prognosis in perio

2. PROGNOSIS
D.HEMA
PG-II
DEPT. OF PERIODONTICS
PMVIDS

3. CONTENTS
 Introduction
 Definitions
 Prognosis & Risk
 Prognosis & Causality
 Types of Prognosis
 Factors in Determination of Prognosis
 Relationship Between Diagnosis and Prognosis
 Reevaluation of Prognosis After Phase I Therapy
 Conclusion
 References

4. INTRODUCTION
If I have this treatment done
how long can I expect to
keep my teeth? • Pathogenesis
• Risk factors
• Treatment
options

5. DEFINITIONS
 Greek word, pro before
gignoskein to fore know or to know.
 The Merriam-Webster Dictionary: “the prospect of recovery as
anticipated from the usual course of disease or peculiarities of the
case.”
 The American Heritage Medical Dictionary: “a prediction of the
probable course and outcome of a disease, and the likelihood of
recovery from a disease.”
Boston: Houghton Mifflin, 2007.

6. • 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. It is established after the diagnosis is made and
before the treatment plan is established.
Carranza, 12th ed.
• 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.
it is advisable to establish a provisional prognosis until phase I
therapy is completed and evaluated.
Carranza, 12th ed.

7. • Short term prognosis:
Where estimation is made for the next 3-5 years.
• Long term prognosis:
Where the teeth are expected to remain in health and function
beyond 5 years.
• Therapeutic prognosis:
Deals with the response of tissues to treatment and successful
arrest of disease process.
• Prosthetic prognosis:
Indicate the ability of remaining teeth to support the prosthesis.
Carranza, SOUTH ASIA 2ND ED

8. Prognosis and Causality
• Causality involves identification of the agents that are
responsible for causing a target disorder.
• It is related to prognosis in a most direct way.
• Treatment of many diseases involves removal of the true
offending or causal agent (or at least reducing its impact).
• To the extent that this can be done, the treatment will be
effective and the prognosis good.
• To the extent that the actual agent is not identified or cannot
be reduced or eliminated, suboptimal outcomes may be
expected and the prognosis will be less favorable.

9. • Risk generally deals with the likelihood that an individual will
develop a disease in a specified period.
• Risk factors are those characteristics of an individual that put
the person at increased risk for developing a disease.
• 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. Ex:
Diabetes & Smoking.
Prognosis and Risk

10. • Prognostic factors can be categorized into those that can be :
 controlled by the patient (daily plaque removal, smoking
cessation, compliance with wearing occlusal guards,
compliance with the recommended preventive maintenance
schedule);
 those impacted by periodontal treatment (probing depth,
mobility, furcation involvement, trauma from occlusion,
bruxism, other parafunctional habits);
 those associated with systemic disease (diabetes
mellitus, immunological disorders, hypothyroidism); and
 those that are uncontrollable (poor root form, poor crown-
root ratio, tooth type, age, genetics).

11. TYPES OF PROGNOSIS
McGuire MK, Nunn ME, 1996, based on studies evaluating tooth
mortality, the following classification has been proposed:
 Good prognosis:
 Control of etiologic factors
 adequate periodontal support
 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.

12.  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 (location and depth make access difficult) or
 Class III furcation involvements;
 >2+ mobility;
 root proximity.
 Hopeless prognosis:
 Inadequate attachment to maintain health, comfort, and function.

13.  good,
fair,
hopeless prognoses
 Poor, questionable
prognoses
McGuire MK, Nunn ME: Prognosis versus actual outcome. II. The effectiveness of
clinical parameters in developing an accurate prognosis. J Periodontol 67:658, 1996.
established with a reasonable
degree of accuracy.
likely to change to other categories
as they depend on a large number
of factors that can interact in
unpredictable number of ways

14. Kwok and Caton, 2007:
have 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 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.

15.  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.

16. Kwok V, Caton J: Prognosis revisited: a system for assigning
periodontal prognosis. J Periodontol 78:2063, 2007.

17. Overall Vs Individual Tooth Prognosis
Overall prognosis:
• concerned with the dentition as a whole.
• 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?

18. Individual tooth prognosis:
• 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.

19. Individual tooth prognosis Overall tooth prognosis
Percentage of bone loss Age
Deepest probing depth Medical History
Horizontal/vertical bone loss Family History
Deepest furcation involvement Oral Hygiene: Good/Fair/Poor
Mobility Compliance: Y/N
Crown to Root ratio: F/UF Maintenance interval: 2 mnths,
2mnths alternate
Root form F/UF 3mnths, 3mnths alternate
Caries or Pulpal Involvement :
Y/N
Parafunctional habit with night guard
Tooth malposition: Y/N Parafunctional habit without night
guard.
Fixed or Removable prosthesis:
Y/N
Adapted from McGuire and Newman(1996)

20. FACTORS IN DETERMINATION OF PROGNOSIS
Overall
Clinical
Factors
Local Factors Systemic/Envi
ronmental
Factors
Prosthetic/Res
torative
factors
Age Plaque/
Calculus
Smoking Abutment
selection
Disease
severity
Subgingival
Restorations
Systemic
diseases
Caries
Plaque control Anatomic
factors
Genetic
factors
Non-vital teeth
Patient
compliance
Tooth mobility Stress Root
resorption

21. Overall Clinical Factors
Patient Age:
• the younger patient, the prognosis is not as good as for the older 
 shorter time frame periodontal destruction has occurred;
 may have aggressive type of periodontitis, or associated systemic
disease or smoking.
 occurrence of so much destruction in a relatively short period
would exceed any naturally occurring periodontal repair.

22. Disease Severity
• H/O previous periodontal disease  susceptibility for future
periodontal breakdown.
• Variables to be recorded for determining the patient’s past history
of periodontal disease:
 pocket depth,
 level of attachment,
 degree of bone loss, and
 type of bony defect.

23. Pocket depth and CAL:
• Pocket depth less imp. than CAL  not necessarily related to bone loss.
> prognosis
Deep pockets
with little bone
loss
shallow pockets
with severe
bone loss
source of infection  contribute to disease progression.

24. Bone loss:
The prognosis also can be related to the height of remaining bone.
so little bone loss that
tooth support is not in
jeopardy
bone loss is so severe that the
remaining bone is obviously
insufficient for proper tooth
support

25. Type of defect:
• 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.
• 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

27. “Watch and wait” approach:
• teeth with questionable prognosis are extracted to enhance:
 Likelihood of partial restoration of the bone support of adjacent
teeth or
 successful implant placement.
• “watch and wait” approach may allow an area to deteriorate to the
point that placing an implant is no longer a viable option.
• practitioner should weigh the potential success of
when assigning a prognosis to questionable teeth.
extraction and
implant placement
Periodontal therapy
and maintenance
vs

28. 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.

29. Patient Compliance and Cooperation:
• Prognosis depends on:
 patient’s attitude,
 desire to retain the natural teeth, and
 willingness and ability to maintain good oral hygiene.
Without these, treatment cannot succeed.
• If patients are unwilling or unable to perform adequate plaque
control and to receive the timely periodic maintenance checkups
and treatments, the dentist can:
 refuse to accept the patient for treatment or
 extract teeth that have a hopeless or poor prognosis and
perform scaling and root planing on the remaining teeth.

30. Systemic and Environmental Factors
Smoking:
• important environmental risk factor impacting the development and
progression of periodontal disease.
• patients who smoke do not respond as well to periodontal therapy
as patients who have never smoked.
slight - moderate
periodontitis
smoke
fair to poor
prognosis
severe
periodontitis
poor to
hopeless
prognosis
good
prognosis
Stop
smoke
smoke
Stop
smoke
Fair
prognosis
• smoking cessation can affect treatment outcome and the prognosis.

31. Systemic Disease or Condition:
Patient’s systemic background affects overall prognosis in several ways.
Diabetes:
 the prevalence and severity of periodontitis are significantly higher
in patients with diabetes than in those without it.
 the level of control of the diabetes is an important variable in this
relationship.
 patients diagnosed with diabetes must be informed of the impact
of diabetic control on the development and progression of disease.
 Well-controlled diabetic patients with slight-to-moderate
periodontitis who comply with their recommended periodontal
treatment should have a good prognosis.

32. • prognosis improves with correction of the systemic problem.
• The prognosis is questionable when surgical periodontal treatment
is required but cannot be provided because of the patient’s health.
• 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

33. Genetic Factors:
• genetic factors may play an important role in determining the nature
of the host response.
• Kornman et al,1998: Genetic polymorphisms in interleukin-1 genes,
resulting in increased production of IL-1β,
Risk-severe generalized chronic periodontitis.
• Hart et al, 1997: Genetic factors also appear to influence serum
IgG2 antibody titers and the expression of FcγRII receptors on the
neutrophil, both of which may be significant in aggressive
periodontitis.
• Other genetic disorders, such as LAD type 1, can influence
neutrophil function, creating an additional risk factor for aggressive
periodontitis.

34. Detection of genetic variations linked to periodontal disease can
potentially influence the prognosis in several ways.
1. early detection can lead to early implementation of preventive
and treatment measures for these patients.
2. Identification 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 with risk of familial aggregation
seen in aggressive periodontitis, can lead to the development of
early intervention strategies & may lead to an improved
prognosis for the patient.

35. 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.

36. 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

37. 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; and developmental grooves.
 root proximity
 location and anatomy of furcations
• Decrease the efficiency of periodontal procedures -ve impact on
the prognosis.

38. • Poor prognosis:
 reduced root surface available for periodontal support,
 the periodontium may be more susceptible to injury by occlusal
forces.
Short, tapered roots with large crowns

39. Cervical enamel projections (CEPs):
• flat, ectopic extensions of enamel that extend beyond the normal
contours of the CEJ.
• 28.6% of mandibular molars and 17% of maxillary molars.
• Mostly found on buccal surfaces of maxillary second molars
• affect plaque removal, can complicate scaling and root planing.
• should be removed to facilitate maintenance.

40. Enamel pearls & bifurcation ridges:
• larger, round deposits of enamel that can be located in furcations or
other areas on the root surface.
• 75% appearing in maxillary third molars
• An intermediate bifurcation ridge has been described in 73% of
mandibular first molars. They may prevent regenerative procedures
from achieving their maximum potential.
• have a negative effect on the prognosis for an individual tooth.

41. Root concavities:
• exposed through loss of attachment can vary from shallow flutings to
deep depressions. difficult to clean.
• They appear more marked on maxillary first premolars, the MB root of
the maxillary first molar, both roots of mandibular first molars, and the
mandibular incisors.

42. Developmental grooves:
• Maxillary lateral incisors (palatogingival groove) or in the lower
incisors, create an accessibility problem.
• plaque-retentive area that is difficult to instrument.

43. Root proximity:
• can result in interproximal areas that are difficult for the clinician
and patient to access.

44. Furcation area:
• may be difficult or impossible to debride by routine periodontal
instrumentation.
• Routine home care methods may not keep it free of plaque
• presence of furcation involvement is one clinical finding that can
lead to a diagnosis of advanced periodontitis and
• Potentially to a less-favorable prognosis for the affected tooth or
teeth.
• Prognosis can be improved by:
 Making the furcation area accessible for oral hygiene
maintenance
 Resecting one of the roots

45. Plunger cusps & open contacts:
• Wedge the food forcefully onto the interdental spaces of the
opposing arch resulting in food impaction.
• Prognosis can be improved by rounding and shortening of the
plunger cusps.

46. Tooth Mobility:
• caused by inflammation and trauma from occlusion correctable.
• resulting from loss of alveolar bonenot likely to be corrected.
• restoring tooth stability is inversely proportional to the extent of bone
loss.
• Flezar et al, 1988: pockets on clinically mobile teeth do not respond
as well to periodontal therapy as pockets on nonmobile teeth
exhibiting the same initial disease severity.
• Rosling et al,1976: if ideal plaque control was attained, similar
healing can be attained in both hypermobile and firm teeth.
• The stabilization of tooth mobility through the use of splinting may
have a beneficial impact on the overall and individual tooth prognosis.

47. Prosthetic and Restorative Factors:
• 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.
• To provide a functional and aesthetic dentition or for a tooth to
serve as abutment assess bone and attachment levels.
• At this point, the overall prognosis and the individual tooth
prognosis overlap because the prognosis of a key individual teeth
may affect the overall prognosis for prosthetic rehabilitation.

48. • For example, saving or losing a key tooth may determine whether
other teeth are saved or extracted or whether the prosthesis used
is fixed or removable.
• When few teeth remain, the prosthodontics 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.

49. Subgingival Restorations:
• Subgingival margins and over hanging restorations may contribute
to increased plaque accumulation, increased inflammation, and
increased bone loss.
• The size of these discrepancies and duration of their presence are
important factors in the amount of destruction that occurs.
• tooth with a discrepancy in its subgingival margins has a
poorer prognosis than a tooth with well-contoured
supragingival margins

50. Pontic design:
• Prosthesis with non-mucosal contact pontics tend to allow for oral
hygiene maintenance than the mucosal contact pontics.
• This plays a key role in maintaining the periodontal health and
thereby affecting the prognosis.
1. Mucosal contact:
 Ridge lap/saddle
 Modified ridge lap
 Ovate
 Conical
2. No mucosal contact:
 Sanitary/hygienic
 Modified sanitary

51. 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.
• 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.

52. RELATIONSHIP BETWEEN DIAGNOSIS
AND PROGNOSIS
• Many of the criteria used in the diagnosis and classification of the
different forms of periodontal disease are also used in developing
a 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, as well as important in
developing a prognosis.
• These common factors suggest that for any given diagnosis, there
should be an expected prognosis under ideal conditions.

53. Prognosis for Patients with Gingival Disease
Gingivitis Associated with Dental Plaque Only:
• the prognosis for patients with gingivitis associated with dental
plaque only is good, provided:
 all local irritants are eliminated,
 factors contributing to plaque retention are eliminated,
 gingival contours conducive to preservation of health are
attained,
 patient cooperates by maintaining good oral hygiene.
Dental Plaque–Induced Gingival Diseases

54. 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.
• frank signs of gingival inflammation that occur in these patients are
seen in the presence of relatively small amounts of bacterial plaque.
• long-term prognosis for these patients depends on:
 control of bacterial plaque
 control or correction of the systemic factor(s).

55. Plaque-Induced Gingival Diseases Modified by
Medications:
• In drug-influenced gingival enlargement, reductions in dental plaque
can limit the severity of the lesions. Sometimes require surgical
intervention.
• Continued use of the drug usually results in recurrence.
• long-term prognosis depends on:
 whether the patient’s systemic problem can be treated with
an alternative medication without gingival enlargement as a
side effect.
 control of bacterial plaque
 likelihood of continued use of medication.

56. 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.
• One possible exception is severe vitamin C deficiency. In early
experimental vitamin C deficiency, gingival inflammation and
bleeding on probing were independent of plaque levels present.
• prognosis depends on:
 severity and duration of the deficiency
 likelihood of reversing the deficiency through dietary
supplementation.

57. Non–Plaque-Induced Gingival Lesions:
• seen in patients with a variety of bacterial, fungal, and viral
infections.
• prognosis depends 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 these patients is linked to management of the
associated dermatologic disorder.
• allergic, toxic, and foreign body reactions, as well as mechanical and
thermal trauma, can result in gingival lesions.
• Prognosis for these patients depends on elimination of the
causative agent.

58. Prognosis for Patients with Periodontitis
Chronic Periodontitis:
• slowly progressive disease associated with well-known local
environmental factors.
• slight-to-moderate periodontitis: prognosis is generally good,
provided the inflammation can be controlled through good oral
hygiene and the removal of local plaque-retentive factors.
• 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.

59. Aggressive Periodontitis:
• These patients often present with limited microbial deposits that
seem inconsistent with the severity of tissue destruction.
• However, the deposits that are present often have elevated
levels of Aggregatibacter actinomycetemcomitans or
Porphyromonas gingivalis.
• 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.

60. Localized aggressive periodontitis:
• occurs around the age of puberty and is localized to first molars and
incisors.
• patient often exhibits a strong serum antibody response to the
infecting agents, contributing to localization of the lesions.
• 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

61. Generalized aggressive periodontitis:
• they present with generalized interproximal attachment loss
• poor antibody response to infecting agents.
• Secondary contributing factors, such as cigarette smoking, are
often present.
• These factors, coupled with the alterations in host defense seen in
many of these patients, may result in a case that does not respond
well to conventional periodontal therapy.
• Therefore these patients often have a fair, poor, or questionable
prognosis, and the use of systemic antibiotics should be
considered to help control the disease

62. Periodontitis as 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.
• 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.

63. • These disorders generally manifest early in life, the impact on the
periodontium may be clinically similar to generalized aggressive
periodontitis.
• The prognosis in these cases will be fair to poor.
• Other genetic disorders do not affect the host’s ability to combat
infections but still affect the development of periodontitis.
• Examples include:
 hypophosphatasia, in which patients have decreased levels
of circulating alkaline phosphatase, severe alveolar bone loss,
and premature loss of deciduous and permanent teeth,
 Ehlers-Danlos syndrome, in which patients may present with
the clinical characteristics of aggressive periodontitis.
• In both examples the prognosis is fair to poor.

64. Necrotizing Periodontal Diseases:
1. Necrotizing ulcerative gingivitis [NUG]
2. Necrotizing ulcerative periodontitis [NUP].

65. NUG:
• primary predisposing factor is bacterial plaque.
• complicated by the presence of secondary factors:
 acute psychologic stress,
 tobacco smoking, and
 poor nutrition, all of which can contribute to
immunosuppression.
• superimposition of these secondary factors on a preexisting
gingivitis can result in the painful, necrotic lesions
characteristic of NUG.

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

67. NUP:
• necrosis extends from gingiva into the pdl and alveolar
bone.
• In systemically healthy patients, it may have resulted from
multiple episodes of NUG, or it may occur at a site
previously affected with periodontitis.
• In these patients, the prognosis depends on alleviating
the plaque and secondary factors associated with NUG.

68. • However, many patients presenting with NUP are
immunocompromised through systemic conditions, such
as HIV infection.
• In these patients the prognosis depends on not only
reducing local and secondary factors, but also on
dealing with the systemic problem.
• In advanced cases, prognosis may be better
established after reviewing the effectiveness of
phase I therapy

69. Prognosis of Endo-Perio lesions
• The prognosis and treatment of each endodontic–periodontal
disease type varies.
• Primary endodontic: endodontic therapy & has good prognosis.
• Primary periodontal: periodontal therapy & prognosis depends
on severity of the periodontal disease and patient response.
• Primary endodontic with secondary periodontal involvement:
first treated with endodontic therapy. periodontal treatment should
be considered after 2-3 months as it allows sufficient time for initial
tissue healing and better assessment of the periodontal condition.
• Prognosis depends primarily on severity of periodontal
involvement, periodontal treatment and patient response.

70. • Primary periodontal with secondary endodontic
involvement: require both endodontic and periodontal
therapies. Prognosis depends primarily upon the severity of
the periodontal disease and the response to periodontal
treatment.
• True combined endodontic–periodontal diseases: Treated
with both endo and perio treatments. Have a more guarded
prognosis than the other types. Assuming the endodontic
therapy is adequate, what is of endodontic origin will heal.
Thus the prognosis of combined diseases rests with the
efficacy of periodontal therapy.
Rotstein I, Simon J. Diagnosis, prognosis and decision-making in the treatment of
combined periodontal endodontic lesions. Periodontology 2000, Vol. 34, 2004, 165–203.

71. Prognosis in Implant Dentistry
Factors that could determine the prognosis of implants are:
 Periodontal status,
 age,
 bone density,
 occlusion,
 smoking,
 genetics,
 systemic diseases,
 microorganisms,
 antibiotics, and
 type of implants.
Abullais SS, AlQahtani NA, Kudyar N, Priyanka N. Success of dental implants:
Must-know prognostic factors. J Dent Implant 2016;6:44-8

72. • Out of all, factors related to the patient seem to be more critical
than those related to the implant in determining the success
and survival of implant.
• Several of these prognostic factors can be modified according
to the need of situation.
• For example, the patient can modify smoking habits, plaque
control, systemic health and clinician can modify implant
selection, site preparation, and loading strategy.
• Both the patient and clinician are equally important for long
term management and maintenance, which will enhance dental
implant success rates for better oral function, esthetics, and
patient welfare

73. Algorithm for determining prognosis and treatment for dental
implants with peri-implant mucosal inflammation-Noguiera et al ,2011
PIMI
Prognosis
system
No PIMI (healthy)
No bleeding/no bone loss
Mild PIMI (mucositis)
Bleeding, no bone loss
Moderate/Severe
PIMI
(peri-implantitis)
Bleeding, bone loss
Systemic PIMI
(peri-implantitis)
Bleeding, bone loss,
systemic condition
Advanced PIMI
(peri-implantitis)
Infection and/or occlusal
trauma, mobility
Diagnosis
Favourable
Unfavourable
Hopeless
OHI
OHI+ISD
OHI+ISD
or GBR
OHI+ISD or
Implant removal
New implant
Implant
removal
New implant
SIT
Favourable
Unfavourable
Prognosis Treatment

74. 1. Systemic phase (evaluation of overall patient health,
consultation as indicated) provisional prognosis.
2. Initial therapy (antiinfective therapy)
a. Emergency treatment
b. Extraction of hopeless teeth
c. Restorative and endodontic therapy
d. Oral hygiene assessment and instruction
e. Debridement (scaling/root planing)
f. Adjunctive treatment
3. Reevaluation of phase I therapy prognosis re-evaluation.
4. Surgical therapy (if indicated)
5. Postsurgical reevaluation and assessment of revised
prognosis
6. Definitive restorative therapy
7. Maintenance therapy
Prognosis evaluation in Periodontal
Therapy

75. • Based on the results of the comprehensive examination,
including assessments of periodontitis, caries, tooth sensitivity, &
• the resulting diagnosis, as well as considering the patient’s needs
regarding esthetics and function,
• a pre-therapeutic prognosis for each individual tooth (root) is
made. Three major questions are addressed:
1. Which tooth/root has a “good” (secure) prognosis?
2. Which tooth/root is “irrational-to-treat”?
3. Which tooth/root has a “doubtful” (unsecure) prognosis?
Pre-therapeutic single tooth prognosis
• good prognosis simple therapy and act as secure abutments
for function.
Lindhe J, Lang NP, Karring T. Treatment planning protocols. Clinical Periodontology
and Implant Dentistry. 5th ed.

76. • “irrational-to-treat” extracted.
Such teeth may be identified on the basis of the following criteria:
Periodontal:
Recurrent periodontal abscesses
Combined periodontal–endodontic lesions
Attachment loss to the apex
Endodontal:
Root perforation in the apical half of the root
Dental:
Vertical fracture of the root
Oblique fracture in the middle third of the root
Caries lesions that extend into the root canal
Functional:
Third molars without antagonists and with periodontitis/caries.

77. • doubtful prognosis: needs comprehensive therapy and must be
brought into the category of good prognosis by means of additional
therapy.
Such teeth may be identified on the basis of the following criteria:
Periodontal:
Furcation involvement
Angular (i.e. vertical) bony defects
“Horizontal” bone loss involving > two thirds of the root
Endodontal:
Incomplete root canal therapy
Periapical pathology
Presence of voluminous posts/screws
Dental:
Extensive root caries.

78. REEVALUATION OF PROGNOSIS AFTER
PHASE I THERAPY
• A frank reduction in
pocket depth and
inflammation after
phase I therapy
better prognosis than
previously assumed.
• Inflammatory changes
present cannot be
controlled or reduced
by phase I therapy
overall prognosis
may be unfavorable
• 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 irritants

79. • In addition, phase I therapy allows the clinician an opportunity to
work with the patient and the patient’s physician to control
systemic and environmental factors such as diabetes and
smoking, which may have a positive effect on prognosis if
adequately controlled.
• Phase I therapy will, at least temporarily, transform the prognosis
of the patient with an active advanced lesion, and the lesion
should be reanalyzed after completion of phase I therapy.

80. The Miller–McEntire Prognosis Scoring System
• Used to determine the long term Prognosis on periodontally
involved molars.
• It is evidence based, statistically derived & accurate
• Data were collected from a complete periodontal examination
and patient history from 102 patients and were used to develop
a quantitative approach for determining prognosis.
• Factors Scored:
1. Age 5. Furcations
2. Probing depth 6. Molar type
3. Mobility 7. Diabetes
4. Smoking

81. • Molars with a score of 4.32 or better, have an excellent long term
prognosis

83. Miller-McEntire Score can be used:
• For determining an accurate prognosis on periodontally
involved molars
• As an aid in treatment planning and communicating with
patients
• As a basis for referral
Miller PD Jr, McEntire ML, Marlow NM, Gellin RG. An evidenced-based
scoring index to determine the periodontal prognosis on molars. J
Periodontol. 2014 Feb;85(2):214-25.

84. CONCLUSION
• Patients almost always ask for reassurance on the chances of
retaining natural teeth and express their doubt on the advisability
of proceeding with therapy.
• There are no reliable algorithms for prognosis, so clinicians must
use their clinical judgement.
• Constant reviewing of the results of treatment coupled with
detailed documentation of the periodontal status will sharpen the
clinicians acumen for accurate assessment of prognosis.
• Needless to say, the determination of prognosis is a vital and
essential step in periodontal treatment planning.

85. REFERENCES
• Newman Takei, Klokkevold Carranza. Determination of Prognosis.
Carranza’s Clinical Periodontology. 12th ed.
• Lindhe J, Lang NP, Karring T. Treatment planning protocols.
Clinical Periodontology and Implant Dentistry. 5th ed.
• Rose LF, Mealey BL, Genco RJ, Cohen DW. Formulating a
periodontal diagnosis and prognosis. Periodontics Medicine,
Surgery, and Implants.
• Rotstein I, Simon J. Diagnosis, prognosis and decision-making in
the treatment of combined periodontal endodontic lesions.
Periodontology 2000, Vol. 34, 2004, 165–203.

86. • Kwok V, Caton J. Prognosis revisited: a system for assigning
periodontal prognosis. J Periodontol 2007 78:2063.
• McGuire MK, Nunn ME. Prognosis versus actual outcome. II.
The effectiveness of clinical parameters in developing an
accurate prognosis. J Periodontol 1998 67:658.
• Nogueira-Filho G, Iacopino AM, Tenenbaum HC.
Prognosis in implant dentistry:a system for classifying the degre
e of peri-implant mucosal inflammation. J Can Dent Assoc.
2011;77:b8
• Abullais SS, AlQahtani NA, Kudyar N, Priyanka N. Success of
dental implants: Must-know prognostic factors. J Dent
Implant 2016;6:44-8

87. • Sameth N, Jotkowitz A. Classification and prognosis
evaluation of individual teeth—A comprehensive
approach. Quintessence Int. 2009 May;40(5):377-87.
• Miller PD Jr, McEntire ML, Marlow NM, Gellin RG. An
evidenced-based scoring index to determine the
periodontal prognosis on molars. J Periodontol. 2014
Feb;85(2):214-25.