PROGNOSIS

PRESENTED BY : DR. RASHMI JHA

GUIDED BY : DR. PRASAD NADIG
 CONTENTS
 Introduction
 Definition
 Classification
 Factors affecting prognosis
 Prognosis for patients with gingivitis
 Prognosis for patients with periodontitis
 Reevaluation of prognosis after phase 1 therapy
 Conclusion
 References
 INTRODUCTION
Prognosis is defined as 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.

 Prognosis is determined before the treatment plan after the diagnosis of the condition is made.

 The determinants of prognosis include the nature of disease/ condition, severity of the disease, the type of
treatment it requires.

For clinician prognosis is important to For patient prognosis is important to

determine which treatment modality is best
and to develop restorative recommendation
determine whether treatment seems
& treatment plans. worthwhile.
 SUPPORTIVE
DIAGNOSIS PROGNOSIS PERIODONTAL TREATMENT
THERAPY
A prediction of the Therapeutic
• Aims to probable course, measures to • After the diagnosis
duration, and support the and prognosis have
generalize signs been established, the
and symptoms to outcome of a patient’s own treatment is planned.
determine which disease based on efforts to control
specific disease a general and to avoid re‐ • The treatment plan is
is present. knowledge of the infection the blueprint for case
pathogenesis of management. It
the disease and includes all
procedures required
the presence of for the establishment
risk factors for and maintenance of
the disease oral health
 Prognosis V/S Risk Factors
PROGNOSIS RISK
Prediction of the course or outcome of the Risk deals with the likelihood that an individual
disease. will develop a disease in a specified period.

Prognostic factors are characteristics that Risk factors are those characteristics of an
predict the outcome of disease once the individual that put risk for developing a disease.
disease is present.
 TYPES OF PROGNOSIS
Diagnostic
Individual
Therapeutic
Overall
Prosthetic

Diagnostic : prognosis of teeth where no

Individual : prognosis of an individual tooth
treatment is provided.
based on local & prosthetic / restorative
factors that have direct effect on its
prognosis
Therapeutic : prognosis after the
appropriate periodontal treatment is
provided.
Overall : prognosis of the teeth based on
the sum of various local , systemic ,
Prosthetic : prognosis for supporting the environmental and other factors which may
prosthetic restoration after appropriate affect the overall heath of the teeth
periodontal treatment has been provided.
 QUESTION-
EXCELLENT GOOD FAIR POOR ABLE HOPELESS

Adequate Moderate to
Advanced Advanced
No bone loss Bone support remaining advanced
bone loss bone losss
bone support bone loss

Excellent Some tooth Grade II/III Non-

Tooth
gingival Adequate mobility. furcation maintainable
mobility
condition possibilities involvements areas
to control
etiologic Grade I
factors and furcation Tooth Extractions
Good patient establish a involvement. Grade I/ II mobility needed
cooperation, maintainable furcation
no systemic or dentition. involvements,
environmental difficult to
factors Adequate maintain areas or Inaccessible Presence of
maintanence and doubtful patient areas uncontrolled
acceptable patient cooperation. systemic or
cooperation. environmental
Adequate patient Presence of disease.
cooperation, no/ systemic or
well controlled Presence of environmental
systemic or Presence of limited
systemic or factors
environmental systemic or
environmental
factors environmental
factors
factor.
• Favorable • Good • Good • Good
• Questionable • Questionable • Fair • Questionable
• Hopeless • Poor • Hopeless
• Questionable
• Hopeless
Hirschfeld &
Becker et al. McGuire & Checchi et
Wasserman
1984 Nunn 1996 al. 2002
1978

• Favorable • Provides • Good • Provides a score

• Questionable probability of • Fair between 1-11
• Unfavorable tooth survival in • Questionable
• Hopeless 10% increments • Unfavorable

Kwok & Faggion et Nibali et al. Miller et al.

Caton 2007 al. 2008 2016 2014
 ACCORDING TO MC GURIE (1996)

CATEGORY DEFINITION
GOOD 25% ATTACHMENT LOSS AND/OR CLASS 1 FURCATION INVOLVEMENT

FAIR 25-50% ATTACHMENT LOSS AND/OR EASILY ACCESSIBLE CLASS II FURCATION

INVOLVEMENT

POOR 50-75% ATTACHMENT LOSS AND/OR CLASS II INACCESSIBLE FURCATION

INVOLVEMENT , CLASS III FURCATION INVOLVEMENT , CLASS II MOBILITY

HOPELESS >75% ATTACHMENT LOSS, CLASS III MOBILITY

 ACCORDING TO KWOK & CATON (2007)

CATEGORY DEFINITION
FAVORABLE Periodontal status of the tooth can be stablilized with comprehensive
periodontal treatment & maintainence. Future loss of periodontal tissue is
unlikely

QUESTIONABLE Periodontal status of tooth is influenced by local/systemic factors that may

or may not be controlled.
Periodontium can be stabilized if these factors are in control

UNFAVORABLE Periodontal status of the tooth is influenced by local/or systemic factors that
cannot be controlled.

HOPELESS Tooth must be extracted

 McGowan, 2017 proposed system uses 6 tooth-level and 3 patient-level
factors to give each tooth a prognosis of Secure, Doubtful, Poor, Or
Irrational to treat.

Bone
Loss: Age Smoking

Tooth Periodontal
Mobility Pocket Depth
THE
TOOTH- PATIENT-
LEVEL
FACTORS LEVEL
Compromising
ASSESSMENT
Furcation
Anatomical Involvement Bleeding Poorly
Factors on Controlled
probing Diabetes
Presence Of
An Infrabony
Defect
 SECURE • BL/Age <0.5 , PD ≤5 mm
• Tooth is suitable for prosthodontic, endodontic, and restorative therapy

DOUBTFUL • BL/Age 0.5-1 , PD 6-7 mm , Degree II furcation, Untreated infrabony defect,

Anatomic factors
• Tooth mobile >1 mm in transverse direction
• Suitable for prosthodontic, endodontic, and restorative therapy after SPT

POOR • BL/Age > 1 , PD ≥ 8 mm , Degree III furcation , Progressive tooth mobility

• Tooth is not suitable for prosthodontic work. Endodontic and restorative therapy
can be considered but tooth is not expected to survive over

IRRATIONAL TO • Circumferential bone loss to the apex , Tooth mobile in axial direction
TREAT • Most appropriate course of clinical care is extraction
 FACTORS IN THE DETERMINATION OF PROGNOSIS

OVERALL SYSTEMIC & ANATOMIC PROSTHETIC &

CLINICAL LOCAL TOOTH
ENVIRONMENTAL FACTORS FACTORS RESTORATIVE
FACTORS MOBILITY
FACTORS • Short tapered FACTORS
• Patients age • Plaque & • Severity
• Smoking root • Abutment
• Disease calculus of tooth
• Systemic disease • Subgingival • Cervical enamel selection
severity mobility
or condition restorations projections • Caries
• Plaque • Genetic factors • Enamel pearls • Non-vital teeth
control • stress • Bifurcation • Root resorption
• Patient ridges
compliance • Root concavities
• Developmental
grooves
• Root proximity
• Furcation
involvement
• Generally Better For • Pocket Depth • Effective Removal Of • Dependent On
Older Patients • Level Of Attachment Plaque Is Critical Patients Attitude,
• Younger Patient : Not • Degree Of Bone Loss Success Of Desire To Retain The
Good ( Shorter Time • Periodontal Therapy Natural Teeth &
Type Of Bony Defect
Frame In Which & To Prognosis Willingness & Ability
Destruction To Maintain Good
Occurred) Oral Hygiene.
PATIENTS DISEASE PLAQUE PATIENT
AGE SEVERITY CONTROL COMPLIANCE
&
COOPERATION
 SMOKING
 Most important environmental risk factor impacting the development &
progression of the periodontal disease.

 Significantly correlated with a decreased response to nonsurgical,

surgical, and regenerative procedures and with increased risk of tooth
loss in a treated population.

 Increases the risk of false negatives in traditional diagnostic tests.

 Cessation of smoking has been shown to improve outcomes of

periodontal treatment and reduce incidence of disease progression
and recurrence.
 SYSTEMIC DISEASE OR CONDITION

Diabetes mellitus has been established as a risk factor for

periodontitis and is associated with increased prevalence,
severity, and progression of disease.

Crucially, studies have shown that the level of diabetic control

affects both prevalence of periodontitis and the response to
treatment with poorly controlled diabetics (glycated
hemoglobin 9%) having a tendency for higher prevalence of
severe periodontitis and increased risk of progression.
 Genetic factors
 Genetic polymorphisms in the IL-1 results in production of IL-1β associated with increase in risk for severe,
generalized periodontitis.

 Genetic factors also appears to influence IgG-2 antibody titres & expression of Fcy RII receptors on the neutrophil,
both of which may be significant in Stage III/IV periodontitis.

 Other genetic disorders such as leukocyte adhesion deficiency type 1, can influence neutrophil function creating an
additional risk factor for stage III/IV periodontitis.

 Detection of genetic variations linked to periodontal disease can potentially influence the prognosis in several ways.

Identification of genetic risk factors later in Identification of the individuals who

Early detection of patients at risk
disease or during the course of treatment have not been evaluated for
because of genetic factors can
can influence treatment recommendations periodontitis , but who are
lead to early implementation of
, such as use of adjunctive antibiotic recognized as being at risk because
preventive & treatment measures
therapy or increased frequency of of the familial aggregation seen in
for patients.
maintenance visits stage III/IV periodontitis
 STRESS
 Physical & emotional stress, as well as substance abuse, may alter patients ability to respond to
the periodontal treatment performed.

LOCAL FACTORS

Plaque & calculus Subgingival restorations

• Good prognosis depends on the • Subgingival margins contribute to
ability of the patient & the clinician increased plaque accumulation ,
to remove etiologic factors as increased inflammation & increased
plaque & calculus are the most bone loss when compared with
important factor in periodontal subgingival margins.
disease. • Overhanging can negatively
impacrt periodontium
 Cervical enamel projections are flat, ectopic Root concavities exposed through loss of
extensions of enamel that extend beyond the attachment can vary from shallow flutings to
normal contours of the cementoenamel junction deep depressions.

ANATOMIC FACTORS

Developmental grooves, which sometimes Prognosis is less favorable for teeth

appear in the maxillary lateral incisors or in the with short, tapered roots and
lower incisors, create an accessibility problem relatively large crowns
 TOOTH MOBILITY
 In teeth with a healthy or diseased periodontium, the height of the supporting periodontal tissues and
the width of the periodontal ligament determine the degree of tooth mobility.

 The stabilization of tooth mobility through the use of splinting may have a beneficial impact on the

PROSTHETIC & RESTORATIVE FACTORS

overall & individual tooth prognosis.

More rigid standards are

The overall prognosis requires required when evaluating the
a general consideration of When few teeth remain, the prognosis of teeth adjacent to
bone levels and attachment prosthodontic needs become edentulous areas.
levels to establish whether more important, and
A tooth with a post that has
enough teeth can be saved sometimes periodontally
undergone endodontic
either to provide functional and treatable teeth may have to be
treatment is more likely to
aesthetic dentition or to serve extracted if they are not
fracture when serving as a
as abutments for a useful compatible with the design of
distal abutment supporting a
prosthetic replacement of the the prosthesis.
distal removable partial denture
missing teeth.
 AIM
To assess how different tooth-prognosis
systems could predict tooth loss in a cohort of
periodontitis patients followed up prospectively
during supportive periodontal care.

CLINICAL RELEVANCE
METHODOLOGY RESULTS
All four systems showed good • Study showed good reproducibility
Clinical and radiographic reproducibility and could identify and ability toidentify teeth at high risk
data of 97 patients teeth at higher risk of being lost of tooth loss during 5 years of
undergoing regular SPC during 5 years of SPC; the risk of supportive periodontal care.
for 5 years were used to tooth loss increased with the However, their sensitivity was low, as
assign tooth prognosis worsening of tooth-prognosis many teeth identified as hopeless
using four different category. Although specificity and were retained.
systems: negative predictive values were
McGuire & Nunn, 1996 good, low sensitivity and positive • The use of these prognostic
Kwok & Caton, 2007 predictive values were detected systems, with some suggested
Graetz et al., 2011 for all systems. modifications, is advisable as a
Nibali et al.,2017 means to establish tooth prognosis
RELATIONSHIP BETWEEN DIAGNOSIS & PROGNOSIS

Factors such as patients age,

severity of disease genetic
susceptibility & presence of
systemic diseases are
important criteria in the These common factors suggest that
diagnosis of the condition. for any given diagnosis there should
be expected prognosis under ideal
condition.
 PROGNOSIS FOR PATIENTS WITH GINGIVAL DISEASE

• All local irritants are eliminated,

Gingivitis • Local factors contributing to biofilm retention are eliminated,
Associated With
• Gingival contours conducive to the preservation of health are attained,
Dental Plaque
Only • The patient cooperates by maintaining good oral hygiene

Biofilm-Induced
Gingival • The long-term prognosis for these patients depends on control of bacterial
Diseases biofilm & control or correction of the systemic factors
Modified by
Systemic Factors

Biofilm-Induced
Gingival • Eliminating the source of inflammation
Diseases • Continued use of the drug and persistence of inflammation usually result
Modified by in recurrence of the enlargement, even after surgical intervention
Medications
 Gingival • In patients with vitamin C deficiency
diseases prognosis depends on the severity and
duration of the deficiency and on the
modified by likelihood of reversing the deficiency
malnutrition through dietary supplementation

• Prognosis for these patients is linked

Non–biofilm- to management of the associated
induced gingival dermatologic disorder and elimination
lesions of the causative agent.
 PROGNOSIS FOR PATIENTS WITH PERIODONTAL DISEASE

In cases where clinical attachment loss & bone loss are not very advanced : GOOD

Provided the inflammation can be controlled through good oral hygiene and removal of local plaque-
retentive factors.

In patients with more severe disease as evidenced by furcation involvement & increased clinical
mobility, or in patients who are non-compliant with oral hygiene practices , the prognosis may be
downgraded to FAIR to POOR.
 TITLE AIM METHODOLOGY RESULT CONCLUSION

An This Data were gathered on • When the study was • The present
Evidenced- retrospective 816 molars in 102 patients completed, 639 molars results indicate
Based study evaluates with moderate-to-severe survived (78%), that the
Scoring Index and assigns periodontitis. The six • 588 survived and were periodontal
to Determine scores to six factors evaluated (age, periodontally healthy prognosis of
the prognostic probing depth, mobility, (92%). molars diagnosed
Periodontal factors and furcation involvement, • In molars with lower scores with moderate-to-
Prognosis on derives a smoking, and molar type) (scores 1-3), the 15-year severe
Molars quantitative were assigned a numeric survival rates ranged from periodontitis can
scoring index score based on statistical 98% to 96%. be calculated
Preston D. used to analysis. • In molars with middle using an
Miller Jr. et determine the All patients were scores (scores 4-6), the evidence-based
al, periodontal evaluated a minimum of 15-year survival rates scoring index
2013 prognosis on 15 years after treatment. ranged from 95% to 90%
JOP molar teeth • For molars with higher
scores (scores 7-10), the
survival rates ranged from
LOE : 3 86% to 67%.
 STAGE III/IV PERIODONTITIS

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.

The deposits that are present often have elevated levels of

Aggregatibacter actinomycetemcomitans or Porphyromonas gingivalis.

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 STAGE III/IV periodontitis would have an
unfavorable prognosis
 Periodontitis as
a manifestation
of systemic
disease

Periodontitis Periodontitis
associated with associated with
hematologic genetic
disorders disorders

Neutropenia Papillon Lefvre

Leukemia Down syndrome
Acquired Syndrome
 Although the primary etiologic factor in
periodontal diseases is bacterial plaque,
systemic disease that alter the ability of the
host to respond to the microbial challenge
presented may affect the progression of the
disease & therefore the prognosis for case.

Decreased numbers of circulating

neutrophils may contribute to widespread
destruction of the periodontium. Unless
the neutropenia can be corrected, these
patients present with a fair to poor
prognosis.
 NECROTIZING PERIODONTAL DISEASES

NECROTIZING NECROTIZNG
ULCERATIVE ULCERATIVE
GINGIVITIS PERIODONTITIS

• Primary predisposing factor is • Necrosis extends from gingiva

bacterial plaque. to periodontium.
• It is complicated by the • Ptatients Are
presence of secondary factors immunocompromised.
such as acute psychological • Prognosis depends not only on
stress, tobacco, smoking & poor reducing local & secondary
nutrition which can contribute to factors but also on dealing with
immunosuppression systemic problem.
 FACTORS AFFECTING STABILITY OF IMPLANT
• Initial stability
• Age and gender • Position in arch • Angulations
• Smoking • Quality • Direction of implant
• Systemic disease • Quantity of bone • The skillfulness of an
• Oral hygiene operator

RELATED TO IMPLANT SURGERY-RELATED

HOST RELATED PLACEMENT SITE- FACTORS
RELATED FACTORS

IMPLANT
IMPLANT FIXTURE- PROSTHESIS-
RELATED FACTORS RELATED FACTOR

• Surface roughness
• Length and diameter of dental • Type of prosthesis,
implant • Retention method
• Macrostructure and microstructure • Occlusal scheme
of an implant fixture
 TITLE AUTHOR METHODOLOGY CONCLUSION

Factors Raikar et al This study was Conducted to • Maximum implants failures (55) were
Affecting the 2017 assess various factors seen in age group above 60 years of
Survival Rate Journal of affecting the survival rate of age.
of Dental international dental implants.
Implants: A society of • Maximum implant failure was seen in
Retrospective preventive & In this study, 5200 patients implants with length >11.5 mm followed
Study community with dental implants which by implants with <10 mm and 10–11.5
dentistry were placed during June mm.
LOE : 2a 2008–April 2015 were
included. • Type I bone showed 0.3% implant
failure, Type II showed 1.95%, Type III
Parameters such as name, showed 3%, and Type IV revealed 0.8%
age, gender, length of implant, failure rate.
diameter of implant, location of
implant, and bone quality were • Maximum implants failure (30/1000) was
recorded. seen in implants with diameter <3.75
mm followed by implants with diameter
>4.5 mm
 RE-EVALUATION OF PROGNOSIS AFTER PHASE I THERAPY

Reduction in pocket depth & inflammation after Phase I therapy

indicates a favorable response to treatment & may suggest a
better prognosis than previously assumed.

If the inflammatory changes present cannot be controlled or

reduced by phase I therapy overall prognosis may be unfavorable.
 CONCLUSION
 Prognosis is a measure of the likely outcome for an individual who undergoes
periodontal treatment.

 Determining prognosis at an early stage before treatment planning would help

the clinician to render the periodontal treatment in confidence.

 There are no reliable parameters for prognosis and clinician judgement is must.

 Even if the treatment done is successful and patient is not maintaining the oral
hygiene and not coming for regular follow-ups the prognosis may downgrade.
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