Monday, April 13, 2009

Determining prognosis

Ian Peace investigates the best route in a world of ‘understandably demanding patients’

How do you determine the prognosis for a periodontally involved tooth? As my experience grows, I find this process involves many different – often unanswerable – questions. Sometimes, gut instinct is needed.

For one thing, there are more teeth I can save – at least in the medium term – but also for the longer term. However, just because I can save a tooth, is it the best thing to do for the patient and the overall treatment plan?

Let us throw together a few ideas on how to determine whether a tooth is saveable or not and, if it is potentially saveable, consider what the best option is. I like to divide my decisions into two categories:

• Is the tooth saveable in its own right?
• If the tooth is saveable, how does this fit into the overall plan?

Factors to consider for the individual tooth/teeth:

• How severe is the disease around the tooth as
indicated by pocket probing depth and attachment loss?
• How important is bleeding at the initial presentation in terms of tooth prognosis?

I don’t pay too much attention to bleeding at the initial presentation, as usually everywhere tends to bleed. I am more interested in bleeding sites at three months’ post-operative and, even then, with caution. Factors to consider for the tooth as a part of an overall treatment plan are:

• How important is the tooth in terms of function and aesthetics?
• If we lose the tooth, how easy is it to replace?
• Is it more cost effective for the patient to retain the tooth, even if only as a temporary measure?
• How important is the tooth to the patient psychologically?
• Will tooth loss make them feel old or de-motivate them?
• What can the patient afford? This may be more dependent upon your ability to sell, rather than what the patient can truly afford!

Melting pot

Where initial non-surgical therapy is involved, I am willing to throw as many teeth into the treatment melting pot as possible. Non-surgical treatment is safe and extremely cost effective per tooth. I usually only remove absolutely hopeless teeth at first presentation where there is bone loss at, or beyond, the apex of the root. Even then, I may retain some of these for a while. It is not until the three-monthly recall (or sometimes up to nine months after initial therapy where the disease was very advanced) that I make my final decisions with regards to tooth prognosis and restorative options.

If non-surgical therapy has not worked (and, in my practice, it is very rare) then we have to sit down and look at the options available. Decisions are then based on the above criteria but in more detail.

For instance, with regards to furcation defects, we would need to look at the nature of the defect, root morphology, bone levels, intra-oral access for treatment and then decide whether the patient is suitable for more advanced procedures. Do we do surgery or maintain furcations non-surgically? Do we hemi-sect, amputate roots or remove the tooth and place a dental implant, bridge or denture?

Decisions, decisions! These decisions are more difficult in the world of understandably demanding patients.

Ian Peace is speaking at the World Aesthetic Congress on 12-13 June in London. For further information and to book please call 0800 371652 or visit


Ian Peace

Ian Peace BDS, MmedSci, runs a private periodontal referral practice in Nottingham, and offers postgraduate periodontal courses aimed at the whole dental team. For further details call 08700 114 512 or email