Post on 28-Apr-2015
DIAGNOSIS, PROGNOSIS AND
TREATMENT PLAN
Hooman KhorshidiDepartment of PeriodonticsShiraz University of Medical Sciences
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Diagnosis
Diagnosis may be defined as identifying disease from an evaluation of the
history, signs and symptoms, laboratory tests, andprocedures
l) patient interview2) medical consultation as indicated3) clinical periodontal examination4) radiographic examination 5) laboratory tests as needed
Healthy periodontal tissues with minimal inflammation
Systemic diseases with periodontal manifestations
Paroxysmal nocturnal hemoglobinuria with severe leukopenia and associated gingival necrosis
Systemic diseases with periodontal manifestations
Wegner’s granulomatosis with gingival involvement
Systemic diseases with periodontal manifestations
Acute monocytic leukemia with thrombocytopenic purpura; gingival enlargement is due to infiltrating leukemic cells, and necrosis
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necrotizing ulcerative gingivitis
Interdental necrosis mesial and distal to the lateral incisor that is characteristic of
necrotizing ulcerative gingivitis
necrotizing ulcerative gingivitis
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Miller class III gingival recession
Miller class II gingival recession
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CAL
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Furcation involvement
I-incipient or early suprabony pocket extension into the furcation area with slight loss of bone;II-extension of the pocket into the furcation leaving a portion of the alveolar bone and periodontal ligament intact allowing only partial penetration of the probe into the furcation areaIII-through and through extension of the pocket into the furcation with complete loss of inter-radicular bone without gingival recessionIV-through and through furcationinvasion with gingival recession
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Class IV furcation involvement
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Restorative corrections
Open contactsOverhangsPoor marginsPoor contours
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OverhangsPoor margins
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Dental plaque-induced gingival diseases
1. Gingivitis associated with dental plaque onlya. without other local contributing factorsb. with local contributing factors
2. Gingival diseases modified by systemic factorsa. associated with the endocrine system1) puberty-associated gingivitis2) menstrual cycle-associated gingivitis3) pregnancy-associated
a) gingivitisb) pyogenic granuloma
4) diabetes mellitus-associated gingivitis
b. associated with blood dyscrasias1) leukemia-associated gingivitis2) other
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Classification of periodontal diseases and conditions
Dental plaque-induced gingival diseases
3. Gingival diseases modified by medicationsa. drug-influenced gingival diseases
1) drug-influenced gingival enlargements2) drug-influenced gingivitisa) oral contraceptive-associated gingivitisb) other
4. Gingival diseases modified by malnutritiona. ascorbic acid-deficiency gingivitisb. other
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Classification of periodontal diseases and conditions
Non-plaque-induced gingival lesions
1. Gingival diseases of specific bacterial origina. Neisseria gonorrhea-associated lesionsb. Treponema pallidum-associated lesionsc. streptococcal species-associated lesionsd. other
2. Gingival diseases of viral origina. herpesvirus infections
1) primary herpetic gingivostomatitis2) recurrent oral herpes3) varicella-zoster infections
b. other
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Classification of periodontal diseases and conditions
Non-plaque-induced gingival lesions
3. Gingival diseases of fungal origina. Candida-species infections
1) generalized gingival candidosis
b. linear gingival erythemac. histoplasmosisd. other
4. Gingival lesions of genetic origina. hereditary gingival fibromatosisb. other
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Classification of periodontal diseases and conditions
Non-plaque-induced gingival lesions
5. Gingival manifestations of systemic conditionsa. mucocutaneous disorders
1) lichen planus2) pemphigoid3) pemphigus vulgaris4) erythema multiforme5) lupus erythematosus6) drug-induced7) other
b. allergic reactions1) dental restorative materials
a) mercuryb) nickelc) acrylicd) other
2) reactions attributable toa) toothpastes/dentifricesb) mouthrinses/mouthwashesc) chewing gum additivesd) foods and additives
3) other
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Classification of periodontal diseases and conditions
Non-plaque-induced gingival lesions
6. Traumatic lesions (factitious, iatrogenic, accidental)a. chemical injuryb. physical injuryc. thermal injury
7. Foreign body reactions8. Not otherwise specified (NOS)
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Classification of periodontal diseases and conditions
Chronic PeriodontitisA. LocalizedB. Generalized
Aggressive PeriodontitisA. LocalizedB. Generalized
Can be further classified on the basis of extent and severity.Extent :
Localized = ≤30% of sites involved Generalized = >30% of sites involved
Severity : Slight = 1 or 2 mm CAL
Moderate = 3 or 4 mm CAL Severe = ≥5 mm CAL
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Classification of periodontal diseases and conditions
Periodontitis as a Manifestation of Systemic Diseases
A. Associated with hematological disorders
1. Acquired neutropenia2. Leukemias3. Other
B. Associated with genetic disorders1. Familial and cyclic neutropenia2 Down syndrome3. Leukocyte adhesion deficiency syndromes4. Papillon-Lefèvre syndrome5. Chediak-Higashi syndrome6. Histiocytosis syndromes7. Glycogen storage disease8. Infantile genetic agranulocytosis9. Cohen syndrome10. Ehlers-Danlos syndrome (Types IV and VIII)11. Hypophosphatasia12. Other
C. Not otherwise specified
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Classification of periodontal diseases and conditions
Necrotizing Periodontal DiseasesA. Necrotizing ulcerative gingivitis (NUG)B. Necrotizing ulcerative periodontitis (NUP)
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Classification of periodontal diseases and conditions
Abscesses of the PeriodontiumA. Gingival abscessB. Periodontal abscessC. Pericoronal abscess
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Classification of periodontal diseases and conditions
Periodontitis Associated With Endodontic LesionsA. Combined periodontic-endodontic lesions
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Classification of periodontal diseases and conditions
Developmental or Acquired Deformities and Conditions
A. Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis1. Tooth anatomic factors2. Dental restorations/appliances3. Root fractures4. Cervical root resorption and cemental tears
B. Mucogingival deformities and conditions around teeth1. Gingival/soft tissue recession
a. facial or lingual surfacesb. interproximal (papillary)
2. Lack of keratinized gingiva3. Decreased vestibular depth4. Aberrant frenum/muscle position5. Gingival excess
a. pseudopocketb. inconsistent gingival marginc. excessive gingival displayd. gingival enlargement (See I.A.3. and I.B.4.)
6. Abnormal colorC. Mucogingival deformities and conditions on
edentulous ridges1. Vertical and/or horizontal ridge deficiency2. Lack of gingiva/keratinized tissue3. Gingival/soft tissue enlargement4. Aberrant frenum/muscle position5. Decreased vestibular depth6. Abnormal color
D. Occlusal trauma1. Primary occlusal trauma2. Secondary occlusal trauma
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Classification of periodontal diseases and conditions
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Evaluation of fremitus
Class I½recession that does not extend to the mucogingivaljunction and is not associated with lossof bone or gingival tissue in the interdentalarea; Class II½recession that extends to the mucogingivaljunction and is not associated with loss ofbone or soft tissue in the interdental area;O Class III½recession that extends to or beyond themucogingival junction with loss of bone or softtissue in the interdental area; andO Class IV½recession extending to or beyond themucogingival junction with severe loss of interdentalbone and/or soft tissue and/or severe toothmalposition.
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M O S T D I F F I C U L T D E C I S I O N P R O C E S S
Developing a Prognosis
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Overall clinical factors :AgeDisease severityPlaque controlPatient compliance
AGE
The more rapidly the
problem develops
The younger the
patient with a given
periodontal problem
the poorer the prognosis
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Disease severity
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Systemic, restorative, environmental and local factorPatient compliance and prosthetic possibilityFactors influencing individual tooth prognosis:Plaque and calculus, subgingivalrestoration, caries, non-vital teeth, root resorption
skills and experience
A dentist with limited skills
should refer significant periodontal problems
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medical status of the patient
impaired immune system
poorly controlled diabetes
use of medicines that may induce hyperplasia
heart or blood pressure problems
clotting problems
use of anticoagulants
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Age of patientSkills and experience of dentistMedical status of the patient (general health)
Immunological statusForm of bone lossPossibility of removing etiologic factorPoor nutritional habits, smoking, alcohol abuse, and drug abuseDental conditions (eg, bruxism, malocclusion) Number, position and form of teeth present, Badly involved key abutment teeth, Severe furcationinvolvement, Poor root form, Root proximity
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Age of patientSkills and experience of dentistMedical status of the patient (general health)Immunological statusForm of bone loss
Possibility of removing etiologic factorPoor nutritional habits, smoking, alcohol abuse, and drug abuseDental conditions (eg, bruxism, malocclusion) Number, position and form of teeth present, Badly involved key abutment teeth, Severe furcationinvolvement, Poor root form, Root proximity
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Habits
Poor nutritional habits,
smoking,
alcohol abuse, and
drug abuse • have negative effects on the
prognosis
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psychologic makeup
The ability of the patient to manage stress, follow through with a demanding oral hygiene regimen, and recognize and manage the periodontal problem affect the prognosis
either positively or negatively.
Skill in identifying and assessing these nondental factors is a key to the dentist’s success as a prognostician
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dental factors
occlusal problems such as bruxism or malocclusion must be resolvable, or they will negatively affect the prognosis. Key teeth must be restorable
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Extent of the disease Its rate of progression Status of key abutment teeth Severity of furca involvements Root formRoot proximity
Dental conditions (bruxism, malocclusion)Number, position and form of teeth present,
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An extensive problem with rapid loss of support, especially with few remaining solid teeth or teeth with short or crowded roots or severe furcation involvements, has a poorer prognosis than that for a case in which fewer of these factors are negative.
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Type of prognosis
Hopeless
Questionable
Poor
Fair
Good
Excellent
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TREATMENT PLAN
Hooman KhorshidiDepartment of PeriodonticsShiraz University of Medical Sciences
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Objectives of treatment plan:
Elimination of disease
Restoration of efficient function
Production of satisfactory appearance
Preliminary phase
Non-surgical phase
Surgical phase
Restorative phase
SPT phase
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Emergency
Extraction of hopeless teeth
OHI and patient information
Plaque control and SRP (supra & sub)
Initial occlusion adjustment
Reevaluation after phase І
Surgical phase
Reconstruction (restorative phase)
Maintenance (supportive periodontal
treatment SPT)
Preliminary phase
Pain
Discomfort
Emergencies
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Hopeless teeth
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Non-surgical phase
Phase 1
Plaque control
Cause related
Patient education
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Phase one therapy
Control of plaque
Control of diet
Control of systemic factors
Control of oral malodor and taste
abnormalities
Control of tobacco smoking
CONTROL OF SYSTEMIC FACTORSCONSULT WITH PATIENT’S M.D.
Control of Hemostasis
Control of Bacteremia
Control of Diabetes
Control of Medications
Patient with plaque induced gingivitis
Three weeks following compliance with excellent oral hygiene and plaque control
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Before phase 1
After phase 1
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Removal of pathologic tissue for biopsy
Removal of caries-endodontic therapy
Removal of hopeless teeth
Removal of calculus
Removal of cariesEndodontic therapy
PHASE ONE EVALUATION
Pocket depthPlaque scoreBleeding on probingCariesOcclusal stabilityMobility, fremitusMucosal health statusMucogingival statusSystemic statusRadiographic evaluationOral malodor and tasteEstheticsModification of phase two treatment plans
Surgical phase
Periodontal
Implant
Endodontic
Impacted teeth
…
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Restorative phase
Cast restoration
No conventional filling
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maintenance
SPT (supportive periodontal therapy )
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