Title: QUESTION?
1QUESTION?
Is my disease fatal?Will I lose my teeth?Will
your treatment help me?What can you do to help
me?
2? 11 ? PROGNOSTIC JUDGMENT TREATMENT PLANNING
?????????
3PROGNOSIS
Prognosis??Forecast??????
4? ? ? ?
??? ? ? ??? ????
?? ? ??? ?? ?
?? ? ??? ?? ?
?? ? ??? ? ??/???
?? ? ??? ? ??/???
5??????
?????
???? ????
??????
?? ??? ??
???? ????
????????
6????????????????????
????????????
7??????
8????????????????,????
- ??????
- ??????CP,?????
- ?????????,????
9????????????
- ????????
- ???????????
- ???
- ?????????
- ?????
- ???????
- ??????????
10????????
- ?????????
- ??????
- ???????????
- ???
- ?????????????
- ????
- ???????????
- ???
11???????
12????
- ???????
- ?????????
- ????? ???
- ??? ???
- ???????
13?????????????????????????
- ?????????
- ???????????
- ????
14????
15????????
- ????
- INITIAL THERAPY
- ?????????
- ????
16??????
- ?????????
- ???????
- ?????
- ???????
- ???
17????
- ???????????
- ??????
- ????
18????,????????????
- ????-????
1st?????46????,?? ???????????
19?????
20??????
- ??????????????????
- ????????
- ?????13?????
21?????
22???
- ?????
- ???????
- GTR
- ????
- ????
23????????????????????
24?????????
- 1st???????????2?3?????????,????
25????
- ????36??1??
- ??
- PLI?CI?DI?GI?BOP?PD?
- ??????????
- ????????????
- ???????????
26??
27?????????
28OVERTHANKS
29????????????? ??????(NOSOCOMIAL
INFECTION)?????????
30??????????
- ????????????????????
- ?????????????(???????)
- ????(???????????????)
- ????????????????
31?????HBV?????10,???????????????
32?????????????
33???????????????????????????????universal
precaution????????????????????,????????????,?????
???????
34 ??????? ?????????????????
???????????????????????????????????????????????
?????????????,????????????????
35??????????????(?????????????)????????2????????
??,????2?,???1?????
36???????????????????????????????,???????????????
?,????????????????????,??????
37?????????????????????????????????????????????????
??????,???????
38?????????????????1?????0.12?????????,??????????
?????????????????????????????????
39?????????????????????????????,????30?????????
????????????????????????????,????110???????????,
???????????
40?????????????,??????????????????????????????????
?????
41Prognosis has different connotations and nuances.
Treatment can alter prognosis.
- The patient has every right to know the answers
to these questions.
42Question?
Is my disease fatal?Will I lose my teeth?Will
your treatment help me?What can you do to help
me?
43What are the therapeutic "odds"?What are the
financial risks? What are the chances that the
treatment will be of benefit?
44Prognosis has three meanings
in dentistry.
45Diagnostic prognosis.
- What are evaluations of the course of the disease
without treatment? - What is the status of the teeth now
- What is the anticipated future of these teeth?
46Therapeutic prognosis.
- Given the state of the art and science of
periodontics and the knowledge and skill of the
practitioner, what effect will periodontal
treatment have on the course of the disease?
47Prosthetic prognosis.
- What is the forecast for the success of the
prosthetic restoration? - Will the prosthesis be therapeutic or
detrimental? - What specific needs dictate that it be
prescribed?
48Judgement of the severity depends on
- 1. pocket depth,
- 2. degree of bone loss,
- 3. tooth mobility,
- 4. crown-root ratio.
49generalized or localized
The distribution of disease Inflammatory factors
Traumatic factors
50Individual tooth therapeutic prognosis
includes such factors as Percentage of bone
loss Probing depth
51Distribution and type of bone lossPresence and
severity of furcation involvementsMobility
52Crown-root ratioPulpal involvementTooth
position and occlusalStrategic value
53Following are factors included in overall
prognosis
54Individual tooth prognoses (distribution and
severity)Degree of involvement, duration, and
history of the disease (rate of progression)
55Patient cooperationEconomic considerationsKnowle
dge and ability of the dentistEtiologic factors
56Accuracy and completeness of the information
gathered at the examinationDentist's ability to
recognize and eliminate or control the factors
causing the disease
57the patient's ability and determination in
maintaining the health of the periodontium and
teeth.
58The overall prognosis depends on the prognoses of
the individual teeth.
59PAST HISTORY (RATE OF DESTRUCTION)
60Probably the most important factor in forecasting
the future health status of a dentition is
knowledge of its past health status.
61Speed of breakdown under controls or uncontrols
The location, shape and depths of the pockets
62Tooth mobility can be controlled or eliminated,
the prognosis is better.The greater the bone
loss, the poorer the prognosis.
63As bone loss exceeds 50, the prognosis worsens
rapidly.The more irregular the bone loss, the
poorer the prognosis.
64the pattern of bone loss horizontal, vertical or
infrabony defects.the age of the patient and the
etiologic factors involved in the patient's
disease.
65poorer prognosis tilted, drifted, or rotated,
hygiene difficult, elimination of pockets impaired
66periodontal disease is complicated by active
systemic factors and traumatism
67morphologic in nature and include the number and
distribution of teeth, tooth morphology,
furcation involvement.
68Extent of involvement. Is the furcation
partially or totally involved?Status of bone
support. If the bone levels are relatively
sound, the effort to save may be justifiable.
69Root length and crown-root ratio must be
considered
70Angulation of root spread. Health of neighboring
teeth.
71The number and distribution of teeth
presentcrown-root ratio,shape and number of the
root
72the height of the alveolar crestpersonal
psychologic and sociologic, financial
considerations.
73OTHER CONSIDERATIONS IN ESTABLISHING PROGNOSIS
74The performance of home care is acceptable and
the caries incidence is low,the prognosis is
better
75The prime consideration is the preservation of
the dentition as a functioning unit.
76In some instancesthe extraction of a single
tooth will make the whole situation untenable.In
other situations isolated extractions will
simplify the problem.
77what is considered to be a hopeless tooth. This
will make treatment planning simpler.
78the characteristics of hopeless periodontally
involved teeth
79Associated with intractable pain relieved,
massive infection reduced by extractionMobility
beyond 3 degrees
80Furcation involvement with little or no
interradicularboneBone loss beyond the apexBone
loss to the apex on one side of the tooth
81Generalized circumferential bone loss to within 3
mm of the apexPocket depth to the apex without
pulpal involvementVertical cracks or fractures
82Inaccessible perforations or accessory
canalsNumber and position of remaining teeth
precluding prostheticExtreme caries
susceptibility
83Objectivesof treatment
84Treatment goals should be evaluated in every case.
85Can treatment objectives of a firm
non-retractable gingiva that does not bleed be
reached? Can the pocket be eliminated? Will the
bone regenerate? Can the tooth be stabilized?
86Can tooth be restored?Can the patient tolerate
the treatment?
87If you believe the answers to these questions to
be "yes," then plan and proceed with the
treatment. If no, alternative treatment,
compromise, or extraction is advisable.
88As definitive laboratory tests are developed to
make diagnosis more accurate, and as further
knowledge concerning the etiology and
pathogenesis of periodontal diseases is
developed, prognosis will change from a
qualitative to a quantitative judgment.
89TREATMENT PLAN
90PresentationPatient consentOrder of
treatmentPhase IPhases Il and IIIMaintenance
therapyProsthetic prescription
91Alternative treatment plansTreatment
criteriaQuality of carePhilosophy of
treatmentRecord keepingReferral
92PresentationPatient consentAfter hearing the
presentation, the patient must decide whether to
undergo treatment.
93PHASE I
94First steps (The initial effort) should be
directed toward the elimination of inflammation
and the institution of a program of plaque
control.
95To reduce pocket depthTo minimize periodontal
traumatismOrthodontics(may precede or follow
any surgical interventions)
96Extractions(Teeth with hopeless
prognoses)RestorationsUsually periodontal
therapy should precede restorative interventions.
the restorations should be temporary
97The provisional splinting during the treatment
period should be evaluated.
98Scheduling of restorative treatment should be
done according to the following general rules
99Normal patients. (Restorative treatment starts
immediately.)Class I (ADA periodontal disease
classification)
100Without occlusal treatment needCaries control
and scaling and root planning. including plaque
control, may be simultaneous. Definitive
restorative treatment should follow completion of
scaling and plaque control.
101With occlusal treatment need Definitive
restorative treatment may immediately follow
completion of scaling, plaque control, and
occlusal adjustment.
102With surgical treatment need Definitive
restorative treatment should not be instituted
for at least 4 to 6 weeks after the patient has
healed.
103Splinting(Wire ligation and composite acid-etch
splinting)Emergency (pain, swelling, infection,
and discomfort)The emergencies all take priority
over other treatment scheduling.
104Medical status a systemic condition that would
complicate treatment, a medical consultation is
necessary.
105PHASES II AND III
106Phase II surgery permits pocket elimination /
reduction The restoration of normal osseous form
ostectomy-osteoplastyosseous surgery combined
with grafting procedures
107root resectionsmucogingival and
gingivectomyperiodontal-endodontic restorative
treatmentprovisional splinting.
108Maintenance therapyThe specialist may see the
patient once a year or every other year for the
less involved cases, whereas the generalist
maintains the patient in the recall system.
Advanced cases may be seen alternately at 2- to
4-month intervals.
109PROSTHETIC PRESCRIPTIONWaiting for a period of
at least 2 months after periodontal
surgery.Partial dentures or a fixed prosthesis
110ALTERNATIVE TREATMENT PLANS
111Alternative treatment plans should be prepared
for the patient who elects to forego splinting
and surgery when these are indicated.
112In this case the patient may be treated through
phase I therapy and be placed on a maintenance
schedule. The establishment of an alternative
plan generally calls for a rigorous maintenance
schedule with scaling and planing performed more
frequently than is otherwise usual.
113Treatment criteria
114Quality of careIn general, periodontal care
seeks the followingRemoval of known etiologic
factorsReduction of all pockets to a minimal
depth to facilitate maintenance by the patient
and the dental hygienistCreation of a
maintainable gingival and osseous architecture
115Restoration of a functional and esthetic
dentitionMaintenance of the resulting health by
the patient, doctor, and hygienist
116PHILOSOPHY OF TREATMENT
117periodontal diseases can be treated successfully
the health of the diseased periodontium can be
restored and the teeth maintained.
118The therapeutic concept of today includes all
forms of therapy, conservative and complex
selected and blended for the successful
management of the individual patient.
119Therapy must be tailored to the needs, both
physical and psychologic, of the patient.
120RECORD KEEPINGThe treatment performed should be
recorded carefully at each visit.
121ReferralThere are three basic reasons for
referral(1) professional, (2) moral an
ethical, and (3) legal.
122Professional Professional referrals are
classified as follows1. MedicalReferral/consul
tation is indicated when a patient's medical
history discloses significant information that
may contribute to or influence the course and
outcome of the treatment or when the dentist
suspects illness.
1232.Dental Referral/consultation is indicated
when the dentist cannot provide the entire
dental therapy the patient needs. When the
examination reveals periodontal disease that the
generalist cannot or does not wish to treat,
referral to a periodontist is in order. Equally
the periodontist is obligated to refer patients
for treatment to the general practitioner or
other specialists.
1243.Moral and ethical
- The specialists or consulting dentists upon
completion of their care shall return the
patient, unless the patient expressly reveals a
different preference, to the referring dentist,
or if none, to the dentist of record for future
care.
125The specialists shall be obligated when there is
no referring dentist and upon a completion of
their treatment to inform patients when there is
a need for further dental care.
126Other reasons for referral includepatient
relocation, dentist-patient personality
conflict, and dentist's preference.Some
dentists do not use specialty, do not use
specialty service
127CommunicationInforming the patient about the
disease conditiona recall-maintenance schedule
should be made.
128DocumentationAll communication, written or
verbal, must be properly documented on the
patients chart.Patients have the right of
access to their records and may acquire copies of
the original documents, not original documents.
129Summary
130It is difficult for the dentist or specialist to
possess expert knowledge and skill in all areas
of dentistry because of the ever-expanding scope
and complexity of dental therapy.
131Today's dentist is confronted with a wide range
of treatment procedures and available
alternatives. At all times during the course of
treatment, the primary focus is the patient's
welfare.
132Effective communication and interaction among the
dentist, the patient, and the specialist are
vital elements of proper treatment.