This document discusses factors involved in determining the prognosis of periodontal disease. It defines prognosis as the prediction of the probable course and outcome of a disease. Prognosis is determined after diagnosis and before treatment planning. It is influenced by the patient's history, risk factors, response to previous treatment, and the clinician's experience. The document outlines various factors to consider like patient age, disease severity, plaque control, systemic conditions, smoking, stress, anatomic factors, mobility, restorations, and response to initial therapy. Both overall prognosis for the dentition and individual tooth prognosis are important. The prognosis can be reevaluated after treatment.

1. PeriodontologyII
Dr.Rawand Samy Mohamed Abu Nahla
Oral Medicine, periodontology&oral Radiology Department.
Dr. Haydar.A.Shafy Faculty Of Dentistry.
El Azhar University.
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2. Lecture 1:
Diagnosis, Prognosis, And Treatment
Planning
Part (3)
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3. Determination of Prognosis
Definitions
 The prognosis is a prediction of the probable course, duration, and outcome of a
disease based on a general knowledge of 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.
 The prognosis is based on specific information about the disease and the manner in which it
can be treated, but it also can be influenced by the clinician’s previous experience with
treatment outcomes (successes and failures) as they relate to the particular case.
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4. It is important to note that determination of prognosis is a dynamic process.
As such, the prognosis initially assigned should be reevaluated after
completion of all phases of therapy, including periodontal maintenance
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5. 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 those characteristics of an individual that put the person
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 of disease 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.
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6. Types of Prognosis
One scheme assigns the following classifications:
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 and/or Class I furcation involvement
(location and depth allow proper maintenance with good patient compliance).
Poor prognosis: 50% attachment loss, Class II furcation involvement (location and depth
make maintenance possible but difficult).
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7. Questionable prognosis: >50% attachment loss, poor crown-to root ratio, poor
root form, Class II furcations (location and depth make access difficult) or Class
III furcation involvements; >2+ mobility; root proximity.
Hopeless prognosis: Inadequate attachment to maintain health, comfort, and
function.
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8. 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.
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9. Overall Versus Individual Tooth Prognosis
Prognosis can be divided into overall prognosis and individual tooth prognosis. The overall
prognosis is concerned with the dentition as a whole. Factors that may influence the overall
prognosis include patient age; current severity of disease; systemic factors; smoking; the presence of
plaque, calculus, and other local factors; patient compliance; and prosthetic possibilities. The overall
prognosis answers the following questions:
• Should treatment be undertaken?
• Is treatment likely to succeed?
• When prosthetic replacements are needed, are the remaining teeth able to support the added
burden of the prosthesis?
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10. The individual tooth prognosis is determined after the overall prognosis and is
affected by it. For example, in a patient with a poor overall prognosis, the
dentist likely would not attempt to retain a tooth that has a questionable
prognosis because of local conditions.
Many of local factors and prosthetic and restorative factors have a direct
effect on the prognosis for individual teeth, in addition to any overall
systemic or environmental factors that may be present.
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11. Factors in Determination of Prognosis
1-Overall Clinical Factors:
1-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.
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12. 2-Disease Severity. Studies have demonstrated that a patient’s history of
previous periodontal disease may be indicative of their susceptibility for
future periodontal breakdown.
Therefore the following variables should be carefully recorded because
they are important for determining the patient’s past history of
periodontal disease: pocket depth, level of attachment, degree of bone
loss, and type of bony defect. These factors are determined by clinical
and radiographic evaluation.
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13. The type of defect also must be determined:
 The prognosis for horizontal bone loss depends on the height of the
existing bone because it is unlikely that clinically significant bone
height regeneration will be induced by therapy.
 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.
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14. 3-Plaque Control.
Bacterial plaque 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.
4-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 maintain good oral hygiene. Without these, treatment cannot succeed.
Patients should be clearly informed of the important role they must play for treatment
to succeed
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15. 2-Systemic and Environmental Factors
1-Smoking.
Epidemiologic evidence suggests that smoking may be the most important environmental
risk factor impacting the development and progression of periodontal disease . Therefore it
should be made clear to the patient 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.
In patients with severe periodontitis, the prognosis may be poor to hopeless. However, it
should be emphasized that smoking cessation can affect the treatment outcome and therefore
the prognosis.
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16. 2-Systemic Disease or Condition.
The patient’s systemic background affects overall prognosis in several ways.
For example, evidence from epidemiologic studies clearly demonstrates that the
prevalence and severity of periodontitis are significantly higher in patients with
type 1 and type 2 diabetes than in those without diabetes and that the level of
control of the diabetes is an important variable in this relationship. Therefore
patients at risk for diabetes should be identified as early as possible and
informed of the relationship between periodontitis and diabetes.
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17. 3-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. In addition to these external factors,
evidence also indicates that genetic factors may play an important role in determining the
nature of the host response. Evidence for this type of genetic influence exists for patients
with both chronic and aggressive periodontitis.
 Genetic polymorphisms in the interleukin-1 (IL-1) genes, resulting in increased
production of IL-1β, have been associated with a significant increase in risk for severe,
generalized, and chronic periodontitis.
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18. 4-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.
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19. 3-Local Factors
1-Plaque and Calculus.
The microbial challenge presented by bacterial plaque and
calculus is the most important local factor inperiodontal
diseases. Therefore, in most cases, having a good prognosis
depends on the ability of the patient and the clinician to remove
these etiologic factors.
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20. 2-Subgingival Restorations.
Subgingival margins may contribute to increased plaque
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 .
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21. 3-Anatomic 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
and enamel pearls; intermediate bifurcation ridges; root concavities; and
developmental grooves. The clinician must also consider root proximity and the location
and anatomy of furcations when developing a prognosis.
Prognosis is poor for teeth with short, tapered roots and relatively large crowns. Because of
the 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.
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22. Scaling with root planing is a fundamental procedure in periodontal
therapy. Anatomic factors that decrease the efficiency of this procedure
can have a negative impact on the prognosis. Therefore the morphology
of the tooth root is an important consideration when discussing prognosis.
Root concavities exposed through loss of attachment can vary from
shallow flutings to deep depressions.
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23. 4-Tooth Mobility.
The principal causes of tooth mobility are loss of alveolar bone,
inflammatory changes in the periodontal ligament, 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
loss of supporting alveolar bone.
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24. 5-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 a
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 the individual tooth prognosis overlap because the prognosis
for key individual teeth.
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25. 6-Caries, Non vital Teeth, 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 non vital teeth does not differ from that of vital
teeth. New attachment can occur to the cementum of both nonvital and vital teeth.
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26. Relationship Between Diagnosis and Prognosis
Many of the criteria used in the diagnosis and classification of the different
forms of periodontal disease are also used in developing a prognosis. Factors
such as patient age, severity of disease, genetic susceptibility, and presence
of systemic disease are important criteria in the diagnosis of the condition,
as well as important in developing a prognosis. These common factors
suggest that for any given diagnosis, there should be an expected prognosis
under ideal conditions.
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27. Reevaluation of Prognosis After Phase I Therapy
A frank reduction in pocket depth and inflammation after phase I therapy
indicates a favorable response to treatment and may suggest a better
prognosis than previously assumed. If the inflammatory changes present
cannot be controlled or reduced by phase I therapy, the overall prognosis may
be unfavorable. In these patients, the prognosis can be directly related to the
severity of inflammation.
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28. Thank you
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