Clin Dent Rev (2017)1:3

DOI 10.1007/s41894-017-0004-2

TREATMENT

Evidence-based decision making in periodontal tooth

prognosis

Carlos Ernesto Nemcovsky1

Received: 12 April 2017 / Accepted: 7 June 2017

 Springer International Publishing AG 2017

Abstract Evidence-based dentistry requires application of current evidence in

making decisions about the care of individual patients. Long-term preservation of
the periodontium is the main objective of periodontal therapy. Before a treatment
plan is established, the diagnosis and etiologic factors of the disease as well as the
prognosis of the remaining teeth should be determined while predicting the final
functional and esthetic result. Tooth prognosis can be classified as good, fair, poor,
questionable, hopeless and indicated for extraction.

Keywords Prognosis
Periodontal
Systemic
Tooth
Treatment

Quick reference/description

Evidence-based dentistry requires application of current evidence in making

decisions about the care of individual patients. Long-term preservation of the
periodontium is the main objective of periodontal therapy. Before a treatment plan
is established, the diagnosis and etiologic factors of the disease as well as the
prognosis of the remaining teeth should be determined while predicting the final
functional and esthetic result.
Tooth prognosis can be classified as good, fair, poor, questionable, hopeless and
indicated for extraction.

& Carlos Ernesto Nemcovsky

carlos@post.tau.ac.il
1
Tel Aviv University, Tel Aviv, Israel

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Symptoms
The following criteria can be used for establishing the prognosis in periodontally
affected teeth (Table 1).
Table 1 Criteria for establishing prognosis
Good
(Control of etiologic factors and adequate
periodontal support assure that tooth is
relatively easy to maintain)
Fair
(Most of the periodontal support remains.
Adequate treatment will allow long-term
tooth survival provided good patient
compliance)
Poor
(Large loss of periodontal support, provided
good patient compliance, treatment will
lead to prognosis improvement and
maintenance but with certain difficulty)
Questionable
(Most of the periodontal support around the
tooth has been lost. Tooth not easily
amenable to maintenance care. Treatment
outcome is not fully predictable)
Hopeless
(Possibilities for successful treatment and
long-term tooth preservation are extremely
limited. Preoperative attachment could be
insufficient to maintain the tooth.
Extraction may be suggested)
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Clin Dent Rev (2017)1:3
Large number of remaining teeth/small number
of teeth involved
Compliance with supportive periodontal therapy (SPT)
Willingness to preserve the teeth
Vertical bone defect
No furcation involvement
Favorable crown-to-root ratio
Tooth is abutment of a fixed partial denture
Surgical regenerative periodontal treatment
can be performed
Good therapist knowledge and skill
Family history of periodontal disease
10075% remaining bone support
Horizontal bone defect
Class I furcation involvement
Class II furcation involvement with vertical
component
Degrees 12 mobility
Surgical periodontal treatment cannot be performed
Small number of remaining teeth/large number
of teeth involved
[7 mm clinical attachment loss
7550% remaining bone support
Unfavorable crown-to-root ratio
Root proximity
Root grooves
5025% remaining bone support
Class II furcation involvement without vertical
component
Degree 3 mobility that may be provisionally
stabilized
Unfavorable tooth position
B25% remaining bone support
Class III furcation involvement
Root resorption
Clin Dent Rev (2017)1:3 Page 3 of 11 3

Table 1 continued

Indicated for extraction Degree 3 mobility that cannot be provisionally stabilized

(No possibility for treatment exists, tooth Large carious lesion that may not be treated
preservation in the arch may cause Endodontic involvement that may not be successfully
irreversible damage, and tooth should be treated
promptly extracted)
Vertical root fracture
Clinical signs of active infection that may not be
controlled
Worsen prognosis Diabetes
Faulty oral hygiene
Smoking
Parafunction
Tooth is free-standing abutment of removable partial
denture

Clinical examination

Periodontitis is an infectious disease with varying severity degrees; therefore, both

patient- and tooth-related factors, as well as the therapist knowledge and skills, must
be taken into consideration when evaluating prognosis.
The therapy should aim at achieving clinically healthy periodontal conditions.
Available periodontal treatment options are:
Surgical periodontal treatment
Nonsurgical periodontal treatment
Defect elimination by resection
Maintenance of the area without or with minimal bone resection
Regenerative procedures
Tooth extraction.

The aim of periodontal surgery is to gain access to contaminated root surfaces for
proper debridement of the lesion, establishing a gingival morphology conducive to
plaque control and, whenever possible, regeneration of the lost periodontal
attachment.
An accurate prognosis is most critical when periodontal therapy is combined with
large oral prosthetic rehabilitation or with dental implants.

Procedure

Until reliable predictors of periodontal disease progression at each site and accurate
tooth prognosis are available, the use of surrogate clinical variables to reflect long-
term tooth survivability can be used.
A few prognostic factors:

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Can be controlled by the patient (daily plaque removal, smoking cessation,

compliance with wearing occlusal guards, compliance with the recommended
preventive maintenance schedule).
May be affected by treatment (probing depth, mobility, furcation involvement,
trauma from occlusion, bruxism, other parafunctional habits).
Can be associated with systemic diseases (diabetes mellitus, immunologic
disorders).
Are uncontrollable (poor root form, poor crown/root ratio, tooth type, age,
genetics).

A simpler classification of the prognostic factors is mentioned in Table 2.

Table 2 Classification of prognostic factors

Patient related Tooth related

Age The number of teeth involved

Systemic condition
Remaining teeth in the arch or mouth
Personal and family history of periodontal
disease
Oral hygiene
Compliance with recall visits
Smoking
Parafunctional oral habits
Willingness to preserve tooth or teeth
Clinical attachment loss
Loss of bone support
Remaining supporting area
Architecture of bone defects
Furcation involvement
Mobility
Crown/root ratio
Caries and/or endodontic involvement
Root defects
Tooth position
Root proximity
Rehabilitation involving the tooth
Type of periodontal treatment performed
Therapist knowledge and skill
Strategic value of the tooth and treatment alternatives

Patient-related factors

Age

The older the patient is, the better the long-term prognosis.
Susceptibility to periodontal breakdown is higher in the younger individual.
If progress of periodontal destruction has been very slow over the last years, then
prognosis is better than in cases where the downhill situation is of recent origin.

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Systemic conditions

Certain drugs can cause gingival hyperplasia, complicating plaque control during
maintenance.
Periodontal deterioration and poor response to treatment are seen in diabetes
patients.
They are at greater risk of developing periodontitis and may require more
aggressive treatment.

Number of remaining teeth

The greater the number of teeth present, the fewer the demands on the remaining
teeth in the dentition. Presence of certain teeth in strategic locations is important for
a more favorable prognosis.

Family history of periodontal disease

There is a genetic influence on tooth prognosis.

Quality of oral hygiene and compliance with supportive periodontal therapy

Recurrent periodontal diseases can be prevented by adequate plaque removal.

Noncomplying individuals have the highest risk of recurrent periodontitis.
Plaque control has an important role in the long-term stability of results
following regenerative periodontal surgery.

Smoking

Smoking has been related to poor immediate- and long-term responses to

periodontal treatment. It is a long-term risk factor in marginal bone loss.
Tooth loss because of periodontal reasons in smokers is 2.5 times higher than in
nonsmokers.

Parafunction

Parafunctional oral habits appeared to decrease tooth survival, while not wearing a
bite guard seemed to worsen this effect.

Willingness of the patient to preserve tooth or teeth

Periodontal regenerative treatment may be performed on teeth with a poor

prognosis, provided the patient is willing to try treatment as an alternative to
immediate extraction.
Inclination toward choosing extraction over other treatment alternatives is
strongly predictive of tooth loss.

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Tooth-related factors

Number of teeth involved

Secondary etiologic local factors should be carefully evaluated when only a few
teeth are affected in patients suffering from chronic periodontal disease.
Extractions might be decided after treatment if teeth show clinical and/or
radiographic signs of deterioration.

Clinical attachment loss

Teeth with advanced loss of attachment and deep probing depths will have a
decreased survival compared to those presenting with shallow probing pocket
depths.
High residual probing depths following active periodontal treatment are
predictive of further disease progression and tooth loss.
In subjects without periodontal care, increasing attachment loss is a significant
predictor of tooth loss over time.

Loss of bone support and remaining supporting area

Radiographic evaluation of the remaining bone support is an important tool for

evaluating tooth prognosis.
Increased percent of bone loss before periodontal treatment is associated with
increased risk of tooth loss.
Insufficient bone support may prevent normal function of the tooth and healing
after periodontal therapy.

Architecture of bone defects

The healing potential of the infrabony lesions is primarily dependent on the defect
morphology and, specifically, the number of associated bone walls. The healing
capacity of intrabony defects is higher than the horizontal, suprabony ones
(Fig. 3).
Single and multiple teeth with horizontal bone loss may be more difficult to treat
than those with angular bony defects (Figs. 1, 2) (Table 3).

Fig. 1 I Periapical radiograph of upper incisors shows horizontal bone loss. II Intraoperative aspect
shows horizontal bone loss on left side. III Intraoperative aspect shows horizontal bone loss on right side

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Fig. 2 Vertical bone defect on mesial aspect of lower molar. In the most coronal aspect, a one-wall
defect, while in the apical area, a twothree-wall defect may be appreciated

Table 3 Treatment and response to treatment in different clinical

conditions
Clinical condition Treatment Response to treatment

Non-contained bony defects Bone grafting in Greater recession and lower

Horizontal bone loss to a level apical to
a degree III furcation involvement
Maxillary molars
Distal root of a mandibular molar
Root-resected molars that are lone-
standing terminal abutments and/or
associated with untreated
parafunction
Class I and II furcation defects (Fig. 4)
Class III furcation involvement
Buccal class II furcation involvement
of mandibular and maxillary molars
Buccal class II furcation defects in
mandibular molars
Approximal class II and for class III
furcations
Narrow and deep infrabony defects
radiographically and clinically
combination with bone defect fill and
regenerative periodontal periodontal regeneration
surgery extent
Periodontal regenerative Not responsive to treatment
treatment
Tunnel preparation Large degree of tooth failure
Resection High incidence of failure
Resection High incidence of failure
Periodontal regeneration Responsive to treatment
Not responsive to treatment
Membrane therapy Responsive to treatment
(Guided tissue
regeneration)
Matrix protein therapies Clinical improvements seen
Matrix protein therapies No predictable results
Regenerative periodontal Respond favorably
surgery

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Fig. 3 Intrabony defect on the mesial aspect of the upper molar reveals the furcation entrance apical to
the bone crest level

Fig. 4 I Periapical radiograph shows loss of periodontal support around posterior lower teeth; furcation
involvement in the first molar is also evident. II Intraoperative aspect shows one-wall intrabony defects
mesial and distal to the first molar; buccal furcation is only minimally involved (class I). III Lingual
aspect reveals extensive furcation involvement at a level apical to the bone crest

The application of combined therapeutic approaches (i.e., barrier, bone

replacement graft with or without biologics) offer advantage over monotherapeutic
alternatives.

Mobility

Deeper probing depths at a site and tooth mobility at baseline are associated with a
bad long-term tooth prognosis.
Intraosseous defects around teeth with limited presurgical mobility (Millers
classes 1 and 2) respond favorably to regenerative periodontal surgery, whereas the
lack of a possibility to stabilize teeth with vertical mobility (Millers class 3) before
treatment might prevent success.

Crown-to-root ratio

A poor crown-to-root ratio has been associated with tooth loss.

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Caries and/or endodontic involvement

Interproximal and cervical carious defects can be secondary etiologic factors for
periodontal disease.
Treatment of perio-endo lesions according to Guided Tissue Regeneration (GTR)
principles, rather than open flap debridement, may result in large healing of the
defects with increased amounts of bone, periodontal ligament and new cementum.

Root defects

Enamel pearls and other projections, root grooves, root resorption, fractures and
fissures should be evaluated as they enhance bacterial plaque accumulation.
Root fractures can be caused by mechanical stress due to occlusal forces;
restorative procedures with the use of intraradicular posts or endodontic procedures
are usually associated with periodontal lesions. Vertical root cracks, fissures or
fractures are an obvious reason for early tooth extraction.

Tooth position

Faulty and tilted tooth positions can be enhancing factors for plaque accumulation,
rendering oral hygiene and maintenance more difficult.
Tooth malposition is associated with more unfavorable prognosis and a lower
survival rate.

Root proximity

Root proximity in the maxilla is most prevalent between the first and second
molar and between the central and lateral incisors and in the mandible the incisor
area.
Splinted crowns in areas of root proximity will not allow for proper maintenance,
orthodontic treatment, root amputation or even tooth extraction, which might be
indicated in these cases.

Rehabilitation involving the tooth

The weakest tooth dictates the prognosis of the whole rehabilitation. Strategic
extractions might be indicated where they may significantly improve the prognosis
of the adjacent teeth or even the overall prognosis of the rehabilitation.
When extensive implant-supported rehabilitation is planned, certain sparse
remaining teeth, although with fair prognosis, might have to be extracted to allow
for better planning and construction of the rehabilitation.
Fixed abutments appear to have increased survival, whereas removable
abutments have decreased survival rates.
Surgical therapy is more effective than nonsurgical scaling and root planning in
reducing the overall mean probing pocket depth and in eliminating deep pockets.

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Therapist knowledge and skill

Treatment plans are frequently influenced by the therapist preferences and skills and
not necessarily based on all the alternatives available for a certain case.

Strategic value of the tooth and treatment alternatives

Miller et al. selected six prognostic factors that could be quantitatively evaluated to
be scored: (1) age, (2) probing depth (PD), (3) furcation involvement, (4) mobility,
(5) molar type and (6) smoking.
A statistically derived score was determined for each factor. The sum of these
scores became the score for that tooth. Of all these prognostic factors, smoking had
the most negative impact, far exceeding the impact of PD, mobility or furcation
involvement. Molar type had a lesser impact, and age had the least impact.
When considering the replacement of teeth by implants, following well-
established facts must be taken into consideration:
1. Short roots (less than 7 mm) are acceptable, while short implants (less than
7 mm) are not predictable.
2. Teeth with loss of periodontal support (root exposure) can be maintained for a
long time, while implants with loss of support (implant surface exposure) are
difficult to maintain.
3. Root proximity is not necessarily detrimental, while implant proximity is
highly problematic.
4. Gingiva is highly vascularized and responds well to aggression, while implant
mucosa is poorly vascularized and does not respond well to aggression.
5. The esthetic outcome of rehabilitation involving proximal teeth is highly
predictable, while the esthetic outcome of implant-supported rehabilitation on
proximal implants is unpredictable.
6. Infection around teeth is limited to the gingival component, while infection
around implants is not limited and extends to the supporting bone.
7. PDL connects the root and bone and prevents bone resorption, while an
implant has no PDL and does not prevent bone resorption after tooth
extraction.
8. Long-term (over 50 years) survival of teeth is evident, while long-term (over
50 years) survival of implants is yet to be proven.
9. Periodontal treatment is highly predictable, while treatment of peri-implantitis
is unpredictable.
10. Periodontal regeneration is achievable, while regeneration of lost supporting
bone and reintegration to implants are rare.
11. Root coverage is predictable, while coverage of the exposed implant surface is
extremely difficult.
12. Malposed teeth may be restored and maintained, while misplaced implants are
difficult to restore and maintain.

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Pitfalls and complications

Periodontal patients seem to be more prone to peri-implant diseases and implant

loss.
Increased susceptibility for periodontitis may also result in an increased
susceptibility to implant loss, loss of supporting bone and postoperative
infection.
Peri-implantitis therapy effectiveness is impaired in patients with poor
compliance.
Even in the absence of periodontitis, inflammation and drainage from an
endodontic abscess can cause a sinus tract along the periodontal ligament to
develop a deep isolated probing depth, which may arrive at the tooth apex or the
furcation area in molars, and performing periodontal surgery in these cases will
cause serious damage to the periodontal tissues.

Further reading
1. Evidence-based decision making in periodontal tooth prognosis and maintenance of the natural
dentition. Rosen E et al (eds) Evidence-based decision making in dentistry. doi 10.1007/978-3-319-
45733-8_4
2. Ioannou AL, Kotsakis GA, Hinrichs JE (2014) Prognostic factors in periodontal therapy and their
association with treatment outcomes. World J Clin Cases 2(12):822827
3. Newman MG, Takei HH, Klokkevold PR, Carranza FA (2012) Clinical risk assessment. Carranzas
clinical periodontology. Elsevier Saunders, Philadelphia, pp 370372
4. Sanz M, Jepsen K, Eickholz P, Jepsen S (2015) Clinical concepts for regenerative therapy in
furcations. Periodontology 2000 68(1):308332
5. Chrcanovic BR, Albrektsson T, Wennerberg A (2014) Periodontally compromised vs. periodontally
healthy patients and dental implants: a systematic review and meta-analysis. J Dent 12:15091527

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