Prognosis

Dr. Nithin Markose Reji

1st year P.G

Contents

Introduction

Definition

Terminology

Classification

Factors determine prognosis

prognosis for patients associated with gingivitis

prognosis for patients associated with

periodontitis

Introduction

Determination of prognosis is a
dynamic process.

It is established after the diagnosis is

made and before the treatment plan
is established.

The prognosis is based on

information about the disease and

the manner in which it can be treated

clinicians previous experience with

treatment outcomes

Terminology

Prognosiscomes from the Greek

Pro-"before

Gnosis-knowledge

Definition

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.

Classification

Hirschfeld and Wasserman

Classification (journal of
periodontol 1978)

Classified into two groups

Favourable Prognosis

Questionable Prognosis-

Lack of consideration of systemic

factors and local factors where the
major drawback of this classification

Becker et al 1984

Three prognostic categories

Good Prognosis

Questionable Prognosis

Hopeless Prognosis

Questionable Prognosis

Bone loss upto 50%

Probing depth 6-8mm

Class II furcration involvement

Presence of deep vertical groove on

max.incisors

Mesial furcation involvement of max.first

premolar

Hopeless Prognosis

Loss of >75% of bone loss

Probing depth > 8mm

Class III furcation

Class III mobility

Poor crown root ratio

Root proximity with min. Interproximal

bone and horizontal bone loss

Patients with poor maintenance

where not as predictable

McGuire MK , Nunn ME ; J Periodontol in 1996

Good prognosis

Fair prognosis

Poor prognosis

Questionable prognosis

Hopeless prognosis

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 and/or

Class I furcation involvement (location and
depth allow proper maintenance with good
patient compliance).

Poor prognosis:

50% attachment loss, Class II furcation

involvement (location and depth make
maintenance possible but difficult).

Questionable
prognosis:

>50% attachment loss, poor crown-to root

ratio, poor root form, Class II furcations or
Class III furcation involvements; >2+
mobility; root proximity.

Hopeless prognosis:

Inadequate attachment to maintain health,

comfort, and function.

Kwok V , Caton J ; J Periodontol 2007

Favourable prognosis

Questionable prognosis

Unfavourable prognosis

Hopeless prognosis

Favorable prognosis:

Comprehensive periodontal treatment and

maintenance will stabilize the status of the
tooth. Future loss of periodontal support is
unlikely.

Questionable prognosis:

Local and/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 and/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.

Overall V/S Individual Tooth Prognosis

The overall prognosis is concerned with the

dentition as a whole.

The individual tooth prognosis is

determined after the overall prognosis and
is affected by it (McGuire MK, J Periodontol
1991).

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.

Grossi et al. studied risk indicators for

attachment loss in a population aged 25
74 years, and reported age as the most
strongly associated factor,

Both the prevalence and severity of

periodontal disease increase with age (Burt
et al, 1994

In addition, aggressive periodontitis in young

individuals often is associated with an
unmodifiable risk factor such as a genetic
predisposition to disease (Papapanou et al,
1998). Therefore young individuals with
periodontal disease may be at greater risk for
continued disease as they age.

Aging is commonly associated with

periodontal disease, although this
relationship is thought to be more related
to cumulative periodontal breakdown over
time than to an age related, intrinsic
deficiency that contributes to susceptibility
to periodontal disease (Genco et al, 1996).
Both the prevalence and severity of
periodontal disease increase with age (Burt
et al, 1994

Disease Severity

It is determined based on

Pocket

depth
Level of attachment
Degree of bone loss
Type of bony defect

Pocket depth is less important than level of

attachment because it is not necessarily related
to bone loss. In general, 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 determination of the level of clinical

attachment 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.

The prognosis also can be related to the

height of remaining bone.

The type of defect also must be

determined. The prognosis for
horizontal bone loss depends on the
height of the existing bone.

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.
(Rosling B, Nyamn S, Lindhe; the effect of systemic
plaque control in periodontal regeneration Journal
of clinical periodontology 1976,3:38)

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.

The center of rotation of the tooth will be nearer the crown. This
results in a more favorable distribution of forces to the
periodontium and less tooth mobility.(Sorrison S, Burman L R : A
Study of case not amenable to periodontal therapy, J Am Dent
Assoc 1944, 44:312)

In dealing with a tooth that has

questionable prognosis chances for
successful treatment should be weighed
up against if under any condition the
tooth under consideration is extracted
strategic
extraction
of
teeth
was
proposed as a means to improve overall
prognosis ( Corn H, Marks MH, trategic
extraction in periodontal therapy Dent
Clin north Am 1969 :13;817)

Plaque control

Removal of plaque is important in the success of

periodontal therapy and prognosis

At present both primary prevention of gingivitis and

primary and secondary prevention of periodontitis are
based on the achievement of sufficient plaque removal.
effective removal of dental plaque is essential to dental
and periodontal health (Le 2000).

Preventing gingivitis could have a major impact on

expenditure for periodontal care(Baehni & Takeuchi 2003).

Microbial plaque biofilm control is an effective way

of treating and preventing gingivitis and is an
essential part of all the procedures involved in the
treatment and prevention of periodontal diseases,(
goodson et al 2004 )It is critical to the long-term
success of all periodontal and dental treatment. .
Good supragingival biofilm control has also been
shown to affect the growth and composition of
subgingival plaque, so that it favors a healthier
microflora and reduces calculus formation.(suomi
et al 1969)

Patient compliance and

cooperation

The prognosis for patients with gingival

and

periodontal

disease

is

critically

dependent on the patients attitude; desire

to retain the natural teeth, and willingness
and ability to maintain good oral hygiene.

Systemic Factors

Smoking

It increase periodontal diseases as well as

it

hinters

proper

healing

after

perio

therapy.

the prognosis in patients who smoke and

have slight to moderate periodontitis is
generally fair to poor. In patients with
severe periodontitis, the prognosis may be

However, smoking cessation can affect the

treatment outcome prognosis.

Patients with slight to moderate periodontitis who

stop smoking can upgraded to a good prognosis

whereas those with severe periodontitis who stop

smoking may be upgraded to a fair prognosis.

SYSTEMIC DISEASE OR CONDITION

The patient's systemic background affects overall prognosis in

several ways.

the prevalence and severity of periodontitis is significantly

higher in patients with type I and type II diabetes than in those
without diabetes

Well-controlled diabetics with slight-to-moderate periodontitis

who comply with their recommended periodontal treatment
should have a good prognosis.

Epidemiological data confirm that diabetes is a major risk

factor for periodontitis; susceptibility to periodontitis is
increased by approximately 3times in people with diabetes

There is emerging evidence to support the existence of a twoway relationship between diabetes and periodontitis, with
diabetes increasing the risk for periodontitis, and periodontal
inflammation negatively affecting glycaemic control.

GENETIC FACTORS

Genetic polymorphisms in the interleukin-1 (IL-1) genes,

resulting in increased production of

IL-1 have been

associated with a significant increase in risk for severe,

generalized, chronic periodontitis.

Genetic factors also appear to influence serum

IgG2

antibody titers and the expression of Fc-RII receptors on the

neutrophil, both of which may be significant in aggressive
periodontitis.

Stress

Physical and emotional stress, as well as

substance abuse, may alter the patients ability to
respond to the periodontal treatment performed.

Methods: A cross-sectional study of 1,426 subjects between the ages

of 25 and 74 years in Erie County, New York, was carried out to assess
these relationships. Subjects were asked to complete a set of 5
psychosocial questionnaires which measure psychological traits and
attitudes including discrete life events and their impact; chronic stress
or daily strains; distress; coping styles and strategies; and hassles and
uplifts.
Conclusions: they found that psychosocial measures of stress
associated with financial strain and distress manifest as depression, are
significant risk indicators for more severe periodontal disease in adults
in an age-adjusted model in which gender (male), smoking, diabetes
mellitus, B. forsythus, and P. gingivalis are also significant risk
indicators.

Local Factors

PLAQUE AND CALCULUS

The microbial challenge presented by bacterial

plaque and calculus is the most important local
factor in periodontal diseases.
effective removal of dental plaque is essential to
dental and periodontal health (Le 2000).
effective removal of dental plaque is essential to
dental and periodontal health (Le 2000).

SUBGINGIVAL RESTORATIONS

Subgingival margins may contribute to increased plaque

accumulation, increased inflammation and increased
bone when compared with supragingival margins

subgingival margins has a poorer prognosis than a tooth

with well-contoured, supragingival margins.

Furthermore, discrepancies in these margins (e.g.,

overhangs) can negatively impact the periodontium.

Several studies have shown that subgingival margin

discrepancy for onlays, (Lang et al, 1983) crowns,
fillings, (Bjorn et al, 1970) and orthodontic bands
(Diamanti- Kipioti et al, 1987) can negatively
influence the health of the adjacent gingival tissues.

Furthermore, it has been hypothesized that

restorations which violate the so-called biologic
width (Ingber et al, 1977) will produce an
inflammatory response that may result in loss of
bone, connective tissue attachment, and migration
of the epithelial attachment (Block et al, 1987).

It is commonly held, that when the

biologic width is violated there is an
attempt by the periodontium to
reestablish the normal dimensions of
the dentogingival junction by a
process of osseous resorption.
This process is thought to lead to
chronic inflammation and
periodontitis (Allen et al, 1970)

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 (CEPs) and
enamel pearls, intermediate bifurcation ridges,
root concavities, and developmental grooves.

Short tapered root

Prognosis is poor for teeth with short

tapered roots and large crowns.
Disproportionate crown-to-root ratio and
the reduced root surface available for
periodontal support, the periodontium may
be more susceptible to injury by occlusal
forces.

Cervical enamel
projections

Cervical enamel projections (CEPs), ectopic

extensions of enamel that extend beyond the
normal

contours

of

the

cementoenamel

junction. Extend into the furcation. Found on

buccal surfaces of maxillary.

Factors related to tooth anatomy

including enamel projections and
enamel pearls have been associated
with attachment loss in molar
furcation areas.Cervical enamel
projections are flat, ectopic deposits
of enamel apical to the normal
cemento-enamel junction (CEJ) level
in molar furcation areas (Masters et
al, 1964).

Enamel pearls are larger, round

deposits of enamel that can be
located in furcations or other areas
on the root surface.

An intermediate bifurcation ridge is described in 73% of

mandibular first molars, crossing from the mesial to the
distal root at the midpoint of the furcation. Interferes with
the attachment apparatus and may prevent regenerative
procedures from achieving their maximum potential.

Scaling with root planing is a fundamental procedure in

periodontal therapy. Anatomic factors that decrease the
efficiency of this procedure can have a negative impact on
the prognosis.

Root

concavities

exposed

through

loss

of

attachment can vary from shallow flutings to

deep depressions. They appear more marked on
maxillary first premolars, the mesiobuccal root of
the maxillary first molar.

These concavities increase the attachment area

and produce a root shape that may be more
resistant to torquing forces.

Other anatomic considerations that

present accessibility problems are
developmental grooves, root
proximity and furcation involvements.

Prosthetic and
Restorative Factors

The overall prognosis requires a general consideration of

bone levels (evaluated radiographically) and attachment
levels (determined clinically) 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.

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.

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.

RELATIONSHIP BETWEEN PROGNOSIS AND

DIAGNOSIS

Factors such as patient age, severity of disease,

genetic susceptibility and presence of systemic
disease are important criteria in the diagnosis of
the condition and in developing a prognosis.

PROGNOSIS FOR
PATIENTS WITH GINGIVAL
DISEASE
DENTAL PLAQUE INDUCED GINGIVAL DISORDER

GINGIVITIS ASSOCIATED WITH DENTAL PLAQUE ONLY

Plaque-induced gingivitis is a reversible

disease that occurs when bacterial plaque
accumulates at the gingival margin.

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.

PLAQUE-INDUCED GINGIVAL DISEASES MODIFIED BY MEDICATIONS

Gingival diseases associated with medications

include drug-influenced gingival enlargement,
often
seen
with
phenytoin,
cyclosporin,
nifedipine, and oral contraceptive-associated
gingivitis.

In drug-influenced gingival enlargement, plaque

control alone does not prevent development of
the lesions, and surgical intervention is usually
necessary to correct the alterations in gingival
contour.

GINGIVAL DISEASES MODIFIED BY

MALNUTRITION

Exception is severe vitamin C deficiency. In

early experimental vitamin C deficiency,

NON-PLAQUEINDUCED GINGIVAL
LESIONS

Prognosis is dependent on elimination of

the source of the infectious agent.

Dermatologic disorders such as lichen

planus, pemphigoid, pemphigus vulgaris,
erythema
multiforme,
and
lupus
erythematosus also can manifest in the oral
cavity as atypical gingivitis

PROGNOSIS FOR
PATIENTS WITH
PERIODONTITIS

CHRONIC PERIODONTITIS

Chronic periodontitis is a slowly progressive

disease associated with well-known local
environmental factors.

(slight-to-moderate
periodontitis),
the
prognosis is generally good provided the
inflammation can be controlled.

In patients with more severe disease.

Furcation involvement.

Increasing clinical mobility.

Prognosis can be changed from fair to poor

AGGRESSIVE PERIODONTITIS

Aggressive periodontitis can present in a localized

or a generalized form.

rapid attachment loss and bone destruction

in an otherwise clinically healthy patient
2. a familial aggregation.
1.

Elevated
levels
actinomycetemcomitans
gingivalis.

of
or

Actinobacillus
Porphyromonas

These patients also may present with phagocyte

abnormalities.

Aggressive
prognosis.

Localized aggressive periodontitis usually occurs

around the age of puberty and is localized to first
molars and incisors.

periodontitis

would

have

poor

PERIODONTITIS AS A MANIFESTATION OF
SYSTEMIC DISEASES.

Periodontitis as a manifestation of systemic

diseases can be divided into two categories.

those
associated
with
hematologic
disorders such as leukemia and acquired
neutropenias.

those associated with genetic disorders

such as familial and cyclic neutropenia,
Down
syndrome,
Papillon-Lefevre
syndrome, and hypophosphastasia.

Although the primary etiologic factor

periodontal diseases is bacterial plaque.

these patients
prognosis.

present

with

in

fair-to-poor

Include hypophosphatasia, where patients have

decreased
levels
of
circulating
alkaline
phosphatase,
severe
alveolar
bone
loss,
premature loss of deciduous and permanent teeth
and the connective tissue disorder.

The prognosis will be fair to poor

Necrotizing Periodontal
Diseases.

(Necrotizing ulcerative gingivitis, NUG)

alveolar bone (necrotizing

periodontitis, NUP).

In NUG, the primary predisposing factor is

bacterial plaque.

Such as acute psychologic stress, tobacco

smoking, and poor nutrition, all of which
can contribute to immunosuppression.

ulcerative

The prognosis for a patient with NUG is

good.

The tissue destruction in these 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 be downgraded to fair.

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.

Many patients presenting with NUP are

immunocompromised
through
systemic
conditions, such as HIV infection. In these
cases, the prognosis is dependent on not
only reducing local and secondary factors,
but also on dealing with the systemic
problem.

Reevaluation of Prognosis After Phase I

Therapy

A frank reduction in pocket depth and

inflammation 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, the
overall prognosis may be unfavorable.

Prognosis V/S Actual Outcome

One hundred treated periodontal patients under maintenance

care were evaluated for 5 years, and 39 of these patients were
followed for 8 years to determine the accuracy of assigned
prognoses based on commonly taught clinical criteria.

In conclusion, it was found that projections were ineffective in

predicting any prognosis other than good, and that prognoses
tended to be more accurate for single rooted teeth than for
multi-rooted teeth.

reference

Carranzas Clinical Periodontology 12th edition-Newman,Takei,

Klokkevold,Carranza

Atlas of cosmetic and reconstructive periodontal surgery- Cohen

Essentials of clinical periodontology and periodontics- Shantipriya Reddy

Journal of periodontology vol II issue II 1975

Journal of periodontology 1978

Journal of clinical periodontology June 1975

Diabetolgia jan 2012 vol 55

Journal of periodontology Nov 2012

annals of periodontology July 1998