CHAPTER 32-33: RISK ASSESSMENT & PROGNOSIS (SAS 3) / DENTAL INDICES

risk

the probability of an individual to develop a specific disease in a given period which may vary from one individual to another

either predisposes to develop periodontal dx or influence the progression of an existing dx

risk elements are:

risk factors

risk determinants

risk indicators

risk predictors / markers

risk assessment

involves identifying elements that either predispose a patient to developing periodontal disease or influence progression of a disease that may already exist

risk factors

are environmental, behavioral or biologic factors

when present, increases the likelihood that an individual will develop the disease

examples of risk factors

tobacco smoking

diabetes mellitus

pathogenic bacteria & microbial tooth deposits

severe periodontal disease

has been found to be a significant risk factor for poor glycemic control

anatomic factors that at risk to periodontitis as they harbor bacterial plaque and present

furcations

root concavities

developmental grooves

cervical enamel projections

enamel pearls

bifurcation ridges

3 specific bacteria have been identified as etiologic agents:

actinobacillus actinomycetemcomitans

porphyromonas gingivalis

bacteroides forsythus

are common sites with root proximity complications.

mx 1st & 2nd molars

subgingivally

dental restorations must be placed ___ (to access caries or to hide the margin in the cosmetic zone).

biologic width

represents the anatomic dimensions of the epithelial attachment and the connective tissue attachment.

A restoration that does violate this would initiate a chronic inflammatory condition that results in bone and attachment loss to reestablish the dimensions

a dental restoration

should not be placed so close to alveolar bone that it does not allow for a connective tissue attachment, an epithelial attachment, and a gingival sulcus.

risk determinants

these are risk factors that cannot be modified

examples of risk determinants

age

genetic factors

socioeconomic status

gender — males are more prone to periodontitis

stress — incidence of ANUG increases during stressful periods

risk indicators

are probable or putative risk factors that have been identified in cross-sectional studies but not have been confirmed through longitudinal studies

factors associated with periodontal disease but not yet proven to be causative due to insufficient evidence

examples of risk indicators

osteoporosis

infrequent dental visits

HIV / acquired immune deficiency syndrome

risk markers / predictors

these are associated with increased risk for disease but do not cause the disease

examples of risk markers / predictors

previous history of periodontal disease

bleeding on probing — together with increased pocket depth may serve an excellent predictor for future attachment loss.

prognosis

a prediction of the probable course, duration and outcome of a disease

established after diagnosis is made and before the treatment plan is formulated

risk factors and prognosis are interrelated

prognosis can be described as:

Excellent prognosis

Good prognosis

Fair prognosis

Poor prognosis

Questionable prognosis

Hopeless prognosis

excellent prognosis

no bone loss

excellent condition

good patient cooperation

no systemic or environmental factors

good prognosis

they are well controlled

adequate remaining bone support

no systemic or environmental factors

adequate patient cooperation if systemic factors are present

adequate possibilities to control etiologic factors & establish a maintainable dentition

fair prognosis

one or more of the ff:

some tooth mobility

grade I furcation involvement

acceptable patient cooperation

adequate maintenance possible

less than adequate remaining bone support

presence of limited systemic or environmental factors

poor prognosis

tooth mobility

moderate to advanced bone loss

grade I and II furcation involvements

presence of systemic or environmental factors

difficult to maintain areas or doubtful patient cooperation

questionable prognosis

inaccessible areas

advanced bone loss

grade II and III furcation involvements

presence of systemic or environmental factors

hopeless prognosis

one or more of the ff:

advanced bone loss

extractions indicated

non-maintainable areas

presence of uncontrolled systemic / environmental factors

2 aspects of prognosis

overall prognosis

individual prognosis

overall prognosis

concerned with the dentition as a whole

is the basic determinant of the extent of dental treatment to be provided

individual prognosis

takes into account the prognosis of each tooth in the oral cavity

prognosis for individual tooth

Mobility

Teeth adjacent to edentulous areas

Location of remaining bone in relation to individual root surfaces

Relation to adjacent teeth

Attachment level

Infrabony pockets

Furcation involvement

Caries,nonvital teeth and root resorption

Developmental defects

prognosis for px with gingivitis associated with dental plaque only

good

provided all local irritants are removed and patient cooperates by maintaining good oral hygiene

prognosis for px with plaque-induced gingival diseases modified by systemic factors

depends not only on control of bacterial plaque, but also control or correction of systemic factors

pregnancy

development of pyogenic granuloma

a reactive hyperplasia in response to local irritants, hormonal factors

gingiva on anterior teeth as most common site

scorbutic gingivitis

gingivitis due to vit C deficiency

prognosis for px with plaque-induced gingival diseases modified by medications

depends on whether the patient’s systemic problem can be treated with alternative medication

prognosis for px with gingival diseases modified by malnutrition

depends on the severity and duration of the deficiency and on the likelihood of reversing the deficiency through dietary supplementation.

prognosis for px with non plaque-induced gingival lesions

depends on the elimination of the source of infection or causative agents

prognosis for px with chronic periodontitis

slight to moderate

prognosis is good provided the inflammation can be controlled through good oral hygiene and removal of plaque retentive factors

severe cases and non-compliant patients: prognosis may be downgraded to fair to poor

hereditary gingival fibromatosis

a rare benign gingival overgrowth characterized by an accumulation of extracellular matrix resulting to fibrotic enlargement of the gingiva

manifestations: drifting / migration of teeth / diastemia

prognosis for px with aggressive periodontitis

poor especially in generalized cases

poor especially in generalized cases

periodontitis as a manifestation of systemic diseases

fair to poor

prognosis for px with periodontitis as a manifestation of systemic diseases & NUP

MO amalgam #12

the restorations has the greatest potential as a risk factor for plaque associated inflammation?

mesial #15

the site with a 7mm CAL would be considered at greatest risk for future loss of attachment?

a diabetic patient with a HbA1c of 9.5%

a patient would be expected to be at greatest risk for periodontal disease

a true statement regarding periodontal prognosis

a distal maxillary molar furcation involvement has a poor prognosis because access for cleaning is poor

smoking

a well-known risk factor for chronic periodontitis

The risk for periodontal disease after smoking cessation lowers continuously.

In the first few years after smoking cessation, the risk ranges between the risk for smokers and that for never-smokers.

Three years following smoking cessation, the risk for periodontal disease is three times higher in former smokers when compared to the risk of never smokers.

After eleven years, the risk for periodontal disease is similar between former smokers and never-smoker

grade I furcation involvement

incipient bone loss or early lesion

interradicular bone is intact

depression on furcal opening described as dimples

grade II furcation involvement

partial bone loss

moderate loss of interradicular bone

probe enters opening of furcation but not through & through

CUL-DE-SAC lesion

grade III furcation involvement

total bone loss

through & through furcation involvement that can only be seen radiographically

grade IV furcation involvement

total bone loss

through & through furcation involvement with gum recession that is clinically visible

emotional stress

a major factor in the development of acute necrotizing ulcerative gingivitis

dental indices

set of values ; usually numerical with maximum & minimum limits

used to describe the variable or a specific conditions on a graduated scale

use the same criteria & method to compare a specific variable in individuals, samples or populations with that same variable as is found in other individuals, samples or populations

patient hygiene performance index (Podshadley A.G. & Haley JV 1968)

6 index teeth — 16, 11, 26, 36, 31, 46

disclosing agent for 30s

each of the 5 subdivisions is scored for the presence of stained debris

scoring for PHP index

0 — no debris (or questionable)

1 — debris is definitely present

oral hygiene index simplified (Greene & Vermillion)

a method for classifying oral hygiene status of population groups

teeth to be examined are:

facial surfaces: 16, 11, 26, 31

lingual surfaces: 36, 46

interpretation for OHIS

good — 0 -1.2

fair — 1.3 - 3.0

poor — 3.1 - 6.0

scoring for bleeding index (Muhlemann H.R 1971)

0 — healthy looking papillary & marginal gingiva, no BOP

1 — healthy looking gingiva, BOP present

2 — BOP, changes in color, no edema

3 — BOP, changes in color, slight edema present

4 — BOP, changes in color, obvious edema present

5 — spontaneous bleeding, changes in color, marked edema present

scoring for modified sulcular bleeding index (Saxer & Muhlemann 1975)

0 — no bleeding

1 — a single discrete bleeding point

2 — several bleeding points or a single line of blood appears

3 — the interdental triangle fills with the blood shortly after probing

4 — profuse bleeding occurs after probing; blood flows immediately into marginal sulcus

scoring for papillary-marginal-attachment index (Maury Massler & Schour L. 1944)

0 — normal

1 — mild papillary enlargement

2 — obvious inc in size, bleeding on pressure

3 — excessive inc in size, spontaneous bleeding

4 — necrotic papilla

5 — atrophy & loss of papilla

scoring for debris index (DI)

0 — no debris or stains present

1 — soft debris covering not more than 1/3 the tooth surface or presence of extrinsic stains w/o other debris regardless of the area covered

2 — soft debris covering more than 1/3 but not more than 2/3 of the exposed tooth surface

3 — soft debris covering more than 2/3 of the exposed tooth surface

community periodontal index of treatment needs (CPITN)

developed primarily to survey & evaluate perio treatment needs rather than determining past & present perio status

records the perio pockets, gingival inflammation, dental calculus, other plaque retentive factors

does not record irreversible changes such as recession, tooth mobility or loss of perio attachment

scoring for community periodontal index of treatment (CIPTN)

0 — healthy periodontium

1 — gingival bleeding after gentle probing

2 — presence of supra / subgingival calculus

3 — pathological pocket of 4-5mm present

4 — pathological pocket of 6mm or more present

X — when only one or no teeth are present in a sextant

treatment for code 0 in CIPTN

no need for perio treatment

treatment for code 1 in CIPTN

need for improving the personal oral hygiene

treatment for code 2 in CIPTN

need for scaling

need for improving the personal oral hygiene

treatment for code 3 in CIPTN

scaling & root planing

need for improving the personal oral hygiene

treatment for code 4 in CIPTN

complex treatment such as deep scaling, root planing, more complex surgical procedures

scoring for gingival index (Loe & Silness)

0 — absence of inflammation / normal gingiva

1 — mild inflammation, slight change in color, slight edema, no BOP

2 — moderate inflammation, moderate glazing, redness, edema & hypertrophy, BOP

3 — severe inflammation, marked redness & hypertrophy ulceration, tendency to spontaneous bleeding

plaque index by O’leary et al 1972

this precise index records the presence of supragingival plaque on all 4 tooth surfaces

the plaque is stained with a disclosing solution

plaque index by Silness & Loe 1964

plaque is not stained with a disclosing solution

only this plaque plays any role in the etiology of gingivitis

the index ascertains the thickness of plaque along the gingival margin

scoring for plaque index

0 — no plaque

1 — thin plaque

2 — moderate plaque

3 — abundant plaque

plaque-induced gingival diseases

most common

result of interaction between plaque bacteria & inflammatory cells of host

modified by systemic factors, by medications, by malnutrition

non-plaque-induced gingival diseases

less common

in response to infections

in response to allergy

in response to trauma

gingival lesions of genetic origin

ways on how to name a complete periodontal diagnosis

distribution ( localized: <30% / generalized: >30% )

severity ( slight: 1-2mm CAL / moderate: 3-4mm CAL / severe: >/= 5mm CAL )

type ( chronic / aggressive )

chronic periodontitis

older px (55 y.o)

any arch is affected

no familial aggregation

slow to moderate attachment loss

horizontal (suprabony) pattern of bone loss

consistent destruction in relation to microbial deposits

often commensurate with observed periodontal destruction

aggressive periodontitis

young px (<35 y.o)

rapid attachment loss

yes to familial aggregation

first molar & incisors are affected

often minimal presence of plaque

vertical / angluar (infrabony) pattern of bone loss

inconsistent destruction in relation to microbial deposits

causative agent of localized aggressive periodontitis

aggregatibacter actinomycetemcomitans (Aa)

causative agent of generalized aggressive periodontitis

porphyromonas gingivalis

causative agent of necrotizing ulcerative gingivitis

spirochetes

causative agent of necrotizing ulcerative periodontitis

fusiform bacteria