth 2025, p.35]] [^36]: Original PDF page 36: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=36|L7 Prognosis of Periodontally Involved Teeth 2025, p.36]] [^37]: Original PDF page 37: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=37|L7 Prognosis of Periodontally Involved Teeth 2025, p.37]] [^38]: Original PDF page 38: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=38|L7 Prognosis of Periodontally Involved Teeth 2025, p.38]] [^39]: Original PDF page 39: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=39|L7 Prognosis of Periodontally Involved Teeth 2025, p.39]] [^40]: Original PDF page 40: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=40|L7 Prognosis of Periodontally Involved Teeth 2025, p.40]] [^41]: Original PDF page 41: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=41|L7 Prognosis of Periodontally Involved Teeth 2025, p.41]] [^42]: Original PDF page 42: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=42|L7 Prognosis of Periodontally Involved Teeth 2025, p.42]] [^43]: Original PDF page 43: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=43|L7 Prognosis of Periodontally Involved Teeth 2025, p.43]] [^44]: Original PDF page 44: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=44|L7 Prognosis of Periodontally Involved Teeth 2025, p.44]] [^45]: Original PDF page 45: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=45|L7 Prognosis of Periodontally Involved Teeth 2025, p.45]] [^46]: Original PDF page 46: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=46|L7 Prognosis of Periodontally Involved Teeth 2025, p.46]] [^47]: Original PDF page 47: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=47|L7 Prognosis of Periodontally Involved Teeth 2025, p.47]] [^48]: Original PDF page 48: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=48|L7 Prognosis of Periodontally Involved Teeth 2025, p.48]] [^49]: Original PDF page 49: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=49|L7 Prognosis of Periodontally Involved Teeth 2025, p.49]] [^50]: Original PDF page 50: [[L7 Prognosis of Periodontally Involved Teeth 2025.pdf#page=50|L7 Prognosis of Periodontally Involved Teeth 2025, p.50]]