DIAGNOSIS, PROGNOSIS AND TREATMENT PLAN

Hooman Khorshidi Department of Periodontics Shiraz 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, and procedures

l) patient interview 2) medical consultation as indicated 3) clinical periodontal examination 4) 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

Wegners 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

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necrotizing ulcerative gingivitis

Interdental necrosis mesial and distal to the lateral incisor that is characteristic of 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 area III-through and through extension of the pocket into the furcation with complete loss of inter-radicular bone without gingival recession IV-through and through furcation invasion with gingival recession

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Class IV furcation involvement

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Restorative corrections
Open contacts Overhangs Poor margins Poor contours

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Overhangs Poor margins

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Classification of periodontal diseases and conditions

Dental plaque-induced gingival diseases

1. Gingivitis associated with dental plaque only a. without other local contributing factors b. with local contributing factors 2. Gingival diseases modified by systemic factors a. associated with the endocrine system
1) puberty-associated gingivitis 2) menstrual cycle-associated gingivitis 3) pregnancy-associated a) gingivitis b) pyogenic granuloma 4) diabetes mellitus-associated gingivitis

b. associated with blood dyscrasias

1) leukemia-associated gingivitis 2) other

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Classification of periodontal diseases and conditions

Dental plaque-induced gingival diseases

3. Gingival diseases modified by medications a. drug-influenced gingival diseases

1) drug-influenced gingival enlargements 2) drug-influenced gingivitis
a) oral contraceptive-associated gingivitis b) other

4. Gingival diseases modified by malnutrition a. ascorbic acid-deficiency gingivitis b. other

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Classification of periodontal diseases and conditions

Non-plaque-induced gingival lesions

1. Gingival diseases of specific bacterial origin a. Neisseria gonorrhea-associated lesions b. Treponema pallidum-associated lesions c. streptococcal species-associated lesions d. other 2. Gingival diseases of viral origin a. herpesvirus infections
1) primary herpetic gingivostomatitis 2) recurrent oral herpes 3) 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 origin a. Candida-species infections

1) generalized gingival candidosis

b. linear gingival erythema c. histoplasmosis d. other 4. Gingival lesions of genetic origin a. hereditary gingival fibromatosis b. other

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Classification of periodontal diseases and conditions

Non-plaque-induced gingival lesions

5. Gingival manifestations of systemic conditions a. mucocutaneous disorders
1) lichen planus 2) pemphigoid 3) pemphigus vulgaris 4) erythema multiforme 5) lupus erythematosus 6) drug-induced 7) other

b. allergic reactions
1) dental restorative materials a) mercury b) nickel c) acrylic d) other 2) reactions attributable to a) toothpastes/dentifrices b) mouthrinses/mouthwashes c) chewing gum additives d) 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 injury b. physical injury c. thermal injury 7. Foreign body reactions 8. Not otherwise specified (NOS)

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Classification of periodontal diseases and conditions

Chronic Periodontitis
A. Localized B. Generalized

Aggressive Periodontitis
A. Localized B. 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 neutropenia 2. Leukemias 3. Other

B. Associated with genetic disorders

1. Familial and cyclic neutropenia 2 Down syndrome 3. Leukocyte adhesion deficiency syndromes 4. Papillon-Lefvre syndrome 5. Chediak-Higashi syndrome 6. Histiocytosis syndromes 7. Glycogen storage disease 8. Infantile genetic agranulocytosis 9. Cohen syndrome 10. Ehlers-Danlos syndrome (Types IV and VIII) 11. Hypophosphatasia 12. Other

C. Not otherwise specified

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Classification of periodontal diseases and conditions

Necrotizing Periodontal Diseases A. Necrotizing ulcerative gingivitis (NUG) B. Necrotizing ulcerative periodontitis (NUP)

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Classification of periodontal diseases and conditions

Abscesses of the Periodontium A. Gingival abscess B. Periodontal abscess C. Pericoronal abscess

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Classification of periodontal diseases and conditions

Periodontitis Associated With Endodontic Lesions A. 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/periodontitis
1. Tooth anatomic factors 2. Dental restorations/appliances 3. Root fractures 4. Cervical root resorption and cemental tears

B. Mucogingival deformities and conditions around teeth

1. Gingival/soft tissue recession
a. facial or lingual surfaces b. interproximal (papillary)

2. Lack of keratinized gingiva 3. Decreased vestibular depth 4. Aberrant frenum/muscle position 5. Gingival excess
a. pseudopocket b. inconsistent gingival margin c. excessive gingival display d. gingival enlargement (See I.A.3. and I.B.4.)

6. Abnormal color

C. Mucogingival deformities and conditions on edentulous ridges

1. Vertical and/or horizontal ridge deficiency 2. Lack of gingiva/keratinized tissue 3. Gingival/soft tissue enlargement 4. Aberrant frenum/muscle position 5. Decreased vestibular depth 6. Abnormal color

D. Occlusal trauma
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1. Primary occlusal trauma 2. Secondary occlusal trauma

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Evaluation of fremitus

Class Irecession that does not extend to the mucogingival junction and is not associated with loss of bone or gingival tissue in the interdental area; Class IIrecession that extends to the mucogingival junction and is not associated with loss of bone or soft tissue in the interdental area; O Class IIIrecession that extends to or beyond the mucogingival junction with loss of bone or soft tissue in the interdental area; and O Class IVrecession extending to or beyond the mucogingival junction with severe loss of interdental bone and/or soft tissue and/or severe tooth malposition.

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Developing a Prognosis
MOST DIFFICULT DECISION PROCESS

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Overall clinical factors : Age Disease severity Plaque control Patient compliance

AGE

The more rapidly the problem develops

the poorer the prognosis The younger the patient with a given periodontal problem

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Disease severity

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Systemic, restorative, environmental and local factor Patient compliance and prosthetic possibility Factors influencing individual tooth prognosis: Plaque and calculus, subgingival restoration, 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 patient Skills and experience of dentist Medical status of the patient (general health)

Immunological status
Form of bone loss Possibility of removing etiologic factor Poor nutritional habits, smoking, alcohol abuse, and drug abuse Dental conditions (eg, bruxism, malocclusion) Number, position and form of teeth present, Badly involved key abutment teeth, Severe furcation involvement, Poor root form, Root proximity
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Age of patient Skills and experience of dentist Medical status of the patient (general health) Immunological status Form of bone loss

Possibility of removing etiologic factor

Poor nutritional habits, smoking, alcohol abuse, and drug abuse Dental conditions (eg, bruxism, malocclusion) Number, position and form of teeth present, Badly involved key abutment teeth, Severe furcation involvement, 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 dentists 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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Dental conditions (bruxism, malocclusion) Number, position and form of teeth present,

Extent of the disease Its rate of progression Status of key abutment teeth Severity of furca involvements Root form Root proximity

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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 Khorshidi Department of Periodontics Shiraz 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 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 FACTORS CONSULT WITH PATIENTS 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

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 caries Endodontic therapy

PHASE ONE EVALUATION

Pocket depth Plaque score Bleeding on probing Caries Occlusal stability Mobility, fremitus Mucosal health status Mucogingival status Systemic status Radiographic evaluation Oral malodor and taste Esthetics Modification 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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