This document discusses factors that determine prognosis in periodontal disease treatment. It defines prognosis as predicting the course and outcome of a disease based on general knowledge of pathogenesis and risk factors. Prognosis depends on overall factors like type and severity of periodontitis, age, systemic conditions, and individual factors like percentage of bone loss, pocket depth, and furcation involvement. A patient's prognosis can range from excellent to hopeless depending on these factors. The document provides details on how factors affect prognosis and clinical implications for determining prognoses as good, fair, poor, questionable or hopeless.

1. The aim of education is the knowledge not of
fact, but of values.

2. Determination of prognosis
Presented by
Deepti
jain

3. Contents:
 Introduction
 Definition
 Prognostication schemes
 Types
 Factors for determining prognosis
 Overall factors
 Individual factors
 Clinical relations
 Prognosis for patients with gingival diseases
 Prognosis for patients with periodontal diseases
 Prognosis for patients with acute periodontal diseases
 Prognosis after phase I therapy
 Conclusion

4. Introduction
 Accurate prognosis….
current established
criteria,
therapeutic
judgment
experience
success and failure of
the past treatment.

5.  Fundamental therapeutic goal …
 Latin word…means… “foreknowledge”
 Prognosis is often confused with risk….
 Excellent, good, and hopeless prognoses ….
 Fair, poor, and even questionable prognoses
depend on a large number of factors ….

6. Prognosis
or
Risk

7. definition
 It is defined as a prediction of duration,
course & termination of a disease & its
response to treatment.
{Hall}
 Prognosis is a prediction of the probable
course and outcome of a disease based on
general knowledge of pathogenesis of the
disease and the presence of risk factors for
the disease.
{Carranza}

8.  A prediction as to the progress, course and
outcome of a disease.
{ glossary of periodontics}

9. Prognostication schemes
 Traditional schemes…..Based on tooth mortality
Author Classes Criteria
Hirschfeld and Wasserman,1978 Favorable
questionable
deep pocket, furcation
involvement , mobilty, extensive
bone loss
Becker,1984 Good
Questionable
hopeless
deep pocket, furcation
involvement , palatal
grooves,repeated abscesses,
extensive bone loss
Mc guire and Nunn, 1996 Good, fair,poor
questionable,hopeless
5-8 years of term, deep pocket,
furcation involvement , palatal
grooves,repeated abscesses,
extensive bone loss, attachment
loss ,anatomic factors

10.  Newer prognostication schemes are based
on….
 Periodontal stability rather than tooth loss
 Overall and individual prognosis
 Long term and short term prognosis
 Has six classes… discussed later

11. Types of prognoses
 Diagnostic Prognosis: An evaluation of the
course of the disease without treatment, the
status of the teeth at present & the anticipated
future of the teeth.
 Therapeutic Prognosis: Given the state of the
art & science of Periodontics & knowledge & skill
of the practitioner, what effect will periodontal
treatment have on the course of the disease.

12.  Prosthetic Prognosis: Given the anticipated
result of periodontal treatment & periodontal
health status obtained for the patient, what is
the forecast for the success of the prosthetic
restoration.

13.  Depending upon the number of teeth
involved:
• dentition as a whole
• Generalised factors
Overall
prognosis
• for individual teeth
• determined after the
overall prognosis
Individual
prognosis

14. Factors For Determining
Prognosis
Overall factors Individual factors
Type of periodontitis Percentage of bone loss
Age Probing depth – periodontal pocket
Systemic background Distribution & type of bone loss
Malocclusion Presence & severity of furcations
periodontal status & prosthetic
possibilities
Mobility
Plaque control Tooth morphology
Smoking Crown to root ratio
Cooperation of the patient Root forms, root concavities, CEPs
Individual tooth prognosis Pulpal involvements
Knowledge & ability of Dentist Caries
Economic consideration Tooth position & occlusal relationship
Genetic factors Relation to adjacent teeth
Stress Subgingival restoration

15. Factors affecting overall prognosis
 Type of Periodontitis
 Slowly progressing Periodontitis… directly related to
severity of inflammation & height of remaining bone
 Rapidly progressing Periodontitis… extensive
inflammatory reaction which has hopeless prognosis
 Juvenile Periodontitis…. Prognosis poor
 refractory Periodontitis… resisitant to treatment. Most cases,
prognosis is poor

16. Juveille periodontits
Chronic periodontitis

17.  Patient’s age…
 Older patient …better prognosis
 Younger patient..poor prognosis
 due to shorter frame of time for bone loss
 familial reasons
 smoking
 although have greater regenerative capacity , but the
destruction exceeds repair

18.  Disease severity
 past history of periodontal disease needs to
acknowledged.
 pocket depth, clinical attachment level,
degree of bone loss, and type of bony defect.

19.  Systemic Background
 Prevalence & severity of periodontitis is higher
in patients with type I & II diabetes.
 Incapacitating conditions eg: Parkinson's disease
adversely affects prognosis
 Other conditions like respiratory disorders,
coronary artery diseases, viral infection which
may further complicate the prognosis.

20.  Hypophosphatsia
 Diabetes mellitus

21.  Malocclusion
 Irregularly aligned teeth, malformation of jaws,
abnormal occlusal relationships interfere with
plaque control.
 Orthodontic or prosthetic correction is essential
for success of periodontal treatment.
 Overall prognosis is poor for the patients with
occlusal deformities that cannot be corrected

22.  Assessment of periodontal status & prosthetic
probabilities
 Overall prognosis requires consideration of bone
levels (radiograph) & attachment levels (clinical).
 Overall & individual prognosis overlap at this point.
 When few teeth remain, the prosthetic needs
become more important & periodontally treatable
teeth may have to be extracted if not compatible
with prosthesis design.

24.  Smoking
 important environmental risk factor for development &
progression of periodontal diseases.
 does not respond well to conventional therapy.
 Patients (smoker) with slight to moderate periodontitis ….
fair to poor prognosis
 A non-smoker with severe periodontitis may have
improved prognosis post trt.
{ Bolin aeklund et al }

25.  Patient co operation & compliance
 patients attitude, desire to retain natural teeth &
ability to maintain good oral hygiene.
 patients should be clearly informed of the
important role they must play for treatment to
succeed.
 unwilling or unable to perform adequate plaque
control… refuse the trt or extract the tooth.

26.  Plaque control
 Bacterial plaque …. primary etiological factor
 Effective removal of plaque on a daily basis is
critical…
 Usage of correct technique
 Interdental aids
 Self irrigation methods

27.  Genetic Factors
• Polymorphishms
• Familial tendency
• Serum IgG2 antibody titres
• Expression of fc- R II receptors on the neutrophil
• Leucocyte adhesion deficiency type I
 E.g.Genetic polymorphism in (IL-1) resulting in increased IL 1  has been
associated with significant risk for severe, generalized chronic periodontitis
 Periodontal disease….multifactorial, patients genotype …more
important { Mc Guire, 1999}

28. Early detection of genetic features
help in….
 Prevention and treatment measures
 influence treatment recommendations, such
as use of adjunctive antibiotic therapy or
increased frequency of maintenance visits
 Young individuals who are at risk because of
familial aggregation can be subjected to early
treatment.

29.  Stress
 Physical & environmental stress as well as
substance abuse may alter patient’s ability to
respond to periodontal treatment.
 These factors have to be realistically faced in
attempting to establish prognosis

30. Factors affecting individual tooth
prognosis
 Percentage of bone loss
 Greater the bone loss, poorer the prognosis
 As bone loss exceeds 50%, the prognosis
worsens rapidly
 More irregular the bone loss, the poorer the
prognosis

31.  Distribution & type of bone loss
 Horizontal bone loss, pocket elimination is easier
 irregular vertical or trough like bone defects, new
attachment attempts or bone grafting must be
considered and they are easier to plan.
 Vertical bone losses with 1 or 2 walled infrabony defects
or inter proximal bony craters …worse prognosis than
horizontal type

32.  Architecture
 Infra bony defect architecture influences the
prognosis
three wall defect
• … fair prognosis
• a scaffold for repair & good regeneration
Two walled craters
have questionable prognosis
One walled defects
have the hopeless prognosis for bone
regeneration

33.  Location of remaining bone in relation to
individual tooth surface
 When greater bone loss has occurred on 1 surface of
a tooth, bone height on the less involved surfaces
determines prognosis
 Because of greater height of bone in relation to
other surface, the center of rotation of tooth will be
nearer the crown better prognosis.

34.  Periodontal pocket
 The following factors are important in
determining prognosis:
 Pocket depth
 Level of attachment
 Degree of bone loss
 Type of pocket

35.  Tooth Mobility
 Teeth with 4-5 mm remaining bone or 2-3 grade
mobility …. doubtful prognosis
 Mobility due to occlusal trauma has favorable
prognosis

36.  Furcation Involvement
 The problems associated are
 Difficulty of access to surgical area
 Inaccessibility of the area to plaque removal by patient
 factors while projecting the prognosis with furcation
involvement
 Extent of involvement of bone
 Status of bone support
 Angulations of root spread
( Hirshfeld and Wasserman)

37. prognosis is unfavorable
prognosis can be improved
prognosis is better

38.  Tooth morphology
 Anatomic factors related to roots, that affect the
periodontal apparatus status include the
following:
 Root form & morphology
 Crown – Root ratio
 Root concavities
 Developmental grooves
 Cervical Enamel projection
 Enamel pearls

39.  Caries, Non-vital teeth,Tooth resorption
 In teeth with extensive caries
 Root resorption….poor prognosis
 Periodontal prognosis of treated non vital
teeth no different from vital teeth.

40. Clinical Implication
 Excellent Prognosis
 No bone loss
 Excellent gingival condition
 Good patient co operation
 No systemic / Environmental factors


41.  Good Prognosis
 Adequate remaining bone support
 Adequate possibilities to control etiological
factors & establish a maintainable dentition
 Adequate patient cooperation
 No systemic/environmental factors; even if
present, well controlled

42.  Fair Prognosis
 Less than adequate remaining bone
 Some teeth mobile
 Grade 1 furcation involvement
 Adequate maintainence possible
 Acceptable patient cooperation
 Presence of limited systemic and
environmental factors

43.  Poor Prognosis
 Moderate to advanced bone loss
 Tooth mobility
 Grade I & II furcation involvement
 Difficult to maintain areas
 Doubtful patient cooperation
 Presence of systemic / environmental factors

44.  Questionable Prognosis
 Advanced bone loss
 Grade II & III furcation involvement
 Tooth mobility
 Inaccessible areas
 Presence of systemic / environmental factors

45.  Hopeless Prognosis
 Advanced bone loss
 Non maintainable area
 Extractions indicated
 Uncontrolled systemic / environmental factors

46. Prognosis For Patients With Gingival
Disease
 Gingivitis associated with Dental plaque only
 Prognosis … good ,
 all local irritants
 local factors contributing to plaque retention
 gingival contours conductive to the preservation of
health are attained
 patient cooperates

47.  Plaque-induced gingival diseases modified by
systemic factors
 control of bacterial plaque
 control or correction of systemic diseases
 Plaque induced gingival diseases modified by
medications
 systemic problem can be treated with
an alternative medication

48.  Gingival disease modified by malnutrition
 severity & duration of the deficiency
 on the likelihood of reversing the deficiency
 Non-Plaque induced gingival lesions
 dependent on elimination of the causative agent
 Control of associated dermatological disorder.

49. Prognosis For Patients With
Periodontitis
 Chronic Periodontitis
 clinical attachment loss & bone loss
are not very advanced, prognosis is good.
 more severe disease, as evidenced by furcation
involvement & increasing mobility, or in patients who are
non compliant with oral hygiene practices, the prognosis
may be fair to poor.

50.  Aggressive Periodontitis
 poor prognosis…
 limited microbial deposits
 phagocyte abnormalities &
 a hyperresponsive monocyte / macrophage phenotype
Good prognosis
 diagnosed early
 treated conservatively

51.  Periodontitis as a manifestation of systemic
diseases
 those associated with hematologic disorders such as
leukemia and acquired neutropenias and
 those associated with genetic disorders such as familial
and cyclic neutropenia

52.  systemic diseases that alter the ability of the host to
respond to the microbial challenge …affect prognosis
 E.g….decreased numbers of circulating neutrophils
…destruction of the periodontium. Unless the
neutropenia can be corrected, these patients present
with a fair-to-poor prognosis.

53. Prognosis for Necrotizing Periodontal
Diseases.
 NUG, …
predisposing factor is bacterial plaque
 presence of secondary factors such as acute psychologic
stress, tobacco smoking, and poor nutrition…
 control of both the bacterial plaque and the secondary
factors, the prognosis for a patient with NUG is good..
 With repeated episodes of NUG, the prognosis may be
downgraded to fair.

54.  patients presenting with NUP are immunocompromised
through systemic conditions, such as HIV infection.
 the prognosis is dependent on not only reducing local
factors but also on reducing secondary factors.

55. Reevaluation of Prognosis After
Phase I Therapy
 reduction in pocket depth and inflammation
after phase I therapy …changes the status of
prognosis.
 If the inflammatory changes present cannot
be controlled or reduced by phase I therapy,
the overall prognosis may be unfavorable

56. Conclusion
Hence the determination of prognosis is a vital & essential step in
periodontal treatment planning. Prognosis not only gives the idea of
how the treatment should be planned rather it also supports the
outcome of the therapy that would be given. With a constant effort
from the clinician, the patient and the patient’s physician one can
improve the prognosis of the current condition by controlling the
primary etiological, secondary and systemic factors.

57. References
 Text book of clinical Periodontology;
Carranza F A , tenth edition
 Text book of clinical Periodontology and
implant dentistry; Lindhe, fifth edition
 Decision making in periodontics, Hall 4th ed.
 Ghaia S, Bissada NF: Prognosis and actual
treatment outcome of periodontally involved
teeth. Periodont Clin Invest 1996; 18:7.

58.  Rosling B, Nyman S, Lindhe J: The effect of systematic
plaque control on bone regeneration in infrabony
pockets.J Clin Periodontol 1976; 3:38.
 Rowland RW: Necrotizing ulcerative gingivitis. Ann
Periodontol 1999; 4:65.
 Lindhe J, Ranney R, Lamster 1, et al: Consensus report:
periodontitis as a manifestation of systemic diseases.
Ann Periodontol 1999; 4:64.
 Prognosis revisited: a system for assigning periodontal
prognosis; vivek kuan , JG caton : journal periodontology
2007 vol 80.
 Sources from net.