Evidence-based literature on periodontal prognosis due to pre-existing conditions.

Describe the tooth

What type of tooth is it?

Please select one Maxillary First Molar Maxillary Second Molar Mandibular Molar Non-molar

Does the patient has diabetes (A1C levels)?

Please select one less than 6.5 6.5 to 7.0 7.1 to 8.0 8.1 to 9.0 more than 9.1

Is the patient a smoker?

Please select one No Casual smoker Smokes 1/2 pack per day smokes 1 pack per day smokes more than 1 pack per day

How old is the patient?

Please select one less than 40 40 or older

What is the probing depth?

Please select one 4mm or less 5mm 6mm 7mm 8mm 9mm 10mm more than 10mm

What is the tooth mobility?

Please select one Grade 0 Grade I (greater than physiologic) Grade II (1 mm mobility) Grade III or more(over 1 mm mobility)

Is the patient an untreated bruxer?

Please select one No Yes

What is the percentage of bone loss?

Please select one 0 to 10 % 11 to 25 % more than 25 %

Describe oral hygiene over multiple visits

Please select one Good (debri covers less than 20% of tooth surfaces) Fair (debri covers 20-33% of tooth surfaces) Poor (debri covers over 33% of teeth surfaces)

What is the grade of furcation involvement?

Please select one Not applicable Grade 0 (no defect) Grade I (defect less than 3mm) Grade II (defect more than 3mm) Grade III or more (encompassing defect)

Is the tooth an abutment for a removable partial denture?

Please select one No Yes

Is the crown-root ratio satisfactory?

Please select one No (more than 1-to-1) Yes (less than 1-to-1)

Is there a family history of periodontal disease?

Please select one No Yes

Is the patient wearing a nightguard?

Please select one No Yes

Is the root form satisfactory?

Please select one No (harbours plaque,i.e. grooved) Yes (normal root shape)