This document provides an overview of periodontal prognosis, including definitions, types of prognosis, and factors that influence prognosis determination. Key factors include overall clinical factors like age, disease severity and plaque control; systemic/environmental factors like smoking and systemic diseases; local factors like plaque, calculus and tooth anatomy; and prosthetic/restorative factors. The relationship between diagnosis and prognosis is also discussed. Prognosis depends on the diagnosis and condition, with generally good prognosis for gingivitis if plaque is removed, and varying prognosis for periodontitis depending on additional risk factors.

1. Dr. Nikhat Fatima. Dept of Periodontics

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. • When people become sick, they have
a great many questions about how
their illness will affect them.
• Most patients and their families want
to know what to expect, even in
situations where little can be done
about their illness.

4. 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.

5. “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.”
Mosby’s Dental Dictionary.

6. • The word prognosis comes from the
Greek prognostikos (of knowledge
beforehand).
It combines pro (before) and gnosis (a
knowing). Hippocrates used the word
prognosis, to mean a foretelling of the
course of a disease.

7. “The physician who cannot inform his
patient what would be the probable issue
of his complaint, if allowed to follow its
natural course, is not qualified to
prescribe any rational treatment for its
cure.”
Hippocrates 460-375 B.C

8. • Prognosis established after the
diagnosis is made and before the
treatment plan is established.

9. • 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.

10. Diagnosis
• The art or act of identifying a
disease from its signs and
symptoms.
• From Greek diagnōsis, from
diagignōskein to distinguish, from
dia- + gignōskein to know.

11. 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.

12. • 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.

13. • 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.

14. Periodontal Prognosis
Importance:
Clinician:
• To determine which treatment modalities
will be most effective.
• To develop restorative recommendation
and treatment plans.

15. Periodontal Prognosis
Importance:
Patient:
To determine whether treatment seems
worthwhile.

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

17. Prognostication: temporal issues and
dynamics
Prognosis usually is expressed in 2 parts:
• Short term (less than 5 years) and
• Long term (more than 5 years).

18. • The determination of prognosis is an
evolving and dynamic process.
• Therefore it is reasonable to try and
predict long-term prognosis for 5 years,
but reassessment is often needed for a
prolonged period.

19. • Prognosis can change after treatment as
well as after recurrent disease activity.
Therefore reprognostication occurs after
each examination of the patient.

20. Periodontal prognostication systems
Hirschfeld and Wasserman 1978.
There were only 2 levels of prognosis used.
• Favorable
• Questionable

21. Becker et al 1984.
There were 3 prognostic categories used
• Good ,
• Questionable, and
• Hopeless

22. McGuire and Nunn 1996.
This system contained more detailed
stratification for individual teeth,
• Good
• Fair
• Poor
• Questionable
• Hopeless

23. Types of prognosis
Excellent prognosis:
•No bone loss
•Excellent gingival condition.
•Good patient cooperation,
no systemic or environmental factors.

24. Good prognosis: One or more of the
following remaining:
Bone support.
Adequate possibilities to control
etiologic factors and establish a maintainable dentition
Adequate patient cooperation,
no systemic or environmental factors,
or if systemic factors present,
they are well controlled.

25. 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.
Presence of limited
systemic or environmental
factors

26. 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.

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

28. Hopeless prognosis: One or more of the
following:
Nonmaintainable
areas.
Extractions
indicated.
Presence of uncontrolled
systemic or environmental
factors.
Advanced bone
loss.

29. • 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.

30. • It is 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.

31. Periodontal
stability
Favorable
Questionable
Unfavorable
Hopeless Extraction needed
Likely
maybe
unlikely

32. Prognosis
Overall
Individual
age,
.
disease
systemic factors
smoking
plaque,
calculus
compliance
prostheses
plaque,
calculus
Factors influence
Prosthetic&
Restorative

33. 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

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

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

36. 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.

37. • 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.

38. 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.

39. 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.

40. 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.

41. 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.

42. • 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.

43. • 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.

44. 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.

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

46. 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.

47. • 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.

48. • 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.

49. • 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.

50. 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.

51. 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.

52. 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.

53. 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.

54. Subgingival
Restorations.
• Subgingival margins
contribute to increased
plaque accumulation,
increased inflammation, and
increased bone loss when
compared with
supragingival margins.
• Overhangings can
negatively impact the
periodontium.

55. 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.

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

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

58. 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.

59. • 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.

60. • 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.

61. • Additionally, special oral
hygiene measures must
be instituted in these
areas.

62. 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.

63. • 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.

64. 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.

65. 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.

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

67. 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.

68. • 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.

69. 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.

70. • 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.

71. 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.

72. • 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.

73. 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.

74. 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.

75. • 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.

76. 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.

77. • 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.

78. • 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.

79. Periodontitis as a
manifestation of systemic
diseases
Periodontitis associated
with genetic disorders
Periodontitis associated
with hematologic disorders
Leukemia
Neutropenia
Acquired
Down
syndrome
Papillon
Lefevre
syndrome
Periodontitis as a Manifestation of
Systemic Diseases

80. • 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.

81. • 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.

82. 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.

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

84. • 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.

85. 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.

86. Conclusion
• There are no reliable algorithms for
prognosis, so clinicians must use
their clinical judgment.
• Constant reviewing of results of
treatment coupled with detailed
documentation of periodontal status
will sharpen the clinician's acumen
for accurate assessment of
prognosis.

87. “Patients and their families will
forgive you for wrong
diagnoses, but will rarely
forgive you for wrong
prognoses; the older you grow
in medicine, the more chary
you get about offering iron
clad prognoses, good or bad.”
— Anonymous

89. References
• Clinical periodontology and implant dentistry:
Jan Lindhe. 5th edition.
• Carranza’s clinical periodontology: 10th edition
• Prognosis revisited: JOP 2007 vol 78
• The Hopeless Tooth: When is Treatment
Futile? Quintessence International, Vol. 30,
Num. 12 1999
• Use of periodontal risk factors in screening
and prognosis –Periodontology 2000 vol- 50.
• Atlas of cosmetic and reconstructive
periodontal Surgery--Edward S. Cohen.