This document outlines the process and factors involved in diagnosing and determining the prognosis of periodontal diseases. Diagnosis involves a thorough medical and dental history, clinical examination including probing, radiographs, and other tests to determine the type, extent, severity and cause of periodontal disease present. The prognosis takes into account disease severity and extent, oral hygiene ability, systemic factors like smoking, genetic risks, and anatomic and restorative challenges that could impact treatment outcomes. Prognosis can range from excellent to hopeless depending on these various clinical factors.

1. DIAGNOSIS

2. CLINICAL DIAGNOSIS
Proper Diagnosis Is Essential To Intelligent Treatment.
Periodontal Diagnosis Should Determine
Whether Disease Is Present
Then
1) Type
2) Extent
3) Distribution
4) Severity
5) Pathogenesis
6) Cause

3. DIAGNOSIS IS DETERMINED AFTER
1)CAREFUL ANALYSIS OF THE CASE HISTORY
2)EVALUATION OF CLINICAL SIGNS AND SYMPTOMS
3)VARIOUS TESTS - EG… PROBING, MOBILITY ASSESSMENT
RADIOGRAPHS
BLOOD TESTS
BIOPSIES

4. PERIODONTAL DISEASES
 GINGIVAL DISEASES
 VARIOUS TYPES OF PERIODONTITIS
 PERIODONTAL MANIFESTATIONS OF SYSTEMIC DISEASES

5. DIAGNOSTIC PROCEDURE SHOULD BE SYSTEMATIC
FIRST VISIT
 Over All Appraisal Of The Patient
 Medical History
 Dental History
 Intraoral Radiograph Survey
 Casts
 Clinical Photograph
 Review Of Initial Examination

6. OVER ALL APPRAISAL OF THE PATIENT
Mental And Emotional Status
Temperament
Attitude
Physiologic Age
MEDICAL HISTORY
Importance Of Medical History
Medical History Should Include Following Questions-
1) Physician Care?
2) Hospitalization?
3) Medicine List?
4) Occupational Disease?
5) Bleeding Tendencies?
6) Allergy?
7) Family Medical History?

7. DENTAL HISTORY
1)VISIT TO DENTIST
2)ORAL HYGIENE
3)PAIN
4)BLEEDING GUMS
5)BAD TASTE
6)BAD BREATH
7)OTHER HABITS

8. INTRA ORAL RADIOGRAPH SURVEY
 14 INTRA ORAL FILMS
 4 POSTERIOR BITE WINGS

9. CASTS
 CASTS FROM DENTAL IMPRESSIONS INDICATE
1)POSITION OF THE GINGIVA L MARGINS
2)POSITION AND INCLINATION OF TEETH
3)PROXIMAL CONTACT RELATIONSHIP AND IMPACTION
AREAS
CLINICAL PHOTOGRAPHS
REVIEW OF INITIAL EXAMINATION

10. SECOND VISIT
1)ORAL EXAMINATION
2)EXAMINATION OF TEETH
3)EXAMINATION OF PERIODONTIUM

11. ORAL EXAMINATION
 ORAL HYGIENE
 ORAL MAL ODOUR
 EXAMINATION OF ORAL CAVITY
 EXAMINTAION OF LYMPH NODES
EXAMINTAION OF TEETH
 EROSION, ABRASION , ATTRITION , ABFRACTION
 DENTAL STAINS
 HYPERSENSITIVITY
 PROXIMAL CONTACT RELATIONS
 TOOTH MOBILITY

12. TOOTH MOBILITY
 GRADE I
 GRADE II
 GRADE III

13.  TRAUMA FROM OCCLUSION
 PATHOLOGIC MIGRATION
 SENSITIVITY TO PERCUSSION
 DENTITION WITH JAW CLOSED
 FUNCTIONAL OCCUSION RELATIONSHIP

14. EXAMINATION OF PERIODONTIUM
 PLAQUE AND CALCULUS
 GINGIVA
 PERIODONTAL POCKETS
 ABSCESS
 EXUDATION ON PRESSURE
 FURCATION INVOLVEMENT

15. GINGIVAL BLEEDING

16. PERIODONTAL POCKET

17. ABSCESS

18. FURCATION INVOLVEMENT

19. EXUDATION ON PRESSURE

20. LABORATORY AIDS TO CLINICAL
DIAGNOSIS
 NUTRITION STATUS
 BLOOD TESTS
 SPECIAL DIET

21. ADVANCED DIAGNOSTIC
TECHNIQUES
 ANALYSIS FOR
GINGIVAL BLEEDING
GINGIVAL TEMPERATURE
PERIODONTAL PROBING
RADIOGRAPHIC ASSESSMENT
MICROBIOLOGIC ANALYSIS

86. 1. Gingival Diseases
Plaque induced
Non Plaque induced
2. Chronic Periodontitis
3. Aggressive Periodontitis
4. Necrotizing periodontal diseases
5. Abscess of Periodontium
6. Periodontitis associated with endodontic
lesions
7. Developmental or acquired deformities and
conditions
World Workshop in Clinical Periodontics
1999

87. PROGNOSIS:
 IT 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 TREATMENT PLAN IS ESTABLISHED.
 PROGNOSTIC FACTORS ARE CHARACTERISTICS THAT
PREDICT THE OUTCOME OF DISEASE ONCE DISEASE IS
PRESENT.

88. DETERMINATION
OF
PROGNOSIS

89. TYPES OF PROGNOSIS
 EXCELLENT PROGNOSIS: No Bone Loss,excellent Gingival
Condition,good Patient Cooperation,no Systemic Or Environmental
Factors.
 GOOD PROGNOSIS: Adequate possibilities to control etiologic
factors and establish a maintainable dentition,adequate patient
cooperation,no systemic or environmental factors.
 FAIR PROGNOSIS: Less-than Adequate- Remaining Bone
Support,some Tooth Mobility,grade1furcation, Invovlement,adequate
Maintanence Possible acceptable Patient Cooperation,presence Of
limited Systemic And Environmental Factors.

90.  POOR PROGNOSIS: Moderate To Advanced Bone Loss,tooth
Mobility,grade1&2 Furcation Involvements,difficult-to-maintain Areas
Or Doubtful Patient Cooperation. presence of uncontrolled systemic
and environmental factors.
 QUESTIONABLE PROGNOSIS: Advanced Bone Loss,grade2&3
Furcation Involments,tooth Mobility,inaccessible Areas. presence of
uncontrolled systemic and environmental factors.
 HOPELESS PROGNOSIS: Advanced bone loss,non maintainable
areas,extactions indicated, presence of uncontrolled systemic and
environmental factors.

91. FACTORS IN DETERMINATION OF PROGNOSIS
 OVERALL CLINICAL FACTORS
PATIENT AGE
DISEASE SEVERITY
PLAQUE CONTROL
PATIENT COMPLIANCE
 SYSTEMIC AND ENVIRONMENTAL FACTORS
SMOKING
SYSTEMIC DISEASE,CONDITION
GENETIC FACTORS
STRESS
 LOCAL FACTORS
PLAQUE AND CALCULUS
SUBGINGIVAL RESTORATIONS

92.  ANATOMIC FACTORS
SHORT,TAPERED ROOTS
CERVICAL ENAMEL PROJECTIONS
ENAMEL PEARLS
BIFURCATION RIDGES
ROOT CONCAVITIES
DEVELOPMENTAL GROOVES
ROOT PROXIMITY
FURCATION INVOLVEMENT
TOOTH MOBILITY
 PROSTHETIC AND RESTORATIVE FACTORS
ABUTMENT SELECTION
CARIES
NONVITAL TOOTH
ROOT RESOPTION

93. OVERALL CLINICAL FACTORS
PATIENT’S AGE :
To Patients With Comparable Levels Of Remaining Connective Tissue
Attachment And Alveolar Bone The Prognosis Is Generally Better For
The Older Of The Two.
For younger patient prognosis is not as good because they may have
aggressive type of periodontitis or disease progression may have
increased because of systemic disease or smoking.
DISEASE SEVERITY:
Patients history of previous periodontal disease may be indicative of
there susceptibility for further periodontal breakdown.

94. These are important determining the patients past
History of pdl disease – pocket depth, level of
Attachment, degree of bone loss and type of bone
Defect these factors are determined by clinical and
Radiographic evaluation.
The determination of the level of clinical attachment reveals
the approx. Extent of root surface that is devoid of pdl.
Radiographic examination shows the amount of root surface
still invested in bone
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 height of the
remaining bone.

95.  Early
 Moderate
 severe

96. Dealing with questionable prognosis
Extraction of questionable tooth
Partial restoration of the bone support
of adjacent teeth

97. 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.
The prognosis of apical disease as a result of endodontic
involvement also worsens the prognosis.
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.

98. PLAQUE CONTROL:
 Bacterial plaque is the primary etiologic factor associated with periodontal
disease.
 Effective removal of plaque on a daily basis by the patient is critical to the
success of periodontal therapy and to the prognosis
PATIENT COMPLIANCE AND COOPERATION:
The prognosis for the patient with gingival and periodontal disease is
critically dependant on the patient’s attitude, desire to retain the natural
teeth and willingness and ability to maintain good oral hygiene. Without this
the dentist refuse to accept the patient for treatment.

99. SYSTEMIC AND ENVIRONMENTAL FACTORS
SMOKING:
 smoking may be the most important environment risk factor impacting the development and progression of
periodontaldisease.
patient
Who smokes
and have
moderate periodontis
Prognosis is fair to poor
Severe periodontitis
Prognosis poor to hopeless
Patient with
Moderate periodontitis
Stop smoking
Good prognosis
Severe periodontitis
Stop smoking
Fair prognosis

100. SYSTEMIC DISEASE OR CONDITION:
The patient’s systemic background affects overall prognosis.
Prevalence and severity of periodontitis are higher in patient’s type i
and type ii diabetes. Well controlled Diabetic patients with slight to
moderate periodontitis have a good prognosis.
Prognosis improves with correction of systemic problem.
GENETIC FACTORS:
These factors play an important role in determining the nature of the
host response.
Exists influence for patients with both chronic and aggressive
periodontitis. Il-1 genes, resulting in increased production of il-1β –
increase in risk for severe generalized, chronic periodontitis.

101. Microbial and environmental factors can be altered thru conventional
periodontal therapy and patient education, genetic factors currently
cannot be altered. And alterations in treatment regimen may lead to
improved prognosis for the patient.
STRESS:
Physical and emotional stress may alter the pt’s ability to respond to
pdl treatment performed.
These factors must be realistically faced in attempting to establish a
prognosis

102. LOCAL FACTORS
PLAQUE AND CALCULUS:
Most important local factor in periodontal diseases.
Good prognosis-removal of etiological factors.
SUBGINGIVAL RESTORATIONS
May contribute to increased plaque accumulation, increased
inflammation ,increased bone loss.
It will have poorer prognosis than a well contoured tooth.
ANATOMIC FACTORS
Short tapered roots and relatively large crowns-reduced root surface
for periodontal support.
Cervical enamel projections - flat ectopic extentions of enamel that
extend beyond the normal contours of cej.

103. Enamel pearls - larger round deposits of enamel that can be located in
furcations or on root surfaces.
They interfere with the attachment apparatus and may prevent
regenerative procedures.
Root concavities - exposed through loss of attachment can vary from
shallow flutings to deep depressions.
Increase attachment area and produce root shape that may be more
resistant to torquing force-difficult to clean.
Developmental grooves - create an accessibility problem and provide
plaque retentive area.
TOOTH MOBILITY
Loss of alveolar bone, inflammatory changes in the pdl and tfo.
Treatment-splinting

104. palatogingival
groove

105.  Furcation Involvement

106. PROSTHETIC AND RESTORATIVE FACTORS
The overall prognosis requires a general considerations of bone and
attachment levels to establish enough teeth can be saved to provide a
functional and aesthetic dentition or to serve as abutments for useful
prosthetic replacement of the missing teeth.
Teeth serve as abutments are subjected to increased functional
demands. More rigid standards are required when evaluating when
evaluating the prognosis of teeth adjacent to edentulous areas.
CARIES ,NON VITAL TEETH AND ROOT RESORPTION
Extensive Caries-the Feasibility Of Adequate Restoration And
Endodontic Theapy Should Be Considered Before Undertaking
Periodontal Treatment. Root resorption resulting from orthodontic
therapy jeopardizes the stability of teeth and adversely effects the
response to periodontal treatment.

107. PROGNOSIS FOR THE PATIENTS WITH
GINGIVAL DISEASE
DENTAL PLAQUE INDUCED GINGIVAL DISEASES
Gingivitis associated with dental plaque only: is a reversible disease that occurs when
bacterial plaque accumulates at the gingival margin.
PLAQUE INDUCED GINGIVAL DISEASES MODIFIED BY SYSTEMIC FACTORS
ENDOCRINE – Related changes associated with puberty, menstruation, pregnancy,
diabetes and presence of blood dyscrasis.
PROGNOSIS – control of plaque and correction of the systemic factors.
Plaque induced
Gingival margin
Local irritants eliminated
Prognosis is good

108. PLAQUE INDUCED GINGIVAL DISEASES MODIFIED BY
MEDICATIONS:
Gingival diseases associated with medications include drug
influnced gingival enlargement, often seen with phenytoin,
cyclosporine and nifedipine and in oral contraceptive associated
gingivitis.
In drug influenced gingival enlargement, reduction in dental plaque
can limit the severity of the lesions
The long term prognosis depends on whether the pt’s systemic
problem can be treated with an alternative medication that does not
have gingival enlargement as a side effect

109. GINGIVAL DISEASES MODIFIED BY MALNUTRITION:
Vitamin- c deficiency gingival inflammation and bleeding on probing
are independent of plaque levels present.
Prognosis - dietary supplementation.
NON – PLAQUE INDUCED GINGIVAL LESIONS:
Can be seen in pt’s with a variety of bacterial, fungal and viral
infections.
Prognosis depends on elimination of the source of the infectious
agent.

110. PROGNOSIS FOR PATIENTS WITH
PERIODONTITIS
CHRONIC PERIODONTITIS: Is a slow progressive disease associated with
well-known local environmental factors.
In slight to moderate periodontitis prognosis is generally good and – good oral
hygiene and the removal of local plaque retentive factors.
In Patients with severe disease furcation involvement increased clinical
mobility the prognosis may be fair to poor.
AGGRESSIVE PERIODONTITIS:
Pt’s have a poor diagonosis :
In LAP- pt’s often exhibits a strong serum ab response to the infecting
agents which may contribute to the localization of the lesions. When
diagnosized early treated With Oral Hygienic Instruction And Systemic
Anti-biotic Therapy Resulting In A Excellent Prognosis.
when advanced disease occurs prognosis is still good, if lesion are treated
with debridement, local and systemic antibiotics and regenerative therapy.
In GAP- patient have a fair, poor or questionable prognosis.

111.  LAP-
 GAP

112. PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC
DISEASES:
DIVIDED INTO TWO CATEGORIES.
 PERIODONTITIS ASSOCIATED WITH HEMETOLOGIC
DISORDERS – LEUKEMIA & ACQUIREDNEUTROPENIA
 PERIODONTITIS ASSOCIATED WITH GENETIC DISORDERS –
HYPOPHOSPHATASIA, DOWN’S SYNDROME, ETC..,
Unless neutropenia is corrected, these pt’s present with a fair to
poor prognosis.
Hypophosphatasia – decrease levels of alp, severe alveolar bone
loss and premature loss of decidious and permanent teeth.
Prognosis is fair to poor.

113. NUG
NUP

114. Conclusion
 Determination of the prognosis of a teeth can be difficult, particularly for
teeth with previous diseases.
 Many factors can influence disease progression and the response to
therapy, and the specific influence of any one factor is unknown and is likely
different from one patient to another.
 In addition, each patient can respond differently at different times.
 All these issues make determination of prognosis difficult.

115. THE TREATMENT PLAN

116. Introduction
 THE TREATMENT PLAN IS THE
BLUE PRINT FOR CASE
MANAGEMENT
 It includes following procedures
1. Teeth to be retained or extracted
2. Pocket therapy by surgical or non surgical
3. Need for occlusal correction prior to pocket
therapy
4. The use of implant therapy

117. 5.Need for temporary restorations
6. Final restorations
7. Need for orthodontic consultation .
8.Endodontic therapy.
9.Esthetic considerations in periodontal therapy
10. Sequence of therapy
No treatment should be done
except for emergencies until
treatment has been established.

118. THE MASTER FOR TOTAL
TREATMENT
 the AIM of it is coordination of all
treatment procedures for the
purpose of creating a well
functioning dentition in a healthy
periodontal environment.
 The primary goal is elimination of
gingival inflammation and
correction of the conditions that

119. Extracting or preserving tooth
 IT IS DIRECTED TO establishing and maintaining the health
of the periodontium through out the mouth rather than to
spectacular efforts to tighten loose teeth.
 Tooth should be extracted when any of the following occurs
1. It is so mobile that function becomes painful.
2. Can cause acute abscess during therapy.
3. When there no use for it in overall therapy.

120. Tooth should be retained
temporarily when
 It maintains posterior stops –prosthetic replacement
 It maintains posterior –implant replacement
 In anterior esthetic areas .
 Removal of hopeless teeth can also performed during
periodontal therapy of neighboring teeth .

121. In formulation of treatment plan
 Esthetic considerations
 Consideration of Occlusal relationship.
 Systemic considerations
 Supportive periodontal care.

122. Therapeutic procedures
 Phases of periodontal therapy
1. Preliminary phase – Treatment of
emergencies
dental or Periapical
Periodontal
Other

123.  ETIOTROPIC PHASE (PHASE I THERAPY)
Plaque control and patient education .
Evaluation of response to etiotropic phase.
 SURGICAL PHASE (PHASE II THERAPY)
 RESTORATIVE PHASE (PHASE III THERAPY )
Evaluation of response to restorative procedures.
 MAINTENANCE PHASE (PHASE IV THERAPY)

124. PREFERRED SEQUENCE OF
PERIODONTAL THERAPY
Emergency phase
Etiotropic phase
Maintenance phase
Surgical phase Restorative
phase