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iii. Prognosis of individual teeth Establishment of tooth prognosis in stage IV periodontitis patients, and especially the differentiation of compromised/ questionable teeth from those of hopeless prognosis is complex and requires a multidisciplinary approach to identify the ability of treatment(s) that may change the assigned prognosis, which is usually linked to the experience and technical ability of the indi- vidual operator(s). Individual tooth prognosis is frequently compli- cated by the need to assess the possibility of a periodontally compromised tooth that is to be used as an abutment for a fixed or a removable restoration. Studies focusing on periodontal prog- nosis have shown that it is difficult to accurately predict tooth survival, something that even specialists tend to underestimate (McGuire & Nunn, 1996). Key for long-term prognosis is the abil- ity to achieve the endpoints of periodontal therapy that were identified in the guideline for the treatment of periodontitis in stages I – III (Loos & Needleman, 2020; Sanz, Herrera, et al., 2020), and the implementation of an effective supportive periodontal care programme. iv. Restorative factors The extent of the edentulous spaces, as well as the number, distri- bution and restorability of teeth that can be retained must be assessed, while considering all restorative scenarios, either focusing on teeth alone and/or with the addition of dental implants. These scenarios must consider the technical complexities of the planned prosthesis, as well as the interventions required to place implants, depending on the availability of adequate ridge dimensions. v. Prognosis of the overall case The overall case prognosis must be established while considering the individual susceptibility of the patient, based on a thorough analysis of the patient's modifiable and non-modifiable risk factors, using the primary grade criteria as well as the grade modifiers defined earlier (Papapanou et al., 2018; Tonetti et al., 2018). The prognosis should also estimate the probability of disease recur- rence/progression, which is a differentiator in the management of stage IV periodontitis patients from other complex restorative cases (Baumer et al., 2011; Lang et al., 2015; Lang & Tonetti, 1996). The case analysis required to make a sound prognostic assessment and an appropriate treatment plan is complex and requires a detailed assessment of what is technically and biologically feasible, cost-effective and in line with the patient's preferences and expectations.
• Primary occlusal trauma in people with periodontitis. • Masticatory dysfunction in people who have experienced multiple tooth loss that cannot be attributed to periodontitis and in the absence of periodontitis. • Masticatory dysfunction in people who have experienced multiple tooth loss that cannot be attributed to periodontitis, but in the presence of stage I – II periodontitis or localized stage III periodontitis • Generalized stage III periodontitis without tooth loss, or without the other criteria that define stage IV periodontitis. This differential diagnosis may be difficult in some borderline cases. A recent cross- sectional study, with limited external applicability (Uy et al., 2021), has shown that stage IV periodontitis cases, when compared with other periodontitis cases, were more likely to present more severe periodontal breakdown, tooth hypermobility and loss of posterior functional tooth units, as well as self-reporting changes in dietary habits due to their oral condition, impaired chewing ability and lower quality of life.
4.1.3 | Phenotypic variation and identification of clinical case types
Stage IV periodontitis cases may present with great phenotypic variation based on the individual patterns of their periodontal breakdown, number of missing teeth, inter-maxillary relationships and residual alveolar ridge, which will result in different degrees of functional and aesthetic compromise, as well as different treatment needs. To provide a simplified workable guideline, four major stage IV periodontitis phenotypes were recognized by the organizing commit- tee, leading to specific clinical case types: • Case type 1: the patient with tooth hypermobility due to second- ary occlusal trauma that can be corrected without tooth replace- ment. It is recognized that there is a continuum of severity and complexity of management between some stage III periodontitis patients, and case type 1 of periodontitis in stage IV. • Case type 2: the patient with pathological tooth migration, charac- terized by tooth elongation, drifting and flaring, which is amenable to orthodontic correction. • Case type 3: partially edentulous patients who can be prostheti- cally restored without full-arch rehabilitation. • Case type 4: partially edentulous patients with a dentition that need full-arch rehabilitation, either tooth- or implant-supported/ retained. These phenotypes and associated clinical case types may overlap on occasion, as one arch may require treatment according to a specific scenario while the other might require a different approach. Furthermore, after orthodontic treatment, it is frequently necessary to retain the teeth in the new position with a fixed type of retainer/splint. SRs covering the specific scenarios have been
4.1.2 | Differential diagnosis
For the practical implementation of the case definition and treatment planning, an appropriate differential diagnosis should be established based on the identification of cases with:
• Opening of diastemata or tooth migration secondary to orthodon- tic relapse.
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