An elaborate presentation on prognosis and treatment plan.

1. DETERMINATION OF
PROGNOSIS AND
TREATMENT PLAN
DR AISHWARYA PANDEY
DEPARTMENT OF PERIODONTOLOGY
BANARAS HINDU UNIVERSITY

2. PROGNOSIS
•The prognosis is a prediction of the
course, duration and outcome of a
disease based on the pathogenesis of the
disease and the presence of risk factors for
the disease.
•It is established after the diagnosis is made
and before the treatment plan is established.

3. •Prognosis is often confused with the term risk. Risk
generally deals with the likelihood that an individual
will develop a disease in a specified period.
•Risk factors are characteristics that put an
individual at increased risk for developing a
disease.
•In contrast, prognosis is the prediction of the course
or outcome of a disease.
•Prognostic factors are characteristics that predict
the outcome once the disease is present. In some
cases, risk factors and prognostic factors are the
same. For example, patients with diabetes or
patients who smoke are more at risk for acquiring
periodontal disease, and once they have it, they
generally have a worse prognosis.

4. TYPES OF PROGNOSIS
•Good prognosis: Control of etiologic factors
and adequate periodontal support ensure the
tooth will be easy to maintain by the patient
and clinician.
•Fair prognosis: Approximately 25%
attachment loss or grade I furcation invasion
(location and depth allow proper maintenance
with good patient compliance).
•Poor prognosis: 50% attachment loss, grade
II furcation invasion (location and depth make
maintenance possible but difficult).
McGuire & Nunn (1996)

5. •Questionable prognosis: >50% attachment
loss, poor crown-to-root ratio, poor root form,
grade II furcation invasion (location and depth
make access difficult) or grade III furcation
invasion; mobility no. 2 or no. 3; root proximity.
•Hopeless prognosis: Inadequate attachment
to maintain health, comfort, and function.

6. •In contrast to schemes based on tooth mortality,
Kwok and Caton (2007) proposed a scheme based
on “the probability of obtaining stability of the
periodontal supporting apparatus.”
•Favorable prognosis: Comprehensive periodontal
treatment and maintenance will stabilize the status
of the tooth. Future loss of periodontal support is
unlikely.
•Questionable prognosis: Local or systemic factors
influencing the periodontal status of the tooth may
or may not be controllable. If controlled, the
periodontal status can be stabilized with
comprehensive periodontal treatment. If not, future
periodontal breakdown may occur.

7. •Unfavorable prognosis: Local or systemic factors
influencing the periodontal status cannot be
controlled. Comprehensive periodontal treatment
and maintenance are unlikely to prevent future
periodontal breakdown.
•Hopeless prognosis: The tooth must be extracted.

9. Recent Classification by McGowan,
Kelly McGowan, Saso Ivanovski (2017)
• This system uses six tooth level and three patient level factors
to give each tooth a prognosis of secure, doubtful, poor or
irrational to treat.
• The ratio of bone loss:age, periodontal pocket depth, extent of
furcation involvement, presence of an infrabony defect,
compromising anatomical factors and the extent of tooth
mobility are the tooth level factors incorporated into the model.
• The patient level assessment uses smoking, poorly controlled
diabetes and bleeding on probing to downgrade the prognosis
by one level as previous research has established that these
factors are significantly associated with an increased risk of
tooth loss.

11. •In many of these cases, it may be advisable to
establish a provisional prognosis until phase I
therapy is completed and evaluated.
•The provisional prognosis allows the clinician to
initiate treatment of teeth that have a doubtful
outlook in the hope that a favorable response
may tip the balance and allow teeth to be
retained.
•The reevaluation phase in the treatment
sequence allows the clinician to examine the
tissue response to scaling, oral hygiene, and
root planing, as well as to the possible use of
chemotherapeutic agents where indicated.
•The patient’s compliance with the proposed
treatment plan also can be determined.

13. Overall Clinical Factors
•Patient Age
•For two patients with comparable levels of remaining
connective tissue attachment and alveolar bone, the
prognosis is generally better for the older of the two. For
the younger patient, the prognosis is not as good
because of the shorter time frame in which the
periodontal destruction has occurred; the younger
patient may have an aggressive type of periodontitis, or
disease progression may have increased because of
systemic disease or smoking.
•In addition, although the younger patient would
ordinarily be expected to have a greater reparative
capacity, the occurrence of so much destruction in a
relatively short period would exceed any naturally
occurring periodontal repair.

14. Disease Severity
• The determination of the level of clinical attachment
reveals the approximate extent of root surface that is
devoid of periodontal ligament; the radiographic
examination shows the amount of root surface still
invested in bone.
•Pocket depth is less important than level of attachment
because it is not necessarily related to bone loss. In
general, a tooth with deep pockets and little attachment
and bone loss has a better prognosis than one with
shallow pockets and severe attachment and bone loss.
• The prognosis also can be related to the height of
remaining bone.

15. •The type of defect also must be determined. The
prognosis for horizontal bone loss depends on the
height of the existing bone.
•In the case of angular, intrabony defects, if the
contour of the existing bone and the number of
osseous walls are favorable, there is an excellent
chance that therapy could regenerate bone to
approximately the level of the alveolar crest.
•When greater bone loss has occurred on one
surface of a tooth, the bone height on the less
involved surfaces should be taken into consideration
when determining the prognosis.

16. Prognosis for tooth A is better than for tooth B, despite less bone on
one of the surfaces of A. Because the center of rotation of tooth A is
closer to the crown, the distribution of occlusal forces to the
periodontium is more favorable than in B.

17. Biofilm Control
•Bacterial biofilm is the primary etiologic factor
associated with periodontal disease.
•Therefore effective removal of plaque on a daily
basis by the patient is critical to the success of
periodontal therapy and to the prognosis.

18. Patient Compliance and Cooperation
• The prognosis for patients with gingival and periodontal
disease is critically dependent on the patient’s attitude, desire
to retain the natural teeth, and willingness and ability to
effectively control biofilm. Without these, treatment cannot
succeed.
• If a patient is unwilling to perform adequate biofilm control and
receive the timely periodic maintenance checkups and
treatments that the dentist deems necessary, the dentist can
refuse to accept the patient for treatment.
• The dentist should make it clear to the patient and in the
patient record that further treatment is needed but will not be
performed because of a lack of patient cooperation.

19. Systemic and Environmental
Factors
•Smoking
•It should be made clear to patients that a direct
relationship exists between smoking and the
prevalence and incidence of periodontitis.
•In addition, patients should be informed that
smoking affects not only the severity of periodontal
destruction but also the healing potential of the
periodontal tissues.
•As a result, patients who smoke do not respond as
well to conventional periodontal therapy as patients
who have never smoked.

20. •Therefore the prognosis in patients who smoke and
have slight to moderate chronic periodontitis is
generally questionable.
•In patients with severe chronic periodontitis, the
prognosis may be unfavorable or hopeless.
•However, it should be emphasized that smoking
cessation can affect the treatment outcome and
therefore the prognosis.
•As such, for patients who stop smoking, the
prognosis can improve to favorable in those with
slight to moderate chronic periodontitis and to
questionable in those with severe chronic
periodontitis.

21. Systemic Disease or Condition
• The patient's systemic background affects overall
prognosis in several ways. For example, the prevalence
and severity of periodontitis is significantly higher in
patients with type I and type II diabetes than in those
without diabetes and that the level of control of the
diabetes is an important variable in this relationship.
• Well-controlled diabetics with slight-to-moderate
periodontitis who comply with their recommended
periodontal treatment should have a good
prognosis.
• Conditions that limit the patient's performance of oral
procedures (e.g., Parkinson's disease) also adversely affect
the prognosis.
• Newer automated oral hygiene devices such as electric
toothbrushes may be helpful for these patients and
improve their prognosis.

22. Genetic Factors
•Periodontal diseases represent a complex
interaction between a microbial challenge and the
host's response to that challenge, both of which
may be influenced by environmental factors such as
smoking.
•Genetic factors may play an important role in
determining the nature of the host response.
•Genetic polymorphisms in the interleukin-1 (IL-1)
genes, resulting in increased production of IL-1
have been associated with a significant increase
in risk for severe, generalized, chronic
periodontitis.
•Genetic factors also appear to influence serum IgG2
antibody titers and the expression of Fc-RII
receptors on the neutrophil, both of which may be
significant in aggressive periodontitis.

23. Stress
•Physical and emotional stress, as well as substance
abuse, may alter the patient’s ability to respond to
the periodontal treatment performed. These factors
must be realistically faced when attempting to
establish a prognosis.

24. LOCAL FACTORS
•Biofilm and Calculus
•The microbial challenge presented by bacterial
biofilm and calculus is the most important local
factor in periodontal diseases.
•Therefore in most cases, having a favorable
prognosis depends on the ability of the patient and
the clinician to remove these etiologic factors.

25. •Subgingival Restorations
•Subgingival margins may contribute to increased
biofilm accumulation, increased inflammation, and
increased bone loss when compared with
supragingival margins. Furthermore, discrepancies
in these margins (e.g., overhangs) can negatively
impact the periodontium.
•The size of these discrepancies and duration of
their presence are important factors in the amount
of destruction that occurs. In general, however, a
tooth with a discrepancy in its subgingival margins
has a worse prognosis than a tooth with well-
contoured supragingival margins.

26. Anatomical Factors
Anatomic factors that may predispose the
periodontium to disease, and therefore affect the
prognosis, include short, tapered roots with large
crowns, cervical enamel projections (CEPs) and
enamel pearls, intermediate bifurcation ridges, root
concavities, and developmental grooves.
Prognosis is poor for teeth with short tapered roots
and large crowns.
Disproportionate crown-to-root ratio and the reduced
root surface available for periodontal support, the
periodontium may be more susceptible to injury by
occlusal forces.

27. Cervical enamel projections (CEPs), ectopic
extensions of enamel that extend beyond the normal
contours of the cementoenamel junction. Extend into
the furcation. Found on buccal surfaces of maxillary.
Enamel pearls are larger, round deposits of
enamel that can be located in furcations or other
areas on the root surface.
An intermediate bifurcation ridge is described in 73%
of mandibular first molars, crossing from the mesial
to the distal root at the midpoint of the furcation.
Interferes with the attachment apparatus and may
prevent regenerative procedures from achieving
their maximum potential.

28. •Tooth Mobility
•The principal causes of tooth mobility are loss of
alveolar bone, inflammatory changes in the
periodontium, and trauma from occlusion.
•Tooth mobility caused by inflammation and trauma
from occlusion may be correctable.
•However, tooth mobility resulting from loss of
alveolar bone is not likely to be corrected.
•The likelihood of restoring tooth stability is inversely
proportional to the extent to which mobility is
caused by the loss of supporting alveolar bone.

29. •Caries, Tooth Vitality, and Root Resorption
• For teeth mutilated by extensive caries, the feasibility of
adequate restoration and endodontic therapy should be
considered before undertaking periodontal treatment.
• Extensive idiopathic root resorption or root resorption
resulting from orthodontic therapy jeopardizes the
stability of teeth and adversely affects the response to
periodontal treatment.
• The periodontal prognosis of treated nonvital teeth does
not differ from that of vital teeth.
• New attachment can occur to the cementum of both
nonvital and vital teeth.

30. •Prosthetic and Restorative Factors
•The overall prognosis requires a general
consideration of bone levels (evaluated
radiographically) and attachment levels (determined
clinically) to establish whether enough teeth can be
saved either to provide functional and aesthetic
dentition or to serve as abutments for a useful
prosthetic replacement of the missing teeth.
•At this point, the overall prognosis and individual
tooth prognosis overlap because the prognosis for
key individual teeth may affect the overall prognosis
for prosthetic rehabilitation.
•For example, saving or losing a key tooth may
determine whether other teeth are saved or
extracted or whether the prosthesis is fixed or
removable.

32. The treatment plan is the blueprint for case
management.
Treatment is planned after diagnosis & prognosis
established.
Includes all procedures required for establishment &
maintenance of oral health.

33. Involves following decisions:
 Emergency treatment (pain, acute infections)
 Removal of nonfunctional and diseased teeth; strategic
extraction of healthy teeth to facilitate the prosthetic
reconstruction of the patient
 Treatment of periodontal diseases (surgical/
nonsurgical; regenerative/resective).
 Endodontic therapy (necessary and intentional)
 Caries removal and placement of temporary and
final restorations
 Occlusal adjustment and orthodontic therapy
 Replacement of missing teeth with removable or fixed dental
prostheses or dental implants
 Aesthetic demands
 Need for temporary restorations.

34. Unforeseen developments during treatment may
necessitate modification of initial treatment plan.
Except for emergencies, no treatment should be
started until treatment plan established.

35. Periodontal therapy can restore chronically inflamed
gingiva and can eliminate infection and alleviate pain

36.  Eliminate pain, exudate, gingival inflammation &
bleeding,
 Reduce periodontal pockets & eliminate
infection,
 Stop pus formation,
 Arrest destruction of soft tissue & bone,
 Reduce abnormal tooth mobility,
 Establish optimal occlusal function,
 Restore tissue destroyed by disease,
 Reestablish physiologic gingival contour,
 Prevent recurrence of disease &

38. A IMMEDIATE
B INTERMEDIATE
C LONGTERM

39. IMMEDIATE GOALS
• Elimination of all infectious and inflammatory
processes that cause periodontal and other oral
problems, and that may hinder the patient’s general
health.
• Basically, the immediate goals are to bring the oral
cavity to a state of health.
• This may require patient education on infectious oral
diseases and disease prevention, periodontal
procedures, endodontics, caries control, oral surgery
and treatment of oral mucous membrane pathologies.

40. INTERMEDIATE GOALS
• Reconstruction of a healthy dentition that not only
fulfills all functional and aesthetic requirements but
lasts many years.
• Restoration of health, function, aesthetics and
longevity involves endodontic, orthodontic,
periodontal, and prosthodontic considerations as well
as the age, health and desires of the patient.
• The intermediate goals may be quickly achieved or
require treatments over months or years, depending
upon the complexity of the case, the therapy involved
and the financial status of the patient.

41. LONGTERM GOALS
• Maintenance of health through prevention and
professional supportive therapy.
• Maintenance of health requires patient education on
disease prevention and oral hygiene at the onset of
treatment, meticulous daily home care by the patient,
and patient adherence to professional recall
maintenance.

42. Periodontal treatment requires long range planning.
Its value to patient is measured in years of healthy
functioning of entire dentition, not by number of
teeth retained at time of treatment.
Treatment is directed to establishing &
maintaining health of periodontium
throughout mouth rather than attempting the
efforts to “tighten loose teeth”.
20

43. Teeth on borderline of hopelessness do not
contribute to overall usefulness of dentition, even if
they can be saved.
They become sources of recurrent annoyance to
patient & detract from value of greater service
rendered by establishment of periodontal health in
the remainder of oral cavity.
22

44. Tooth should be extracted when any of following
occurs:
It is so mobile that function becomes painful.
It can cause acute abscesses during therapy.
There is no use for it in overall treatment plan.
23

45. Tooth can be retained temporarily, postponing
decision to extract it until after treatment, when any
of following occurs:
It maintains posterior stops; it can be removed
after treatment when it can be replaced by
prosthesis.
It maintains posterior stops & may be functional
after implant placement in adjacent areas – When
implant is restored, these teeth can be extracted, if
required. 24

46. Removal of hopeless teeth can also be performed
during periodontal surgery of neighboring teeth -
reduces appointments for surgery in same area.
In complex cases, interdisciplinary consultation
with other specialty areas is necessary before final
plan made.
26

47. May necessitate:
Occlusal adjustment
Restorative, prosthetic, & orthodontic procedures
Splinting
Correction of bruxism & clenching habits
30

48. Should be carefully evaluated.
May require special precautions during course of
periodontal treatment.
May also affect tissue response to treatment
procedures and threaten preservation of
periodontal health after treatment is
completed.
Patient’s physician should always be consulted when
the patient presents with medical or systemic
problems that may affect the periodontal therapy.
31

49. Paramount importance for case maintenance.
Entails all procedures for maintaining periodontal
health after it has been attained.
Consists of instruction in oral hygiene & checkups at
regular intervals, according to patient’s needs.
To examine condition of periodontium & status of
restoration as it affects periodontium.
32

50. Preliminary phase
Nonsurgical phase (Phase I Therapy)
Evaluation of response to Nonsurgical Phase
Surgical Phase (Phase II Therapy)
Restorative Phase (Phase III Therapy)
Maintenance Phase (Phase IV Therapy)
36
Phases of PeriodontalTherapy

51. A. Preliminary
Phase
37
Treatment of emergencies:
Dental/ periapical
Periodontal
Other
Extraction of hopeless teeth and provisional
replacement if needed (may be postponed to more
convenient time)

52. B. Nonsurgical Phase (Phase I Therapy)
Plaque control and patient education:
Diet control (in patients with rampant caries)
Removal of calculus & root planing
Correction of restorative & prosthetic irritational
factors
Excavation of caries & restoration (temporary/
final, depending on whether a definitive prognosis
for tooth has been determined & on location of
caries)
38

53. Antimicrobial therapy (local/ systemic)
Occlusal therapy
Minor orthodontic movement
Provisional splinting & prosthesis
C. Evaluation of response to Nonsurgical phase
Rechecking:
Pocket depth and gingival inflammation
Plaque and calculus, caries
39

54. D. Surgical Phase (Phase II Therapy)
Periodontal access surgery (regenerative or
resective)
Periodontal plastic surgery ( mucogingival surgery,
aesthetic crown lengthening)
Pre-prosthetic surgery ( prosthetic crown
lengthening; implant site preparation and implant
placement)
Extraction of hopeless teeth
E. Restorative Phase (Phase III Therapy)
Final restorations
Fixed & removable prosthodontic appliances 40

55. F. Maintenance Phase (Phase IV Therapy)
Periodic rechecking:
Plaque & calculus
Gingival condition (pockets, inflammation)
Occlusion, tooth mobility
Other pathologic changes
41

56. 34

57. 35

58. Preferred sequence of periodontal
therapy
43

59. Although phases of treatment have been
numbered, recommended sequence does not
follow the numbers.
Phase I/ Nonsurgical phase - directed to elimination
of etiologic factors of gingival & periodontal diseases.
When successfully performed, this phase stops
progression of dental & periodontal disease.
44

60. Immediately after completion of Phase I therapy,
- patient should be placed on Maintenance
phase (Phase IV)
To preserve results obtained & prevent any further
deterioration & recurrence of disease.
45

61. While on maintenance phase, with its periodic
checkups & controls, patient enters into Surgical
phase (Phase II) & Restorative (reparative) phase
(Phase III) of treatment.
Include periodontal surgery to repair & improve
condition of periodontal & surrounding tissues.
This may include regeneration of bone and gingiva
for function and aesthetics, placement of implants &
restorative therapy.
46

62. Objective of overall treatment plan is creation &
maintenance of oral health, function, & esthetics.
Outcome is long term & in most cases requires
coordination of several disciplines of dentistry.
A motivated patient is prerequisite, & success will
depend on this motivation being sustained
through maintenance care.
64

63. Carranza’s Clinical Periodontology 13th edition
Clinical periodontology & Implant dentistry 6th
edition – Jan Lindhe
Bruce L. Philstrom. Periodontal risk assessment,
diagnosis & treatment planning. Perio 2000.
2001;25:37-58.
70

64. 72