Section 5C

Non-Surgical

Pocket

Therapy:

Dental Occlusion

Marlin E. Gher*
'Private practice, Carlsbad,

California

Question Set

1. What evidence exists that establishes a relationship between excessive occlusal forces and the initiation, development, and/or exacerbation ofperiodontal diseases? 2. What evidence exists that occlusal therapy can modify the progression of Periodontitis or aid in the treatment ofPeriodontitis? 3. What are the effects of occlusal forces on wound healingfollowing various periodontal 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 clinical practice and research on occlusal therapy in relation to periodontal health?

INTRODUCTION
The effects of occlusal forces on the progression of Periodontitis have been researched 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 occlusion could produce a lesion of occlusal trauma which could accelerate the progression of Periodontitis and direct the inflammatory process into the periodontal ligament.47 These early papers relied on retrospective analysis of occlusal wear pat-

terns,

Ann Penodontol

1996;1:567-580.

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 effect of occlusal forces on the progression of Periodontitis and suggested that the various patterns of attachment loss and intraosseous 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-

mobility patterns, autopsy material,

Vol. 1, No. 1, November 1996

40 After examining the literature up to that date. the reviewer concluded that the role of occlusal trauma in the pathogenesis of Periodontitis was controversial and the influence of occlusion on periodontal therapy remained unresolved.20'2226 Studies conducted using squirrel monkeys also found bone loss and increased tooth mobility associated with "jiggling forces" used to simulate a traumatogenic occlusion. Pihlstrom et al. Ericsson.37 39 In a report that evaluated patients with periodontal disease and occlusal parafunction.30 The resolution of inflammation in the presence of continuing mobility29 or jiggling trauma.there is no or only weak correlation between periodontal disease and bruxism. and Nyman using beagle dogs as their animal model. Studies using beagle dogs indicated that heavy occlusal forces when combined with plaque induced Periodontitis led to accelerated attachment loss. and to establish maintenance programs to maintain periodontal health. treat parafunction. horizontal loss of crestal bone height.39 They concluded that teeth with occlusal contacts in working..34 however. when simulated traumatogenic occlusion was combined with Periodontitis.568 Girier man studies. however. no significant reduction of sulcular fluid flow was detected after the elimination of occlusal interferences. the etiologic agents responsible for Periodontitis. animal models were loss.27 31 The squirrel monkey studies. led to decreased mobility and increased bone density. 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. treat discomfort during function. The results of these studies led clinicians to place greater emphasis on the elimination of dental plaque.38 He found a significant decrease in sulcular fluid flow after inflammation was reduced by oral hygiene instructions and scaling procedures. The authors also reported that elimination of traumatic jiggling forces in the presence of continuing Periodontitis did not lead to bone regeneration or a reduction in mobility. encourage repair of the periodontal attachment apparatus.28 Human research studies reported from 1986-1987 questioned the effect of occlusal forces on the progression of Periodontitis. concluded that ". in the absence of Periodontitis. in a few cases. however. led to increased tooth mobility and bone loss. found little or no effect of traumatic jiggling forces on the rate of plaque associated attachment loss. supported the use of occlusal adjustment. and radiographic bone loss. Orthodontic treatment was also found to be appropriate for a variety of reasons including the facilitation of occlusal and restorative treatment. however. Splinting was found to be indicated for the stabilization of teeth for a variety of restorative and functional needs. but no change in attachment level or alveolar bone level. The subject of occlusal treatment was reviewed by the World Workshop in Clinical Periodontics in 1989. evaluated the association between occlusal trauma. These research groups differed in their findings. and to achieve functional relationships in conjunction with restorative dentistry.28 Occlusal therapy was deemphasized in the treatment of Periodon- to study the effects of traumatogenic occlusion on periodontal attachment and bone developed titis since it appeared to have a minimal role in maintaining the attachment level once plaque was eliminated. however. splinting. and non-working positions had no greater severity of Periodontitis than teeth without these contacts. balancing. The 1989 Consensus Report."37 Hakkarainen evaluated the effect of the resolution of inflammation versus the resolution of occlusal trauma on sulcular fluid flow. Studies by both Lindhe and Ericsson21 and Perrier and Poison32 presented clinical and histologic data which indicated that heavy occlusal forces. the researchers could artificially induce experimental Periodontitis and superimposing a traumatogenic occlusion to evaluate its effects on bone and attachment loss. Houston et al.. to aid in the treatment of gingival Annals of Periodontology .20 26 In these animal models. Bone loss was present principally in the form of widened periodontal ligament spaces and.20 35 The prominent studies of the 1970s and 1980s were published by Poison and Zander used squirrel monkeys as their animal model27 35 and by Lindhe. severity of Periodontitis.

1. theories. From the thousands of articles published on periodontal disease since 1988. the most important at the top of the list: 1) randomized controlled trials. It became evident that since 1988 research efforts have shifted away from dental occlusion to other areas of periodontal diagnosis and therapy. therefore. No. discussing philosophy of occlusion. in a split mouth design. periodontal disease. to improve plaque conto eliminate food impaction problems. 4) non-controlled case studies. periodontal plas- Burgett et al. Research in the fields of dental implants. tic surgery. RANDOMIZED CONTROLLED TRIALS periodontal regeneration. and glossary. and 7) indirect evidence. small differences in findings to be estimated. To reduce possible ambiguity in the evaluation of the articles being reviewed in this paper. A review of these articles was conducted to eliminate reviews. bite force. This can lead to misinterpretation of research findings and development of therapy that may not be based on sound clinical principles. and osseous The search also was expanded to include articles on risk factors to determine if occlusion had been implicated as a risk factor in these research efforts. defects. indirect evidence.Review: Non-Surgical Pocket Therapy: Dental Occlusion 569 The multitude of articles. This review follows the following outline: randomized controlled trials. November 1996 . Those patients who received occlusal adjustment had a statistically significant mean probing attachment gain of 0. with modified Widman flap surgery or scaling and root planing. All patients received initial periodontal therapy and were randomly divided into two groups who received either occlusal adjustment or no occlusal adjustment prior to definitive periodontal therapy.72. and articles on occlusal adjustment technique. trol. and an ability to rank treatments by superiority which will not be reversed for subgroups. 5) descriptive studies.56 Fifty patients with moderate to advanced Periodontitis were entered in the study. cohort or longitudinal studies. the use of antibiotics to treat Periodontitis. 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. dental occlusion. 3) case-controlled studies.4155 This reduced the initial search to 9 possibly pertinent articles. A computer search was conducted to locate articles that could be used to evaluate the effects of occlusal forces on the progression of Periodontitis. indirect evidence. and techniques published on dental occlusion have spawned a number of descriptive terms which are at times confusing and misused. laboratory studies. Meta-analysis was. The patients were then treated. animal studies. 1. The proper use of meta-analysis to evaluate the findings of articles related to a specific subject requires a large number of studies that address the subject to be evaluated. The reviewed articles were ranked and their findings discussed according to the following rank order. The search included key words such as occlusion.76-81 Meta-analysis was considered as a method to evaluate the articles in this review. non-controlled case studies.42 mm when compared to the patients with no oc- Vol. future research. laboratory studies. Periodontitis. summary.5678 The 12 most pertinent articles are summarized and presented in rank order in Table 1 56-59. and diagnostic techniques to identify pathogenic microorganisms and active attachment loss have drawn the interest of researchers away from dental occlusion. and to correct root proximity problems. not used for this review due to the limited number of articles on the effect of occlusal forces on Periodontitis published since 1988 and the use of research animal models which have in the past resulted in conflicting results. reported results from a randomized clinical trial designed to test the effect of occlusal adjustment as a component of the treatment of Periodontitis. etc. 6) indirect evidence. 2) cohort or longitudinal studies. only 96 related occlusion or occlusal forces to periodontal diseases. a glossary of pertinent terms is included at the end of this paper. and those which did not provide direct clinical or research findings. This expanded the bibliography to those reviewed in this paper. animal studies. The search was limited to articles published in English after 1988.73.

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572 Gher clusal adjustment and a mean probing attachment gain of 0.08 ± 0. it is difficult to quantify and separate the effects of compromised plaque control due to the inaccessibility of the furcation from the other variables. and tooth mobility were found to be the factors most closely related to attachment loss. and tooth mobility at the second examination.25 mm). There was no significant effect of occlusal adjustment on the reduction of probing depth. had tooth mobility at the base line examination. smoked. Teeth with furcation involvement were found to have increase tooth loss and attachment loss versus teeth without furcation involvement. who were originally examined in 1959 and reexamined in 1987. The author attempted to relate attachment loss and tooth loss over the 8-year period to furcation involvement and tooth mobility.5 mm to account for lost teeth in the attachment loss data. Forty-five percent (45%) of these teeth were lost by the end of the study. The authors also stated that "Surprisingly. reported on the findings from group of 165 adults. Of the remaining teeth evaluated. Several problems make it difficult to relate these findings to the effect of occlusal forces or mobility on Periodontitis. this difference may be of limited clinical importance to the clinician.3% of the adults examined had a mean attachment loss of 2 mm or more from 1959 to 1987. calculus. Wang et al. we did not find any significant difference in reduction of tooth mobility between the adjusted and the not adjusted the effect of occlusion on the comparison of the surgical treatment being evaluated. smoking." In a review of data from a domized controlled human study. had higher levels of gingivitis. The surgical techniques used included pocket elimination surgery.487 teeth evaluated were mobile at the baseline examination.58 The purpose of the study was to evaluate the change in attachment level in a sample population of adults over a period of years. 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.02 mm. residing in Tecumseh. molars with furcation involvement and mobility has significantly more attachment loss than furcation involved molars with no mobility. Mobile teeth were reported to have significantly more attachment loss (-1. Results of the re-examination indicated that 10.82 89 groups. Occlusal adjustment was included as a standard component of initial periodontal treatment in the original study to minimize previous ran- COHORT OR LONGITUDINAL STUDIES Ismail et al. only 13. MI. Increased age. and gingival curettage. modified Widman flap surgery. Due to the complexities of dental furcation anatomy. and had a lower education level and irregular dental attendance. Three-hundred thirteen (313) (83%) of the teeth lost had an initial attachment loss of 2 mm or less. A paired t test indicated that during the maintenance period. The 24 patients evaluated had been professional maintained for 8 years without missing appointments.41) mm during the maintenance period than nonmobile teeth (-0. This study did not evaluate occlusion and did not indicate if occlusion was an etiologic factor in the disa Annals of Periodontology .36 The cause(s) of the ongoing tooth mobility such as continuing occlusal trauma or continued plaque induced inflammation were not reported. plaque.9% (376 teeth) of the teeth present at the beginning of the study were lost during the 28-year evaluation period. While the clinical attachment gain was considered statistically significant. One hundred (100) of the 3. The cause of tooth loss was not identified and therefore its effect on the attachment loss measurements could not be determined. Considering any of these factors to be risk markers does not establish a cause and effect relationship.57 They reported findings gathered from The University of Michigan longitudinal periodontal clinical trial. Loss of a tooth was artificially assigned an attachment loss of 3. This study identified individuals with higher levels of attachment loss as having the following risk markers: were older. evaluated the influence of furcation involvement and tooth mobility on periodontal attachment loss and tooth loss for molar teeth.48 ± 0.

and the lack of use of dental care. and greater bone loss. endodontic involvement. bleeding on probing. furcation involvement. malposed teeth. McGuire and McGuire and Nunn reported on their ability to accurately predict future prognosis from commonly evaluated clinical factors. lower educational attainment. and bone loss Vol. gingival index. tooth mobility. Abnormal occlusal contacts. Porphyromonas gingivalis. patients received amination a were identified. bleeding index. sociolevel. non-working contacts in lateral excursions.72 Prognostic factors associated with tooth loss during the maintenance period included initially greater: probing depths. functional mobility. restorative purposes. early loss of the first molar. gingivitis.. probing depth. prior attachment loss. Bactroides forsythus. listed from the most commonly identified to the least commonly identified by these studies. clinical attachment loss. November 1996 . Other studies have attempted to identify "risk factors" for Periodontitis. or loss of alveolar bone height when comparing teeth with and without abnormal occlusal contacts.7173 Mobility and parafunctional habits were identified as two of several "prognostic factors" that correlated with tooth loss or with a worsening individual tooth prognosis during a 5 to 8 year maintenance period after treatment. tooth wear. This study could not determine if tooth mobility and radiographically widened periodontal ligaments were risk factors for the progression of Periodontitis or markers of the disease process. as worsening prognosis. positive BANA test. plaque index. race. mobility. The authors also noted that these findings relate to well maintained patients and may not apply when evaluating poorly maintained individuals. premature contacts of anterior teeth. the gold standard for advancing Periodontitis. as well poor crown-to-root ratio. more severe furcation involvement. clinical attachment level. smoking.63 67 bone loss.60 62 attachment loss. and caries. the authors concluded that there was no significant differences in probing depth. prognostic factors associated with a worsening prognosis for individual teeth included: deeper initial probing depths. premature contacts in centric relation. and an occlusal analysis. calculus. and the presence of a parafunctional habit with no biteguard. and smoking. unsatisfactory root form.70 Those factors reported as risk factors. parafunctional habits without a bite guard. diabetes mellitus. In "well maintained" patients. increased percent of sites with plaque. poor root form.73 Tooth loss in this study was due to periodontal disease. the presence of Prevotella intermedius.72 Initial tooth mobility was associated with a prognosis that was unlikely to improve but was not associated with a gender (male). however.Review: Non-Surgical Pocket Therapy: Dental Occlusion 573 ease fied as a process or in the tooth risk factor. mobility identi- None of these studies identified occlusion a as 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. i. tobacco use. The inability to associate the prognostic factors of mobility and parafunction with advancing attachment loss. These economic 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. and posterior tooth contacts during protrusion. diabetes. risk factor for Periodontitis. 1. occlusal analysis and mobility measurements were rarely included in the factors being evaluated as risk factors. systemic disease. included: age. bone loss. more attachment loss. 1.e. After analyzing the data collected. Teeth with significant mobility. mobility. and the inability to separate out other prognostic factors such as furcation involvement.68 69 and tooth loss. In a series of papers on prognosis. the inclusion of teeth lost due to nonperiodontal reasons. and attachment loss inhibit our ability to draw conclusions about mobility or parafunction in relation to progressive Periodontitis. endodontic involvement.59 The complete periodontal exincluding radiographs. No. Unfortunately the authors could not associate initial prognostic factors with progressive attachment loss. or radiographically widened periodontal ligaments were associated with deeper probing depths. recording of probing depths.

or mobility throughout the reported period despite the persistent forces that caused drifting of the teeth and significant changes in the occlusion. Biopsies of the sites were obtained diagnosed as rapidly progressive Periodon- Annals of Periodontology . Six weeks after initial therapy. Occlusal adjustments led to a clinically stable occlusion. with no signs of bleeding. Over the next 2 years. and improved function. However. documented the restorative and surgical treatment of a patient with advanced Periodontitis. and surgical treatment where needed. being presented principally to illustrate points which have been previously presented in well designed studies. Paul et al. reported the treatment of a case titis with localized occlusal trauma involving tooth #10. Experimental Periodontitis was initiated and maintained for 180 days by placing a ligature around the premolars. considered occlusal adjustment to be a valuable treatment to reduce mobility and improve clinical function of a tooth with severe attachment loss.77 Six beagle dogs had their teeth cleaned before entering the study and 3 times each week during the study. use of systemic antibiotics. pockets involving tooth #10 had been reduced from 8 mm to 3 mm without surgical therapy or occlusal adjustment. evaluated the effect of splinting on the progression of experimental Periodontitis. however.76 Five dogs had their mandibular 2nd and 3rd premolars and mandibular 1st molars extracted. therefore. The authors stated that the reduced periodontium may have contributed to the lack of stability of the splinted teeth. The following case studies are. After 3 months of healing. non-resilient splints were placed connecting the dental implants to the 4th premolar on the right side. 6 months later. INDIRECT EVIDENCE. Attachment loss and down growth of plaque were evaluated with radiographs and biopsies after the 180-day test period.574 Gher NON-CONTROLLED CASE STUDIES Non-controlled case studies are relatively unreliable sources of information upon which to base a philosophy of treatment. one in each quadrant. Each dog had jiggling forces applied to a test premolar while a contralateral tooth served as a nonjiggling control. tooth #10 remained mobile and radiographically apparent bone loss remained despite minimal probing depths.75 Six months foUowing the placement of 4 fixed partial dentures (FPD). ANIMAL STUDIES In a beagle dog study. Wolffe et al. Benefits of treatment demonstrated for one patient may not reliably transfer to other patients and the conclusions drawn from the results of successful therapy in a few patients under conditions where a multitude of variables were either unrecognized or poorly controlled may lead the clinician to incorrect conclusions. The authors. increased sulcus depth. The effect of jiggling occlusal forces on probing depths in beagle dogs with normal periodontal tissues was evaluated by Neiderud et al.74 Treatment consisted of scaling and root planing. After jiggling forces had been applied for 90 days. The 4th premolar on the left side remained unsplinted and served as a control with persistent mobility from prior attachment loss. the occlusion remained stable. They concluded that increased tooth mobility at the control tooth did not exacerbate periodontal attachment loss in this model. Multiple occlusal adjustments over the next year resulted in "reeruption" of the tooth which reduced the crown-root ratio. This case demonstrated the ability to reduce probing depth and eliminate inflammatory periodontal disease without occlusal adjustment. The periodontium remained healthy. eliminated occlusal interferences. a probe was inserted into the sulcus of the test and control teeth and stabilized in position with composite resin. Ericsson et al. microbiological monitoring. the patient developed a malocclusion due to a shift of one the FPDs in response to forces generated by the patient's tongue. Titanium implants were then installed in the position of the 1st molar and 3rd premolar in the right side of the mandible. The researchers found that splinting the test premolars failed to retard attachment loss or to inhibit the apical down growth of the microbial plaque.

and markedly increased tooth mobility. beyond two sound teeth. Cross-arch splinting did not result in a significant sharing of the occlusal forces. It also documented that changes in mobility may persist for several months after etiologic factors are reduced and inflammation is resolving. 1. This study does document an increase in mobility due to periodontal inflammation and a decrease in that mobility as inflammation is decreased.81 Loads of 300 N to 600 N applied in axial and nonaxial directions were analyzed. Removal of the dental plaque led to reduced tooth mobility and a decrease in the inflammatory lesion. alveolar bone height. when periodontal support was diminished. LABORATORY STUDIES Photoelastic model and finite element model studies have evaluated the transmission of occlusal forces to the periodontium. taken at the time of ligature removal and 15 days and 3 months later. No. An enlarged "supracrestal connective tissue compartment" had also developed which resulted in significantly greater clinical probing depth measurements. also. Forces applied in non-axial directions led to an increase the level of stress delivered to the alveolar bone. This study did not evaluate the effects of occlusal forces on Periodontitis but did demonstrate a physiologic response of the periodontal tissues to occlusal forces. This result appeared to be independent of occlusal forces in this experimental model. both control and experimental sides had increased blood flow. and on tooth mobility. Probing depth which increased due to the experimental Periodontitis was reduced after removal of the microbial plaque. Block sections. The measurements revealed that despite clinically healthy gingival tissues. INDIRECT EVIDENCE. In a related study. due to resolution of inflammation after plaque removal and to reduced mobility of the teeth. Giargia et al. The authors suggested that the reduced probing depth was a result of the soft tissue changes. The premolar exhibited greater stress distribution to the bone than the molar when non-axial forces were applied. but no regeneration of lost bone. reported a reduction of probing depth and mobility after removal of plaque retaining ligatures in a beagle dog model. plaque retaining ligatures were removed and a supragingival debridement was performed. Increasing the number of splinted teeth.80 They found that optimal stress distribution occurred when splinting the compromised tooth to 2 sound teeth. November 1996 . did not significantly decrease the stress transmitted to the periodontium. Using a finite element model. Aydin et al.78 This study evaluated the effect of experimental Periodontitis on the histologic appearance of the periodontal soft tissues. This increased probing depth was related to a decrease in collagen density and a more vascular connective tissue that was less resistant to probing without loss of connective tissue attachment. Experimental Periodontitis led to the formation of an inflammatory lesion. In a study in a rat model that evaluated the effect of experimental traumatic occlusion on periodontal blood flow. were used for histometric and morphometric evaluation. The authors' comments on the effect of reduced mobility on probing depth changes appeared to be more related to their awareness of the results of the prior Neiderud study than to the results of this study.Review: Non-Surgical Pocket Therapy: Dental Occlusion 575 and used for histometric and morphometric measurements. reported an increase in blood flow to both the pulp and periodontal ligament after the initiation of heavy occlusal forces. Vol. In the later stages of the experiment. 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. Stress levels increased. 1. evaluated the stresses induced by various loading forces on a mandibular 3-unit fixed partial denture using a molar and a premolar as abutments. the teeth which had become mobile due to the jiggling forces had lost marginal bone.80 81 Wylie et al. After 120 days of experimentally induced Periodontitis. Kvinnsland et al.79 In the early stages of the study the experimental "traumatized" side had an increased blood flow when compared to the control side. extensive bone loss.

occlusal therapy can be an aid to help reduce mobility.29. These studies are." The artidemonstrate that occlusal forces are transmitted to the periodontal attachment apparatus80'81 and those forces can cause changes in the bone and connective tissue. periodontal ligament atrophy from disuse.59 Tooth mobility can be a result of a variety of factors including loss of alveolar bone. occlusal forces which lead to widening of the periodontal ligament (physiologic adaptation). occlusal design. there have been few well-designed human studies that can help answer the question "does occlusal trauma modify the disease.56 The extent to which this is clinically meaningful in the treatment of Perio- FUTURE RESEARCH ing periodontal therapy are possible and are badly needed. attachment loss. results are inconclusive on the interactions between occlusion and the progression of attachment loss due to inflammatory periodontal disease. Double-blind controlled prospective human studies to determine the effects of occlusal forces and mobility on wound healing follow- and periodontal plastic surgery. and tooth mobility on wound healing have also not been adequately evaluated. periodontal attachment level have been documented when occlusal adjustment was included as a component of periodontal therapy. disruption of the periodontal supporting tissues by inflammation. Once periodontal health is established. 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 patient comfort and function and not based on the assumption that occlusal adjustment is necessary to stop the progression of Periodontitis.74. any relationship found between tooth mobility and progressing Periodontitis does not necessarily indite or defend occlusion as a cofactor in the progression of inflammatory periodontal disease. These studies could answer questions concerning the effects of occlusion and mobility on regenerative periodontal therapy such as guided tissue regeneration Prospective studies on the effects of occlusal forces on the progression of Periodontitis are not ethically acceptable in humans. regain some bone lost due to traumatic occlusal forces. Annals of Periodontology . The effects of normal occlusion. and equilibration techniques. Periodontitis can be treated and periodontal health maintained without occlusal adjustment and despite the obvious presence of traumatic occlusal forces.75 However. 21. and to treat a variety of clinical problems related to occlusal instability and restorative needs. 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 occlusion.21-27'77-79 These changes can effect tooth mobility and clinical probing depth. or any process which effects the supporting periodontal structures.576 Gher Studies like these can be used to demonstrate the mechanics of transmission of forces from teeth to the periodontium. Therefore.23.28 74'77 While occlusal forces do not initiate Periodontitis. however.57-59 others found no relationship between attachment loss and abnormal occlusal contacts. parafunctional habits. retrospective in nature and therefore may find it difficult to establish cause and effect relationships.40 71 Based on the literature. While some studies found a relationship between increased attachment loss and tooth mobility. Studies that attempt to identify risk factors for Periodontitis should also include occlusal analysis in the study parameters to evaluate this variable. statistically greater gains in clinical flammatory periodontal cles reviewed clearly progression of attachment loss due to in- dontitis is unclear. Animal studies could help to define the effects of occlusal forces on peri-implant bone loss and to determine if excessive occlusal forces can effect the progression of plaque induced peri-im- plantitis.

Yuodelis RA. or perverted 272.Review: Non-Surgical Pocket Therapy: Dental Occlusion 577 GLOSSARY OF TERMS Attachment and alveolar bone which function as a unit to support the teeth.3:219-223. Helv OdontolActa 1961. Stillman PR. Glickman I. 8. Bruxism: A habit of grinding. function.59:405-414. Dent Cosmos 1917. Occlusal adjustment: Reshaping the occluding surfaces of teeth by grinding to create harmonious contact relationships between the upper and lower teeth or orthodontic movement of the teeth to create a more harmonious occlusal relationship.36:141-147.30: 95-112.5:33-39. Co-factor: An aspect of personal behavior or life-style. (also referred to as functional mobility) Mobility. Periodontal reaction to functional occlusal stress.31:184-194. Gingival vascular supply in induced occlusal traumatism.) 1962. Periodontics 1965. The forces so generated may damage both the tooth and the attachment apparatus..29:9-15. J Periodontol Occlusion: The contact of opposing teeth. Weinmann JP. Smulow JB. 3. 1. Traumatogenic occlusion: Any occlusion that produces forces that cause an injury to the attachment apparatus. The management of pyorrhea. brought into inhibits the contact. The influence of in- Akiyoshi M. Effect of excessive occlusal forces upon the pathway of gingival inflammation in humans. an environmental exposure. 5. or clamping the teeth.39:101- 105. Kohler CA. 6. Occlusal forces: Forces that are generated and transmitted to the supporting structures of the teeth when the teeth are beyond physiologic limits. 13. Primary occlusal trauma: Injury resulting from excessive occlusal forces applied to a tooth or teeth with normal periodontal occlusal trauma: Injury refrom normal occlusal forces applied sulting to a tooth or teeth with inadequate periodontal support. Glickman I. J Periodontol 1959.38:45-52. J Periodontol 1965. Herzog H. Alterations in the pathway of gingival inflammation into the underlying tissues induced by excessive occlusal forces. Goldman HM. The prevalence and possible role of non-working contacts in periodontal disease. J Dent Res 1954. 4. apparatus: The cementum. Fremitus: A palpable or visible movement of a tooth when subjected to occlusal forces. Macapanpan LC. Smulow JB. achieving remaining occluding surfaces stable and harmonious con- Any contact that 1967.9:939-941. J Periodontol - jury to the periodontal membrane on the spread of gingival inflammation. Premature occlusal contact: A condition of tooth contact that diverts the mandible from a normal path of closure. 12. Glickman I. Disease markers: Factors that are indicative of the disease. Secondary REFERENCES 1. Clamping and grinding habits: Their relation with severity of periodontal disease. 2. Experimental traumatogenic occlusion in sheep. Glickman I.33:263- Occlusal trauma: An ment apparatus or tooth cessive occlusal forces. Mann WV. J Periodontol 1968. Occlusal interference: from tacts. No. or an inborn or inherited characteristic which by itself does not cause a disease process but which can modify the course or expression of a disease process.38:280-293. injury to the attachas a result of ex- by Occlusal traumatism: the overall process which a traumatogenic occlusion produces injury in the periodontal attachment apparatus. 9. J Am Dent Assoc 1944. Vol. Muhlemann H. Tooth mobility and microscopic tissue changes produced by experimental occlusal trauma. Box HK.33:7-13. Smulow JB. tooth: A visually perceptible movement of the tooth away from its normal position when a light force is applied. 10. clenching. Further observations on the effects of trauma from occlusion. but that are not thought to be etiologic or may be historical measures of the disease or disease progression. (This movement may be within physiologic limits or periodontal ligament. November 1996 . Smulow JB. Ramfjord SP. Marginal Periodontitis A histological study of the incipient stage. J Oral Surg 1956. Parafunction: abnormal as in bruxism. 1. 7. J Periodontol 1967. Mori K. Leof M. Oral Health 1935. Adaptive alterations in the periodontium of the rhesus monkey in chronic trauma from occlusion. 11. support.

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