The document discusses prognosis in periodontal disease, detailing definitions, types, and factors affecting the prognosis of specific diseases. It emphasizes the importance of patient compliance, systemic factors like smoking, and local factors such as biofilm presence in determining the prognosis for treatment. Additionally, it highlights the classification of prognosis into categories ranging from good to hopeless, and the need for ongoing reassessment after treatment phases.

1. PROGNOSIS
DR.OINAM MONICA DEVI

2. Contents
• Definition
• Types of Prognosis
• Factors in Determination of Prognosis
• Prognosis of Specific Periodontal Diseases
• Determination and Reassessment of Prognosis
• Conclusion

3. Definition
A 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 ( Carranza, 13th e
d).
• 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.

4. PROGNOSIS
After the diagnosis Before the treatment plan
•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.
•Prognosis initially assigned should be reevaluated after completion of all
phases of therapy, including periodontal maintenance.

5. Classification of Prognosis (McGuire MK ,1996;Kwok V, 2007)
• 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.
• Poor prognosis: 50% attachment loss, grade II furcation invasion.
• Questionable prognosis: >50% attachment loss, poor crown-to root
ratio, poor root form, grade II furcation invasion or grade III furcation
invasion; mobility no. 2 or no. 3; root proximity.
• Hopeless prognosis: Inadequate attachment to maintain health,
comfort, and function.

6. 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.
• 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.

7. Overall Prognosis
• The overall prognosis is concerned with the dentition as a whole.
• Factors that may influence the overall prognosis include
1. Patient age
2. Current severity of disease
3. Systemic factors
4. The presence of biofilm or calculus
5. Patient compliance
6. Prosthetic possibilities

8. 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?

9. Individual Prognosis
• 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.

10. Factors to Consider When Determining a Prognosis
Overall Clinical
Factors
•Patient age
•Disease severity
•Biofilm control
•Patient compliance
Systemic and
Environmental
Factors
•Smoking
•Systemic disease
or condition
•Genetic factors
•Stress
Local Factors
•Biofilm and
calculus
•Subgingival
restorations
Anatomic Factors
•Short, tapered roots
•Cervical enamel
projections
•Enamel pearls
•Bifurcation ridges
•Root concavities
•Developmental
grooves
•Root proximity
•Furcation invasion
•Tooth mobility
•Caries
•Tooth vitality
•Root resorption
Prosthetic and
Restorative
Factors
•Abutment selection

11. Factors in Determination of Prognosis
• 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.
• In younger patient, the occurrence of so much destruction in a relatively
short period would exceed any naturally occurring periodontal repair.

12. Disease Severity
• A patient's history of previous periodontal disease may be indicative of
their susceptibility to future periodontal breakdown.
• Variables determining the patient's past history of periodontal disease:
probing pocket depth, level of attachment, amount of bone loss, and type of
bony defect must be assessed properly.

13. • Clinical attachment loss 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.
• Probing pocket depth is less important than level of attachment because it is
not necessarily related to bone loss.
• In general, a tooth with deep probing depths and little attachment and bone loss
has a better prognosis than one with shallow pockets and severe attachment
and bone loss.

14. • Prognosis is adversely affected if the base of the pocket is close to the root
apex.
• The presence of apical disease as a result of endodontic involvement also
worsens the prognosis.
• The prognosis also can be related to the height of remaining bone but bone level
assessment alone insufficient for determining the overall prognosis

15. Generalized mild chronic
periodontitis in a healthy,
nonsmoking 67-year-old female.
Overall prognosis is favourable
Generalized moderate-to-severe
chronic periodontitis in a healthy,
nonsmoking 49-year-old female.
Overall prognosis is
questionable/unfavorable.
Carranza, 13th ed

16. • 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.

17. 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.
Carranza, 13th ed

18. • The practitioner should weigh the potential success of one treatment option
(extraction and implant placement) versus the other (periodontal therapy
and maintenance) carefully when assigning a questionable prognosis to
teeth.
• Strategic extraction of teeth with unfavorable or questionable prognoses
may improve the prognosis of adjacent teeth, enhance the prosthetic
treatment, and increase the success rate of implants replacing the
strategically extracted teeth.
Carranza, 13th ed

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

20. 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.
• 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.

21. Systemic and Environmental Factors
Smoking
• Patients should be informed that smoking affects not only the severity of
periodontal destruction but also the healing potential of the periodontal
tissues.
• The prognosis in patients who smoke and have slight to moderate chronic
periodontitis is generally questionable.
• 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.

22. Systemic Disease or Condition
• Evidence from epidemiologic studies clearly demonstrates that the prevalence
and severity of chronic periodontitis are significantly higher in patients with
poorly controlled diabetes than in those whose diabetes is well controlled or
those who do not have diabetes.
• Similarly, in patients with other systemic disorders that could affect disease
progression, prognosis improves with correction of the systemic problem.
• Incapacitating conditions that limit the patient's performance of oral procedures
(e.g., Parkinson disease) also adversely affect the prognosis.
• Newer “automated” oral hygiene devices, such as electric toothbrushes, may be
helpful for these patients and may improve their prognosis.

23. Genetic Factors
• Evidence indicates that 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-1β, have been associated with a significant increase in risk for
severe, generalized, and chronic periodontitis.
• It has been demonstrated that knowledge of the patient's IL-1 genotype and
smoking status can aid the clinician in assigning a prognosis.

24. • Detection of genetic variations linked to periodontal disease can potentially
influence the prognosis in several ways.
1. Early detection of patients at risk because of genetic factors can lead to
early implementation of preventive and treatment measures for these
patients.
2. Identification of genetic risk factors later in the disease or during the course
of treatment can influence treatment recommendations, such as the use of
adjunctive antibiotic therapy or increased frequency of maintenance visits.
3. 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.

25. 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.

26. Local Factors
Biofilm and Calculus
• The microbial challenge presented by bacterial biofilm and calculus is the
most important local factor in periodontal diseases.
• Having a favorable prognosis depends on the ability of the patient and the
clinician to remove these etiologic factors.

27. Subgingival Restorations
• Subgingival margins may contribute to increased biofilm accumulation,
increased inflammation, and increased bone loss when compared with
supragingival margins.
• Discrepancies in these margins (e.g., overhangs) and duration of their presence
are important factors in the amount of destruction that occurs.
• A tooth with a discrepancy in its subgingival margins has a worse prognosis
than a tooth with well-contoured supragingival margins.

28. Anatomic Factors
• Anatomic factors that may 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 assigning a prognosis.
• Prognosis is less favorable for teeth with short, tapered roots and relatively large
crowns.

29. • Cervical enamel projections (CEPs) on the root surface interferes with the
attachment apparatus and may prevent regenerative procedures from achieving
their maximum potential.
• The morphology of the tooth root is an important consideration when discussing
prognosis.
• Root concavities increase the attachment area and produce a root shape that may
be more resistant to torquing forces, they also create areas that can be difficult
for both the dentist and the patient to clean.
• Developmental grooves, which sometimes appear in the maxillary lateral
incisors or in the lower incisors, create an accessibility problem.
• Root proximity can result in interproximal areas that are difficult for the
clinician and patient to access.

30. 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.
• The likelihood of restoring tooth stability is inversely proportional to the extent to
which mobility is caused by the loss of supporting alveolar bone.
• A longitudinal study of the response to treatment of teeth with different degrees of
mobility revealed that pockets on clinically mobile teeth do not respond as well to
periodontal therapy as pockets on nonmobile teeth exhibiting the same initial
disease severity.
• The stabilization of tooth mobility through the use of splinting may have a
beneficial impact on the overall and individual tooth prognosis.

31. 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.

32. Prosthetic and Restorative Factors
• The overall prognosis and individual tooth prognosis overlap because the
prognosis for key individual teeth may affect the overall prognosis for
prosthetic rehabilitation.
• 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.
• Teeth that serve as abutments are subjected to increased functional demands.
• 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.

33. Prognosis for Patients With Gingival Disease
Biofilm-Induced Gingival Diseases
Gingivitis Associated With Dental Plaque Only
• Biofilm-induced gingivitis is a reversible disease that occurs when bacterial
biofilm accumulates at the gingival margin.
• The prognosis is good for patients with gingivitis associated with bacterial
biofilm only favorable, provided
1. All local irritants are eliminated
2. Other local factors contributing to biofilm retention are eliminated
3. Gingival contours conducive to the preservation of health are attained
4. The patient cooperates by maintaining good oral hygiene

34. Biofilm-Induced Gingival Diseases Modified by Systemic Factors
• The frank signs of gingival inflammation that occur in patients having systemic
disorders are seen in the presence of relatively small amounts of bacterial
biofilm.
• The long-term prognosis for these patients depends not only on control of
bacterial biofilm but also on control or correction of the systemic factors.

35. Biofilm-Induced Gingival Diseases Modified by Medications
• Gingival diseases associated with medications include drug influenced gingival
enlargement, often seen with phenytoin, cyclosporine, and nifedipine and in oral
contraceptive–associated gingivitis.
• In drug-influenced gingival enlargement, the severity of the lesions is associated
with inflammation, which is usually induced by bacterial biofilm.
Gingival overgrowth in a 5-year-old male patient who was taking cyclosporine for the management of
aplastic anemia.
Carranza, 13th ed

36. • Eliminating the source of inflammation, either trauma or biofilm, can limit the
severity of the gingival overgrowth.
• Surgical intervention is usually necessary to correct the alterations in gingival
contour.
• The long-term prognosis depends on whether the etiology of the inflammation
can be completely eliminated or the patient‘s systemic problem can be treated
with an alternative medication that does not have gingival enlargement as a side
effect.
The gingival overgrowth was resected surgically
Carranza, 13th ed

37. • In oral contraceptive–associated gingivitis, frank signs of gingival
inflammation can be seen in the presence of relatively little biofilm.
• The long-term prognosis in these patients depends not only on the control
of bacterial biofilm but also on the likelihood of continued use of oral
contraceptives.

38. Gingival Diseases Modified by Malnutrition
• The prognosis in vitamin C deficiency patients may depend on the severity and
duration of the deficiency and on the likelihood of reversing the deficiency
through dietary supplementation.

39. Non-Biofilm-Induced Gingival Lesions
• Non-biofilm-induced gingivitis in patients is not usually attributed to biofilm
accumulation, prognosis depends on elimination of the source of the infectious
agent.
• Prognosis for patients suffering from dermatologic disorders like lichen planus,
pemphigoid, etc manifesting in the oral cavity as atypical gingivitis is linked to
management of the associated dermatologic disorder.
• Prognosis for patients presenting with gingival lesions as a result of allergic,
toxic, foreign-body reactions, mechanical and thermal trauma depends on the
elimination of the causative agent.

40. Prognosis for Patients With Periodontitis
• In patients with more severe disease, as evidenced by furcation invasion and
tooth mobility, or in patients who are noncompliant with oral hygiene practices,
the prognosis may be questionable or unfavorable, and even hopeless.

41. Periodontitis as a Manifestation of Systemic Diseases
• Periodontitis as a manifestation of systemic diseases can be divided into the
following two categories :
1. Periodontitis associated with hematologic disorders such as leukemia and
acquired neutropenias
2. Periodontitis associated with genetic disorders such as familial and cyclic
neutropenia, Down syndrome, Papillon- Lefèvre syndrome, and
hypophosphatasia
• The prognosis in these cases will be questionable or unfavorable.

42. • Other genetic disorders do not affect the host's ability to combat infections
but still affect the development of periodontitis.
(1) Hypophosphatasia, in which patients have decreased levels of circulating
alkaline phosphatase, severe alveolar bone loss, and premature loss of
deciduous and permanent teeth.
(2) Ehlers-Danlos syndrome, a connective tissue disorder, in which patients
may present with clinical characteristics of aggressive periodontitis.
• In both examples the prognosis is questionable or unfavorable.

43. Necrotizing Periodontal Disease
• In Necrotizing ulcerative gingivitis (NUG), the primary predisposing factor is
bacterial plaque, 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.
• With control of both the bacterial plaque and the secondary factors, the prognosis
for a patient with necrotizing ulcerative gingivitis (NUG) is favorable.
• The tissue destruction in NUG cases is not reversible, and poor control of the
secondary factors may make these patients susceptible to recurrence of the
disease.
• With repeated episodes of NUG, the prognosis may worsen to questionable.

44. • The clinical presentation of Necrotizing Ulcerative Periodontitis (NUP) is
similar to that of NUG, except the necrosis extends from the gingiva into the
periodontal ligament and alveolar bone.
• In systemically healthy patients, this progression may have resulted from
multiple episodes of NUG, or the necrotizing disease may occur at a site
previously affected with periodontitis.
• In these patients, the prognosis depends on alleviating the biofilm and
secondary factors associated with NUG.

45. Determination and Reassessment of Prognosis
• Determination of prognosis of a tooth or teeth requires a careful and thorough
assessment of the presence of disease and its severity and extent.
• An accurate prognosis cannot be made without an accurate diagnosis.
• Once disease has been properly and accurately diagnosed, determining the
prognosis can still be difficult, particularly for teeth with disease.
• Many factors can influence disease progression and the response to therapy, and
the specific influence of any one factor is unknown and likely different from
one patient to another.

46. • The outcome of therapy significantly depends on the treatment to be
rendered, the quality of the treatment, the skills and knowledge of the treating
clinician, and patient home care.
• Prognosis of teeth with minimal disease is favorable and by far the easiest to
assign with accuracy and precision.
• Once disease progresses to a point that teeth are no longer functional or
treatable, the prognosis is again easy to determine.

47. • It is not always possible to accurately determine the prognosis prior to initiating
periodontal treatment.
• During the periodontal examination, due to the lack of anesthesia, it may not be
possible to accurately and carefully probe a tooth to determine the true extent
of bone loss and severity of disease.
• The prognosis may change as more specific diagnostic information is discovered
and improve with periodontal treatment or disease progression.
• An inability to enhance the host response will negatively influence the prognosis.

48. • A frank reduction in probing depth and inflammation after therapy indicates a
favorable response to treatment and may suggest a better prognosis than
previously assumed.
• If the inflammatory changes cannot be controlled or reduced by therapy, the
overall prognosis may be unfavorable.
• Given two patients with comparable bone destruction, the prognosis may be
better for the patient with the greater degree of inflammation because a larger
component of that patient's bone destruction may be attributable to local
etiologic factors.

49. Prognosis changes with treatment. The maxillary left first and second molars were initially assigned an
unfavorable prognosis due to advanced bone loss and deep grade II furcation invasion (A, B).
Both teeth were vital, stable, and did not require any restorative treatment.
Both teeth were treated with periodontal surgery.
After 5 years, they remain healthy and functional, and the prognosis improved to favorable (C, D).
Carranza, 13th ed

50. • The progression of periodontitis generally occurs in an episodic manner, with
alternating periods of quiescence and shorter destructive stages.
• No methods are available at present to accurately determine whether a given
lesion is in a stage of remission or exacerbation.
• Advanced lesions, if active, may progress rapidly to a hopeless stage, whereas
similar lesions in a quiescent stage may be maintainable for long periods.
• Stable lesions in a patient in periodontal maintenance may also break down and
advance due to changes in biofilm control, stress level, or systemic health.
• Prognosis along with diagnosis must be carefully evaluated and reassessed
throughout the course of treatment and over time during supportive maintenance
therapy.
Conclusion

51. References
1. Newman, Takei, Klokkevold, Carranza. Carranza’s, clinical periodontology, 10th
ed; 632-34.
2. Newman, Takei, Klokkevold, Carranza. Carranza’s, clinical periodontology, 13th
ed; 1880-1916.
3. Kwok V, Caton J. Prognosis revisited: a system for assigning periodontal
prognosis. J Periodontol. 2007;78:2063.
4. McGuire MK, Nunn ME. Prognosis versus actual outcome.II. The effectiveness
of clinical parameters in developing an accurate prognosis. J Periodontol.
1996;67:658.

52. Thank you