Data gathered during periodontal assessment also helps to answer questions about prognosis that are highly relevant to patients and practitioners: what is the likelihood of tooth loss without treatment? How likely will treatment prevent tooth loss? Will treatment work? Is it worth the effort to treat? Which teeth will most likely be lost? Is the patient better off without certain teeth? Which teeth should be removed? How difficult will it be to remove teeth?
This chapter will describe thought processes that can help answer these questions and provide guidance for treatment planning and extractions.
Case
A 47-year old female African American patient presents to you to get “periodontal work and anything else needed done.” She states that she could not take care of her teeth for a while, and would like to keep them as long as possible now that she has dental insurance. She also would like to “improve her smile.” She used to be seen by a corporate dental chain office until about 15 years ago when she lost her job. She reports that her gums bleed when she flosses and that floss catches between her teeth. She also tells you that she clenches her teeth, especially when driving. She brushes her teeth twice a day with a soft brush and fluoridated toothpaste, flosses twice daily, and rinses with an antiseptic mouthwash.
She checks “high blood pressure” on the medical history form and lists “Amlodipine” as the only medication she is taking. She does not report any allergies, but records “gall bladder removal” under the surgery item on the form. When questioned, she reports that she had her gall bladder removed 2 years ago after experiencing severe pain, and her blood pressure presented a problem for the surgery. Since then, she is taking amlodipine once a day, but does not experience any side effects. She used to smoke cigarettes about a pack every day for 20 years, before she quit 2 years ago after the surgery. She denies taking any recreational drugs, but says she treats herself and drinks a few glasses of wine once a week with friends.
Vital signs: 5′ 11?, 230 lb, blood pressure 138/93 mm Hg, pulse 79 beats per minute.
The intraoral exam reveals significant periodontal disease as evidenced through bleeding on probing, pocketing, attachment loss, recession, and tooth mobility. The majority of posterior maxillary teeth are missing, and mandibular molars have begun to migrate into this space. Fremitus was noted on maxillary incisors nos. 8 and 9. See Fig. 4.1, for clinical appearance and Fig. 4.2, for radiographs.
What can be learned from this case?
This case presents more severe periodontal disease than the cases presented earlier in this book, and the patient already is missing some teeth. If the patient wants to “improve her smile,” then part of addressing this chief complaint will be the need to replace missing teeth and prevent more teeth from getting lost, which of course involves “periodontal work.” So, what will be the “periodontal work?”
For this, we need to look at this case methodically, identifying the periodontal disease and its contributing factors, and developing a treatment plan as presented in Chapters 2 and 3. Starting with the periodontal diagnosis, we evaluate the six dimensions of this patient’s periodontal disease (Table 4.2).
The clinical findings are typical for periodontitis, such as bleeding on probing, pocketing, attachment loss, bone loss, tooth mobility, and gingival recession. The amount of attachment or bone loss is more severe than the average attachment loss seen at this age, and a possible explanation for this is her past history of heavy tobacco use. Given the current disease trajectory of this patient with above-average attachment loss, the risk of future attachment loss seems higher than average.
The systemic and local contributing factors in this case are shown in Table 4.3.
Using the tables from Chapter 3, the etiologies listed here translate into the following treatment (Table 4.4).
The initial part of the treatment plan is specific and clear, but becomes tentative toward the end. This is common with treatment planning complex cases as the later definite restorative treatment plan depends on the outcome of initial disease control, which may me be worse or better than anticipated.
For prognosis, the following questions need to be asked:
Findings in the periodontal chart are as follows:
What is the Likelihood of Tooth Loss?
Given the disease trajectory, tooth loss is unlikely in the short term (5 years) in this case. In the long term, the maxillary premolars (teeth nos. 4, 5, and 12) and central incisors (teeth nos. 8 and 9) have the highest risk as they have the most severe attachment loss, largest amount of bone loss, preexisting tooth mobility, and worst crown-to-root ratio of all teeth along with simple, conical-shaped, relatively short tooth roots. The mandibular canines will be the least likely teeth to be lost given their good level of bone support, long root length, low amount of attachment loss, and absence of most periodontal disease-associated factors.
Will Treatment Reduce the Chance of Tooth Loss?
Systemic factors in this patient are likely not an impediment to periodontal treatment. The patient has hypertension, but not to a degree that poses a high risk for a myocardial infarct or stroke during dental treatment. The patient’s local contributing factors can be partially controlled. Plaque and calculus can most likely be treated with oral hygiene instruction and scaling and root planing, and pocket-reduction surgery can be effective. However, furcation treatment may be more difficult, and the patient has multiple occlusal conditions (Class III relationship, severe bone loss complicating orthodontic therapy) that may not be correctable. Therefore, periodontal treatment may produce some improvement in inflammation and pocketing, but the restoration of periodontal health is questionable.
Should Teeth Be Removed?
Removal of the supraerupted mandibular 2nd and 3rd molars would likely simplify periodontal treatment, as it will remove four teeth with significant pocketing, and allow better access to the distal surface of the first molar. Even though the incisors have short roots and a significant amount of bone loss, it may be best to maintain these teeth with conservative periodontal therapy. Removal of these teeth will result in a difficult implant therapy scenario involving significant vertical and horizontal tissue loss.
Judging How Likely a Patient Will Lose Teeth
For most patients, keeping their teeth is the primary motivation for dental care. The ability to accurately predict and then ensure tooth survival is key to maintaining the continued trust of patients.
Prognosis—What Does it Mean?
There are three basic types of questions that need to be asked:
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Which teeth need to be removed?
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Are there teeth that should be sacrificed for improved survival of key teeth?
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Are there teeth that should be sacrificed to create a better dental implant site?
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For teeth that should be removed, how likely is it that the site becomes suitable for dental implants?
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For teeth that should be removed, could immediate implant therapy be an option?
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For teeth that should be removed, what is the risk of surgical complications at a given site?
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For sites where teeth need to be removed, how likely are long-term complications without tooth replacement?
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The answer to these questions require extrapolation of the current periodontal condition into the future based on the patient’s evidence of past periodontal disease activity, and the prognosis can change depending on the success of dental treatment. Usually, periodontal prognosis is worse at the beginning of treatment and improves with treatment. For instance, a patient may present with severe periodontal disease, poor oral hygiene, and several slightly mobile teeth initially. At the onset of treatment, the risk of tooth loss seems high and the chance of treatment success low given the initial appearance. However, if this patient develops good oral hygiene and tissues respond favorably to treatment, pocketing, tooth mobility, and inflammation, it results in a better chance of tooth survival.
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