This document discusses factors that are considered when determining a prognosis for periodontal disease. It outlines different types of prognoses from excellent to hopeless based on factors like bone loss and furcation involvement. Overall clinical factors like age, disease severity, plaque control, and patient compliance are discussed. Systemic factors like smoking and genetic factors are also outlined. Local factors like plaque, calculus, and subgingival restorations are covered. The relationship between prognosis and restorative and prosthetic needs is also summarized.

1. M.SHIVA SHANKER
IV B.D.S

2. Overview
Introduction and definition.
Types of prognosis
Overall versus individual tooth prognosis
Factors in determination of prognosis
Overall Clinical Factors
Systemic and Environmental Factors
Local Factors
Prosthetic and Restorative Factors
Relationship between diagnosis and prognosis
Prognosis for Patients with Gingival Disease
Prognosis for Patients with Periodontitis
Reevaluation of prognosis after phase-I therapy.
Conclusion

3. Definitions: Prognosis
1. The expected course of a disease.
2. The patient's chance of recovery.
The prognosis predicts the outcome of a disease
and therefore the future for the patient.

4. Diagnosis
 The art or act of identifying a disease
from its signs and symptoms.

5. Prognosis vs. risk
 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.

6.  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.

7. Essential elements of prognosis
1. Intended outcome
2. Timing of the projection
3. Consideration of individual teeth versus
the overall dentition.

8. Types of prognosis
Excellent prognosis:
NO BONE LOSS
EXCELLENT GINGIVAL CONDITION
GOOD PATIENT COOPERATION

9. Good prognosis: One or more of the
following remaining:
Adequate Bone support
Adequate possibilities to control
etiologic factors & establish a
maintainable dentition
Adequate patient cooperation, no
systemic or environmental factors

10. Fair prognosis: One or more of the
following:
Adequate remaining bone support
Some tooth mobility
Grade I furcation involvement
Adequate maintenance possible
acceptable patient cooperation

11.  Poor prognosis: One or more of the following:
 Moderate to advanced bone loss.
 Tooth mobility
 Grade I and II furcation involvements,
difficult-to-maintain areas or
doubtful patient cooperation
.Presence of systemic
or environmental factors.

12. Questionable prognosis: One or more of the
following:
 Advanced bone loss.
 Grade II & III furcation involvements
 Tooth mobility
 Inaccessible areas
 Presence of systemic or environmental factors

13. Hopeless prognosis: One or more of the
following:
 Advanced bone loss
 Non maintainable areas
 Extraction needed

14.  Excellent, good, and hopeless prognoses are
the only prognoses that can be established with
a reasonable degree of accuracy.
 Fair, poor, and questionable prognoses depend
on a large number of factors that can interact in
an unpredictable number of ways.

15. Likely
maybe
unlikely
Favorable
Questionable
Unfavorable
Hopeless prognosis
PERIODONTAL STABILITY
EXTRACTION NEEDED

16. .
Prognosis
OVERALL INDIVIDUAL
FACTORS
INFLUENCE
Age
Disease
Smoking
Systemic factors
Plaque, calculus
Compliance
prostheses
Prosthetic &
Restorative
Plaque , calculus

17. Factors in determination of prognosis
1) Overall Clinical Factors
 Patient age
 Disease severity
 Plaque control
 Patient compliance
2) Systemic and Environmental
Factors
 Smoking
 Systemic disease or condition
 Genetic factors
 Stress

18. 3) Local Factors
Plaque and calculus
Sub gingival restorations
4) Anatomic factors:
 Short, tapered roots
 Cervical enamel projections
 Enamel pearls
 Bifurcation ridges
 Root concavities
 Developmental grooves
 Root proximity
 Furcation involvement

19. 5) Tooth mobility
6) Prosthetic and Restorative
Factors
 Abutment selection
 Caries
 Nonvital teeth
 Root resorption

20. Overall Clinical Factors
Patient Age.
The prognosis is generally better for
the older patients.
 For the younger patient, the
prognosis is not as good because of
the shorter time frame in which the
periodontal destruction has
occurred.

21.  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.

22. Disease Severity
Following variables should be 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.

23. 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.

24. Patient Compliance and
Cooperation.
 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.

25. Systemic and Environmental Factors
Smoking
 Smoking may be the most
important environmental
risk factor impacting the
development and progression
of periodontal disease.
 Smoking affects not only the
severity of periodontal
destruction, but also the
healing potential of the
periodontal tissues.

26.  Prognosis in patients
who smoke and have
slight to moderate
periodontitis is
generally fair to poor.
 Patients with severe
periodontitis, the
prognosis may be poor
to hopeless.

27.  Smoking cessation can
affect the treatment
outcome and prognosis.
 Patients with slight to
moderate periodontitis
who stop smoking can often
be upgraded to a good
prognosis, whereas those
with severe periodontitis
who stop smoking may be
upgraded to a fair
prognosis.

28. Systemic Disease or
Condition.
 Patients diagnosed with
diabetes must be informed
of the impact of diabetic
control on the development
and progression of
periodontitis.
 Prognosis in these cases
depends on patient
compliance relative to both
medical and dental status.

29.  Similarly, in patients with
other systemic disorders
that could affect disease
progression, prognosis
improves with correction
of the systemic problem.

30. Genetic Factors
Genetic polymorphisms in the
interleukin-1 (IL-1) resulting in
increased production of IL- 1β
associated with a increase in
risk for severe, generalized,
chronic periodontitis.

31.  The knowledge of the
patient's IL-1 genotype and
smoking status can aid the
clinician in assigning a
prognosis.
 Genetic factors also appear to
influence serum
immunoglobulin G2 (IgG2)
antibody titers and expression
of FcyRII receptors on the
neutrophil, both of which may
be significant in aggressive
periodontitis.

32.  Other genetic disorders, such as leukocyte
adhesion deficiency type 1, can influence
neutrophil function creating an additional risk
factor for aggressive periodontitis.
 Finally, the familial aggregation that is
characteristic of aggressive periodontitis
indicates that additional, as yet unidentified,
genetic factors may be important in
susceptibility to this form of disease.

33.  Detection of genetic variations linked
to periodontal disease can potentially
influence the prognosis in several ways.
First, early detection of patients at risk
because of genetic factors can lead to
early implementation of preventive and
treatment measures for these patients.

34. Second, identification of genetic risk
factors later in the disease or during the
course of treatment can influence
treatment recommendations, such as
use of adjunctive antibiotic therapy or
increased frequency of maintenance
visits.

35. Third, identification of young individuals
who have not been evaluated for
periodontitis, but who are recognized as
being at risk because of the familial
aggregation seen in aggressive
periodontitis, can lead to the development
of early intervention strategies.
 In each of these cases, early diagnosis,
intervention, and alterations in the
treatment regimen may lead to an
improved prognosis for the patient.

36. 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 in attempting
to establish a prognosis.

37. Local Factors
Plaque and Calculus
 The microbial challenge
presented by bacterial plaque
and calculus is the most
important local factor in
periodontal diseases.
 Therefore, in most cases, having
a good prognosis depends on
the ability of the patient and the
clinician to remove these
etiologic factors.

38. Sub gingival Restorations.
 Sub gingival margins
contribute to increased
plaque accumulation,
increased inflammation, and
increased bone loss when
compared with
supragingival margins.
 Overhanging can negatively
impact the periodontium.

39. 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
 Developmental grooves.
 Root proximity and
 Location and anatomy of furcations.

40. Tooth Mobility.
 The principal causes of tooth
mobility are loss of alveolar
bone, inflammatory changes in
periodontal ligament, and
trauma from occlusion.

41.  The stabilization of tooth
mobility through the use
of splinting may have a
beneficial impact on the
overall and individual
tooth prognosis.

42. Prosthetic and Restorative
Factors
 The overall prognosis requires a
general consideration of bone
levels and attachment levels 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.

43.  When few teeth remain, the
prosthodontic needs become more
important, and sometimes
periodontally treatable teeth may
have to be extracted if they are not
compatible with the design of the
prosthesis.

44.  More rigid standards are required
when evaluating the prognosis of
teeth adjacent to edentulous
areas.
 A tooth with a post that has
undergone endodontic treatment
is more likely to fracture when
serving as a distal abutment
supporting a distal removable
partial denture.

45.  Additionally, special oral
hygiene measures must
be instituted in these
areas.

46. Caries, Nonvital 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.

47.  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.

48. Relationship between diagnosis and 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. These are also important in
developing a prognosis.
 These common factors suggest that for
any given diagnosis there should be an
expected prognosis under ideal
conditions.

49. Prognosis for Patients with Gingival Disease
Dental Plaque-Induced Gingival
Diseases
Gingivitis Associated with
Dental Plaque only
 Plaque-induced gingivitis is a
reversible disease that occurs when
bacterial plaque accumulates at the
gingival margin. This disease can
occur on a periodontium that has
experienced no attachment loss or on
a periodontium with nonprogressing
attachment loss.

50.  In either case, the prognosis for
patients with gingivitis associated with
dental plaque only is good, provided all
local irritants are eliminated.

51. Plaque-Induced Gingival Diseases Modified by
Systemic Factors
 The inflammatory response to
bacterial plaque at the gingival
margin can be influenced by
systemic factors, such as
endocrine-related changes
associated with puberty,
menstruation, pregnancy and
diabetes, and the presence of
blood dyscrasias.

52.  In many cases the frank signs of gingival
inflammation that occur in these patients
are seen in the presence of relatively small
amounts of bacterial plaque.
 Therefore the long term prognosis for
these patients depends not only on control
of bacterial plaque, but also on control or
correction of the systemic factors.

53. Plaque-Induced Gingival Diseases Modified by
Medications
 Gingival diseases associated
with medications include
drug-influenced gingival
enlargement seen with
phenytoin, cyclosporine, and
Nifedipine and in oral
contraceptive-associated
gingivitis.
 In drug-influenced gingival
enlargement, reductions in
dental plaque can limit the
severity of the lesions.

54.  However, plaque control alone
does not prevent development
of the lesions. And surgical
intervention is usually
necessary to correct alterations
in gingival contour. Continued
use of the drug usually results in
recurrence of the enlargement
even after surgical intervention
.
 Therefore long-term prognosis
depends on whether the
patient’s systemic problem can
be treated with an alternative
medication that does not have
gingival enlargements side
effect.

55. Gingival Diseases Modified by
Malnutrition
 Although malnutrition has been
suspected to play a role in the
development of gingival diseases, most
clinical studies have not shown a
relationship between the two.

56.  One possible exception is
severe vitamin C deficiency.
 The prognosis in these
patients may depend on the
severity and duration of the
deficiency and on the
likelihood of reversing the
deficiency through dietary
supplementation.

57. Non-Plaque-lnduced Gingival Lesions
 Non-plaque induced gingivitis can be
seen in patients with a variety of
bacterial, fungal, and viral infections.
Since gingivitis in these patients is not
usually attributed to plaque
accumulation, prognosis depends on
elimination of the source of the
infectious agent.

58. Prognosis for Patients with Periodontitis
Chronic Periodontitis.
 Chronic periodontitis can
present in a localized or
generalized form.
 In cases where clinical
attachment loss and bone loss
are not very advanced (slight to
moderate periodontitis), the
prognosis is generally good,
provided the inflammation can
be controlled through good oral
hygiene and the removal of
local plaque-retentive factors.

59.  In patients with more severe
disease, as evidenced by
furcation involvement and
increasing clinical mobility,
or in patients who are
noncompliant with oral
hygiene practices, the
prognosis may be
downgraded to fair to poor.

60. Aggressive Periodontitis
Aggressive periodontitis can present in a
localized or a generalized form.
Two common features of both forms are
(1) Rapid attachment loss and bone
destruction in an otherwise clinically
healthy patient and
(2) Familial aggregation.

61.  These patients also may present with
phagocyte abnormalities and a hyper
responsive monocyte/macrophage
phenotype.
 These clinical, microbiologic, and
immunologic features would suggest that
patients diagnosed with aggressive
periodontitis would have a poor
prognosis.

62.  However, when diagnosed
early, these cases can be
treated conservatively with
oral hygiene instruction and
systemic antibiotic therapy,
resulting in an excellent
prognosis.
 When more advanced disease
occurs, the prognosis can still
be good if the lesions are
treated with debridement,
local and systemic antibiotics,
and regenerative therapy.

63. PAPILLON
LEFERVE
SYNDROM
E
Periodontitis as a Manifestation of Systemic
Diseases
PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASES
PERIODONTITIS ASSOCIATED
WITH HEMATOLIGIC DISORDERS
PERIODONTITIS ASSOCIATED
WITH GENETIC DISORDERS
LEUKEMIA NEUTROPENIA
ACQUIRED
DOWN S
SYNDROME

64.  Although the primary
etiologic factor in
periodontal diseases is
bacterial plaque, systemic
diseases that alter the
ability of the host to
respond to the microbial
challenge presented may
affect the progression of
disease and therefore the
prognosis for the case.

65.  Decreased numbers of
circulating neutrophils
(as in acquired
neutropenias) may
contribute to widespread
destruction of the
periodontium. Unless
the neutropenia can be
corrected, these patients
present with a fair to
poor prognosis.

66. Necrotizing Periodontal Diseases
 Necrotizing periodontal disease
can be divided into necrotizing
ulcerative gingivitis NUG, and
necrotizing ulcerative
periodontitis NUP.
 In NUG the primary predisposing
factor is bacterial plaque.
However, this disease is usually
complicated by the presence of
secondary factors such as acute
psychologic stress, tobacco
smoking, and poor nutrition, all
of which can contribute to
immunosuppression.

67.  With control of both the bacterial
plaque and the secondary factors,
the prognosis for a patient with NUG
is good.

68.  The clinical presentation of NUP is
similar to that of NUG, except the
necrosis extends from the gingiva into
the periodontal ligament and alveolar
bone.
 However, many patients presenting with
NUP are immunocompromised through
systemic conditions, such as human
immunodeficiency virus (HIV)
infection. In these patients the
prognosis depends on not only reducing
local and secondary factors, but also on
dealing with systemic problem.

69. Reevaluation of prognosis after phase I therapy
 A frank reduction in pocket depth and
inflammation and 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 overall prognosis may be
unfavorable.

70. Conclusion
 Prognosis puts lights on future of
disease progression or demission
depending on factors affecting it