Definition, Types, prognostic factors, and prognosis of periodontal diseases

1. PROGNOSIS

2. CONTENTS
• Definition
• Classification
• Prognosis and Risk
• Relationship between diagnosis and prognosis
• Prognostic factors
• Treatment plan and prognosis
• Prognosis for patients with gingival disease
• Prognosis of patients with periodontitis
• Prognosis of patients with Necrotizing diseases
• Reevaluation of prognosis after phase I therapy

3. 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.

4. Prognosis and Risk
• 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.

5. CLASSIFICATION
• Excellent prognosis: No bone loss, excellent gingival condition, good patient co-operation,
no systemic or environmental factors.
• Good prognosis: Adequate remaining bone support, adequate possibilities to control
etiologic factors and establish a maintainable dentition, adequate patient co-operation, no
systemic or environmental factors, or if systemic factors are present, they are well
controlled.
• Fair prognosis: Less-than adequate remaining bone support, some tooth mobility, grade I
furcation involvement, adequate maintenance possible, acceptable patient co-operation,
presence of limited systemic or environmental factors.
• Poor prognosis: 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.
• Questionable prognosis: Advanced bone loss, grade II and III furcation involvements,
tooth mobility, inaccessible areas, presence of systemic or environmental factors.
• Hopeless prognosis: Advanced bone loss, non maintainable areas, extractions indicated,
presence of uncontrolled systemic or environmental factors.

6. • Kwok and Caton, 2007:
• 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 periodontalstatus 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.

8. 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 months,
2months alternate
Root form F/UF 3months, 3months 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

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

10. OVERALLCLINICALFACTORS

11. Patient Age
• Younger patient – shorter time – more periodontal destruction-
poor or fair prognosis
• May have aggressive type of periodontitis, or associated
systemic disease or smoking
• occurrence of so much destruction in a relatively short period
• Older patient – longer time – better prognosis

12. Disease Severity
Previous periodontal disease of periodontal disease:
• pocket depth,
• level of attachment,
• degree of bone loss,
• type of bony defect

13. Pocket depth and CAL
• The determination of the level of clinical attachment (CAL)
reveals the approximate extent of root surface
• Deep pockets with little attachment and bone loss has
a better prognosis than one with shallow pockets and
severe attachment and bone loss
• If CAL is less good to fair prognosis

14. Bone loss
• Related to the height of remaining bone.
• Prognosis for horizontal bone loss depends on the height of the
existing bone.
• Angular defects - if the contour of the existing bone & 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 = good prognosis
• 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
• Less boneloss = better prognosis

15. Plaque Control
• Bacterial plaque - primary etiologic factor associated with
periodontal disease.
• Effective removal of plaque on a daily basis by patient
Increased Success of periodontal therapy
Good prognosis

16. Patient Compliance/ Cooperation
• Depends on
• the patient's attitude,
• desire to retain the natural teeth,
• willingness and ability to maintain good oral
hygiene,
• timely periodic maintenance checkups

17. SYSTEMIC / ENVIRONMENTAL
FACTORS

18. Smoking
• Risk factor
• Direct relationship - smoking and the prevalence and
incidence of periodontitis
• ▶ Affects severity
• ▶ Affects healing
• ▶ Slight to moderate periodontitis - fair to poor
• ▶ Severe periodontitis - poor to hopeless

19. SYSTEMIC DISEASE/ CONDITION
• ▶ Prevalence and severity of periodontitis - significantly
higher - type I and II diabetes
• ▶ Prognosis dependent on patient compliance, dental and
medical status
• ▶ Well controlled patients – slight to moderate
periodontitis - good prognosis

20. GENETIC FACTOR
• Genetic polymorphism in IL-1 genes resulting in
overproduction of IL-1b - severe, generalized, chronic
periodontitis.
• Genetic factors also influence serum IgG2 antibody titers and
the expression of Fc-gRII receptors on the neutrophil -
aggressive periodontitis.
• Genetic factors cannot be altered.
• Early diagnosis, intervention, and alterations in the treatment
regimen may lead to an improved prognosis

21. Plaque / Calculus
• The microbial challenge in bacterial plaque and calculus is the
most important local factor in periodontal diseases.
Subgingival Restorations
• Subgingival margins may contribute to
• increased plaque accumulation,
• increased inflammation
• increased bone loss
• Subgingival margins has a poor prognosis than a tooth with
well-contoured, supragingival margins

22. LOCAL FACTORS

23. ANATOMIC FACTORS
• short, tapered roots with large crowns,
• cervical enamel projections (CEPs)
• enamel pearls,
• intermediate bifurcation ridges,
• root concavities,
• developmental grooves.
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

24. Short tapered roots
• 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.
• Teeth with short, tapered roots and relatively large
crown – Poor prognosis

25. 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
molars.

26. Enamel pearls
• They are larger, round deposits of enamel that can be
located in furcations or other areas on the root surface.

27. Root concavities
• 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.

28. • Other anatomic considerations that present accessibility
problems are developmental grooves, root proximity and
• furcation involvements.

29. Tooth Mobility
Principal causes-
• ▶ Loss of alveolar bone
• ▶ Inflammatory changes in the periodontal ligament
• ▶ Trauma from occlusion.
• ▶ stabilization by use of splinting
• Grade I to II – good to fair
• Grade III – Hopeless

30. Caries, Non-vital Teeth & Root Resorption
• For teeth mutilated by extensive caries endodontic
therapy should be considered before undertaking
periodontal treatment.
• ▶ Extensive idiopathic root resorption or root resorption
that has occurred as a result of orthodontic therapy, risks
the stability of teeth and adversely affects the response to
periodontal treatment = poor prognosis

31. RELATIONSHIP BETWEEN DIAGNOSIS
AND PROGNOSIS
• Factors such as
• patient age,
• severity of disease,
• genetic susceptibility,
• Presence of systemic disease are important in developing
both diagnosis as well as prognosis

32. PROGNOSIS FOR PATIENTS WITH
GINGIVAL DISEASE
• DENTAL PLAQUE INDUCED GINGIVAL DISEASES
• Gingivitis Associated with Dental Plaque Only:
• Reversible
• provided all local irritants are eliminated
• patient cooperates by maintaining good oral hygeine.
• Prognosis - good
• Plaque induced gingival diseases modified by systemic
factors:
• Long term prognosis depends - control of bacterial plaque
along with correction of the systemic factors
• Prognosis - fair

33. Plaque induced gingival disease modified by
medications:
• The long-term prognosis depends on whether the patient's
systemic problem can be treated with an alternative
medication
Gingival diseases modified by malnutrition:
• Prognosis of these patients depend upon the severity and
duration of the deficiency and on the likelihood of reversing
the deficiency through dietary supplements.

34. Non plaque induced gingival lesions
▶ Seen in patients with a variety of bacterial, fungal and
viral infections, Allergic, toxic, and foreign body reactions,
as well as mechanical and thermal trauma
Treatment of the etiology=better prognosis

35. PROGNOSIS OF PATIENTS WITH
PERIODONTITIS
Chronic periodontitis
• In cases where clinical attachment loss and bone loss are
not very advanced
• Slight to moderate periodontitis - prognosis - good.

36. Aggressive periodontitis
• Localized aggressive periodontitis
• Diagnosed early - can be treated conservatively with oral
hygiene instruction and systemic antibiotic therapy - good
prognosis.
• Advanced diseases, prognosis can be good if the lesions
are treated with debridement, local and systemic antibiotics,
and regenerative therapy
• Generalized form – fair, poor or questionable prognosis
due to generalized interproximal loss, poor antibody response
and thus poor response to conventional periodontal therapy

37. Periodontitis As A Manifestation Of
Systemic Diseases
▶ It can be divided into two categories:
• Periodontitis associated with hematologic disorders such as
leukemia and acquired neutropenia.
• Periodontitis associated with genetic disorders such as familial
and cyclic neutropenia, down syndrome and hypophosphatasia.
• ▶ Primary etiologic factor - bacterial plaque
• ▶ Systemic diseases affect the progression of disease and thus
fair prognosis.

38. Necrotizing Periodontal
Diseases
• With control of both bacterial plaque and secondary
factors prognosis (NUG) – good
• The necrosis extends from the gingiva into the periodontal
ligament and alveolar bone- poor

39. PROGNOSIS FOR PERIODONTAL DISEASES:
No: DISEASES PROGNOSIS
1. Gingivitis Good
2. Gingival disease modified by systemic factors and medications Depends on the systemic factors.
2. Localised Chronic Periodontitis Good to Fair
3. Generalised Chronic Periodontitis Fair to Poor
4. Localised Aggressive Periodontitis Good
5. Generalised Aggressive Periodontitis Fair to Poor or Hopeless
6 NUG Good
7 NUP Poor

40. REEVALUATION OF PROGNOSIS
AFTER PHASE I THERAPY
• Reduction in pocket depth and inflammation after
Phase I therapy indicates a favorable response to
treatment and may suggest a better prognosis.
• If the inflammatory changes not controlled or reduced by
phase I therapy- overall prognosis - unfavorable.