Evidence-based decision making in periodontal tooth prognosis and maintenance of the natural dentition

Abstract

The main objective of periodontal therapy is long-term preservation of the periodontium. Before a treatment plan is established, diagnosis and etiological factors of the disease as well as the prognosis of the remaining teeth should be determined, while predicting the final functional and esthetic result. An accurate prognosis is most critical when periodontal therapy is combined with large oral prosthetic rehabilitation or with dental implants; in these complex cases, an accurate long-term prognosis of the involved teeth must be established at the time of treatment planning. According to several patient- and tooth-related factors, tooth prognosis can artificially be classified into good, fair, poor, questionable, hopeless, and indicated for extraction; however, borders are not always evident. Among the factors affecting tooth prognosis related to the patient, 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, and willingness to preserve tooth or teeth can be enumerated. Among the tooth-related factors, 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 can be enumerated. Evidence-based dentistry requires application of current evi- dence in making decisions about the care of individual patients, actually closing the gap between clinical research and real clinical practice. Evidently, evidence-based dentistry requires integration of the best evidence from literature with clinical expertise as well as patient preferences and therefore informs, but never replaces, clinical judgment. The present chapter will review all prognosis-related factors while at the same time trying to suggest a chart that might help in determining tooth prognosis for every single case. The alternatives for each case must be considered; in most cases where teeth are extracted for periodontal reasons, implant therapy will demand large bone augmentation procedures, and therefore, morbidity, duration, and success of these must be carefully evaluated before periodontal therapy is discarded. Furthermore, periodontal patients seem to be more prone to peri-implant diseases and implant loss.