Section 5C
Non-Surgical Pocket Therapy:
Marlin E. Gher*
'Private practice, Carlsbad,
Question Set
1. What evidence exists that establishes a
relationship between excessive occlusal forces
and the initiation, development, and/or ex-
acerbation ofperiodontal diseases?
2. What evidence exists that occlusal ther-
apy can modify the progression of Periodon-
titis or aid in the treatment ofPeriodontitis?
3. What are the effects of occlusal forces
on wound healingfollowing various periodon-
tal surgical procedures; e.g., guided tissue
and guided bone regeneration, mucogingival
surgery, osseous regeneration, etc?
4. What evidence exists that "preventive"
occlusal adjustment is justifiedfor the health
of the periodontium?
5. What are the future directions for clini-
cal practice and research on occlusal therapy
in relation to periodontal health?
Ann Penodontol 1996;1:567-580.
Dental Occlusion
California
INTRODUCTION
The effects of occlusal forces on the pro-
gression of Periodontitis have been re-
searched and debated for decades.1 36 Early
theories implicated traumatogenic occlusion
as the etiology of Periodontitis.13 When the
role of microorganisms as causative agents
in Periodontitis became evident, emphasis
switched to the evaluation of traumatogenic
occlusion as a cofactor in the progression of
Periodontitis.417 Glickman in the early
1960s proposed that a traumatogenic occlu-
sion could produce a lesion of occlusal
trauma which could accelerate the progres-
sion of Periodontitis and direct the inflam-
matory process into the periodontal liga-
ment.47 These early papers relied on
retrospective analysis of occlusal wear pat-
terns, mobility patterns, autopsy material,
and patterns of attachment loss and pocket
formation to develop the theories that linked
traumatogenic occlusion and Periodontitis.
Later studies by Waerhaug associated the
location and severity of attachment loss with
the location of the "plaque front" on the
tooth.1819 These studies questioned the ef-
fect of occlusal forces on the progression of
Periodontitis and suggested that the various
patterns of attachment loss and intraos-
seous defect formation could be explained by
the "down growth of subgingival plaque."
Controlled prospective studies were
needed to investigate this controversial issue
and substantiate the effects of occlusal
forces on the progression of Periodontitis.
Due to the ethical questions and difficulty in
designing well-controlled prospective hu-
Vol. 1, No. 1, November 1996
568
man studies, animal models were developed
to study the effects of traumatogenic occlu-
sion on periodontal attachment and bone
loss.20 35 The prominent studies of the 1970s
and 1980s were published by Poison and
Zander used squirrel monkeys as their ani-
mal model27 35 and by Lindhe, Ericsson, and
Nyman using beagle dogs as their animal
model.20 26 In these animal models, the re-
searchers could artificially induce experi-
mental Periodontitis and superimposing a
traumatogenic occlusion to evaluate its ef-
fects on bone and attachment loss. Studies
by both Lindhe and Ericsson21 and Perrier
and Poison32 presented clinical and histo-
logic data which indicated that heavy occlu-
sal forces, in the absence of Periodontitis,
led to increased tooth mobility and bone
loss. Bone loss was present principally in the
form of widened periodontal ligament spaces
and, in a few cases, horizontal loss of crestal
bone height.
These research groups differed in their
findings, however, when simulated trauma-
togenic occlusion was combined with Perio-
dontitis. Studies using beagle dogs indicated
that heavy occlusal forces when combined
with plaque induced Periodontitis led to ac-
celerated attachment loss.20'2226 Studies
conducted using squirrel monkeys also
found bone loss and increased tooth mobil-
ity associated with "jiggling forces" used to
simulate a traumatogenic occlusion.27 31 The
squirrel monkey studies, however, found lit-
tle or no effect of traumatic jiggling forces on
the rate of plaque associated attachment
loss. The authors also reported that elimi-
nation of traumatic jiggling forces in the
presence of continuing Periodontitis did not
lead to bone regeneration or a reduction in
mobility.30 The resolution of inflammation in
the presence of continuing mobility29 or jig-
gling trauma,34 however, led to decreased
mobility and increased bone density, but no
change in attachment level or alveolar bone
level. The results of these studies led clini-
cians to place greater emphasis on the elim-
ination of dental plaque, the etiologic agents
responsible for Periodontitis, and to estab-
lish maintenance programs to maintain per-
iodontal health.28 Occlusal therapy was
deemphasized in the treatment of Periodon-
Annals of Periodontology
Girier
titis since it appeared to have a minimal role
in maintaining the attachment level once
plaque was eliminated.28
Human research studies reported from
1986-1987 questioned the effect of occlusal
forces on the progression of Periodontitis.37 39
In a report that evaluated patients with per-
iodontal disease and occlusal parafunction,
Houston et al. concluded that "...there is no
or only weak correlation between periodon-
tal disease and bruxism."37 Hakkarainen
evaluated the effect of the resolution of in-
flammation versus the resolution of occlusal
trauma on sulcular fluid flow.38 He found a
significant decrease in sulcular fluid flow af-
ter inflammation was reduced by oral hy-
giene instructions and scaling procedures,
however, no significant reduction of sulcular
fluid flow was detected after the elimination
of occlusal interferences. Pihlstrom et al.
evaluated the association between occlusal
trauma, severity of Periodontitis, and radio-
graphic bone loss.39 They concluded that
teeth with occlusal contacts in working, bal-
ancing, and non-working positions had no
greater severity of Periodontitis than teeth
without these contacts.
The subject of occlusal treatment was re-
viewed by the World Workshop in Clinical
Periodontics in 1989.40 After examining the
literature up to that date, the reviewer con-
cluded that the role of occlusal trauma in
the pathogenesis of Periodontitis was con-
troversial and the influence of occlusion on
periodontal therapy remained unresolved.
The 1989 Consensus Report, however, sup-
ported the use of occlusal adjustment,
splinting, and orthodontic treatment for a
wide variety of clinical problems faced by the
dentist. These included the use of occlusal
adjustment to reduce mobility and fremitus,
encourage repair of the periodontal attach-
ment apparatus, treat discomfort during
function, treat parafunction, and to achieve
functional relationships in conjunction with
restorative dentistry. Splinting was found to
be indicated for the stabilization of teeth for
a variety of restorative and functional needs.
Orthodontic treatment was also found to be
appropriate for a variety of reasons including
the facilitation of occlusal and restorative
treatment, to aid in the treatment of gingival
 Review: Non-Surgical Pocket Therapy: Dental Occlusion
and osseous defects, to improve plaque con-
trol, to eliminate food impaction problems,
and to correct root proximity problems.
The multitude of articles, theories, and
techniques published on dental occlusion
have spawned a number of descriptive terms
which are at times confusing and misused.
This can lead to misinterpretation of re-
search findings and development of therapy
that may not be based on sound clinical
principles. To reduce possible ambiguity in
the evaluation of the articles being reviewed
in this paper, a glossary of pertinent terms
is included at the end of this paper.
This review follows the following outline:
randomized controlled trials; cohort or lon-
gitudinal studies; non-controlled case stud-
ies; indirect evidence, animal studies; indi-
rect evidence, laboratory studies; summary;
future research; and glossary.
A computer search was conducted to lo-
cate articles that could be used to evaluate
the effects of occlusal forces on the progres-
sion of Periodontitis. The search included
key words such as occlusion, dental occlu-
sion, bite force, Periodontitis, periodontal
disease, etc. The search was limited to arti-
cles published in English after 1988. From
the thousands of articles published on per-
iodontal disease since 1988, only 96 related
occlusion or occlusal forces to periodontal
diseases. A review of these articles was con-
ducted to eliminate reviews, and articles on
occlusal adjustment technique, discussing
philosophy of occlusion, and those which did
not provide direct clinical or research find-
ings.4155 This reduced the initial search to 9
possibly pertinent articles. It became evident
that since 1988 research efforts have
shifted away from dental occlusion to other
areas of periodontal diagnosis and therapy.
Research in the fields of dental implants,
periodontal regeneration, periodontal plas-
tic surgery, the use of antibiotics to treat
Periodontitis, and diagnostic techniques to
identify pathogenic microorganisms and ac-
tive attachment loss have drawn the inter-
est of researchers away from dental
occlusion. A journal-by-journal review of
the major peer reviewed journals was then
conducted to identify additional pertinent
articles not found in the computer search.
569
The search also was expanded to include
articles on risk factors to determine if occlu-
sion had been implicated as a risk factor in
these research efforts. This expanded the
bibliography to those reviewed in this pa-
per.5678 The 12 most pertinent articles are
summarized and presented in rank order in
Table 1 56-59.72.73.76-81
Meta-analysis was considered as a method
to evaluate the articles in this review. The
proper use of meta-analysis to evaluate the
findings of articles related to a specific sub-
ject requires a large number of studies that
address the subject to be evaluated; small
differences in findings to be estimated; and
an ability to rank treatments by superiority
which will not be reversed for subgroups.
Meta-analysis was, therefore, not used for
this review due to the limited number of ar-
ticles on the effect of occlusal forces on Per-
iodontitis published since 1988 and the use
of research animal models which have in the
past resulted in conflicting results. The re-
viewed articles were ranked and their find-
ings discussed according to the following
rank order, the most important at the top of
the list: 1) randomized controlled trials; 2)
cohort or longitudinal studies; 3) case-con-
trolled studies; 4) non-controlled case stud-
ies; 5) descriptive studies; 6) indirect evi-
dence, animal studies; and 7) indirect
evidence, laboratory studies.
RANDOMIZED CONTROLLED TRIALS
Burgett et al. reported results from a ran-
domized clinical trial designed to test the ef-
fect of occlusal adjustment as a component
of the treatment of Periodontitis.56 Fifty pa-
tients with moderate to advanced Periodon-
titis were entered in the study. All patients
received initial periodontal therapy and were
randomly divided into two groups who re-
ceived either occlusal adjustment or no oc-
clusal adjustment prior to definitive perio-
dontal therapy. The patients were then
treated, in a split mouth design, with modi-
fied Widman flap surgery or scaling and root
planing. Those patients who received occlu-
sal adjustment had a statistically significant
mean probing attachment gain of 0.42 mm
when compared to the patients with no oc-
Vol. 1, No. 1, November 1996
570 Gher

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Annals of Periodontology
Review: Non-Surgical Pocket Therapy: Dental Occlusion 571

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Vbi. J, No. i, November 1996

572
clusal adjustment and a mean probing at-
tachment gain of 0.02 mm. There was no
significant effect of occlusal adjustment on
the reduction of probing depth. While the
clinical attachment gain was considered sta-
tistically significant, this difference may be
of limited clinical importance to the clini-
cian. The authors also stated that "Surpris-
ingly, we did not find any significant
difference in reduction of tooth mobility be-
tween the adjusted and the not adjusted
groups."
In a review of data from a previous
domized controlled human study, Wang et
al. evaluated the influence of furcation in-
volvement and tooth mobility on periodontal
attachment loss and tooth loss for molar
teeth.57 They reported findings gathered
from The University of Michigan longitudinal
periodontal clinical trial. The data used were
from 24 of 78 patients who had been treated
with initial periodontal treatment followed
by periodontal surgery using one of three
surgical techniques. The surgical techniques
used included pocket elimination surgery,
modified Widman flap surgery, and gingival
curettage. The 24 patients evaluated had
been professional maintained for 8 years
without missing appointments. The author
attempted to relate attachment loss and
tooth loss over the 8-year period to furcation
involvement and tooth mobility. Loss of a
tooth was artificially assigned an attach-
ment loss of 3.5 mm to account for lost teeth
in the attachment loss data. Teeth with fur-
cation involvement were found to have in-
crease tooth loss and attachment loss versus
teeth without furcation involvement. Mobile
teeth were reported to have significantly
more attachment loss (-1.08 ± 0.41) mm
during the maintenance period than non-
mobile teeth (-0.48 ± 0.25 mm). A paired t
test indicated that during the maintenance
period, molars with furcation involvement
and mobility has significantly more attach-
ment loss than furcation involved molars
with no mobility. Several problems make it
difficult to relate these findings to the effect
of occlusal forces or mobility on Periodonti-
tis. Occlusal adjustment was included as a
standard component of initial periodontal
treatment in the original study to minimize
Annals of Periodontology
Gher
the effect of occlusion on the comparison of
the surgical treatment being evaluated.36
The cause(s) of the ongoing tooth mobility
such as continuing occlusal trauma or con-
tinued plaque induced inflammation were
not reported. Due to the complexities of den-
tal furcation anatomy, it is difficult to quan-
tify and separate the effects of compromised
plaque control due to the inaccessibility of
the furcation from the other variables.82 89
COHORT OR LONGITUDINAL
ran-
STUDIES
Ismail et al. reported on the findings from
a group of 165 adults, residing in Tecumseh,
MI, who were originally examined in 1959
and reexamined in 1987.58 The purpose of
the study was to evaluate the change in at-
tachment level in a sample population of
adults over a period of years. Results of the
re-examination indicated that 10.9% (376
teeth) of the teeth present at the beginning
of the study were lost during the 28-year
evaluation period. One hundred (100) of the
3,487 teeth evaluated were mobile at the
baseline examination. Forty-five percent (45%)
of these teeth were lost by the end of the
study. Three-hundred thirteen (313) (83%)
of the teeth lost had an initial attachment
loss of 2 mm or less. The cause of tooth loss
was not identified and therefore its effect on
the attachment loss measurements could
not be determined. Of the remaining teeth
evaluated, only 13.3% of the adults exam-
ined had a mean attachment loss of 2 mm
or more from 1959 to 1987. This study iden-
tified individuals with higher levels of at-
tachment loss as having the following risk
markers: were older; smoked; had tooth
mobility at the base line examination; had
higher levels of gingivitis, calculus, plaque,
and tooth mobility at the second examina-
tion; and had a lower education level and ir-
regular dental attendance. Increased age,
smoking, and tooth mobility were found to
be the factors most closely related to attach-
ment loss. Considering any of these factors
to be risk markers does not establish a
cause and effect relationship. This study did
not evaluate occlusion and did not indicate
if occlusion was an etiologic factor in the dis-
 Review: Non-Surgical Pocket Therapy:
ease process or in the tooth mobility identi-
fied as arisk factor.
A retrospective study by Jin and Cao in
1992 attempted to relate clinical signs of a
traumatogenic occlusion with severity of
Periodontitis in 32 patients with moderate to
advanced chronic adult Periodontitis.59 The
patients received complete periodontal ex-
a their ability to accurately predict future
amination including radiographs, recording
of probing depths, gingival index, bleeding
index, clinical attachment loss, plaque in-
dex, tooth mobility, tooth wear, and an oc-
clusal analysis. Abnormal occlusal contacts;
i.e., premature contacts in centric relation,
non-working contacts in lateral excursions,
premature contacts of anterior teeth, and
posterior tooth contacts during protrusion,
were identified. After analyzing the data col-
lected, the authors concluded that there was
no significant differences in probing depth,
clinical attachment level, or loss of alveolar
bone height when comparing teeth with and
without abnormal occlusal contacts. Teeth
with significant mobility, functional mobil-
ity, or radiographically widened periodontal
ligaments were associated with deeper prob-
ing depths, more attachment loss, and
greater bone loss. This study could not de-
termine if tooth mobility and radiographi-
cally widened periodontal ligaments were
risk factors for the progression of Periodon-
titis or markers of the disease process.
Other studies have attempted to identify
"risk factors" for Periodontitis,60 62 attach-
ment loss,63 67 bone loss,68 69 and tooth loss.70
Those factors reported as risk factors, listed
from the most commonly identified to the
least commonly identified by these studies,
included: age, race, tobacco use, increased
percent of sites with plaque, the presence of
Prevotella intermedius, Bactroides forsythus,
bleeding on probing, prior attachment loss,
probing depth, lower educational attainment,
gender (male), calculus, Porphyromonas gin-
givalis, positive BANA test, gingivitis, socio-
economic level, diabetes mellitus, systemic
disease, mobility, early loss of the first mo-
lar, and the lack of use of dental care. These
articles did not clearly distinguish which of
these factors were true risk factors and
which were disease markers and therefore
could not establish which were etiologic.
Dental Occlusion 573
None of these studies identified occlusion as
a risk factor for Periodontitis; however, oc-
clusal analysis and mobility measurements
were rarely included in the factors being
evaluated as risk factors.
In a series of papers on prognosis, Mc-
Guire and McGuire and Nunn reported on
prognosis from commonly evaluated clinical
factors.7173 Mobility and parafunctional hab-
its were identified as two of several "prog-
nostic factors" that correlated with tooth
loss or with a worsening individual tooth
prognosis during a 5 to 8 year maintenance
period after treatment. In "well maintained"
patients, prognostic factors associated with
a worsening prognosis for individual teeth
included: deeper initial probing depths,
more severe furcation involvement, endo-
dontic involvement, smoking, diabetes, mal-
posed teeth, unsatisfactory root form, and
the presence of a parafunctional habit with
no biteguard.72 Initial tooth mobility was as-
sociated with a prognosis that was unlikely
to improve but was not associated with a
worsening prognosis.72
Prognostic factors associated with tooth
loss during the maintenance period included
initially greater: probing depths, furcation
involvement, mobility, and bone loss as well
as poor crown-to-root ratio, poor root form,
parafunctional habits without a bite guard,
and smoking.73 Tooth loss in this study was
due to periodontal disease, restorative pur-
poses, endodontic involvement, and caries.
Unfortunately the authors could not asso-
ciate initial prognostic factors with progres-
sive attachment loss, the gold standard for
advancing Periodontitis. The inability to as-
sociate the prognostic factors of mobility and
parafunction with advancing attachment
loss; the inclusion of teeth lost due to non-
periodontal reasons; and the inability to
separate out other prognostic factors such
as furcation involvement, bone loss, and at-
tachment loss inhibit our ability to draw con-
clusions about mobility or parafunction in
relation to progressive Periodontitis. The au-
thors also noted that these findings relate to
well maintained patients and may not apply
when evaluating poorly maintained individ-
uals.
Vol. 1, No. 1, November 1996
574
NON-CONTROLLED CASE STUDIES
Non-controlled case studies are relatively
unreliable sources of information upon
which to base a philosophy of treatment.
Benefits of treatment demonstrated for one
patient may not reliably transfer to other pa-
tients and the conclusions drawn from the
results of successful therapy in a few pa-
tients under conditions where a multitude of
variables were either unrecognized or poorly
controlled may lead the clinician to incorrect
conclusions. The following case studies are,
therefore, being presented principally to il-
lustrate points which have been previously
presented in well designed studies.
Paul et al. reported the treatment of a case
diagnosed as rapidly progressive Periodon-
titis with localized occlusal trauma involving
tooth #10.74 Treatment consisted of scaling
and root planing, microbiological monitor-
ing, use of systemic antibiotics, and surgical
treatment where needed. Six weeks after in-
itial therapy, pockets involving tooth #10
had been reduced from 8 mm to 3 mm with-
out surgical therapy or occlusal adjustment.
However, 6 months later, tooth #10 re-
mained mobile and radiographically appar-
ent bone loss remained despite minimal
probing depths. Multiple occlusal adjust-
ments over the next year resulted in "re-
eruption" of the tooth which reduced the
crown-root ratio, eliminated occlusal inter-
ferences, and improved function. This case
demonstrated the ability to reduce probing
depth and eliminate inflammatory periodon-
tal disease without occlusal adjustment. The
authors, however, considered occlusal ad-
justment to be a valuable treatment to re-
duce mobility and improve clinical function
of a tooth with severe attachment loss.
Wolffe et al. documented the restorative
and surgical treatment of a patient with ad-
vanced Periodontitis.75 Six months foUowing
the placement of 4 fixed partial dentures
(FPD), one in each quadrant, the occlusion re-
mained stable. Over the next 2 years, the pa-
tient developed a malocclusion due to a shift
of one the FPDs in response to forces gener-
ated by the patient's tongue. The authors
stated that the reduced periodontium may
Annals of Periodontology
Gher
have contributed to the lack of stability of the
splinted teeth. Occlusal adjustments led to a
clinically stable occlusion. The periodontium
remained healthy, with no signs of bleeding,
increased sulcus depth, or mobility through-
out the reported period despite the persistent
forces that caused drifting of the teeth and sig-
nificant changes in the occlusion.
INDIRECT EVIDENCE, ANIMAL
STUDIES
In a beagle dog study, Ericsson et al. eval-
uated the effect of splinting on the progres-
sion of experimental Periodontitis.76 Five
dogs had their mandibular 2nd and 3rd pre-
molars and mandibular 1st molars ex-
tracted. Titanium implants were then
installed in the position of the 1st molar and
3rd premolar in the right side of the man-
dible. After 3 months of healing, non-resil-
ient splints were placed connecting the
dental implants to the 4th premolar on the
right side. The 4th premolar on the left side
remained unsplinted and served as a control
with persistent mobility from prior attach-
ment loss. Experimental Periodontitis was
initiated and maintained for 180 days by
placing a ligature around the premolars. At-
tachment loss and down growth of plaque
were evaluated with radiographs and biop-
sies after the 180-day test period. The re-
searchers found that splinting the test
premolars failed to retard attachment loss or
to inhibit the apical down growth of the mi-
crobial plaque. They concluded that in-
creased tooth mobility at the control tooth
did not exacerbate periodontal attachment
loss in this model.
The effect of jiggling occlusal forces on
probing depths in beagle dogs with normal
periodontal tissues was evaluated by Neide-
rud et al.77 Six beagle dogs had their teeth
cleaned before entering the study and 3
times each week during the study. Each dog
had jiggling forces applied to a test premolar
while a contralateral tooth served as a non-
jiggling control. After jiggling forces had been
applied for 90 days, a probe was inserted
into the sulcus of the test and control teeth
and stabilized in position with composite
resin. Biopsies of the sites were obtained
 Review: Non-Surgical Pocket Therapy: Dental Occlusion
and used for histometric and morphometric
measurements. The measurements revealed
that despite clinically healthy gingival tis-
sues, the teeth which had become mobile
due to the jiggling forces had lost marginal
bone. An enlarged "supracrestal connective
tissue compartment" had also developed
which resulted in significantly greater clini-
cal probing depth measurements. This in-
creased probing depth was related to a de-
crease in collagen density and a more
vascular connective tissue that was less re-
sistant to probing without loss of connective
tissue attachment.
In a related study, Giargia et al. reported
a reduction of probing depth and mobility af-
ter removal of plaque retaining ligatures in a
beagle dog model.78 This study evaluated the
effect of experimental Periodontitis on the
histologic appearance of the periodontal soft
tissues, alveolar bone height, and on tooth
mobility. After 120 days of experimentally
induced Periodontitis, plaque retaining liga-
tures were removed and a supragingival de-
bridement was performed. Block sections,
taken at the time of ligature removal and 15
days and 3 months later, were used for his-
tometric and morphometric evaluation. Ex-
perimental Periodontitis led to the formation
of an inflammatory lesion, extensive bone
loss, and markedly increased tooth mobility.
Removal of the dental plaque led to reduced
tooth mobility and a decrease in the inflam-
matory lesion, but no regeneration of lost
bone. Probing depth which increased due to
the experimental Periodontitis was reduced
after removal of the microbial plaque. The
authors suggested that the reduced probing
depth was a result of the soft tissue changes,
due to resolution of inflammation after
plaque removal and to reduced mobility of
the teeth. The authors' comments on the ef-
fect of reduced mobility on probing depth
changes appeared to be more related to their
awareness of the results of the prior Neide-
rud study than to the results of this study.
This study does document an increase in
mobility due to periodontal inflammation
and a decrease in that mobility as inflam-
mation is decreased. This result appeared to
be independent of occlusal forces in this ex-
perimental model. It also documented that
575
changes in mobility may persist for several
months after etiologic factors are reduced
and inflammation is resolving.
In a study in a rat model that evaluated
the effect of experimental traumatic occlu-
sion on periodontal blood flow, Kvinnsland
et al. reported an increase in blood flow to
both the pulp and periodontal ligament after
the initiation of heavy occlusal forces.79 In
the early stages of the study the experimen-
tal "traumatized" side had an increased
blood flow when compared to the control
side. In the later stages of the experiment,
both control and experimental sides had in-
creased blood flow. This study did not eval-
uate the effects of occlusal forces on
Periodontitis but did demonstrate a physio-
logic response of the periodontal tissues to
occlusal forces.
INDIRECT EVIDENCE, LABORATORY
STUDIES
Photoelastic model and finite element
model studies have evaluated the transmis-
sion of occlusal forces to the periodon-
tium.80 81 Wylie et al. used a photoelastic
model to simulate the effect of splinting a
periodontally involved tooth to one or more
sound teeth when placing a cantilevered
fixed partial denture.80 They found that op-
timal stress distribution occurred when
splinting the compromised tooth to 2 sound
teeth. Increasing the number of splinted
teeth, beyond two sound teeth, did not sig-
nificantly decrease the stress transmitted to
the periodontium. Cross-arch splinting did
not result in a significant sharing of the oc-
clusal forces.
Using a finite element model, Aydin et al.
evaluated the stresses induced by various
loading forces on a mandibular 3-unit fixed
partial denture using a molar and a premo-
lar as abutments.81 Loads of 300 N to 600 N
applied in axial and nonaxial directions were
analyzed. Forces applied in non-axial direc-
tions led to an increase the level of stress de-
livered to the alveolar bone. The premolar
exhibited greater stress distribution to the
bone than the molar when non-axial forces
were applied. Stress levels increased, also,
when periodontal support was diminished.
Vol. 1, No. 1, November 1996
576
Studies like these can be used to demon-
strate the mechanics of transmission of
forces from teeth to the periodontium. They
can not be used to interpolate results to
broader and more involved interactions such
as those involving occlusion and inflamma-
tory periodontal disease.
SUMMARY
Despite decades of debate and multiple
publications that discuss the theory of oc-
clusion, occlusal design, and equilibration
techniques, there have been few well-de-
signed human studies that can help answer
the question "does occlusal trauma modify
the progression of attachment loss due to in-
flammatory periodontal disease." The arti-
cles reviewed clearly demonstrate that
occlusal forces are transmitted to the perio-
dontal attachment apparatus80'81 and those
forces can cause changes in the bone and
connective tissue.21-27'77-79 These changes can
effect tooth mobility and clinical probing
depth.23,28 74'77 While occlusal forces do not
initiate Periodontitis, results are inconclu-
sive on the interactions between occlusion
and the progression of attachment loss due
to inflammatory periodontal disease.
While some studies found a relationship
between increased attachment loss and
tooth mobility,57-59 others found no relation-
ship between attachment loss and abnormal
occlusal contacts.59 Tooth mobility can be a
result of a variety of factors including loss of
alveolar bone, attachment loss, disruption of
the periodontal supporting tissues by in-
flammation, occlusal forces which lead to
widening of the periodontal ligament (phys-
iologic adaptation), periodontal ligament at-
rophy from disuse, or any process which
effects the supporting periodontal struc-
tures. Therefore, any relationship found be-
tween tooth mobility and progressing Perio-
dontitis does not necessarily indite or defend
occlusion as a cofactor in the progression of
inflammatory periodontal disease.
Periodontitis can be treated and periodon-
tal health maintained without occlusal ad-
justment and despite the obvious presence
of traumatic occlusal forces. 21,29,74,75 How-
ever, statistically greater gains in clinical
Annals of Periodontology
Gher
periodontal attachment level have been doc-
umented when occlusal adjustment was in-
cluded as a component of periodontal
therapy.56 The extent to which this is clini-
cally meaningful in the treatment of Perio-
dontitis is unclear. The effects of normal
occlusion, parafunctional habits, and tooth
mobility on wound healing have also not
been adequately evaluated.
Once periodontal health is established,
occlusal therapy can be an aid to help re-
duce mobility, regain some bone lost due
to traumatic occlusal forces, and to treat a
variety of clinical problems related to oc-
clusal instability and restorative needs.40 71
Based on the literature, it appears that a
clinician's decision whether or not to use
occlusal adjustment as a component of
periodontal therapy should be related to an
evaluation of clinical factors involving pa-
tient comfort and function and not based
on the assumption that occlusal adjust-
ment is necessary to stop the progression
of Periodontitis.
FUTURE RESEARCH
Prospective studies on the effects of occlu-
sal forces on the progression of Periodontitis
are not ethically acceptable in humans.
Double-blind controlled prospective human
studies to determine the effects of occlusal
forces and mobility on wound healing follow-
ing periodontal therapy are possible and are
badly needed. These studies could answer
questions concerning the effects of occlusion
and mobility on regenerative periodontal
therapy such as guided tissue regeneration
and periodontal plastic surgery.
Studies that attempt to identify risk fac-
tors for Periodontitis should also include oc-
clusal analysis in the study parameters to
evaluate this variable. These studies are,
however, retrospective in nature and there-
fore may find it difficult to establish cause
and effect relationships. Animal studies
could help to define the effects of occlusal
forces on peri-implant bone loss and to de-
termine if excessive occlusal forces can effect
the progression of plaque induced peri-im-
plantitis.
 Review: Non-Surgical Pocket Therapy: Dental Occlusion
GLOSSARY OF TERMS
Attachment apparatus: The cementum,
periodontal ligament, and alveolar bone
which function as a unit to support the
teeth.
Bruxism: A habit of grinding, clenching,
or clamping the teeth. The forces so gener-
ated may damage both the tooth and the at-
tachment apparatus.
Co-factor: An aspect of personal behavior
or life-style, an environmental exposure, or
an inborn or inherited characteristic which
by itself does not cause a disease process
but which can modify the course or expres-
sion of a disease process.
Disease markers: Factors that are indic-
ative of the disease, but that are not thought
to be etiologic or may be historical measures
of the disease or disease progression.
Fremitus: A palpable or visible movement
of a tooth when subjected to occlusal forces,
(also referred to as functional mobility)
Mobility, tooth: A visually perceptible
movement of the tooth away from its normal
position when a light force is applied. (This
movement may be within physiologic limits
or beyond physiologic limits.)
Occlusion: The contact of opposing teeth.
Occlusal adjustment: Reshaping the oc-
cluding surfaces of teeth by grinding to cre-
ate harmonious contact relationships be-
tween the upper and lower teeth or
orthodontic movement of the teeth to create
a more harmonious occlusal relationship.
Occlusal forces: Forces that are gener-
ated and transmitted to the supporting
structures of the teeth when the teeth are
brought into contact.
contact that
Occlusal interference: Any
inhibits the remaining occluding surfaces
from achieving stable and harmonious con-
tacts..
Occlusal trauma: An injury to the attach-
ment apparatus or tooth as a result of ex-
cessive occlusal forces.
Occlusal traumatism: the overall process
by which a traumatogenic occlusion pro-
duces injury in the periodontal attachment
apparatus.
Parafunction: abnormal or perverted
function, as in bruxism.
577
Premature occlusal contact: A condition
of tooth contact that diverts the mandible
from a normal path of closure.
Primary occlusal trauma: Injury result-
ing from excessive occlusal forces applied to
a tooth or teeth with normal periodontal
support.
occlusal trauma: Injury re-
Secondary
sulting from normal occlusal forces applied
to a tooth or teeth with inadequate periodon-
tal support.
Traumatogenic occlusion: Any occlu-
sion that produces forces that cause an in-
jury to the attachment apparatus.
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