Evidence-based decision making in periodontal tooth prognosis

Transcription

1 Clin Dent Rev (2017) 1:3 TREATMENT Evidence-based decision making in periodontal tooth prognosis Carlos Ernesto Nemcovsky 1 Received: 12 April 2017 / Accepted: 7 June 2017 / Published online: 30 June 2017 Ó Springer International Publishing AG 2017 Abstract Evidence-based dentistry requires application of current evidence in making decisions about the care of individual patients. Long-term preservation of the periodontium is the main objective of periodontal therapy. Before a treatment plan is established, the diagnosis and etiologic factors of the disease as well as the prognosis of the remaining teeth should be determined while predicting the final functional and esthetic result. Tooth prognosis can be classified as good, fair, poor, questionable, hopeless and indicated for extraction. Keywords Prognosis Periodontal Systemic Tooth Treatment Quick reference/description Evidence-based dentistry requires application of current evidence in making decisions about the care of individual patients. Long-term preservation of the periodontium is the main objective of periodontal therapy. Before a treatment plan is established, the diagnosis and etiologic factors of the disease as well as the prognosis of the remaining teeth should be determined while predicting the final functional and esthetic result. Tooth prognosis can be classified as good, fair, poor, questionable, hopeless and indicated for extraction. & Carlos Ernesto Nemcovsky carlos@post.tau.ac.il 1 Tel Aviv University, Tel Aviv, Israel

2 3 Page 2 of 11 Clin Dent Rev (2017) 1:3 Symptoms The following criteria can be used for establishing the prognosis in periodontally affected teeth (Table 1). Table 1 Criteria for establishing prognosis Good (Control of etiologic factors and adequate periodontal support assure that tooth is relatively easy to maintain) Fair (Most of the periodontal support remains. Adequate treatment will allow long-term tooth survival provided good patient compliance) Poor (Large loss of periodontal support, provided good patient compliance, treatment will lead to prognosis improvement and maintenance but with certain difficulty) Questionable (Most of the periodontal support around the tooth has been lost. Tooth not easily amenable to maintenance care. Treatment outcome is not fully predictable) Hopeless (Possibilities for successful treatment and long-term tooth preservation are extremely limited. Preoperative attachment could be insufficient to maintain the tooth. Extraction may be suggested) Large number of remaining teeth/small number of teeth involved Compliance with supportive periodontal therapy (SPT) Willingness to preserve the teeth Vertical bone defect No furcation involvement Favorable crown-to-root ratio Tooth is abutment of a fixed partial denture Surgical regenerative periodontal treatment can be performed Good therapist knowledge and skill Family history of periodontal disease % remaining bone support Horizontal bone defect Class I furcation involvement Class II furcation involvement with vertical component Degrees 1 2 mobility Surgical periodontal treatment cannot be performed Small number of remaining teeth/large number of teeth involved [7 mm clinical attachment loss 75 50% remaining bone support Unfavorable crown-to-root ratio Root proximity Root grooves 50 25% remaining bone support Class II furcation involvement without vertical component Degree 3 mobility that may be provisionally stabilized Unfavorable tooth position B25% remaining bone support Class III furcation involvement Root resorption

3 Clin Dent Rev (2017) 1:3 Page 3 of 11 3 Table 1 continued Indicated for extraction (No possibility for treatment exists, tooth preservation in the arch may cause irreversible damage, and tooth should be promptly extracted) Worsen prognosis Degree 3 mobility that cannot be provisionally stabilized Large carious lesion that may not be treated Endodontic involvement that may not be successfully treated Vertical root fracture Clinical signs of active infection that may not be controlled Diabetes Faulty oral hygiene Smoking Parafunction Tooth is free-standing abutment of removable partial denture Clinical examination Periodontitis is an infectious disease with varying severity degrees; therefore, both patient- and tooth-related factors, as well as the therapist knowledge and skills, must be taken into consideration when evaluating prognosis. The therapy should aim at achieving clinically healthy periodontal conditions. Available periodontal treatment options are: Surgical periodontal treatment Nonsurgical periodontal treatment Defect elimination by resection Maintenance of the area without or with minimal bone resection Regenerative procedures Tooth extraction. The aim of periodontal surgery is to gain access to contaminated root surfaces for proper debridement of the lesion, establishing a gingival morphology conducive to plaque control and, whenever possible, regeneration of the lost periodontal attachment. An accurate prognosis is most critical when periodontal therapy is combined with large oral prosthetic rehabilitation or with dental implants. Procedure Until reliable predictors of periodontal disease progression at each site and accurate tooth prognosis are available, the use of surrogate clinical variables to reflect longterm tooth survivability can be used. A few prognostic factors:

4 3 Page 4 of 11 Clin Dent Rev (2017) 1:3 Can be controlled by the patient (daily plaque removal, smoking cessation, compliance with wearing occlusal guards, compliance with the recommended preventive maintenance schedule). May be affected by treatment (probing depth, mobility, furcation involvement, trauma from occlusion, bruxism, other parafunctional habits). Can be associated with systemic diseases (diabetes mellitus, immunologic disorders). Are uncontrollable (poor root form, poor crown/root ratio, tooth type, age, genetics). A simpler classification of the prognostic factors is mentioned in Table 2. Table 2 Classification of prognostic factors Patient related Age Systemic condition Remaining teeth in the arch or mouth Personal and family history of periodontal disease Oral hygiene Compliance with recall visits Smoking Parafunctional oral habits Willingness to preserve tooth or teeth Tooth related The number of teeth involved Clinical attachment loss Loss of bone support Remaining supporting area Architecture of bone defects Furcation involvement Mobility Crown/root ratio Caries and/or endodontic involvement Root defects Tooth position Root proximity Rehabilitation involving the tooth Type of periodontal treatment performed Therapist knowledge and skill Strategic value of the tooth and treatment alternatives Patient-related factors Age The older the patient is, the better the long-term prognosis. Susceptibility to periodontal breakdown is higher in the younger individual. If progress of periodontal destruction has been very slow over the last years, then prognosis is better than in cases where the downhill situation is of recent origin.

5 Clin Dent Rev (2017) 1:3 Page 5 of 11 3 Systemic conditions Certain drugs can cause gingival hyperplasia, complicating plaque control during maintenance. Periodontal deterioration and poor response to treatment are seen in diabetes patients. They are at greater risk of developing periodontitis and may require more aggressive treatment. Number of remaining teeth The greater the number of teeth present, the fewer the demands on the remaining teeth in the dentition. Presence of certain teeth in strategic locations is important for a more favorable prognosis. Family history of periodontal disease There is a genetic influence on tooth prognosis. Quality of oral hygiene and compliance with supportive periodontal therapy Recurrent periodontal diseases can be prevented by adequate plaque removal. Noncomplying individuals have the highest risk of recurrent periodontitis. Plaque control has an important role in the long-term stability of results following regenerative periodontal surgery. Smoking Smoking has been related to poor immediate- and long-term responses to periodontal treatment. It is a long-term risk factor in marginal bone loss. Tooth loss because of periodontal reasons in smokers is 2.5 times higher than in nonsmokers. Parafunction Parafunctional oral habits appeared to decrease tooth survival, while not wearing a bite guard seemed to worsen this effect. Willingness of the patient to preserve tooth or teeth Periodontal regenerative treatment may be performed on teeth with a poor prognosis, provided the patient is willing to try treatment as an alternative to immediate extraction. Inclination toward choosing extraction over other treatment alternatives is strongly predictive of tooth loss.

6 3 Page 6 of 11 Clin Dent Rev (2017) 1:3 Tooth-related factors Number of teeth involved Secondary etiologic local factors should be carefully evaluated when only a few teeth are affected in patients suffering from chronic periodontal disease. Extractions might be decided after treatment if teeth show clinical and/or radiographic signs of deterioration. Clinical attachment loss Teeth with advanced loss of attachment and deep probing depths will have a decreased survival compared to those presenting with shallow probing pocket depths. High residual probing depths following active periodontal treatment are predictive of further disease progression and tooth loss. In subjects without periodontal care, increasing attachment loss is a significant predictor of tooth loss over time. Loss of bone support and remaining supporting area Radiographic evaluation of the remaining bone support is an important tool for evaluating tooth prognosis. Increased percent of bone loss before periodontal treatment is associated with increased risk of tooth loss. Insufficient bone support may prevent normal function of the tooth and healing after periodontal therapy. Architecture of bone defects The healing potential of the infrabony lesions is primarily dependent on the defect morphology and, specifically, the number of associated bone walls. The healing capacity of intrabony defects is higher than the horizontal, suprabony ones (Fig. 3). Single and multiple teeth with horizontal bone loss may be more difficult to treat than those with angular bony defects (Figs. 1, 2) (Table 3). Fig. 1 I Periapical radiograph of upper incisors shows horizontal bone loss. II Intraoperative aspect shows horizontal bone loss on left side. III Intraoperative aspect shows horizontal bone loss on right side

7 Clin Dent Rev (2017) 1:3 Page 7 of 11 3 Fig. 2 Vertical bone defect on mesial aspect of lower molar. In the most coronal aspect, a one-wall defect, while in the apical area, a two three-wall defect may be appreciated Table 3 Treatment and response to treatment in different clinical conditions Clinical condition Treatment Response to treatment Non-contained bony defects Horizontal bone loss to a level apical to a degree III furcation involvement Bone grafting in combination with regenerative periodontal surgery Periodontal regenerative treatment Greater recession and lower bone defect fill and periodontal regeneration extent Not responsive to treatment Maxillary molars Tunnel preparation Large degree of tooth failure Distal root of a mandibular molar Resection High incidence of failure Root-resected molars that are lonestanding terminal abutments and/or associated with untreated parafunction Resection High incidence of failure Class I and II furcation defects (Fig. 4) Periodontal regeneration Responsive to treatment Class III furcation involvement Not responsive to treatment Buccal class II furcation involvement of mandibular and maxillary molars Buccal class II furcation defects in mandibular molars Approximal class II and for class III furcations Narrow and deep infrabony defects radiographically and clinically Membrane therapy (Guided tissue regeneration) Matrix protein therapies Matrix protein therapies Regenerative periodontal surgery Responsive to treatment Clinical improvements seen No predictable results Respond favorably

8 3 Page 8 of 11 Clin Dent Rev (2017) 1:3 Fig. 3 Intrabony defect on the mesial aspect of the upper molar reveals the furcation entrance apical to the bone crest level Fig. 4 I Periapical radiograph shows loss of periodontal support around posterior lower teeth; furcation involvement in the first molar is also evident. II Intraoperative aspect shows one-wall intrabony defects mesial and distal to the first molar; buccal furcation is only minimally involved (class I). III Lingual aspect reveals extensive furcation involvement at a level apical to the bone crest The application of combined therapeutic approaches (i.e., barrier, bone replacement graft with or without biologics) offer advantage over monotherapeutic alternatives. Mobility Deeper probing depths at a site and tooth mobility at baseline are associated with a bad long-term tooth prognosis. Intraosseous defects around teeth with limited presurgical mobility (Miller s classes 1 and 2) respond favorably to regenerative periodontal surgery, whereas the lack of a possibility to stabilize teeth with vertical mobility (Miller s class 3) before treatment might prevent success. Crown-to-root ratio A poor crown-to-root ratio has been associated with tooth loss.

9 Clin Dent Rev (2017) 1:3 Page 9 of 11 3 Caries and/or endodontic involvement Interproximal and cervical carious defects can be secondary etiologic factors for periodontal disease. Treatment of perio-endo lesions according to Guided Tissue Regeneration (GTR) principles, rather than open flap debridement, may result in large healing of the defects with increased amounts of bone, periodontal ligament and new cementum. Root defects Enamel pearls and other projections, root grooves, root resorption, fractures and fissures should be evaluated as they enhance bacterial plaque accumulation. Root fractures can be caused by mechanical stress due to occlusal forces; restorative procedures with the use of intraradicular posts or endodontic procedures are usually associated with periodontal lesions. Vertical root cracks, fissures or fractures are an obvious reason for early tooth extraction. Tooth position Faulty and tilted tooth positions can be enhancing factors for plaque accumulation, rendering oral hygiene and maintenance more difficult. Tooth malposition is associated with more unfavorable prognosis and a lower survival rate. Root proximity Root proximity in the maxilla is most prevalent between the first and second molar and between the central and lateral incisors and in the mandible the incisor area. Splinted crowns in areas of root proximity will not allow for proper maintenance, orthodontic treatment, root amputation or even tooth extraction, which might be indicated in these cases. Rehabilitation involving the tooth The weakest tooth dictates the prognosis of the whole rehabilitation. Strategic extractions might be indicated where they may significantly improve the prognosis of the adjacent teeth or even the overall prognosis of the rehabilitation. When extensive implant-supported rehabilitation is planned, certain sparse remaining teeth, although with fair prognosis, might have to be extracted to allow for better planning and construction of the rehabilitation. Fixed abutments appear to have increased survival, whereas removable abutments have decreased survival rates. Surgical therapy is more effective than nonsurgical scaling and root planning in reducing the overall mean probing pocket depth and in eliminating deep pockets.

10 3 Page 10 of 11 Clin Dent Rev (2017) 1:3 Therapist knowledge and skill Treatment plans are frequently influenced by the therapist preferences and skills and not necessarily based on all the alternatives available for a certain case. Strategic value of the tooth and treatment alternatives Miller et al. selected six prognostic factors that could be quantitatively evaluated to be scored: (1) age, (2) probing depth (PD), (3) furcation involvement, (4) mobility, (5) molar type and (6) smoking. A statistically derived score was determined for each factor. The sum of these scores became the score for that tooth. Of all these prognostic factors, smoking had the most negative impact, far exceeding the impact of PD, mobility or furcation involvement. Molar type had a lesser impact, and age had the least impact. When considering the replacement of teeth by implants, following wellestablished facts must be taken into consideration: 1. Short roots (less than 7 mm) are acceptable, while short implants (less than 7 mm) are not predictable. 2. Teeth with loss of periodontal support (root exposure) can be maintained for a long time, while implants with loss of support (implant surface exposure) are difficult to maintain. 3. Root proximity is not necessarily detrimental, while implant proximity is highly problematic. 4. Gingiva is highly vascularized and responds well to aggression, while implant mucosa is poorly vascularized and does not respond well to aggression. 5. The esthetic outcome of rehabilitation involving proximal teeth is highly predictable, while the esthetic outcome of implant-supported rehabilitation on proximal implants is unpredictable. 6. Infection around teeth is limited to the gingival component, while infection around implants is not limited and extends to the supporting bone. 7. PDL connects the root and bone and prevents bone resorption, while an implant has no PDL and does not prevent bone resorption after tooth extraction. 8. Long-term (over 50 years) survival of teeth is evident, while long-term (over 50 years) survival of implants is yet to be proven. 9. Periodontal treatment is highly predictable, while treatment of peri-implantitis is unpredictable. 10. Periodontal regeneration is achievable, while regeneration of lost supporting bone and reintegration to implants are rare. 11. Root coverage is predictable, while coverage of the exposed implant surface is extremely difficult. 12. Malposed teeth may be restored and maintained, while misplaced implants are difficult to restore and maintain.

11 Clin Dent Rev (2017) 1:3 Page 11 of 11 3 Pitfalls and complications Periodontal patients seem to be more prone to peri-implant diseases and implant loss. Increased susceptibility for periodontitis may also result in an increased susceptibility to implant loss, loss of supporting bone and postoperative infection. Peri-implantitis therapy effectiveness is impaired in patients with poor compliance. Even in the absence of periodontitis, inflammation and drainage from an endodontic abscess can cause a sinus tract along the periodontal ligament to develop a deep isolated probing depth, which may arrive at the tooth apex or the furcation area in molars, and performing periodontal surgery in these cases will cause serious damage to the periodontal tissues. Further reading 1. Evidence-based decision making in periodontal tooth prognosis and maintenance of the natural dentition. Rosen E et al (eds) Evidence-based decision making in dentistry. doi / _4 2. Ioannou AL, Kotsakis GA, Hinrichs JE (2014) Prognostic factors in periodontal therapy and their association with treatment outcomes. World J Clin Cases 2(12): Newman MG, Takei HH, Klokkevold PR, Carranza FA (2012) Clinical risk assessment. Carranza s clinical periodontology. Elsevier Saunders, Philadelphia, pp Sanz M, Jepsen K, Eickholz P, Jepsen S (2015) Clinical concepts for regenerative therapy in furcations. Periodontology (1): Chrcanovic BR, Albrektsson T, Wennerberg A (2014) Periodontally compromised vs. periodontally healthy patients and dental implants: a systematic review and meta-analysis. J Dent 12: