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Abstract
Objective: Occlusal adjustment is commonly recommended for patients with peri-
odontitis and traumatic occlusion. The objective of this systematic review was to ana-
lyze the available evidence for the association between traumatic occlusal forces and
periodontitis.
Methods: Two focused questions were proposed: What is the effect of traumatic occlusal
forces on periodontal parameters in patients with and without periodontitis? And what
is the effect of occlusal interventions on periodontal parameters in patients with peri-
odontitis? A systematic review of clinical and observational studies was performed and
presented in narrative form.
Results: After title and abstract review a total of 30 articles were retrieved and of these
14 full-text articles were retrieved for analysis. Two RCTs, 1 cohort, 4 retrospective and
7 cross-sectional studies were included. Cross-sectional studies reported a significant
association between occlusal discrepancies and probing depth and clinical attachment
level. However, the magnitude of the effect is negligible when groups with and without
occlusal discrepancies are compared. Intervention studies reported a minimal effect on
probing depth and clinical attachment level after occlusal adjustment in patients with
periodontitis as compared to teeth without occlusal adjustment.
Conclusions: Available human studies showed that there is limited evidence that trau-
matic occlusion is associated with periodontitis and to support the implementation of
occlusal adjustment to significantly improve the periodontal condition in patients with
periodontitis.
worse prognosis (p<0.0001). In contrast, Reyes et al. (2009) occlusal forces on periodontal parameters or had
concluded that premature contacts in centric relation were a focus on the frequency of traumatic occlusal
not statistically associated with abfractions or increased forces or occlusal trauma in patients with and
clinical attachment level. A previous systematic review con- without periodontitis.
cluded that there is some association between occlusal ad- • A study that assessed occlusal interventions (oc-
justment and improvement in periodontal parameters (Foz clusal grinding, occlusal adjustment) in patients
et al. 2012). Nonetheless, it is a common recommendation with periodontitis and a follow-up period of at
to control the occlusion as part of the periodontal treat- least 3 months.
ment but scientific support for this remains inconclusive. • Included raw data or was based on results from
Therefore, the objective of this systematic review was to adjusted risk ratios (RR), odds ratio (OR) and
analyze the available evidence for the association between 95% confidence interval (CI).
traumatic occlusal forces and periodontitis.
Exclusion criteria
Materials and methods Animal studies, case reports, case series and reviews.
The protocol for this systematic review is registered
Search strategy
at PROSPERO (CRD42018114845). In addition, the
PRISMA checklist was followed (Preferred Reporting The search was carried out by two independent reviewers
Items Systematic review and Meta-Analyses). (JEB, CRM) in Medline via Pubmed, Scielo and Google
A general question with two focused questions were Scholar to identify all the available evidence and grey literature
proposed: as well. The search strategy included the following keywords:
General question: • ((((occlusal intervention [Title/Abstract]) OR occlusal
What is the association between traumatic occlusal grinding [Title/Abstract]) OR occlusal adjustment
forces and periodontitis? [Title/Abstract]) AND periodontitis [Title/Abstract])
Focused questions: OR clinical attachment loss [Title/Abstract].
1. What is the effect of traumatic occlusal forces • (((trauma from occlusion [Title/Abstract]) OR
on periodontal parameters in patients with and occlusal trauma [ Title/Abstract]) AND periodon-
without periodontitis? titis [Title/Abstract]) OR clinical attachment loss
2. What is the effect of occlusal interventions on [Title/Abstract].
periodontal parameters in patients with peri- • ((bruxism [Title/Abstract]) AND periodontitis
odontitis? [Title/Abstract]) OR clinical attachment loss [Ti-
tle/Abstract].
Inclusion criteria • (((dental premature contacts [Title/Abstract]) OR
occlusal discrepancies [Title/Abstract]) AND peri-
Inclusion criteria were defined by the PI(E)COT (Pa-
odontitis [Title/Abstract]) OR clinical attachment
tients/population, Intervention/Exposure, Compari-
loss [Title/Abstract].
son, Outcome and Time) strategy for questions one and
• (((((traumatic occlusion [Title/Abstract]) OR
two as follows:
excessive occlusal force [Title/Abstract]) OR
• P: periodontal patients and patients receiving
pathologic occlusion [Title/Abstract]) OR dys-
any occlusal intervention.
functional occlusion [Title/Abstract]) AND clini-
• I(E): exposure is traumatic occlusal forces and
cal attachment loss [Title/Abstract]) OR gingival
intervention is occlusal adjustment.
recession [Title/Abstract].
• C: comparison is no traumatic occlusal forces
• ((((traumatic occlusion [Title/Abstract]) OR exces-
or no occlusal adjustment.
sive occlusal force [Title/Abstract]) OR pathologic
• O: main outcome is clinical attachment level
occlusion [Title/Abstract]) OR dysfunctional
(CAL) in teeth/subjects with and without the
occlusion [Title/Abstract]) AND periodontitis
exposure or mean change in CAL in the inter-
[Title/Abstract].
vention and comparison groups.
Manual searches of the Journal of Periodontology,
• T: follow-up period of at least 3 months for
Journal of Periodontal Research, and the Journal of Clini-
intervention studies.
cal Periodontology, along with a search for unpublished
Type of studies included: for the first question,
studies was performed. Articles identified from reference
cohort, case-control and cross-sectional studies were
lists of previous systematic reviews were also identified
selected. For the second question, only randomized
for selection. The language was limited to articles written
clinical trials (RCTs) were selected.
in English, Spanish and Portuguese and focused only in
Studies were considered based on the following
human studies in adults.
criteria:
• A study that assessed the effects of traumatic
150 Journal of the International Academy of Periodontology (2019) 21/4
Study selection tions 5.1.0 (Higgins and Green 2011). Equally, for observa-
Two independent reviewers screened (JEB, CRM) the titles tional studies, the Newcastle-Ottawa Scale (NOS) was used
and abstracts to identify potential articles according to the (Wells et al. 2012).
inclusion criteria and limits. Each identified article with a
Quantitative analysis and qualitative synthesis
possible match had a full-text evaluation. Selected studies
for this systematic review were analyzed for data extraction. A meta-analysis was not possible due to a low number of
Any discrepancies between the reviewers were resolved with homogeneous studies. A qualitative synthesis analyzing the
a third reviewer (JIC, CCR). most relevant aspects and results of the included studies is
presented. The reporting of this review is in accordance to
Data extraction the PRISMA (Preferred Reporting Items for Systematic
The following information was obtained by two independent Review and Meta-Analyses) statement.
reviewers (JEB, CRM) from each study using a predeter-
mined data extraction form: authors, year of publication, Results
population, type of study (RCT, cohort, case-control, cross- Study selection
sectional), intervention, comparison, number of patients, A systematic search in Medline, Scielo, Google Scholar
mean CAL, mean probing depth (PD), mean change and and manual search resulted in 4900 citations over a 30-year
standard deviation of the primary outcome (CAL) and other timeframe. After title and abstract review, 4870 articles were
outcomes (PD, mobility) in the intervention and comparison excluded. Thirty articles were retrieved and reviewed in full-
groups, number of people with the exposure in the case and text and consequently 16 articles were excluded because
control groups, adjusted risk ratios (RR), odds ratio (OR) and they did not meet the inclusion criteria (Hakkarainen 1996,
95% confidence interval (CI). Hakkarainen et al. 1988, Ikeda 1998, Ishigaki et al. 2008,
Doshi et al. 2010, Takeuchi et al. 2010, Gusmao et al. 2011,
Quality assessment
Krishna et al. 2013, Moisei et al. 2015, Bermudez et al. 2016,
Quality assessment was performed by two reviewers (JEB, Martinez-Canut et al. 2017, Kumar et al. 2018, Meynardi et al.
CRM) and any discrepancies were resolved with a third 2018, Kato et al. 2018, Popa et al. 2018a, Popa et al. 2018b).
reviewer (JIC, CCR). For RCTs, the quality of the study Finally, 14 articles were analyzed in full-text and included in
was assessed using the risk of bias tool as described in the the qualitative synthesis (figure 1).
Cochrane Handbook for Systematic Reviews of Interven-
Study characteristics
of follow up of
One cohort study (Di Febo et al. 2015), four retrospective
*
al. 2009, Reyes et al. 2009, Branchosfsky et al. 2011, Zhou et al.
2017, Hutabarat and Nasution 2017) and two RCTs (Burgett
*
1) Assessment of Observational studies were used to answer the first focused
question. A cohort study (Di Febo et al. 2015) on 100 patients
OR 95% CI
outcome
1.5-
Prosthetic
abutment
-
Periodontitis
subjects
Study
p<0.0001).
depth
depth
centric prematurity
patients
patients
Objective
the intervention.
Quality assessment
The quality of the cohort study of Di Febo et al. (2015)
Number
subjects
was low quality (table 2). The two RCTs (Burgett et al.
Harrel and 91
Nunn and 89
Harrel and 85
Harrel and 89
1992, Joo et al. 2014) were low quality as they had high
of
2004 /
2001 /
2009 /
2001 /
Harrel
Year /
Nunn
Nunn
Nunn
Table 4. Cross-sectional studies
Year / Number of Exposure/com-
Objective Population Outcomes Main Results
authors subjects parison
No significant differences occurred for PD (5.4 mm vs. 5 mm), CAL (4.4 mm vs.
To determine the reliability of signs
1992 / Occlusal trauma PD, CAL, 4.2mm) between teeth with and without abnormal premature contacts. Teeth
of trauma from occlusion and their Periodontitis
Jin and 32 / no occlusal bone height, with positive signs of trauma from occlusion (TOI- trauma from occlusion index)
relationship with the severity of patients
Cao trauma mobility presented deeper PD (5.7mm vs. 4.2mm), CAL (6.1mm vs. 2.7mm) and less
periodontitis
bone height (61.4% vs. 72.3%) as compared to TOI negative teeth (p<0.01).
To determine the association of Occlusal trauma A statistically significant association (p<0.05) in posterior teeth between func-
2017 / Moderate and
high occlusal force with the signs and high occlusal PD, CAL, tional mobility, tooth wear, widened periodontal ligament and increased PD
Zhou et 30 severe peri-
of occlusal trauma and periodontal force / no occlu- BOP and CAL was found. High occlusal force was associated with increased PD. In
al. odontitis
conditions in periodontitis patients sal trauma anterior teeth, no associations were found.
Teeth with trauma from occlusion presented increased probing depth 4.30 mm
2017 /
To evaluate the relationship of Trauma from oc- ± 2.18 as compared to 3.70 mm ± 1.98 in teeth without trauma. Clinical attach-
Huta- Periodontitis Severity of
8 trauma from occlusion and the clusion / balanced ment level was 7.33 mm ± 2.75 in teeth with trauma from occlusion vs. 5.55
barat and patients periodontitis
severity of periodontitis contacts mm ± 2.44 in teeth without trauma. The proportion of teeth with severe CAL was
Nasution
Campiño et al.: Association between traumatic occlusal forces and periodontitis: A systematic review
higher in teeth with trauma from occlusion (80.8% vs. 52.8%; p<0.05).
153
group. No difference in
better improvement in
To date the question to what extent a traumatic occlusion
affects periodontal tissues has been without any defini-
between groups.
tive answer. This systematic review aimed to review the
ity (p<0.05).
scientific evidence of studies performed in humans for
this question. Only randomized clinical trials (RCTs)
Results
Main
parison (SD)
Other out-
-2.22
of the effect in clinical attachment level and probing
depth was negligible between intervention and control
change Inter-
comes Mean
vention (SD)
0.08 mm
0.69 mm
attachment 0.75 mm
Clinical
level
teeth)/no oc-
Intervention/
(n=20 teeth)
tion (n=20
adjustment
Periodontitis
patients
reduction to improve
To explore the effec-
To test the influence
periodontal therapy
tiveness of occlusal
in association with
tooth mobility
study subjects
16
of
RCT
1992 /
2014 /
et al.
al.
Campiño et al.: Association between traumatic occlusal forces and periodontitis: A systematic review 155
To circumvent the time variable, case-control studies may of these effects was minimum (<0.8 mm) and hence the
offer some useful information. Case-control studies focus on clinical significance of the intervention remains inconclusive.
the disease instead of the exposure, in this case the response Cross-sectional studies offer limited information re-
of periodontal tissues. Cases would be defined on the basis garding the cause-effect approach but could help identify
of having either periodontitis or loss of clinical attachment potential associations between factors and outcomes in
level depending on how the question is presented. Controls certain events. Seven studies were retrieved (Jin and Cao
should be comparable to cases except that they do not have 1992, Bernhardt et al. 2006, Kundapur et al. 2009, Reyes et al.
the disease. However, with these studies the problem arises 2009, Branschosfsky et al. 2001, Zhou et al. 2017, Hutabarat
that a subject could have loss of clinical attachment level and Nasution 2017) and showed that there is a statistically
and not have periodontitis (reduced periodontium) and significant association between occlusal discrepancies and
thus making difficult to conclude that traumatic occlusion probing depth and loss of clinical attachment level. In the
is responsible for that finding. Loss of clinical attachment same manner, signs of trauma from occlusion were statis-
level manifested by recession without increased probing tically associated with increased periodontal destruction.
depth could be related to exposures other than periodontitis. Nonetheless, except for the study by Jin and Cao (1992), that
The role of excessive occlusal forces on the development of reported a difference in clinical attachment level of 3.4 mm
gingival recessions has been questioned and it is not possible between groups, the magnitude of this difference between
to make a positive association. Unfortunately, no case-control teeth with and without occlusal discrepancies in most stud-
studies were identified in this systematic review. ies is minimal (<0.9mm) and thus lacks clinical relevance.
Retrospective studies analyze exposures as risk factors Since the answer for the original question could not be
and their outcomes in a historic manner and hence bias and definitively answered from human studies, we considered
confounders could be increased. Four retrospective studies animal studies. Animal models allow most variables to be
(Nunn and Harrel 2001, Harrel and Nunn 2001, Harrel controlled and results can be gained quickly as opposed to
and Nunn 2004, Harrel and Nunn 2009) were identified human studies. This allows studying signs, symptoms and
when in fact they come from the same study setting. Teeth treatment strategies that would be otherwise not feasible in
with occlusal discrepancies presented initial deeper probing humans. Animal studies, now considered classic, that ad-
depths (5.53 mm vs. 4.77 mm; difference 0.7 mm). Teeth dressed the impact of traumatic occlusion on periodontal
that received complete periodontal treatment (nonsurgical tissues have unequivocally concluded the following accepted
+ surgical treatment) and occlusal adjustment presented an statements (Ericsson and Lindhe 1982, Lindhe and Erics-
improvement in probing depths. However, the magnitude son 1982, Lindhe and Svanberg 1974, Nakatsu et al. 2014):
156 Journal of the International Academy of Periodontology (2019) 21/4
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