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SARANRAJ JPS PUBLICATION DR. SYED WALi PEERAI

Bl. IAITHIIEYAI IAMAL/lliAM
Essentials of
PERIODONTICS &
ORAL IMPLANTOLOGY

DR. SYED WALi PEERAN

DR. KARTHIKEYAN RAMALINGAM
Essentials Of
PERIODONTICS & ORAL IMPLANTOLOGY
Published by Dr. Syed Wali Peeran and Dr. Karthikeyan Ramalingam @
Saranraj JPS Publication,
Tamil Nadu, India

© Dr. Syed Wali Peeran &

Dr. Karthikeyan Ramalingam
1st Edition 2021
ISBN: 978-81-950475-4-3
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopy, recording or any information storage and retrieval system without the permission in writing from the
publisher.
Note: As new information becomes available, changes become necessary. The editors/author/contributors and the publishers have,
as far as it is possible, taken care to ensure that the information given in this book is accurate and up to date. In veiw of the possibility
of human error or advances in medical science neither the editor nor the publisher nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete. Readers
are strongly advised to conirm. This book is for sale in India only and cannot be exported without the permission of the publisher in
writing. Any disputes and legal matters to be settled under Chennai jurisdiction only.

Published in India
 Dr. Syed Wali Peeran is Professor of Periodontology and Oral lmplantology.
He finished his postgraduation in Periodontology in 2008 and has a doctoral degree.
He has a postgraduate certificate in advanced oral implantology and a
fellowship from international congress of oral implantologists.
He is the Editor in Chief and the founding editor for the journals-
Dentistry & Medical Research and Case Reports in Odontology.
He has over 63 national and international publications to his credit.
He has attended various national and international conferences and workshops.
He has also authored "Perio-Quest- MCQs in Periodontics with Self-Assessment
Picture Test" published by EMMESS publishers. He has been a reviewer for Libyan
Journal of Medicine,Journal of Nature, Biology and Medicine and various other
journals. He is a Life member of Indian Academy of Osseo Integration,
Indian Society of Periodontology, Indian immunological Society,
Indian Society of Oral lmplantologists and Indian Dental association.

Dr. Syed Wali Peeran, B.D.S, M.D.S (Peria), Ph.D. FICO/., PGCOI.
Professor, Department of Periodontics & Oral lmplantology,Faculty of Dentistry, Sebha
University, Sebha, Libya.

Dr. Karthikeyan Ramalingam is a Professor of Oral Pathology and Microbiology.

He finished his graduation and post graduation from Saveetha Dental College,
Chennai. He was the College topper in Part I and Part II postgraduate University
examinations.
He had secured the Gold medal in Pathology & Microbiology and Community
Dentistry in University examinations.He has guided postgraduates in oral pathology for
their seminars, research studies, journal discussions, library dissertations, thesis
preparation and in submitting articles for publication in various national and
international journals. He has also handled lectures and practical demonstrations
for undergraduates in oral histology,dental anatomy, forensic odontology, oral
pathology and microbiology. He has 65 international and national publications to his
credit. He is the Co-author of Textbook of Prosthodontics by Jaypee Brothers Medical
Publishers (P) Ltd. He has also contributed multiple choice questions and clinical
pictures to Perio-Quest- MCQs in Periodontics with Self-Assessment Picture Test by
EMMESS publishers. He is the Editor for Journals - Dentistry and Medical Research &
Case reports in Odontology.He is also the Reviewer for Journal of Oral and
Maxillofacial Pathology and North American Journal of Medical Sciences
(Indexed with PUBMED) and Journal of Cranio-Maxillary diseases.
He is a member of International Association of Oral Pathologists since 2016.
He is a Life member of Tamilnadu Dental Council since 2001, Life member of
Indian Association of Oral and Maxillofacial Pathologists since 2006 and a Life
member of Saveetha Dental College Old Students Association since 2001.
Dr. Karthikeyan Ramalingam, B.D.S, M.D.S
Professor, Department of Oral Pathology & Microbiology,Faculty of Dentistry, Sebha University,
Sebha,Libya
 Dr. ABDULNASIR MAQBOOL AHMED.
MSc, FICOI (U.S.A), Private Practice,
U.A.E.
Dr. Abhilash.
P.R. M.D.S
(Oral Pathology and Microbiology),
Reader, Department of Oral Pathology
and Microbiology,
Oxford Dental College & Hospitals,
Bangalore, Karnataka, India.
Dr. Ahmed Taher El-Hassan.
M.Sc (Oral Sciences-Periodontics),
Diplomate of American Board of
Periodontics, NOBE, WREB.
Assistant Professor, Benghazi University,
Benghazi, Libya.
Dr. Aisha Ahmed.
MB.ChB
ECFMG Certified Physician.
Department of Medicine, Faculty of
Medicine, Sebha University, Sebha,
Libya.
Dr. Bandar M.A. AL-Makramani.
BOS, HOD, MDSc, Ph.D
Assistant Professor, Fixed Prosthodontics,
Department of Prosthodontics, College
of Dentistry, Jazan University, Kingdom
of Saudi Arabia.
Dr. Fatma Mojtaba Al Said.
BOS., MPH (USA),
Faculty of Dentistry, Sebha University,
Sebha, Libya.
Dr. Franciso AL.
College of Dentistry, Jizan University,
KSA
Dr. Fuad Al Sanabani.
MSc, PhD
Department of Oral and Maxillofacial
Prosthodontics, Jazan University, Jazan,
Kingdom of Saudi Arabia
Dr. Ismail Abbas Darout.
DDS, Ph.D. (Dr .odont),
Postdoc Peria, Associate Professor
and Head, Department of Preventive
Dental Sciences, College of Dentistry,
Jazan University, Kingdom of Saudi
Arabia.
Dr. Khaled Awidat Abdalla.
B.D.S., C.E.S., DuODF (France),
Assistant Professor, Department of
Oral Biology and Orthodontics,
Sebha University, Sebha, Libya.
Dr. Manohar Murugan
M.Sc. (Microbiology), Ph.D.,
Assistant Professor, Department of
Medical Microbiology, Faculty
of Medicine, Sebha University, Sebha,
Libya.
Powered by TCPDF (www.tcpdf.org)
Dr. MOHAMMAD NAZISH ALAM.
BOS., MOS.
Asst. Prof, Department of Periodontics,
College of Dentistry, Jazan university
Dr. Nagabushan.
B.D.S., M.D.S
(Oral Medicine and Radiology),
Department of Oral Medicine and Radiology,
India.
Dr. Neha.
MOS.,
Department Of Periodontics and lmplantology,
Surendera Dental College and Research Institute,
Sriganganagar, Rajasthan.
Dr. R. Ganesh.
B.D.S., M.D.S. (Pedodontics)
Reader, Department of Pediatric and
Preventive dentistry, SRM University,
Tamil Nadu, India.
Dr. Rashmi Rai.
BOS., MOS.
Senior lecturer, public health dentistry,lndex
institute of dental sciences, Indore
Dr. Santosh Kumar.BB
BOS, MOS (Peria), M.Perio RCSEd (U.K),
MICOI (U.S.A) ), Specialist Periodontist and
lmplantologist, Kuwait.
Dr. Salhya Selhuraman.
B.D.S, M.A, PG0CA,
Surendra Dental College and Research
Institute, Sriganganagar, Rajasthan. India.
Dr. Shaesta Begum.
BOS, MOS (Periodontics),
Reader, Depatment of Periodontics, Farooqia
Dental College & Hospital, Mysore, Karnataka.
India.
Dr. Shamimul Hasan.
BOS, MOS
Assistant Professor, Department of Oral
Medicine and Radiology, Faculty of Dentistry,
Jamia Milia lslamia, New Delhi.India
Dr. Soumya K Nair.
B.D.S., MOS.,
Private practitioner, Mysore, India.
Dr. Suchelra N. Malleshi.
B.D.S., M.D.S (Oral Medicine and Radiology),
Department of Oral Medicine and Radiology,
J.S.S Dental College, Karnataka, India.
Dr. Supriya Ebenezer.
BOS., MOS.
Reader, Department of Periodontics,
Mathrusri Ramabai Ambedkar Dental
College and Hospital, Bangalore, India.
Dr. Syed Ali Peeran.
M.D.S. (Prostho)., MBA(HA), M.Phil (H.A),
Department of Prosthodontics, Assistant
Professor, Jazan University, Jazan, KSA.
Dr. Syed Kuduruthullah. S.K
M.0.S.(Oral Path)
Lecturer, Ajman University,
Ajman, U.A.E.
Dr. Syed Nahid Basheer.
BOS., MOS.
Assistant Professor, Department of Restorative
Dental Science, College of Dentistry, Jazan
University, Gizan, Kingdom of Saudi Arabia.
Dr. Syeda Nikhat Mohammadi.
BOS., MOS.
Senior lecturer, public health dentistry,
Pravara institute of dental sciences, Loni.
Maharashtra.
Dr. Tazeen.D
B.D.S., M.D.S (Peria).
Assistant Professor, Department of Periodontics,
Jazan University, Jazan, KSA.
Prof. Dr. Abdul Hafeez Khan
M.Sc., Ph.D.
Chairman, Department of Parasitology, Faculty
of Medicine, Sebha University, Sebha, Libya.
Prof. Dr. Abdul Hafeez Khan
M.Sc., Ph.D.
Chairman, Department of Parasitology, Faculty
of Medicine, Sebha University, Sebha, Libya.
Prof. Dr. Madhumala Thiruneervannan
BOS., M.D.S (Peria),
Head, Department of Periodontics, Vinayaka
Mission's Sankarachariyar Dental College,
Salem, India.
Prof. Dr. Marei Hamad Al Mugrabi.
B.D.S., M.Dent.Sc. (Periodontics-Dublin),Ph.D.
Head, Department of Periodontics, Benghazi
University, Libya.
Prof. Dr. Nurgul KOMERIK.
DDS., Ph.D.
Post Doc. Biruni University, Dental School,
Dept. of Oral Surgery, Istanbul, TURKEY
Prof. Dr. P.G. Naveen Kumar.
B.D.S., M.D.S., (Community Dentistry),
Head, Department of Community and
Preventive dentistry, College of Dental
Sciences, Davangere, Karnataka, India.
Prof. Dr. PC Anila Namboodiripad.
BDS, MDS., Department of Oral and M axillofacial
Pathology, India
Prof. Dr. R Thiruneervannan
BDS., MDS.
Principal, Vinayaka Mission's Sankarachariyar Dental
College, Salem, Tamil Nadu, India.
Prof. Dr. Syed Khalid Alla!.
MDS.
Associate Fellow AAID, Department of oral
mplantology, Vivekenanda dental college,
TN, India
Prof. Dr. V.Gopinalh.
M.D.S.
Professor, Department of Periodontology and
lmplantology, Chhattisgarh dental college
and research institute, Rajnandgaon, India
Prof. DR.V.HARIKRISHNA.
M.D.S.
Department of Orthodontics and Dentofacial
Orthopaedics. Chhattisgarh Dental college
and research institute, Rajnandgaon, India.
Chapter 39 Periodontal Prognosis
CHAPTER

38 Periodontal Prognosis

Karthikeyan Ramalingam & Syed Wali Peeran

Chapter Outline:
• Periodontal Prognosis • Factors to consider when assigning individual tooth prognosis
• Definitions And Terminology – Plaque /calculus
• Elements of prognosis – Tooth mobility
• Tooth mortality versus Stability of periodontium – Quantity of alveolar bone loss
– Periodontal stability – Morphology of the osseous deformity
• Rationale and biological basis – Anatomic factors
• Importance of prognosis – Sub-gingival restorations
• Factors to consider when assigning Overall Prognosis (concerned – Prosthetic/Restorative factors
with the dentition as a whole): overall clinical factors • Previous prognostication systems
• Oral hygiene, Plaque control, and effectiveness of periodontal • A Suggested Protocol
maintenance program • Indications for extraction of periodontally involved teeth
• Patient compliance, attitude towards therapy and perceived value • Miller–McEntire periodontal prognostic index
of natural dentition • Conclusion
– Systemic/Environmental factors • Review Questions
– Smoking – Essay Questions
– Systemic disease/condition – Short notes
– Genetic factors (Genetic Predisposition) • Principal references and suggested further reading
– Stress

Prognosis is derived from a Greek word – ‘pro’ meaning such conditions, as well as on specific information and
prior and ‘gnosis’ meaning knowledge. It also means exercise of clinicaljudgement in the particular case”.
“foreknowledge” as derived from Latin. It is the prospect ♦ Prognosis is based on the diagnosis and therapeutic
of recovery as anticipated from the usual course of disease possibilities according to the duration, evolution and
or peculiarities of the case. resolution of the disease.( Cortelli et al. )
Definitions And Terminology: ♦ Chronic disease can be defined as a disease that
Prognosis is a prediction as to the progress, course, and has a prolonged course, that does not resolve
outcome of a disease. (Glossary of Periodontal Terms, spontaneously, and for which a complete cure is
2001) rarely achieved. (Rose et al.)
Prognosis is defined as “prediction of the probable course, ♦ Risk factors are those characteristics of an individual
duration and outcome of a disease, injury or developmental that put a person at increased risk for developing a
abnormality in a patient, based ona general knowledge of disease.They are confirmed by longitudinal studies.

Periodontics & Oral Implantology 1

 Treatment considerations in Periodontology Section - VI

♦ Risk indicator or risk marker implies that the factor, Tooth mortality versus Stability of
although associated with increased risk for disease periodontium
development, is not necessarily causal in the strictest
sense.They are known from cross-sectional studies Tooth retention is one of the endpoints used in determining
or case-control studies. the periodontal prognosis. However, survival and stability
♦ Prognostic factors are characteristics that predict the should be considered separately.
outcome of disease once the disease is present. Tooth mortality:
♦ A prognostic factor is an environmental, behavioural Beckeret al reported that only 33.3% of teeth with hopeless
or biologic factor which, when present, directly prognosis were lost. However, these retained teeth were
affects the probability of a positive outcome of not necessarily stable, functional or comfortable.
therapy rendered for the disease. (Armitage 1996) Lindhe and Nyman lost only 2.3% of teeth with >50%
It is determined following initial examination, and attachment loss. So, teeth with advanced loss of periodontal
following active therapy phase. It is established after support could be kept healthy under strict maintenance
the diagnosis and before formulating the treatment care.
plan, considering the pathogenesis and the presence Tooth loss observation is definitive, but follow-up time can
of risk factors for the disease. be lengthy. It usually does not occur naturally and usually
based on the decision of patient/clinician. As it is influenced
Elements of prognosis: by non-periodontal factors, it is less useful for patient
The various elements of prognosis include management.
♦ Intended outcome Periodontal stability:
Periodontal disease is multi-factorial in nature and proceeds
♦ Temporal component - Timing of the projection
chronically with episodes of exacerbation and remission.
♦ Consideration of individual tooth versus the overall All patients are not equally at risk and tooth surfaces are
dentition variably affected. It can be influenced by local and general
One essential element of prognosis is the definition of risk factors that may be controlled.
intended outcome. Traditional prognostication systems Periodic examination of clinical attachment level can help
are based on tooth mortality. However, the periodontal to identify disease activity. But reproducibility of clinical
status of retained teeth is variable and uncertain to attachment level is influenced by probing force, soft tissue
predict. health, and tooth anatomy.
Prognosis can also be described in terms of the Disease activity assessment also varies with investigators.
stability of the supporting tissues, which should be As periodontal stability is dynamic in nature, it should be
continuously evaluated by level of clinical attachment assessed periodically. Hence, it would be better to decide
and radiographic bone measurements. prognosis based on periodontal stability.
The timing can be described arbitrarily as short term and Rationale and biological basis:
long term. Long-term usually refers to periods of
more than 5 years and periods of less than 5years are ♦ Prognosis “is an art based on a science.” (Prichard)
called short term. Studies have shown that prediction ♦ Prognosis formulation is the art of clinical forecasting.
accuracy was ~50% when good prognosis was excluded. (Rose et al.)
However, periodontal prognosis is dynamic in ♦ It is an educated guess at forecasting of the probable
nature and should be reevaluated periodically as course and final outcome of a disease.
treatment and maintenance progresses. It can change
♦ Our knowledge is incomplete so is our periodontal
after treatment as well as recurrent disease activity.
prognosis. However,still it helps in treatment
planning.

2 Periodontics & Oral Implantology

Chapter 38 Periodontal Prognosis

♦ To develop restorative recommendation and

Fig. 38.1 Influence of prognosis on treatment planning
decisions
Importance of prognosis:
It should be related to the goals or objectives that the
patient and clinicians aspire to achieve. It should also be
related to a particular time frame. Determining a prognosis
can be compared to a balancing a scale by weighing the
positive factors against the negative.
Clinician:
♦ To determine which treatment modalities will be
most effective.
treatment plans.
♦ Should indicate the likelihood of success or failure of
treatment.
Patient:
♦ To determine whether treatment seems worthwhile
♦ Can get an idea on how long the effect of treatment
will last?
Periodontal prognosis refers to the expected longevity
of teeth with or without periodontal therapy. It can be
considered for overall dentition and also a prognosis
for individual teeth. It is useful for making decisions on
whether to treat, retain or remove periodontally involved
teeth. The art and science of periodontal prognosisrefers
to the scientific basis about periodontal disease in deciding
whether to retain the tooth or not.
An overall prognosis helps to communicate between
patients and professionals. Many general factors can affect
whole dentition while local factors can affect only individual
teeth. Periodontal disease does not progress uniformly.
Sites of disease activity may vary between molars and
incisors. Individual tooth prognosis helps to develop a
valid treatment plan and can be adjusted based on general
factors.

Prognostic factors

That can be controlled Those impacted by

by the patient: Those associated with Those that are
periodontal treatment: systemic disease:
• Daily plaque removal. uncontrollable:
• Probing depth
• Smoking cessation. • Diabetes mellitus • Poor root form
• Mobility
• Compliance with • Immunological • Poor crown-root ratio
• Furcation involvement disorders
wearing occlusal • Tooth type
• Trauma from • Hypothyroidism
guards. • Age
occlusion
• Compliance with the • Genetics
• Bruxism
recommended
preventive • Other parafunctional
habits

Fig 38.2: Prognostic factors

Periodontics & Oral Implantology 3

 Treatment considerations in Periodontology Section - VI

Factors to consider when assigning Overall Langet al have reported that sites that bled every 3
Prognosis (concerned with the dentition as a months in 1 year have 30% chance of experiencing clinical
attachment loss of ≥ 2mm.
whole): overall clinical factors
However, systematic reviews suggest that bleeding
The overall prognosis is formulated from the collective on probing was not predictive for further disease
prognosis of individual teeth. The prognosis of certain progression and demise of involved teeth.
strategic teeth can significantly influence the overall
prognosis than other individual teeth. Suppuration:

Many parameters affect the prognosis and can be Suppuration:The formation of pus. (Glossary of periodontal
categorized into two groups, terms, 2001)
• Factors related to the ability to restore and  It indicates underlying pathology and must be
maintain health considered in the overall prognosis.
• Factors related to functional demands.  It is a general indicator of the overall level of
periodontal inflammation.
Several long-term studies have discussed various
prognostic factors including tooth type (non-molar Persistent deep pockets:
teeth versus molars), furcation involvement, tooth If pocket depth is greater than 6mm, it is difficult to
mobility, alveolar bone loss and patient compliance to achieve complete calculus removal. Such pockets
periodontal maintenance therapy. However, it is not have more bleeding on probing and greater percentage
possible to adequately predict the risk of future show disease progression.
attachment loss or the risk of developing periodontal
lesions in the future. Thus, patients without a previous  Deep pockets harbor periodontal pathogens
history of periodontitis is at a lower risk than patients and are harder for the patient and the clinician to
previously affected by periodontitis. maintain a healthy state.
Patient age:  It is conceivable that deeper pockets might
serve as reservoirs for periodontal pathogens.
• Age is a significant risk characteristic for They have 3 times greater risk than shallow sites
periodontitis and almost all studies have found that
old age groups show greater prevalence and for experiencing disease activity.
severity of periodontal destruction than younger age  The patient with presence of numerous persistent
cohorts. deep pockets may indicate a patient whose
 Chronicity of Periodontal disease: This could response to therapy has been less favorable and
be related to presence of disease for a who may be under considerable risk of further
longer period in older patients than younger
periodontal breakdown.
ones.
 Cumulative periodontal destruction: Age  Residual pocket of 6mm or more depth are risk
reflects the individual’scumulative oral history. factors for periodontal disease progression, tooth
• Patients with older age probably have a better loss and represent incomplete periodontal
prognosis than patients of younger age. treatment of outcome and require further therapy.
• A more aggressive form of periodontitis is seen in
younger age.  Patient with persistent deep pockets might be
Disease Severity: assigned a less favorable prognosis.
Bleeding on probing;  The absence of probing depth is a good
The absence of bleeding on probing over forecaster for future periodontal stability.
several appointments could indicate an improved Amount of Remaining Attachment:
prognosis compared with a tooth with similar levels of
periodontal destruction that repeatedly bled on probing. The amount of remaining periodontal attachment is of
prognostic significance.
4 Periodontics & Oral Implantology
Chapter 38 Periodontal Prognosis

 A tooth or a dentition with severe attachment Systemic/Environmental factors:

loss will have a less favorable prognosis than one
with minimal attachment loss. Smoking:
 It is a predictor for future risk of attachment loss Tobacco smoking is a major modifiable risk factor for
and can estimate patient’s susceptibility. development of periodontitis. It also affects the treatment
 The clinical indicators of inflammation are edema, response adversely.
erythema, bleeding, and suppuration. If considered
separately, they are weak predictors of future It has been reported that smoking increases attachment loss
attachment loss. in the maxillary lingual and mandibular anterior regions.
 Loss of attachment can measure disease Smoking decreases the likelihood of an improved
progression but cannot predict future disease prognosis after treatment by 60% when compared
activity. with non-smokers.
Oral hygiene, Plaque control, and effectiveness Patients with slight to moderate periodontitis who stop
of periodontal maintenance program: smoking can often be upgraded to a good
Effective plaque control and oral hygiene are critical for the prognosis, whereas those with severe periodontitis who
success of the periodontal therapy. The patient’s ability to stop smoking may be upgraded to a fair prognosis.
perform adequate plaque control is important to determineStudies have shown that clinicians tend to underestimate
whether the disease process can or cannot be arrested. the effects of tobacco smoking on prognosis while
The effectiveness of periodontal maintenance is the most overestimating the estimating the effects of tooth level
critical factor in assuring long-term success. factors.

Patient compliance, attitude towards therapy and Systemic disease/condition:

perceived value of natural dentition: Systemic conditions should be considered in formulating a
Compliance is of particular importance in periodontal periodontal prognosis.
therapy. A number of retrospective and prospective A compromised medical status has a negative influence
cohort studies have shown that good compliance is on dental prognosis. It can directly influence healing and
associated with better periodontal outcomes especially indirectly influence the behavioural and physical
lesser attachment loss., including reduced tooth loss. approaches to oral hygiene.
Hence,compliance should be considered while
Diabetes - Poorly controlled diabetes, in particular, is
formulating periodontal prognosis.
a significant risk factor for higher prevalence, extent,
If the patients are unwilling or unable to perform adequate and severity of periodontal attachment loss. Such patients
plaque control and to receive the timely periodic with poor glycaemic control have a poor prognosis than
maintenance checkups and treatments that the well-controlled diabetics or non-diabetics.
dentist deems necessary, the dentist can either refuse
Immunodeficiency states - Any condition that causes
to accept the patient for treatment, or he can extract
a suppression of the host defences can predispose to
teeth that have a hopeless or poor prognosis.
periodontal disease.
A well-motivated patient is a most valued asset in successful
 Such AIDS patients have a poor prognosis unless
therapy. The patient’s compliance with oral hygiene efforts
they are under anti-retroviral therapy.
is critical for success.
 Neutrophil defects like Chediak-Higashi or Papillon-
Miyamoto et al have reported that complete
Lefevre syndrome, Leukocyte adhesion
patient compliance with increased frequency of
deficiency and other systemic diseases that lower
periodontal maintenance can improve the dental
neutrophil counts or impairs neutrophil function can
prognosis by reducing tooth loss among molars and
be associated with increased risk for periodontal
minimization of alveolar bone loss among non-molars.
disease.
Periodontics & Oral Implantology 5
 Treatment considerations in Periodontology Section - VI

Low dietary intake of calcium and vitamin C also may Factors to consider when assigning individual
confer some risk. tooth prognosis:
Osteoporosis is also implicated in rapid loss of attachment,
particularly in women. According to Matthews and Tabesh (2004), local factors
were defined as anything that influences the oral health
Genetic factors (Genetic Predisposition): status at a particular site or sites with no known systemic
influence. It can be anatomical factors like root grooves
Studies have shown genetics risk factors to be of significance. or iatrogenic factors like subgingival restorations.
Familial aggregation of aggressive periodontitis has been
reported. The important factors in determining prognosis for
individual tooth includes probing depth, furcation
Heritability of chronic periodontitis has been supported involvement, crown to root ratio, fixed abutment status
by twin studies. The dissimilar progression of gingivitis and percent bone loss.
to destructive periodontitis explains the concept that
heredity plays a greater role in periodontal susceptibility, Plaque /calculus:
accounting for perhaps as much as 50% of the risk for
chronic periodontitis. The plaque is the most important etiologic agent in the
gingivitis, and it has a role in periodontitis.
The individuals possessing IL-1 gene polymorphism are
about 2.7 times more likely to lose teeth than those The microbial challenge presented by bacterial plaque and
without the genotype calculus is the most important local factor in periodontal
diseases.
Gene polymorphisms in IL-10 and FcγR may increase
susceptibility to severe periodontitis. Therefore, a good prognosis depends on the ability of the
patient and the clinician to remove these etiologic factors.
The risk is increased by 7.7 fold in genotype –positive
individuals who are also long-time heavy smokers. Tooth mobility;
There are limited treatment options available for such Hypermobile teeth are considered to have a questionable
patients. Gene therapy is possible that can produce certain prognosis, and they lose more clinical attachment with
compensation ranging from host modulation to more time.
frequent maintenance intervals.
Hypermobile teeth with furcation involvement had greater
Stress: risk of attachment loss than non-mobile teeth.
Physical and emotional stress may alter the patient’s ability Better healing responses after periodontal treatment are
to respond to the periodontal treatment performed. notedin firm rather than mobile teeth.
Parafunctional habits like bruxism, clenching, Mobility also has been associated with less favourable
factitialbehaviour could be a manifestation of stress. results after regenerative surgical therapy and has increased
Heavy occlusal loading can lead to bone loss and increase riskfor tooth loss during maintenance.
tooth mobility. The stabilization of tooth mobility through the use of
TMJ dysfunction and excessive occlusal wear could also be splinting may have a beneficial impact on the overall and
noted. individual tooth prognosis.
A Recent meta-analysis suggests that psychological stress When 4-6mm of bone is lost, there is a large amount of
can lead to increased periodontal disease and a worse stress on remaining periodontium leading to destruction
overall prognosis. and further increased mobility.
However, tooth mobility does not mean periodontal disease.
It could be due to primary occlusal trauma by excessive
occlusal forces on healthy periodontium or secondary
6 Periodontics & Oral Implantology
Chapter 38 Periodontal Prognosis

occlusal trauma by normal masticatory load on weakened Additional roots: Rarely, maxillary first premolar can
periodontium. show a third root. It is called mini-molar, as it has one
palatal and two buccal roots. Such tooth can have 2-3
Treated loose teeth can respond favourably to therapy.
furcation entrances and can be affected by periodontal
Quantity of alveolar bone loss: disease.
Root proximity (too close roots- difficulty in
 Greater the bone loss, poorer is the prognosis.
instrumentation)
 Untreated sites of bone loss are more prone for Furcation entrance dimension - if the Furcation
additional bone deterioration. entrance is narrower than a standard curette
 Radiographs are not sensitive indicators for Root concavities. (Difficult instrumentation)
ongoing progressive periodontal disease as Developmental grooves (palato-gingival groove and
• Radiographs can underestimate actual bone grooves on proximal surfaces -accessibility problem)
loss by 9 – 20%. Bifurcation ridges
• Undamaged cortical plates can conceal The retention rates of furcation involved teeth
medullary bone resorption. ranged from 43 – 98%. Such high retention rates could be
due to overestimation of initial furcation involvement.
 The previous bone loss is not a good predictor for
Dannewitz et al have reported that teeth with Class I
future osseous destruction.
or II furcations had a prognosis comparable with teeth
Morphology of the osseous deformity: without furcation involvement after active periodontal
therapy.
 It is important for the prognosis of an individual
Regional anatomy
teeth.
Proximity to maxillary sinus/ mental foramen
 It is based on the topography of the surrounding
Mandibular tori
bone.
 A tooth with 50% horizontal bone loss has better Shallow vestibule
long-term prognosis than tooth with 30% localized, Sub-gingival restorations:
deep and wide infrabony defect.
Anatomic factors: Subgingival margins may contribute to increased plaque
accumulation, increased inflammation, and increased bone
Root and furcation anatomy:
loss when compared with supragingival margins.
 Multi-rooted teeth like maxillary and mandibular Restorations extending sub-gingivally are an etiologic factor
molars with maxillary premolars displayed the for periodontal disease.
highest incidence of attachment loss.
 Maxillary anterior teeth and mandibular premolars
showed the lowest incidence. Root anatomy in
combination with other factors can affect the
prognosis.
Presence and severity of Furcation involvement
(access to the furcation area is difficult) – worse
prognosis
Crown-root relationship - Short, tapered roots
(improper crown to root ratio)
Cervical enamel projections (interferes with
Fig. 38.3 IOPA showing overhanging restoration
attachment apparatus)
associated with periodontal disease
Enamel pearls.(interferes with attachment apparatus)
Periodontics & Oral Implantology 7
 Treatment considerations in Periodontology Section - VI

Prosthetic/Restorative factors: * Endodontic-periodontal lesions may compromise

prognosis.
The prosthetic and restorative factors should
* Teeth with untreated occlusal discrepancies have
be considered before determining prognosis. It is a
a poor prognosis than teeth in occlusal harmony.
point where the overall and the individual prognosis
Hence, occlusion should be considered as a
meet. The prognosis for key individual teeth may affect
tooth-level variable than a patient-level variable
the overall prognosis for rehabilitation.
to establish periodontal health.
The clinician is under a dilemma whether to involve the * Limiting arch:The one arch which may be
compromised tooth into the prosthesis. Such teeth should significantly worse than the others and may exert
be considered under special circumstances, assess all the a disproportionate influence on the treatment
other criteria including patient’s objectives. plan is termed the limiting arch
♦ Strategic value of the involved tooth/teeth If prognosis refers to the clinical condition of a tooth at any
♦ Extent of carious destruction point, then it should give a good indication of the overall
♦ Pulpal involvement clinical status of that tooth. By evaluating the change in
prognosis over time with baseline characteristics, disease
♦ Non-vital tooth
progress can be analysed.
♦ Root resorption.
Previous prognostication systems:
♦ Root canal anatomy and accessory canals
♦ Fixed abutment status including the measure of Hirschfeld and Wasserman(1978) observed 600
occlusal load and patient’s ability to perform plaque maintenance patients for an average of 22 years. They had
control. only two levels of prognosis – favourable and questionable.
The teeth with furcation involvement, a deep& non-
♦ Clinical crown to root ratio eradicable pocket, extensive alveolar bone loss, marked
♦ Number of remaining teeth mobility in conjunction with probing depth ( 2 – 2.5 on a
♦ Greater the number of remaining teeth, greater is the scale of 3). The predictability of a correct prognosis
ability to share occlusal forces and thus reducing the became more variable over extended period of time. The
load on an individual tooth. number of teeth lost was used to classify patients as, well
maintained – zero to 3 teeth lost, downhill – 4 to 9 teeth
♦ Many dentists say, “Give me two good cuspids and lost and extreme downhill – 10 – 23 teeth lost. Hirschfeld
two good molars, I can restore the full arch”. This and Wasserman divided their patients into 3 groups – well-
statement may be true if other factors are suitable. It maintained, downhill and extreme downhill to evaluate
can be a difficult situation if the remaining teeth are tooth loss. In such patients, posterior teeth were more
incisors. likely to be lost.
♦ Tooth position and occlusal relationship Beckeret al followed two groups of post-treatment patients
♦ If a tooth is severely tipped, occlusal forces are not with and without maintenance therapy. They studied tooth
directed parallel to the long axis of the tooth, and it mortality and described 3 prognostic categories – good,
compromises the ability to withstand occlusal loading questionable and hopeless. They assessed bone level,
in function. probing depth and furcation involvement. They also
considered palatal grooves, extensive caries, and repeated
♦ The position of teeth in the arch influences abscesses. This detailed classification improved prediction
treatment planning. in well-maintained patients and effectivefor a period of
♦ Financial aspects. 5-6 years. The teeth with more than one of the following
♦ Follow-up intervals. problems,
♦ Parafunctional habits. ♦ Questionable prognosis–
* Bone loss close to 50% of root length
8 Periodontics & Oral Implantology
Chapter 38 Periodontal Prognosis

* Probing depth of 6 to 8 mm * Class III mobility with tooth movement in mesial-

* Class II furcation involvement with minimal inter-
radicular space
* Presence of deep, vertical grooves on palatal
aspect of maxillary incisors
* Mesial furcation involvement in maxillary first
bicuspids
♦ Hopeless prognosis
* > 75% loss of supporting bone
* > 8 mm probing depth
* Class III furcation involvement
Table 38.1: Prognostic categories (McGuire and Nunn (1991))
distal and vertical dimensions.
* Poor crown/root ratios
* Root proximity with minimal inter-proximal bone
and evidence of horizontal bone loss.
* History of repeated periodontal abscess
formation.
McGuire and Nunn (1991) determined that commonly
used clinical parameters lacked accuracy in forecasting
tooth retention. They assessed 2484 teeth in periodontal
patients under maintenance for 15 years and gave a
prognosis.They had classified 5 prognostic categories – Good,
Fair, Poor, Questionable and Hopeless.

Type Presence of 1 or more of the following parameters

Good prognosis Control of the etiologic factors and adequate periodontal support as measured clinically and
radiographically to ensure that the tooth would be relatively easy to maintain by the patient
and clinician assuming proper maintenance.
Fair prognosis Approximately 25% attachment loss as measured clinically and radiographically and/or Class
I furcation involvement. The location and depth of the furcation would allow proper mainte-
nance with good compliance.
Poor prognosis 50% attachment loss with Class II furcations. The location and the depth of furcations would
allow proper maintenance but with difficulty
Questionable prog- Greater than 50% attachment loss resulting in poor crown-to-root ratio. Poor root form.
nosis Class II furcation not easily accessible for maintenance care or Class III furcations. Mobility of
2 or greater. Close root proximity.
Hopeless prognosis Inadequate attachment to maintain the tooth. Extraction performed or suggested

Ghiai and Bissada(1996) reported that it was hard to predict absence of bleeding on probing, stable probing depth and
the retention of individual teeth, except when the initial no additional loss of bone or clinical attachment result in
forecast was good.They assessed 580 teeth in maintenance reduced tooth loss by periodontal disease.
program.When re-examined after 5-13 years, 71% of teeth
Checchi et al in 2002 proposed a simplification of the
with good prognosis and 53.3% of fair prognosis were
McGuire (1991) classification of periodontal prognosis.
correctly assigned. 51.8% of teeth performed better than
This simplified classification includes three prognosis
expected and 55.2% of poor prognosis group resulted in
gradients: good, questionable, and hopeless. The authors
hopeless category.
elected to define prognosis based on residual bone levels
Thus, both the groups of investigators agree that and/or furcation involvement.The criteria put forth where
reliable forecast could not be given with accuracy using as follows:
conventionalassessments unless the initial prognosis
was good. Surrogate variables for periodontal health like

Periodontics & Oral Implantology 9

 Treatment considerations in Periodontology Section - VI

Teeth with bone Bone loss Teeth with less

QUESTIONABLE

GOOD
HOPELESS
loss greater than between 50% than 50% bone loss
75% or teeth that and 75%, or the or not fitting one
had at least two presence of an of the two previous
characteristics angular defect categories.
of ‘questionable’ or furcation
category; involvement;

Fig. 39.4 Classification of periodontal prognosis (Checchi et al.)

If a tooth exhibited both characteristics, it was downgraded. These terms for prognosis should be readily communicable
Results showed that 0.07% of teeth with good prognosis to the patient and the clinician.The categories for prognosis
were lost, 3.63% were lost from the questionable prognosis could be described by terms such as,
category, and 11.34% were lost from the hopeless prognosis
subgroup. While previous prognosis classifications were ♦ Excellent
shown to be accurate for the “good’’ and “hopeless’’ ♦ Very good
prognosis, this simplified approach performed very well for ♦ Good
“good’’ and “questionable’’ prognosis but seemed to have
been pessimistic in assigning “hopeless’’ prognosis. ♦ Fair
♦ Guarded
Kwok and Caton(2007) have proposed a new classification
system with 4 parameters – favourable, questionable, ♦ Questionable
unfavourable and Hopeless. ♦ Doubtful
♦ Favourable – periodontal status can be stabilized ♦ Poor
with comprehensive periodontal treatment and
♦ Hopeless
maintenance. The future periodontal loss is unlikely.
Excellent prognosis: Teeth with excellent prognosis have
♦ Questionable – periodontal status is influenced by
one or more of the following - No bone loss, excellent
local and systemic factors that may or may not be
gingival condition, good patient co-operation,andno
controlled. Periodontium can be stabilized with
systemic/environmental factors.
comprehensive periodontal treatment and
maintenance, if these factors are controlled; Good prognosis: Teeth with a good prognosis has one or
otherwise future periodontal breakdown may both of the following characteristics: adequate remaining
occur.“Questionable’’ prognosis a term that means periodontal support and ease of maintenance.
that a tooth may or may not respond well to Fair prognosis: Teeth with a fair prognosis has one or
treatment and many factors such as patient/host both of the following characteristics: Attachment loss to
susceptibility, age, location of the tooth and degree the point that the tooth cannot be considered to have a
of bone loss among others must be weighted to good prognosis and presence of a Class I furcation lesion
better determine its prognosis.(Ioannou et al.) (with the limitation that the furcation is believed to be
♦ Unfavourable – periodontal status is influenced by maintainable).
local and systemic factors that cannot be controlled. Guarded prognosis: Teeth with upto 50% attachment loss,
Periodontal breakdown is likely to occur even with 6-8mm pocket depth, Class II furcation invasion, Grade II
comprehensive periodontal treatment and mobility, Root proximity with moderate attachment loss.
maintenance.
♦ Hopeless – tooth must be extracted.
10 Periodontics & Oral Implantology
Chapter 38
Questionable prognosis: Teeth with questionable prognosis
exhibit one or more the following characteristics: Severe
attachment loss resulting in a poor crown-to-root ratio;
poor root form; root proximity; Class II or III furcation
lesions (not amenable to maintenance) and mobility of 2+
or greater.
It means that there are additional factors involved in
preventing complete control of a tooth or arch. There is an
element of doubt in the prediction of success or failure. It
is better to admit doubt than to mislead the patient.
Poor Prognosis: Teeth with a poor prognosis exhibit one
or both of the following characteristics: > 75% attachment
loss, > 8mm pocket depth, Class III furcation lesions or
furcation invasion on a maxillary first premolar (that can
presumably be maintained, but with difficulty), Grade III
mobility, Recurrent periodontal abscess and extensive
developmental grooves.
Hopeless prognosis: Inadequate attachment to maintain
the tooth in health, comfort, and function. It includes >75%
bone loss, 8 – 10mm probing depth, Class III furcation
involvement, Hypermobility, Severe root proximity with
adjacent tooth, poor crown: root ratio, history of repeated
periodontal abscess formation. In such cases, extraction is
recommended. Tooth must be extracted.
A Suggested Protocol:
Prognosis should be regarded as a dynamic parameter, and
every treatment plan should allow for specific intervals
to re-evaluate the patient’s status. It is recommended
to proceed initially on a tooth-by-tooth basis in
assessment of prognosis and then formulate the prognosis
for the entire arch.
Analysis of patient’s expectations, motivation and change in
habits as therapy is performed, presence and possibility of
risk factors and occasional rehabilitation should be a part
of the treatment protocol.
Establishing an adequate prognosis is a difficult task. The
advantages and limitations of each criteria is
important when an ethical question arises to decide
the status of maintaining teeth.
♦ A careful and complete collection of data is the first
step towards formulating a diagnosis and prognosis.
This necessitates evaluation of patient’s social and
medical history for risk factors like diabetes, tobacco
Periodontics & Oral Implantology
Periodontal Prognosis
use, stress, immunodeficiency diseases, and stress.
If there are risk factors, assess the level of existing
disease and modes to improve control of these
factors.
♦ Next step is comprehensive periodontal examination
along with radiographs. It should include a 6-point
probing’s for each tooth along with measurement of
gingival recession, mobility, furcation involvement and
bleeding on probing or presence of exudate.
♦ Data collection is followed by assignment of a
presumptive diagnosis, using the American Academy
of Periodontology Classification system. The
components of the diagnosis include disease type,
extent, and severity. It should give an idea about the
overall periodontal health.
♦ Next, prognosis for individual teeth should be
assigned, using criteria discussed earlier.
♦ After tooth and arch prognosis have been assigned,
a full-mouth assessment should be performed, and a
whole-dentition prognosis should be given.
* Is the disease localized or generalized?
* Are there any local risk factors that predispose to
gingival or periodontal disease?
* Is there any attachment loss? If present, is the
disease early, moderate or advanced?
♦ Early disease – attachment loss of 3mm or less (Probing
depth of 3-6mm with normal gingival margin)
♦ Moderate disease – attachment loss of 3-6mm (Probing
depth of 6-9mm with normal gingival margin)
♦ Advanced disease – attachment loss of >6mm (Probing
depth of >9mm with normal gingival margin)
* There is a possibility of generalized early or
moderate disease with areas of advanced disease
in the same patient.
* Correlate the attachment loss with age of
patient.
♦ Advanced attachment loss in younger patients
suggests aggressive disease with poor prognosis than
a similar level of attachment loss in older patients.
♦ Younger the patient, worse is the overall prognosis.
* The overall prognosis of generalized
advanced periodontal disease is bleak.
11
Treatment considerations in Periodontology
* The overall prognosis of early or moderate
periodontal disease is generally good.
* Patient’s ability and consistency to perform
plaque control is critical in determining overall
prognosis.
♦ Better the plaque control, better is the overall long-
term prognosis.
* Some clinical circumstances may also affect the
individual tooth prognosis. This is particularly
true in the presence ofa strong risk factor such
as smoking.
♦ Prognosis for individual teeth:
* Most important consideration is amount of
attachment loss.
♦ Teeth with less than 4mm of attachment loss (Probing
depth of 7mm or less with normal gingival margins)
have a good prognosis if they are not going to be
used as abutments.
♦ Teeth with >7mm attachment loss (Probing depth of
10mm or more with normal gingival margins) have a
poor prognosis.
* The crown-root ratio measures attachment
loss. It is important especially in cases of root
resorption where attachment loss occurs from
the apical end.
* Presence of furcation invasion
♦ Teeth with minimal (Class I) or no furcation invasion
have a good prognosis.
♦ Greater, the amount of attachment loss in the
furcation area, results in worse the long-term
prognosis of the tooth.
♦ Teeth with a complete bone loss in the coronal
aspect of furcation (Class III) have a poor prognosis.
* Teeth like maxillary premolars with pronounced
root concavities have poor prognosis than those
with relatively straight roots.
* Severe tooth mobility is an indicator of poor long-
term prognosis.
♦ After assignment of individual prognosis, Teeth with
good periodontal prognosis should be maintained
provided that the patient maintains adequate plaque
control.
12 Periodontics & Oral Implantology
Section - VI
♦ The overall treatment plan is equally important as
periodontal prognosis. The arch integrity should
be assessed. The cost of treatment and projected
longevity of tooth to be treated should be considered.
Is it worthy to treat a tooth with guarded-poor
prognosis by endodontic and prosthetic treatment, if
it is expected to be lost in few years?
♦ Questionable or hopeless teeth can be deleted
from the arch diagrams. This could suggest possible
prosthetic schemes. A prognosis can then be assigned
to each arch.
♦ After an initial examination, the prognosis is based on
initial disease status, expected treatment results and
the uncertainty of controlling the modifying factors.
♦ The treatment plan in most cases will begin with
initial non-surgical therapy.
♦ It is desirable to defer final decisions regarding
surgical intervention and tooth extraction until the
re-evaluation.
♦ A formal re-evaluation of treatment response should
be done 6 to 8 weeks after non-surgical therapy. This
thorough assessment of the signs of inflammation
and periodontal probing measurements to check for
improvement is carried over.
♦ The original diagnosis is either revised or retained
based on the evaluation after the initial therapy.
Thus response to initial therapy, or lack of
response, may alter the prognosis.
* If the response is generally good, then the patient
may be placed on maintenance (i.e., appointed for
regularly scheduled assessment and debridement
appointments).
* If the response is generally good, but some
problem areas remain, then additional therapy
will be recommended.This may be enhanced non-
surgical techniques to mechanical debridement,
or surgery.
* If the response is generally poor, then a cause
should be sought. This may be as simple as poor
home care, although systemic factors should be
considered.
♦ Technological advances have given a positive outlook
on the prognosis of teeth with severe periodontal
disease.
Chapter 38 Periodontal Prognosis

* The use of regenerative therapy can improve the This tooth preservation may decrease with increase in
prognosis of a lower 2nd molar with distal intra- monitoring period.
bony defect. If a tooth with poor periodontal prognosis is retained,
* Similarly, less desirable teeth with periodontal greater will be the amount of bone loss in the future that
disease can be removed and replaced with dental complicates the eventual replacement with implants.
implants. It could be a viable alternative to root ♦ Referral to periodontist to confirm the prognosis
amputation following endodontic therapy and and possibility of further treatment before indicating
prosthetic rehabilitation. extraction.
♦ Reevaluation should be performed after active ♦ Severity of attachment loss is an indicator for future
therapy - whether that be entirely non-surgical or a risk too.
combination of non-surgical and surgical treatment,
or as post-treatment. ♦ Tooth mobility – it may reduce with decrease in
inflammation with treatment and should not be a
* In cases of regenerative periodontal therapy, it is sole factor to decide extraction.
customary to wait for a little longer to carry out
the reevaluation. ♦ >50% of radiographic bone loss, level of bone crest,
inter-radicular bone resorption and crown-root ratio
* With this post-treatment reevaluation, the should be evaluated.
individual prognosis as well as overall prognosis
is redetermined. ♦ Furcation-involved premolars in periodontally
compromised patients have been advised extraction
* The findings at this post-treatment reevaluation, and replacement with implants.
and the prognosis rendered,will serve as the new
baseline for the patient as he or she moves into ♦ Prosthetic planning is a criterion to indicate
the maintenance phase. extraction.
Indications for extraction of periodontally ♦ Presence and severity of molar furcation involvement
involved teeth: should be evaluated.
There is a possibility of healing and maintenance of ♦ Presence of periodontal-endodontic lesions.
treated teeth for a long period by regular periodontal ♦ Socio-economic and cultural aspects of patients
maintenance. However, in some cases, the severity should be considered.
of periodontal destruction does not allow healing and
♦ Teeth with poor prognosis in patients with systemic
tooth extraction would be indicated in such patients. Past
diseases should be removed.
disease experience accounted for highest percentage of
indications for extraction. ♦ Similarly, tooth that compromise patient’s overall
health like patient undergoing organ transplant,
The presence of risk factors, evaluation of
chemotherapy or radiotherapy in affected area should
susceptibility and other prognostic factors should be
be removed.
considered in the clinical decision making to decide
extraction of affected tooth/teeth. A systematic review concluded that the only patient-
related factors that are clearly associated with tooth loss
Here is the dilemma? Do we extract or retain such
due to periodontal disease were older age and smoking
teeth? Traditionally, questionable teeth were
(Chambrone, Chambrone, Lima, & Chambrone, 2010).
frequently given the benefit of doubt and received
periodontal treatment. However, current trend is to
remove such teeth and replace them with implants.
Even teeth with doubtful prognosis at onset may have a
better prognosis after adequate treatment. Many
retrospective studies reveal that the preservation rate of
periodontally questionable teeth ranged from 38% - 97%.
Periodontics & Oral Implantology 13
 Treatment considerations in Periodontology Section - VI

Untreatable tooth with impaired Unfavourable aesthetics.

function.
• Untreatable Endo-Perio lesion.
• Tooth Fracture esp Vertical
tooth fractures.
• Gross caries.
• Grade-3 tooth mobility.
• Extraction in case of unfavorable
aesthetics should be carried
over taking into consideration
the best interests and wishes
of the patient.

Extraction during treatment plan Teeth with risk of dental

• To avoid the failure or
compromise of prosthetic/
restoration planning.
infection in patients with
systemic conditions. eg.,
• extraction prior to
bisphosphonate therapy.
• extraction prior to
radiotherapy.

Fig. 38.5 Reasons for extraction periodontally involved teeth

Miller–McEntire periodontal prognostic index:

Miller–McEntire periodontal prognostic index (2014)is
an evidence-based quantitive scoring system that
incorporates six prognostic factors that includes:
1. Age.
2. Probing depth
3. Numberof furcation involvement per molar.
• No furcation involvement= 0
4. Mobility
• Class 1: Tooth is mobile, but is not impacting
prognosis.
• Class 2: Tooth is mobile and is impacting
prognosis.
• Class 3:Tooth is mobile and while perhaps hopeless,
may be treated under circumstances.

• One furcation = 1 5. Molar type.

• Two furcations = 2. 6. Smoking status, to assign a prognostic value to

molars.
• Three furcations or thru and thru furcations on
mandibular molars = 3.

14 Periodontics & Oral Implantology

Chapter 38 Periodontal Prognosis

Fig 38.6: Miller–McEntire periodontal prognostic index

Periodontics & Oral Implantology 15

 Treatment considerations in Periodontology Section - VI

Miller and McEntire system increases the accuracy of Review Questions:

determining the long-term prognosis for periodontally
involved molar teeth. Essay Questions:
Milleret alin his study found the individual
prognostic components smoking status, probing
depth, mobility, furcation involvement, molar type (not
statistically significant [NS]), and age (NS) to rank from
most predictive to least predictive of molar survival.
The index helps in predicting the survival of the tooth
following treatment and helps in decision making for
Short notes:
the dentists about the tooth extraction and referral to
a periodontist.
McGowan et al (2017) proposed a new tooth-level
prognosis model that uses 9 evidence-based quantifiable
parameters to provide a prognosis of secure, doubtful, poor,
or irrational to treat. Six tooth-level risk predictors (bone
Principal references and suggested further
loss; age, pocket depth, furcation involvement, infrabony
defects, anatomical factors, and mobility) and 3 patient level reading:
modifiers (smoking, diabetes, and bleeding on probing) are
used to determine the expected course of disease with
specific reference to the suitability of the tooth for future
dental treatment.
Conclusion:
The prediction of success could enhance with improvement
in patient’s oral hygiene efforts or after successful
completion of a difficult clinical procedure. Similarly,
prognosis could worsen, if anatomical complications are
encountered during therapy.
The basic determination in establishing prognosis is
whether or not the tooth or arch can be kept healthy and
functional and for how long. Most prognosis is
discussed in 5-year intervals with respect to established
treatment objectives.
One must continuously make a conscious effort to
evaluate the patient’s progress over the years and analyze
the factors influencing success or failure of therapy. An
experienced clinician will integrate all the risk factors,
the patient’s expectations, willingness and ability to follow
complete treatment recommendations to suggest the best
option for the patient’s oral health.
1. Define prognosis. How would you determine
the overall prognosis of a patient with moderate
periodontitis?
2. What are local factors. What are the factors to be
considered when assigning the individual tooth
prognosis?
3. What is the role of smoking in periodontal
prognosis.
4. Write briefly the Miller–McEntire periodontal
prognostic index.
♦ AlJehani YA. Risk factors of periodontal disease: review
of the literature.Int J Dent. 2014;2014:182513.
♦ Checchi L, Montevecchi M, Gatto MRA, Trombelli
L: Retrospective study of tooth loss in 92 treated
periodontal patients. J Clin Periodontol 2002; 29:
651–656.
♦ Dababneh R, Rodan R. Anatomical landmarks of
maxillary bifurcated first premolars and their
influence on periodontal diagnosis and treatment.
Journal of International Academy of Periodontology
2013; 15:1: 15
♦ GhiaiS,Bissada NF. Prognosis and actual treatment
outcome of periodontally involved teeth.Periodontal
ClinInvestig. 1996 Spring;18(1):7-11.
♦ Greenstein G,Greenstein B,Cavallaro J. Prerequisite
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Contin Educ Dent. 2007 Aug;28(8):436-46; quiz 447,
470.
♦ Harrel SK, Nunn ME. The effect of occlusal
discrepancies on periodontitis. II. Relationship of
occlusal treatment to the progression of periodontal
disease. J Periodontol 2001; 72: 495-505.

16 Periodontics & Oral Implantology

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♦ Ioannou AL, Kotsakis GA, Hinrichs JE. Prognostic
factors in periodontal therapy and their association
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♦ Kotsakis GA, Kher U. A critical review of periodontal
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♦ Lindskog S,BlomlöfJ,PerssonI,NiklasonA,HedinA,Er
icssonL,EricssonM,JärncrantzB,PaloU,TellefsenG,Z
etterströmO,Blomlöf L.Validation of an algorithm
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♦ Martinez-Canut P,Alcaraz J,Alcaraz J Jr,Alvarez-Novoa
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♦ Matuliene G, Pjetursson BE, Salvi GE, Schmidlin K,
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♦ McGowan T, McGowan K, Ivanovski S. A Novel
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