journal of dentistry 40 (2012) 1025–1035

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Review

Occlusal adjustment associated with periodontal

therapy—A systematic review

Adriana M. Foz, Hilana P.C. Artese, Anna Carolina R.T. Horliana,

Claudio M. Pannuti, Giuseppe A. Romito *
Department of Periodontics, Dental School, University of São Paulo, Brazil

article info abstract

Article history: Objectives: Occlusal adjustment as part of periodontal therapy has been controversial for
Received 13 March 2012 years, mostly because the literature does not provide enough evidence regarding the
Received in revised form influence of trauma from occlusion (TfO) on periodontitis. The need for occlusal adjustment
5 September 2012 in periodontal therapy is considered uncertain and requires investigation. The aim of this
Accepted 7 September 2012 systematic review was to identify and analyse those studies that investigated the effects of
occlusal adjustment, associated with periodontal therapy, on periodontal parameters.
Data: A protocol was developed that included all aspects of a systematic review: search
Keywords: strategy, selection criteria, selection methods, data collection and data extraction.
Occlusal adjustment Sources: A literature search was conducted using MEDLINE via PubMed, the Cochrane
Dental occlusion Central Register of Controlled Trials, and EMBASE.
Traumatic Study selection: Three reviewers screened the titles and abstracts of articles according to the
Periodontal disease established criteria. Every article that indicated a possible match, or could not be excluded
Periodontal debridement based on the information given in the title or abstract, was considered and evaluated. On
final selection, four articles were included.
Conclusions: Although the selected studies suggest an association between occlusal adjust-
ment and an improvement in periodontal parameters, their methodological issues (ex-
plored in this review) suggest the need for new trials of a higher quality. There is insufficient
evidence at present to presume that occlusal adjustment is necessary to reduce the
progression of periodontal disease.
Clinical significance: Although it is still not possible to determine the role of occlusal adjust-
ment in periodontal treatment, adverse effects have not been related to occlusal adjust-
ment. This means that the decision made by clinicians whether or not to use occlusal
adjustment in conjunction with periodontal therapy hinges upon clinical evaluation,
patient comfort, and tooth function.
# 2012 Elsevier Ltd. All rights reserved.

* Corresponding author at: Av. Prof. Lineu Prestes, 2227, Cidade Univeristária, CEP 05508-900, São Paulo, Brazil. Tel.: +55 11 3091 7833;
fax: +55 11 3091 7833.
E-mail address: garomito@usp.br (G.A. Romito).
0300-5712/$ – see front matter # 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2012.09.002
1026 journal of dentistry 40 (2012) 1025–1035
1. Introduction
The relationship between trauma from occlusion (TfO) and
periodontal disease has been discussed for more than a
century. Periodontal disease is characterized by gingival
inflammation, periodontal pocket formation, bone loss and
clinical attachment loss (CAL).1 Conversely, TfO has been
defined as an ‘‘injury resulting in tissue changes within the
attachment apparatus as a result of occlusal force(s)’’.2
Nowadays, it is well known that subgingival biofilm plays a
major role in the pathogenesis of periodontal disease,3,4
stimulating an immune response that can lead to periodontal
breakdown.5,6 Susceptibility to periodontal disease, its severi-
ty and progression are all influenced by environmental factors,
besides genetic and acquired risk factors that can modify the
host response.7–9
Nevertheless, prior to this insight, it was believed that TfO
could be the main cause of alveolar bone loss, since Karolyi’s
pioneering work10 had indicated a possible relationship
between excessive occlusal forces and periodontal break-
down. Subsequent decades saw a great number of contribu-
tions from different authors, but their conclusions were still
based on histological studies from human autopsies and
animal experiments.11–16
Until the early 80s, animal studies helped to identify
subgingival biofilm as the main risk factor for periodontitis,
but it was still believed that TfO could influence the severity
and progression of periodontitis.14–26 Despite their conclu-
sions, some studies presented histological evidence from
human biopsies that suggested only a weak association
between TfO and periodontal breakdown.13,27,28
A few observational studies reported a positive relationship
between TfO and CAL, and demonstrated that periodontally
compromised teeth presenting TfO had less bone support29,30
and greater pocket probing depth (PD).29–34
Based on those animal and epidemiological studies, if TfO
had any relationship to the progression of periodontitis, then
its elimination could also enhance clinical periodontal
conditions.14 Occlusal adjustment, defined as ‘‘reshaping
the occluding surfaces of teeth by grinding, to create
harmonious contact relationships between the upper and
lower teeth,’’2 aims to remove any present occlusal trauma.
Occlusal adjustment, which was routinely conducted
during an initial preparation phase as part of the preliminary
procedures to control periodontal disease,35–38 has been
considered part of periodontal therapy by many authors in
several fields of study. Still, its importance and indication have
not been established, since the literature does not prove any
influence of TfO on periodontitis.
It has been related that occlusal adjustment could be
beneficial at both tooth and periodontal level,39 although
much of the existing research does not provide valuable
information regarding the potential for this therapy to
contribute towards the elimination of periodontal dis-
ease.40–42 In a recent systematic review,43 the authors stated
that the evidence available was inconclusive, although their
search was limited to randomized clinical trials (RCTs) with
a follow-up period of at least three months. This restricted
their analysis to just one study. Even though RCTs represent
the highest quality of evidence, a wider look at all the
available data is needed, since the present conclusions
remain ambiguous and do not represent the compilation of a
great deal of evidence. Nonetheless, the information
obtained from the existing interventional studies may
advance our knowledge and might help us to design future
investigations.
In short, occlusal adjustment in periodontal therapy is of
unknown benefit, and its indication and importance ought to
be evaluated.
2. Aim
The main question of this systematic review is: ‘‘In periodon-
tally compromised patients, is there any scientific evidence
that occlusal adjustment as part of periodontal therapy
provides additional benefit on periodontal parameters, when
compared to periodontal therapy alone?’’ Therefore, the aim
of this study is to identify and analyse all the existing studies
that have sought answers to this question, and also to perform
a meta-analysis, if such an analysis can be reliably or
meaningfully performed.
3. Materials and methods
3.1. Protocol development
A protocol was developed to answer the main question of this
study, and includes all aspects of a systematic review:
selection criteria, search strategy, selection methods, data
collection, data extraction, and assessment of the risk of bias.
3.2. Criteria for considering studies for this review
3.2.1. Types of studies
Only interventional studies were eligible for inclusion in this
systematic review.
3.2.2. Types of interventions
Eligible interventions were conducted in order to eliminate
periodontal disease. Occlusal adjustment by grinding was the
additional treatment for all test groups, compared with
periodontal therapy alone.
3.2.3. Types of participants
Studies that included the following participants were eligible
for this systematic review:
1. Study population was all adults (25 years or older).
2. Study population had a clinical diagnosis of periodontal
disease.
3.2.4. Types of outcome measures
Studies presenting any of the following outcomes were eligible
for this systematic review:
1. Periodontal clinical parameters (such as CAL, PD, and tooth
mobility).
 journal of dentistry 40 (2012) 1025–1035
2. Laboratorial parameters related to periodontal disease.
3.2.5. Inclusion criteria
Studies that presented the following interventions and
analysis were eligible for this systematic review:
1. Periodontal treatment.
2. Occlusal adjustment by grinding.
3. Relationship between occlusal adjustment and periodontal
response.
3.2.6. Exclusion criteria
The following types of studies were not eligible for this
systematic review: case–control studies, cross-sectional stud-
ies, case series and case report, analytical and narrative
reviews and animal studies.
3.2.7. Search strategy
A literature search was conducted using MEDLINE via
PubMed, the Cochrane Central Register of Controlled Trials,
and EMBASE. Manual searches from some important
journals were also conducted (the Journal of Periodontology,
the Journal of Periodontal Research, and the Journal of Clinical
Periodontology), along with a search for unpublished studies.
Reference lists of main articles related to the theme were
also assessed to guarantee that all evidence available was
found and revised.
A search strategy for databases was performed to find
studies that matched the following terms: ‘‘Occlusal Adjust-
ment’’ [Mesh], ‘‘Dental Occlusion, Traumatic’’ [Majr], ‘‘Peri-
odontitis’’ [Mesh], ‘‘Periodontal Diseases’’ [Mesh] (for MEDLINE
via PubMed), and Occlusal Adjustment, Traumatic dental
occlusion, Periodontal Disease and Periodontitis (for Cochrane
Central Register of Controlled Trials and EMBASE).
3.2.8. Search limits
Databases were searched up to April 2011, with no limits on
the year of publication. The only limits included in the search
strategy were:
1. Human studies.
2. Adult patients.
3. English language.
3.2.9. Selection methods
Initially, three independent reviewers (AF, AH and HA)
screened the titles and abstracts of articles according to the
limits mentioned above. Every article that indicated a possible
match, or could not be excluded based on the information
given in the title or abstract, was considered and evaluated.
Finally, the studies selected for this systematic review were
submitted for validation and data extraction. Any disagree-
ment regarding inclusion was resolved through discussion
with two other review authors (CMP and GAR).
3.2.10. Qualitative analysis
In order to evaluate their quality, the articles included in this
systematic review were evaluated for any risk of bias, as
described in the Cochrane Handbook for Systematic Reviews
of Interventions 5.1.0.44
1027
4. Results
Our search strategy identified 376 references, of which 234
were considered irrelevant for this review, due to the fact that
their titles did not match the inclusion criteria. Abstracts from
142 potentially relevant articles were assessed (first selection),
and 133 of them were discarded because they had already
failed to meet all of the proper inclusion criteria (second
selection). Finally, the full texts of nine articles were read, five
of which did not meet the eligibility criteria and were
excluded. The final selection for this systematic review was
four articles, all of which had their data extracted for further
evaluation. Fig. 1 presents a flow chart of the selection process.
4.1. Study characteristics
4.1.1. Types of selected studies
Four studies were selected for this review.45–48 Three of them
were clinical trials,45,46,48 but only Burgett et al.48 conducted a
randomized parallel trial. Hakkarainen45,46 conducted two
cross-over trials. Harrel and Nunn47 presented a retrospective
study, analysing data obtained from the clinical records of a
private practice over 24 years. Characteristics of the included
studies are described in Table 1.
4.1.2. Population characteristics
All the studies that were included in this review provided
information about the number of participants; 200 patients
were evaluated in total. One of the studies48 classified its
population (n = 50) as having moderate to severe periodontal
disease, with an average age of 44.2 years (range: 25–69 years).
In her first study,45 Hakkarainen included 47 adult patients
(mean age was 49 years, ranging from 33 to 76 years), suffering
from localized advanced periodontitis. In a later study,46 the
authors observed 14 adult patients (mean age of 49 years,
ranging from 35 to 65 years), with localized advanced
periodontitis. Harrel and Nunn47 evaluated a population that
had moderate to severe periodontal disease (n = 89), whose
ages varied between 25 and 88 years. The diagnostic criteria
for periodontitis were not cited in neither of the included
studies.
4.1.3. Duration characteristics (time of study)
Burgett et al.48 followed up on their patients’ condition over
two years; during this period, the patients were maintained
with prophylaxis every three months. Reexamination visits
took place at one year and again at two years. The follow-up
time for both studies conducted by Hakkarainen45,46 was 28
days, when results were assessed 14 days after each treatment
(treatment appointments were conducted on day 0 and day 14,
when patients received both an examination and treatment,
and another examination appointment was conducted on day
28). Harrel and Nunn47 extracted data from patients who
returned for a new periodontal exam at least one year after the
first exam. The maximum follow-up period was 14.5 years.
4.1.4. Types of interventions
The following types of interventions were observed in the
included studies:
1028 journal of dentistry 40 (2012) 1025–1035
Fig. 1 – Selection process.
1. Scaling and root planing.
2. Modified Widman flap surgery.
3. Hygiene phase treatment: scaling and root planing, polish-
ing of teeth, smoothing of restorations, fluoride treatment.
4. Oral hygiene instructions.
5. Osseous surgery, osseous regenerative procedure, soft
tissue grafting.
6. Occlusal adjustment by grinding.
Burgett et al.48 performed a clinical trial in which patients
received periodontal treatment consisting of two different
therapies assigned randomly for each side of the mouth: (1)
scaling and root planing (2) and modified Widman flap
surgery. Some of these individuals (test group; 22 participants)
were randomly assigned to receive occlusal adjustment within
their periodontal therapy programme.
Harrel and Nunn47 analysed data from clinical records of a
private practice, and divided all 89 included patients into three
groups based on their treatment: fully treated patients,
partially treated patients (who completed the non-surgical
part of the treatment but had not completed the recom-
mended surgical therapy) and non-treated patients (patients
who had received none of the recommended treatments
between initial and final exams). Among 89 patients, 56
presented with occlusal discrepancies. Occlusal adjustment
was recommended to those 56 patients in association with
periodontal therapy. Nevertheless, only 26 of these 56
individuals received occlusal adjustment (17 fully treated
patients and nine partially treated patients).
4.1.5. Types of outcome measures
The following types of outcome measures were observed in
the included studies:
1. CAL
2. PD
3. Mobility
4. Sulcular fluid flow
Table 1 – Included studies.
Study/design Main objectives Population/periodontal Inclusion criteria Occlusal analysis Periodontal treatment Follow-up
diagnosis time
Hakkarainnen, 198645/ To evaluate gingival 47 individuals with Non diabetic nor Occlusal Group A: on day 0 test tooth 28 days
clinical trial crevicular fluid flow in ‘‘localized, advanced pregnant patients, interference either received scaling and root
teeth with occlusal periodontitis’’ assigned to presenting one pre in centric relation, planing, and on day 14 same
discrepancies, before either Group A (n = 24) or molar or anterior tooth protrusion or lateral tooth received occlusal
and after occlusal Group B (n = 23) with PD  5 mm, excursions adjustment. Group B: on day
adjustment and scaling mobility and occlusal 0 test tooth received
and root planing. interference. occlusal adjustment, and on
day 14 same tooth received
scaling and root planing.

Hakkarainnen To evaluate collagenase 14 individuals with Non diabetic nor Occlusal Group A: on day 0 test tooth 28 days
et al., 198846/

journal of dentistry 40 (2012) 1025–1035

activity and protein ‘‘localized, advanced pregnant patients, interference either received scaling and root
clinical trial content of sulcular fluid periodontitis’’, assigned to presenting one anterior in centric relation, planing, and on day 14 same
after scaling and either Group A (n = 7) or tooth with PD  5 mm, protrusion or lateral tooth received occlusal
occlusal adjustment of Group B (n = 7) mobility and occlusal excursions adjustment. Group B: on day
teeth with periodontal interference. 0 test tooth received
pockets. Participants could not occlusal adjustment, and on
have had antibiotics in day 14 same tooth received
the last 5 months. scaling and root planing.

Burgett et al., 199248/ To test the influence of 50 participants with Adults diagnosed with Occlusal After hygienic phase, test 2 years
clinical trial occlusal adjustment in moderate to advanced moderate to advanced interferences in group received OA, and
association with periodontitis randomly periodontitis who had centric relation, control group had no OA.
periodontal therapy on assigned to OA or no OA agreed to participate in eccentric After OA on test group, all
attachment levels, (test group = 22; control the trial, including mandibular motion, patients received a split
pocket depth, and tooth group: n = 28) maintenance care and and balancing side mouth periodontal
mobility and whether rescoring visits. interferences treatment, randomly
OA was of greater assigned: one side of the
significance in non- mouth received surgical
surgically treated therapy and other side
periodontal defects. received scaling and root
planing only.

Harrel and To evaluate the effects 89 participants with Patients who had Initial contacts, Untreated group: had a At least one
Nunn, 200147/ of occlusal adjustment moderate to advanced undergone two discrepancies in periodontal treatment year,
retrospective on the progression of periodontitis complete periodontal centric relations or recommended, but did not maximum
treated or untreated exams (within at least lateral excursions come back to the clinic for 14.5 years
periodontitis. one year difference one year; partially treated
between them) and who group: had completed non-
received a periodontal surgical phase of therapy,
treatment plan after but did not have surgical
first exam. treatment performed; fully
treated group had completed
all non-surgical and surgical

1029
phases of treatment.
1030 journal of dentistry 40 (2012) 1025–1035
5. Collagenase activity in sulcular fluid
6. Protein content in sulcular fluid
4.1.6. Excluded studies characteristics
Three hundred and seventy-two studies were excluded
because they did not match the inclusion criteria for this
review. Although a strict search strategy was conducted to
look for all available evidence, most of the search results were
not related to the question purposed in this systematic review,
nor had a study design that would allow being included in this
review. The reasons for these exclusions were: no evaluation
of the relationship between periodontal treatment and
occlusal adjustment; no assessment of periodontal responses
to both treatments; population studies were neither adult nor
periodontally compromised. Table 2 describes the character-
istics of five studies that were excluded after full text
assessment, as well as the reason for their exclusion.
4.1.7. Qualitative analysis
Table 3 presents the individual quality criteria for each
included study. The characteristics of included and excluded
studies are described in Tables 1 and 2, respectively. Individual
outcomes of the included studies are described in Table 4.
4.1.8. Quantitative analysis
It was not possible to conduct a meta-analysis of the results of
the included studies, since the outcomes, measurements and
methodologies of these studies were not similar.
5. Discussion
Occlusal adjustment in periodontal therapy has been contro-
versial since its earliest use. So far, its importance in the
treatment of periodontal disease has not been established,
mostly because the effects of occlusal trauma on the period-
ontium remain unclear. The existing research regarding the
relationship between TfO and periodontal disease has
Table 2 – Excluded studies.
Study Reasons for exclusion
40
Haddad et al., 1974 Did not evaluate the effects of OA in
periodontal parameters
Vollmer and Did not perform periodontal
Rateitschak, 197541 treatment (scaling and root planing) in
association with OA
Fleszar et al., 198059 Did not evaluate the effects of OA on
periodontal parameters
Moozeh and Did not perform periodontal
39
Bissada, 1981 treatment (scaling and root planing) in
association with OA; patients were
periodontally healthy
Kerry et al., 198258 Did not evaluate the effects of OA in
comparison to no OA during
periodontal therapy
produced conflicting results, and while some authors believe
in a plausible association,11,14,16,34,49–52 many other stud-
ies13,27,28,30,53–55 could not produce favourable results, which
leads us to conclude that there is not enough evidence to prove
the relationship.
Because of the contemporary controversy, this study aimed
to systematically review the available evidence on the
influence of occlusal adjustment associated with periodontal
therapy. A strict methodology was applied to the search for
relevant studies, and to their selection and analysis, in order to
minimize bias in the results of this review. Many studies that
aimed to evaluate occlusal adjustment were not included,
since they did not match all the inclusion criteria. All the
outcomes that could be related to periodontitis were taken
into consideration, which allowed those studies that did not
present any clinical parameters as primary outcomes to be
included in this review.45,46
Within the included studies, only one48 was a randomized
clinical trial that aimed to evaluate the influence of occlusal
adjustment in association with periodontal therapy on
periodontal clinical parameters (CAL, PD and tooth mobility).
This trial had shown that patients who received occlusal
adjustment associated with periodontal therapy had obtained
greater gains in clinical attachment on both sides of the mouth
during the follow-up period (examinations at one year and at
two years). On the other hand, occlusal adjustment did not
appear to have any influence on PD during the two-year
follow-up. It is important to observe, however, that this study
poses some methodological problems that could introduce
bias to the outcomes obtained. First of all, differences in PD
could be due to inadequate oral hygiene, since the plaque
index and gingival index were neither assessed nor reported
during the reexamination visits. Another important issue is
that the participants enrolled in this study had to be adults
who had been diagnosed with moderate to advanced
periodontitis, but were not necessarily found to have occlusal
discrepancies, which could mean that not all patients would
actually need an occlusal adjustment.
Design Main objectives
Cohort To evaluate chewing time; to observe duration of
intervals between occlusal contacts during
function; and to evaluate effects of occlusal
adjustment on chewing contacts
Clinical trial To determine whether tooth mobility decreases
after OA; to determine whether OA can influence
marginal gingivitis
Cohort To determine whether tooth mobility influences
results on periodontal treatment
Clinical trial To compare tooth mobility following two
methods of eliminating occlusal discrepancies
Clinical trial To compare tooth mobility at different time
periods during periodontal treatment and to
relate changes in mobility to each method of
treatment
 journal of dentistry 40 (2012) 1025–1035
Table 3 – Quality assessment.
Study Hakkarainnen,
198645
Random sequence generation Yes
Allocation concealment No
Blinding of participants and personnel No
Blinding of outcome assessment No
Complete outcome data addressed No
Other biases Yes
‘‘Yes’’ indicates a low risk of bias, ‘‘No’’ indicates a high risk of bias, and ‘‘Unclear’’ indicates either lack of information or uncertainty over the
potential for bias.
In a retrospective study,47 an analysis was conducted of
data obtained from 24 years of a private practice to evaluate
the effects of occlusal adjustment in association with
periodontal therapy. Although the study did not follow a trial
methodology, it contained enough information to be included
in this review. Statistical analyses were performed at the tooth
level instead of the individual level, when groups were divided
as described: teeth with untreated occlusal discrepancies,
teeth with treated occlusal discrepancies, and teeth with no
occlusal discrepancies. Therefore, it has been demonstrated
that teeth with untreated occlusal discrepancies had worse
periodontal responses related to PD, prognosis, tooth mobility
and furcation involvement compared to teeth with treated
occlusal discrepancies and teeth with no occlusal discrepan-
cies. It was concluded that the impact of occlusal adjustment
in association with periodontal therapy is significant and
should be investigated further.
These findings should be interpreted with care, since the
study protocol does not fit an adequate design, which reduces
the quality of the study. It is not possible to ensure that all
teeth gathered in the same statistical analysis group received
the same treatments, especially within the same period of
time. If a treatment protocol is not followed, bias in the
outcomes is possible.
The positive influence of occlusal adjustment on tooth
mobility was also observed in one of the studies conducted by
Hakkarainen,45,46 although the author, among with her co-
workers, could not observe any changes in a later study.46
In the earlier study, although a modest improvement in the
mobility of teeth with excessive occlusal contacts could be
seen 28 days after occlusal adjustment and periodontal
therapy,45 sulcular fluid flow (SFF) was unaltered. SFF has
been related to inflammation and periodontal destruction,56
and a decrease in this flow could be expected after a source of
trauma was removed. On the other hand, a significant
( p < 0.05) reduction in the rate of SFF was observed after
scaling and root planing, but in teeth with occlusal inter-
ferences and also in teeth that had occlusal adjustment.45
Teeth that had their interferences adjusted did not derive any
additional benefit from SFF, possibly indicating that occlusal
interferences do not affect this outcome.
Although fluid flow did not change after occlusal adjust-
ment, the later study observed that its quality could be
influenced after this intervention.46 It was shown that occlusal
adjustment performed on teeth with occlusal discrepancies
reduced the protein content and collagenase activity of the
sulcular fluid. These factors, which can be influenced by tooth
1031
Hakkarainnen Burgett Harrel and
et al., 198846 et al., 199248 Nunn, 200147
No Yes No
No Unclear No
No No No
No Unclear No
No Yes Yes
Yes Yes No
mobility, are also related to inflammation and the progression
of periodontal disease. It has been suggested that increased
collagenase activity is related to the destructive phase of the
progression of periodontitis.57 Yet, as observed in the other
included studies, the two studies mentioned above also have
methodological issues that do not facilitate any remarkable
conclusion, especially because their follow-up times were only
28 days.
It is important to notice that none of the included studies
explained how occlusal adjustment was conducted. TfO might
be related to parafunctional habits, as well as the number of
remaining teeth and its insertion levels. Occlusal adjustment
should be conducted in order to solve the ethiologic factors for
TfO. This issue represents an important risk of bias for
interpreting results of these studies.
It was not possible to conduct a meta-analysis in the
present study, since the results of the included studies were
too different to be gathered into a single piece of analysis.
Although the four studies evaluated in this review had
demonstrated a possible improvement in periodontal
parameters when occlusal adjustment is associated with
periodontal therapy, there are still conflicts between them.
Burgett et al.48 could not conclude that occlusal adjustment
had any influence on PD, while a statistical analysis
conducted by Harrel and Nunn47 has shown that improve-
ment in probing depths was directly related to occlusal
adjustment performed on teeth with excessive occlusal
contacts. These results are probably due to differences
related to methodologies and specially statistical analysis.
Considering that each study had their own way to treat and
analyse their data, their results should not be compared as
well. Burgett et al. conducted their analysis on a patient
level, while Harrel and Nunn used the method of GEE to
analyse their data on a tooth level.
Other studies that could not be included in this review (for
reasons provided in Table 2) had also pointed to a positive
effect on periodontal parameters from occlusal adjustment.
Vollmer and Rateitschak41 had observed an improvement on
tooth mobility 30 days after occlusal adjustment alone, with
no other periodontal therapy associated. This improvement,
however, could not be seen on rates of sulcular fluid flow.
Another clinical trial excluded from this systematic
review was conducted by Kerry et al.,58 whose patients
underwent a hygienic phase of treatment consisting of initial
scaling, root planing and occlusal adjustment. Although it
was excluded for the fact that it did not provide any
information about the specific role of occlusal adjustment
 1032
Table 4 – Individual outcomes from included studies.

Study Results

PD Mobility—all teeth SFF

Mean (mm)  SD—all teeth Mean (mm)—test teeth

Group Aa Group Ba Group A Group B Group A Group B

**
Hakkarainnen, Day 0 6.4  0.3 7.4  0.4 1.3  0.1 1.4  0.1 2.3 3.4
198645
Day 14 Not mentioned Not mentioned Not mentioned Not mentioned 1.1*** 1.9
Day 28 Not mentioned Not mentioned Not mentioned Not mentioned 1.1 1.3***

Study Results

journal of dentistry 40 (2012) 1025–1035

Mobility—test teeth Protein content on Collagenase activity on
SFF—test teeth SFF—test teeth

Group Aa Group Ba Group A Group B Group A Group B

Hakkarainnen Day 0 1.1  0.1 1.3  0.2 41  9 60  13 2931  96 3543  240

et al., 198846
Day 14 Not mentioned Not mentioned 29  7 37  7§ 2031  299§ 2815  186§
Day 28 1.0  0.0 0.9  0.1 22  5 24  6§ 1680  308§ 1409  262§
Study Results

PD CAL Mobility
Mean (mm)  SD Mean (mm)  SDb

Occlusal No occlusal Occlusal No occlusal

adjustment adjustment adjustment adjustment

Burgett Baseline 3.65 (0.78) 3.50 (0.63) 3.50 (0.78) 3.47 (1.20) Mean mobility
et al., 199248 for all of the
teeth of all
patients
was 0.75.
1 year 2.97 (0.37) 2.88 (0.46) 0.32 (0.54) 0.07 (0.44) Clinical attachment
gain was
greater when
tooth mobility
was <0.75
(for both
groups).
 2 years 2.99 (0.97) 2.96 (0.42) 0.42 (0.67)£ 0.02 (0.53)£
Study Results

PD Mobility—percentage of teeth per group

Mean (mm)  SD
0 1 2 3

journal of dentistry 40 (2012) 1025–1035

Harrel and Baseline No occlusal problem 4.77 mm (1.31) 42% 40% 14% 5%
Nunn, 200147
Treated occlusal 5.53 mm (1.51) 34% 31% 28% 7%
problem
Untreated occlusal 5.59 mm (1.29) 45% 39% 16% <1%
problem
Study Results
c
Mean PD per year Improvement No change Worsening
Harrel and Post treatment No occlusal problem 0.048 mm 13% 75% 13%
Nunn, 200147
Treated occlusal 0.122 mm££ 16% 63% 20%
problem
Untreated occlusal 0.066 mm££ 0% 63% 37%
problem
a
Group A: day 0 = scaling and root planing; day 14 = occlusal adjustment. Group B: day 0 = occlusal adjustment; day 14 = scaling and root planing.
b
Negative measures mean loss of clinical attachment levels.
c
Negative measures mean an improvement on probing depths.
**
At baseline, difference between mean PD of each group was statistically significant ( p < 0.05).
***
SFF (sulcular fluid flow) diminished significantly after intervention, when compared to previous exam ( p < 0.05).
§
Collagenase activity diminished significantly after intervention, when compared to previous exam ( p < 0.05).
£
Difference between mean CAL of each group was statistically significant ( p < 0.05).
££
Difference between mean PD between test and control groups ( p < 0.0001).

1033
1034 journal of dentistry 40 (2012) 1025–1035
associated with periodontal therapy, a significant reduction
in the number of mobile teeth was observed after this initial
hygienic phase.41,46
The lack of evidence in this area might be partially due to
ethical considerations, since it is not possible to run a protocol
on untreated periodontal disease to evaluate longitudinally
the results of occlusal adjustment treatment by itself.60,61
Besides that, it has also not yet been established whether
trauma from occlusion influences periodontal breakdown. As
has been discussed here, the evidence has shown that occlusal
discrepancies might induce greater alveolar bone loss and
CAL. If this is actually true, leaving occlusal discrepancies
untreated to observe attachment loss would be considered
extremely unethical. It has been stated that ‘‘prospective
studies on the effect of occlusal forces on the progression of
periodontitis are not ethically acceptable in humans’’ by The
World Workshop in Periodontics.61 This fact hampers the
development of protocols that could help to define the role of
occlusal adjustment in periodontal therapy. Even though the
available evidence points to the benefit of occlusal adjustment
on periodontal parameters among periodontally compro-
mised patients, studies have not been able to explain the
direct influence of occlusal adjustment in reducing probing
depths and improving clinical attachment.
It is still necessary to develop stricter protocols that will
help to determine the role of occlusal adjustment in conjunc-
tion with periodontal treatment. It is important to state,
however, that no adverse effects have been related to occlusal
adjustment, which means that although its benefits are not
proven, it is also not detrimental. The decision made by
clinicians whether or not to use occlusal adjustment in
conjunction with periodontal therapy hinges upon clinical
evaluation, patient comfort, and tooth function. The evidence
thus far is insufficient to presume that occlusal adjustment is
necessary to reduce the progression of periodontal disease.
6. Conclusions
Within the limits of this systematic review, few studies could
be analysed to reach a solid conclusion about the influence of
occlusal adjustment associated with periodontal therapy, on
periodontal clinical parameters. Even though the benefits of
occlusal adjustment are yet to be proven, evidences so far have
not shown any adverse effects associated to this therapy.
However, new studies are required to answer the question of
this systematic review.
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