Prognosis

Submitted by
Nithin
Markose Reji
1 st year pg

Introduction
It is established after the diagnosis is made and before the treatment plan is established. 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 clinicians previous experience with treatment
outcomes (successes and failures) as they relate to the particular case. It is important to note
that determination of prognosis is a dynamic process. As such, the prognosis initially
assigned should be re evaluated after completion of all phases of therapy, including
periodontal maintenance.
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 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. 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.

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
Historically, prognosis classification schemes have been designed based on studies evaluating
tooth mortality. One scheme assigns the following classifications:

Hirschfeld and Wasserman Classification in 1978

Classified into two groups
Favourable Prognosis
Questionable Prognosis- Extensive bone loss, Deep Pocket, Furcation & Mobility

Lack of consideration of systemic factors and local factors where the major side effect

Becker et al 1984
Three prognostic categories
Good Prognosis
Questionable Prognosis
Hopeless Prognosis
Patients with poor maintenance where not as predictable

McGuire MK , Numm ME ; J Periodontol in 1996

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 (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.

It should be recognized that good, fair, and hopeless prognoses in this classification system
could be established with a reasonable degree of accuracy. However, poor and questionable
prognoses were likely to change to other categories because they depend on a large number of
factors that can interact in an unpredictable number of ways.( Chace R Sr, low SB ; J
Periodontol 1993)
In contrast to schemes based on tooth mortality, Kwok and Caton have proposed a scheme
based on the probability of obtaining stability of the periodontal supporting apparatus. This
scheme is based on the probability of disease progression as related to local and systemic
factors

Kwok V , Caton J ; J Periodontol 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 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.

In many of these cases, it may be 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. The reevaluation phase in the treatment
sequence allows the clinician to examine the tissue response to scaling, oral hygiene, and root
planing, as well as to the possible use of chemotherapeutic agents where indicated.

Overall Versus Individual Tooth Prognosis

Prognosis can be divided into overall prognosis and individual tooth prognosis. The overall
prognosis is concerned with the dentition as a whole. Factors that may influence the overall
prognosis include patient age; current severity of disease; systemic factors; smoking; the
presence of plaque, calculus, and other local factors; patient compliance; and prosthetic
possibilities. The individual tooth prognosis is determined after the overall prognosis and
is affected by it (McGuire MK, J Periodontol 1991). 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.

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. For
the younger patient, the prognosis is not as good because of the shorter time frame in which
the periodontal destruction has occurred; the younger patient may have an aggressive type of
periodontitis, or disease progression may have increased because of systemic disease or
smoking.

Effect of age on the periodontium

JCP , U van der Velden in 1984
It is generally known that the degree of periodontal breakdown increases with increasing
age. The periodontal tissues themselves show evidence of aging, there are indications that the
composition of the plaque changes, and the reaction of the periodontium to the presence of
plaque probably changes as well. Research findings do suggest that the degree of periodontal
breakdown increases with age, that with increasing age inflammation of the periodontium
tends to develop more rapidly and that in the process of aging the periodontium shows a
slower rate of wound healing. This implies that (1) the susceptibility lo periodontal disease is
more significant for the rate of periodontal destruction than the length of time plaque is
present (the age effect) and (2) the greater the susceptibility to periodontal disease, the slower

the rate of wound healing and the more rapidly inflammation of the periodontium tends to
develop.

Disease Severity.

Studies have demonstrated that a patients history of previous

periodontal disease may be indicative of their susceptibility for future periodontal breakdown
Therefore the following variables should be carefully recorded because they are important for
determining the patients past history of periodontal disease: pocket depth, level of
attachment, degree of bone loss, and type of bony defect. These factors are determined by
clinical and radiographic evaluation.
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. 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. However, deep pockets are a source of
infection and may contribute to progressive disease.
Prognosis is adversely affected if the base of the pocket (level of attachment) is close to the
root apex. The presence of apical disease as a result of endodontic involvement also worsens
the prognosis. However, surprisingly good apical and lateral bone repair can sometimes be
obtained by combining endodontic and periodontal therapy.
The type of defect also must be determined. The prognosis for 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. In the case of angular, intrabony defects, if the
contour of the existing bone and the number of osseous walls are favourable, there is an

excellent chance that therapy could regenerate bone to approximately the level of the alveolar
crest.
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.
Because of the greater height of bone in relation to other surfaces, the centre of rotation of the
tooth will be nearer the crown. This results in a more favourable distribution of forces to the
periodontium and less tooth mobility.

In dealing with a tooth with a questionable prognosis, the chances of successful treatment
should be weighed against any benefits that would accrue to the adjacent teeth if the tooth
under consideration were extracted. Strategic extraction of teeth was first proposed as a
means of improving the overall prognosis of adjacent teeth and/or enhancing the prosthetic
treatment plan. It has now been expanded to include the extraction of teeth with a
questionable prognosis to enhance the likelihood of partial restoration of the bone supporting

of the adjacent teeth or successful implant placement. With the growing evidence of the longterm success of dental implants, it is proposed that a watch and wait approach may allow
an area to deteriorate to the point that placing an implant is no longer a viable option. This
meansthat the practitioner should weigh the potential success of one treatment option
(extraction and implant placement) versus the other (periodontal therapy and maintenance)
carefully when assigning a prognosis to questionable teeth.

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.

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. Without these, treatment cannot succeed. Patients should be clearly
informed of the important role they must play for treatment to succeed. If patients are
unwilling or unable to perform adequate plaque control and to receive the timely periodic
maintenance checkups and treatments that the dentist deems necessary, the dentist can
(1) refuse to accept the patient for treatment or
(2) extract teeth that have a hopeless or poor prognosis and perform scaling and root planning
on the remaining teeth.
The dentist should make it clear to the patient and in the patient record that further treatment
is needed but will not be performed because of a lack of patient cooperation.

Systemic and Environmental Factors

Smoking.

Epidemiologic evidence suggests that smoking may be the most important environmental
risk factor impacting the development and progression of periodontal disease. a direct
relation exist between smoking and the prevalence of periodontal disease.(papanau 1992 ,
AAP 1996 ).Therefore it should be made clear to the patient that a direct relationship
exists between smoking and the prevalence and incidence of periodontitis. In addition,
patients should be informed that smoking affects not only the severity of periodontal
destruction but also the healing potential of the periodontal tissues. As a result, patients
who smoke do not respond as well to conventional periodontal therapy as patients who
have never smoked. Therefore 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 poor to hopeless. However, it should be emphasized that smoking
cessation can affect the treatment outcome and therefore the 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.

Evidence for Cigarette Smoking as a Major

Risk Factor for Periodontitis
Jerome Haber et al Journal of Periodontology January 1993, Vol. 64,
The role of smoking as a risk factor for Periodontitis was assessed separately in diabetic and
nondiabetic study groups. Subject listings stratified for age (19 to 40 years) and sex were
obtained for subjects with insulin-dependent diabetes mellitus (IDDM) and nondiabetic
subjects. For both the IDDM group (n = 132) and the nondiabetic group (n = 95), age and sex
stratified samples were constructed by random selection of subjects from each subject listing.
Patients were recruited by phone, examined, and their medical and dental histories obtained.
Among nondiabetic subjects, the prevalence of Periodontitis was markedly higher among
current smokers compared with never smokers (P 0.005) in both the 19 to 30 year-old (46%
vs. 12%) and 31 to 40 year-old groups (88% vs. 33%). The subject mean percent of sites with

gingival pocket depth 4 mm was higher among current smokers than never smokers (P =
0.001) in the 19 to 30 (8.2% vs. 3.4%) and 31 to 40 (14.3% vs. 4.3%) age groups. The effects
of smoking among IDDM subjects were similar to that observed in the nondiabetic
population. There were no differences between current and never smokers in the proportion
of sites positive for plaque. Attributable risk percents from prevalence data suggest that
among nondiabetic subjects, a large proportion, perhaps as much as 51% of the Periodontitis
in the 19 to 30 year old group and 32% of the Periodontitis in the 31 to 40 year old group, is
associated with smoking. These findings suggest that smokers are a high risk group for
Periodontitis, and that smoking may be the single most important environmental risk factor
for Periodontitis.

Systemic Disease or Condition.

The patients systemic background affects overall prognosis in several ways. For example,
evidence from epidemiologic studies clearly demonstrates that the prevalence and severity of
periodontitis are significantly higher in patients with type 1 and type 2 diabetes than in those
without diabetes and that the level of control of the diabetes is an important variable in this
relationship. Therefore patients at risk for diabetes should be identified as early as possible
and informed of the relationship between periodontitis and diabetes. Similarly, patients

diagnosed with diabetes must be informed of the impact of diabetic control on the
development and progression of periodontitis. It follows that the prognosis in these cases
depends on patient compliance relative to both medical and dental status. Well-controlled
diabetic patients with slight-to-moderate periodontitis who comply with their recommended
periodontal treatment should have a good prognosis. Similarly, in patients with other systemic
disorders that could affect disease progression, 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 patients health. Incapacitating conditions that
limit the patients 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

Genetic Factors
Periodontal diseases represent a complex interaction between a microbial challenge and the
hosts response to that challenge, both of which may be influenced by environmental factors
such as smoking. In addition to these external factors, evidence also indicates that genetic
factors may play an important role in determining the nature of the host response. Evidence
for this type of genetic influence exists for patients with both chronic and aggressive
periodontitis. 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, and chronic periodontitis. It has been demonstrated that knowledge of the
patients 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
the expression of FcRII receptors on the neutrophil, both of which may be significant in
aggressive periodontitis. Other genetic disorders, such as leukocyte adhesion deficiency type
1, can influence neutrophil function, creating an additional risk factor for aggressive
periodontitis
The influence of genetic factors on prognosis is not simple. Although microbial and
environmental factors can be altered through conventional periodontal therapy and patient
education, genetic factors currently cannot be altered. However, 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. Second,
identification of genetic risk factors 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. 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 toan improved prognosis for the patient.

Stress
Physical and emotional stress, as well as substance abuse, may alter the patients ability to
respond to the periodontal treatment performed. These factors must be realistically faced
when attempting to establish a prognosis

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

Subgingival Restorations.
Subgingival margins may contribute to increased plaque accumulation, increased
inflammation, and increased bone loss

when compared with supragingival margins.

Furthermore, discrepancies in these margins (e.g., overhangs) can negatively impact the
periodontium . The size of these discrepancies and duration of their presence are important
factors in the amount of destruction that occurs. In general, however, a tooth with a
discrepancy in its subgingival margins has a poorer prognosis than a tooth with wellcontoured supragingival margins.

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.
The clinician must also consider root proximity and the location and anatomy of furcations
when developing a prognosis.
Prognosis is poor for teeth with short, tapered roots and relatively large crowns . Because of
the 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 (CEPs) are flat, ectopic extensions of enamel that extend
beyond the normal contours of the cementoenamel junction. CEPs extend into the furcation of
28.6% of mandibular molars and 17% of maxillary molars CEPs are most.likely to be found
on buccal surfaces of maxillary second molars. Enamel pearls are larger, round deposits of
enamel that can be located in furcations or other areas on the root surface. Enamel pearls are
seen less frequently (1.1% to 5.7% of permanent molars; 75% appearing in maxillary third
molars) than CEPs. An intermediate bifurcation ridge has been described in 73% of

mandibular first molars, crossing from the mesial to the distal root at themidpoint of the
furcation. The presence of these enamel projections on the root surface interferes with the
attachment apparatus and may prevent regenerative procedures from achieving their
maximum potential. Therefore their presence may have a negative effect on the prognosis for
an individual tooth. 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. Therefore the morphology of the tooth root is an important
consideration when discussing 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, both roots of mandibular first molars, and the mandibular
incisors and . Any tooth, however, can have a proximal concavity. Although these concavities
increase the attachment area and produce a root shape that may be more resistant to torquing
forces, they also create areas that can be difficult for both the dentist and the patient to clean.

Other anatomic considerations that present accessibility problems are developmental grooves,
root proximity, and furcation involvements. The presence of any of these can worsen the
prognosis. Developmental grooves, which sometimes appear in the maxillary lateral incisors
(palatogingival groove or in the lower incisors, create an accessibility problem. They initiate
on enamel and can extend a significant distance on the root surface, providing a plaqueretentive area that is difficult to instrument. These palatogingival grooves are found on 5.6%
of maxillary lateral incisors and 3.4% of maxillary central incisors. Similarly, root proximity
can result in interproximal areas that are difficult for the clinician and patient to access.
Finally, access to the furcation area is usually difficult to obtain. In 58% of maxillary and
mandibular first molars, the furcation entrance diameter is narrower than the width of

conventional periodontal curettes. Maxillary first premolars present the greatest difficulties,
and therefore their prognosis is usually unfavorable when the lesion reaches the mesiodistal
furcation. Maxillary molars also present some difficulty; sometimes their prognosis can be
improved by resecting one of the buccal roots , thereby improving access to the area. When
mandibular first molars or buccal furcations of maxillary molars offer good access to
thefurcation area, their prognosis is usually better.

Tooth Mobility.
The principal causes of tooth mobility are loss of alveolar bone, inflammatory changes in the
periodontal ligament, and trauma from occlusion. Tooth mobility caused by inflammation and
trauma from occlusion may be correctable. However, tooth mobility resulting from loss of
alveolar bone is not likely to be corrected. The likelihood of restoring tooth stability is
inversely proportional to the extent to which mobility is caused by
loss of supporting alveolar bone. A longitudinal study of the response to treatment of teeth
with different degrees of mobility revealed that pockets on clinically mobile teeth do not
respond as well to periodontal therapy as pockets on nonmobile teeth exhibiting the same
initial disease severity. Another study, however, in which ideal plaque control was attained,
found similar healing 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.

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. At this point, the overall
prognosis and the individual tooth prognosis overlap because the prognosis for key individual
teeth may affect the overall prognosis for prosthetic rehabilitation. 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 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.
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. 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. Additionally,
special oral hygiene measures must be instituted in these areas.

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.

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.

Prognosis for Patients with Gingival Disease

Dental PlaqueInduced 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. In either case, the prognosis for patients
with gingivitis associated with dental plaque only is good, provided all local irritants are
eliminated, other local factors contributing to plaque retention are eliminated, gingival
contours conducive to the preservation of health are attained, and the patient cooperates by
maintaining good oral hygiene.

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. 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.
Plaque-Induced Gingival Diseases Modified by Medications.

Gingival diseases associated with medications include drug-influenced

gingival

enlargement, often seen with phenytoin, cyclosporine, and nifedipine and in oral
contraceptiveassociated gingivitis. In drug-influenced gingival enlargement, reductions in

dental plaque can limit the severity of the lesions. However, plaque control alone does not
prevent development of the lesions, and surgical intervention is usually necessary to correct
the alterations in gingival contour. Continued use of the drug usually results in recurrence of
the enlargement, even after surgical intervention. Therefore the long-term prognosis depends
on whether the patients systemic problem can be treated with an alternative medication that
does not have gingival enlargement as a side effect.
In oral contraceptiveassociated gingivitis, frank signs of gingival inflammation can be seen
in the presence of relatively little plaque. Therefore, as seen in plaque-induced gingival
diseases modified by systemic factors, the long-term prognosis in these patients depends on
not only the control of bacterial plaque but also on the likelihood of continued use of the oral
contraceptive.
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. 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.
.

NonPlaque-Induced Gingival Lesions.

Nonplaqueinduced gingivitis can be seen in patients with a variety of bacterial, fungal, and
viral infections. Since the gingivitis in these patients is not usually attributed to plaque
accumulation, 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. Finally, 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.
Prognosis for Patients with Periodontitis

Chronic Periodontitis.

Chronic periodontitis is a slowly progressive disease associated

with well-known local environmental factors. It can present in a localized or generalized form
. In cases in which the clinical attachment loss and bone loss are not very advanced (slight-tomoderate periodontitis), the prognosis is generally good, provided the inflammation can be
controlled through good oral hygiene and the removal of local plaque-retentive factors. 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.
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) a familial aggregation. 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 hyperresponsive
monocyte/macrophage phenotype.These clinical, microbiologic, and immunologic features
would suggest that patients diagnosed with aggressive periodontitis would have a poor
prognosis.
However, the clinician should consider additional specific features of the localized form of
disease when determining the prognosis . Localized aggressive periodontitis usually occurs
around the age of puberty and is localized to first molars and incisors. The patient often
exhibits a strong serum antibody response to the infecting agents, which may contribute to
localization of the lesions . When diagnosed early, thesecases 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.
In contrast, although patients with generalized aggressive periodontitis also are young
patients (usually under age 30), they present with generalized interproximal attachment loss
and a 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 (scaling with root planing, oral hygiene instruction, and
surgical intervention). 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

Periodontitis as Manifestation of Systemic Diseases.

Periodontitis as a 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-Lefvre 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. For example,
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. Similarly, genetic disorders that alter the way

the host responds to bacterial plaque (as in leukocyte adhesion deficiency [LAD] syndrome)
also can contribute to the development of periodontitis. Because 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 hosts 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, and the connective tissue disorder, Ehlers-Danlos
syndrome, in which patients may present with the clinical characteristics of aggressive
periodontitis. In both examples the prognosis is fair to poor.
Necrotizing Periodontal Diseases.

Necrotizing periodontal disease can be divided into

necrotic diseases that affect the gingival tissues exclusively (necrotizing ulcerative gingivitis
[NUG]) and necrotic diseases that affect deeper tissues of the periodontium, resulting in loss
of connective tissue attachment and alveolar bone (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.
Therefore superimposition of these secondary factors on a pre-existing gingivitis can result in
the painful, necrotic lesions characteristic of NUG. With control of both the bacterial plaque
and the secondary factors, the prognosis for a patient with NUG is good. However, 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. In systemically healthy patients,

this progression may have resulted from multiple episodes of NUG, or the necrotizing disease
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. 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 the
systemic problem.
In advanced cases, prognosis may be better established after reviewing the effectiveness of
phase I therapy. Determination of the prognosis of a tooth or teeth can be difficult,
particularly for teeth with previous disease. Many factors can influence disease progression
and the response to therapy, and the specific influence of any one factor is unknown and
likely different from one patient to another. In addition, each patient can respond differently
at different times. All these issues make determination of a prognosis difficult.

Therefore the prognosis is often determined after initial treatment is provided, assuming a
favorable outcome. The prognosis is delayed until after initial therapy because the etiology
depends on the host response. During initial therapy, the patients motivation and
commitment, acknowledged as critical in all periodontal therapy, also can be determined, as
well as the host response and healing capacity of the patient. Clearly, enhancing the host
response to plaques microbial challenge will significantly and positively influence the
periodontal prognosis. Likewise, an inability to enhance the host response will negatively
influence the prognosis. Either outcome, however, will allow the clinician to determine a
more accurate prognosis.

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. In these patients, the prognosis can be directly related
to the severity of inflammation. Given two patients with comparable bone destruction, the
prognosis may be better for the patient with the greater degree of inflammation because a
larger component of that patients bone destruction may be attributable to local irritants. In
addition, phase I therapy allows the clinician an opportunity to work with the patient and the
patients physician to control systemic and environmental factors such as diabetes and
smoking, which may have a positive effect on prognosis if adequately controlled.
The progression of periodontitis generally occurs in an episodic manner, with alternating
periods of quiescence and shorter destructive stages . No methods are available at present to
determine accurately whether a given lesion is in a stage of remission or exacerbation.
Advanced lesions, if active, may progress rapidly to a hopeless stage, whereas similar lesions
in a quiescent stage may be maintainable for long periods. 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

Prognosis Versus Actual Outcome

Journal of Periodontology
January 1991, Vol. 62, No. 1, Pages 51-58 , DOI 10.1902/jop.1991.62.1.51
(doi:10.1902/jop.1991.62.1.51)

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. The results suggested that this
population reflected many of the same characteristics seen in well-maintained patients. The
ultimate fate of teeth initially labeled as hopeless varied substantially, and even though the
average prognosis of the teeth studied at each interval remained relatively stable over time,
individual prognosis categories and individual tooth prognoses changed frequently. Possible
reasons for these shifts are discussed. 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. Further evaluation of the data is
needed to determine how each of the prognostic indicators relate to the success or failure of
our projection.

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

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annals of periodontology July 1998