Quartz 4

L6 The role of Occlusion in Periodontal therapy

22 min read

The Role of Occlusion in Periodontal Therapy1

Presented by Dr. Hughes & Dr. Pradeep

Reading Resources and Literature

2017 World Workshop Publications2

  • **Occlusal trauma and excessive occlusal forces: Narrative review, case definitions, and diagnostic considerations

    • The lecture is based on the 2017 World Workshop and the new classification system.**
    • Authors: Jingyuan Fan, Jack G. Caton

  • Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions

    • Authors: Søren Jepsen, Jack G. Caton, Jasim M. Albendar, Nabil F. Bissada, Philippe Bouchard, Pierpaolo Cortellini, Korkud Demirel, Massimo de Sanctis

Core Textbooks3

  • **Lindhe’s Clinical Periodontology and Implant Dentistry (Seventh Edition)

    • Chapter 32.**
    • Two-Volume Set
    • Edited by: Tord Berglundh, William V. Giannobile, Niklaus P. Lang, and Mariano Sanz
    • Publisher: WILEY Blackwell

  • **Newman and Carranza’s Clinical Periodontology and Implantology (14th Edition)

    • Chapter 43.**
    • Publisher: NBB
    • Section VI: Occlusion
    • Chapter 32: Periodontal Response to External Forces
    • Authors: Flavia Q. Pinh, Paulo M. Camargo, Henry H. Takei, Fernim A. Carranza

Aims and Learning Objectives

Lecture Objectives4

  • To define occlusal trauma—primary, secondary, acute, and chronic—and its clinical presentation.
  • To review the relationship between occlusal trauma and the initiation and progression of periodontitis, mobility, attachment loss, and abfraction.
  • To understand the causes of tooth mobility and the criteria for how, why, and when to treat.
  • To understand the role of occlusion in periodontal therapy.
  • To identify the clinical and radiographic signs of trauma from occlusion.

Physiology of the Periodontium

Function of the Periodontal Ligament5

The periodontal ligament provides a viscoelastic cushioning effect, absorbing occlusal forces and adapting to variations in those forces.

  • The PDL contains mechanoreceptors and different fibers, such as potential fibers, that specifically function to absorb or take up occlusal loads.

Adaptive Capacity to Occlusal Forces

Physiological Response to Force6

  • Mechanoreceptors and cells of the periodontium respond to variations of forces on the dentition.
    • The PDL has a specific adaptive capacity to withstand forces.
  • Periodontal ligament (PDL) fibres are best able to tolerate forces directed down the long axis of the teeth.
  • Adaptive changes in the periodontium occur if the magnitude, direction, duration, and frequency of the force is altered.

Adaptive Hypermobility

  • Changes occur in the PDL space and surrounding alveolar bone depending on the type of force.
  • Adaptive hypermobility results in a widening of the PDL space but no pocketing.
  • Constant forces, lateral forces, or rotational forces are more injurious than intermittent forces.

Clinical Note

  • Pockets without bone loss could be due to trauma from occlusion.

Definitions and Classifications of Occlusal Trauma

World Workshop Case Definitions

Traumatic Occlusal Force7

Traumatic occlusal force is defined as any occlusal force resulting in injury of the teeth and/or the periodontal attachment apparatus. These were historically defined as “excessive forces” to denote that the forces exceed the adaptive capacity of the individual person or site.

Occlusal Trauma

Occlusal trauma is a histologic term used to describe the injury to the periodontal attachment apparatus. The clinical presentation of occlusal trauma is exhibited as described in the case definitions established by the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions (Workgroup 3).

Definitions of Injury and Force8

  • Trauma from occlusion: Damage or injury to the periodontium (and other structures) as a result of excessive occlusal forces.
  • Traumatic occlusion: Refers to excessive and abnormal occlusal forces on a dentition (renamed traumatic occlusal force).
  • Excessive occlusal forces: An occlusal force that exceeds the reparative capacity of the periodontal attachment apparatus, resulting in occlusal trauma and/or causing excessive tooth wear and other injuries.

Types of Occlusal Forces

Classification of Forces9

  • Physiological force: 5N or less; occurs during chewing and swallowing roughly and intermittently for 5 minutes a day. (Note: Maximum bite forces range from 250-850N depending on age, jaw shape, tooth type, and sex).
  • Impact force: High magnitude over a short period. If it exceeds the buffer capacity of the PDL, it may result in fracture of the tooth or bone.
  • Continuous forces: For example, orthodontic tooth movement.
  • Jiggling forces: Forces in two directions (e.g., a high filling), resulting in a widened PDL and mobility
    • Jiggling forces act in both horizontal and vertical directions and are considered more dangerous than other forces.

Mechanisms of Trauma

Traumatizing forces may act on one or more teeth through premature contact, bruxism, or alteration of tooth position.

Histological Descriptions and Animal Studies

Histological Diagnosis10

Histology is the only accurate way of diagnosing trauma from occlusion (TFO). Studies show distinct zones of pressure and tension within the periodontium.

Pressure Side Characteristics

  • Mild inflammation.
  • Increased vascularization, hemorrhage, and thrombosis in the PDL.
  • Bone resorption; occasionally root resorption or cemental tears.
  • High magnitude forces can lead to PDL necrosis and decomposition of cells, vessels, matrix, and fibers.
    • In orthodontic movement, pressure side characteristics occur on the side toward which the tooth is moving (e.g., the mesial side of a second premolar moving mesially).
  • Indirect bone resorption.

Tension Side Characteristics

  • Elongation of the PDL fibres.
  • Bone and cementum formation.

Jiggling Forces and Tissue Adaptation11

Characteristics of Jiggling Trauma12

Jiggling trauma involves forces directed alternatively in different directions, creating a combination of pressure and tension sites along the root.

  • Mild inflammatory changes in the ligament cause active bone resorption.
  • Increased width of the periodontal ligament occurs on both sides.
  • Results in increasing mobility.
  • The force is eventually compensated by tooth hypermobility; once adapted, the condition is no longer progressive.
  • In a non-inflamed periodontium, supra-alveolar connective tissue remains healthy, no loss of attachment occurs, and mobility remains stable.
    • Jiggling trauma can occur if a patient has a high point on a restoration while undergoing orthodontic treatment.

Jiggling forces on a normal healthy periodontium result in hypermobility but no loss of attachment (LOA).

Primary Versus Secondary Occlusal Trauma

Primary Occlusal Trauma Definition13

Primary occlusal trauma is injury resulting in tissue changes from excessive occlusal forces applied to a tooth or teeth with normal periodontal support. - This occurs when excessive forces (e.g., 10 Newtons instead of the physiological 5 Newtons) are applied to a healthy, non-compromised periodontium.

Common Examples

  • High filling
  • Orthodontic treatment
  • High spots on prosthetic replacements
  • Extrusion of the tooth (e.g., overeruption)
  • Bruxism

Secondary Occlusal Trauma Definition14

Secondary occlusal trauma is injury resulting in tissue damage from normal or excessive occlusal forces applied to a tooth or teeth with reduced periodontal support. The periodontium may be healthy or diseased; the force may be normal or reduced but exceeds the adaptive capacity of the periodontium. - In secondary trauma, the compromised periodontium cannot withstand even normal/physiologic loads (e.g., 5 Newtons).

Clinical Scenarios of Traumatic Forces15

Traumatic forces can occur in the following periodontal conditions:

  1. Normal periodontium with normal height of bone.
  2. Normal periodontium with reduced height of bone.
  3. Marginal periodontitis with reduced height of bone.

Acute Versus Chronic Trauma

Acute Trauma16

Acute trauma results from abrupt occlusal impact, such as biting on a hard object. - Other causes include opening bottle caps with teeth, and clinical symptoms like tooth pain are typically more severe than in chronic conditions.

  • Symptoms: Tooth pain, sensitivity to percussion, and increased tooth mobility.
  • Outcomes: Healing, pulp/periodontal inflammation, or transition into a chronic injury (potentially with drifting).

Chronic Trauma

Chronic trauma is more common and significant than acute trauma, resulting in gradual changes.

  • Signs: Tooth wear, drifting, and a radiographically widened PDL space
    • Chronic trauma may lead to the development of angular bone defects over a period of 6 to 8 months.
  • Causes: Commonly caused by parafunction such as bruxism and clenching.

Clinical Management

An occlusion is considered traumatic if it produces periodontal injury. Treatment is based on an assessment of the periodontal status.

Parafunction and Structural Defects17

  • Bruxism (Tooth Grinding): A habit of grinding, clenching, or clamping the teeth. The force generated may damage the tooth and attachment apparatus. Night grinding duration can range from 5 to 38 minutes, with 66% of the force generated by the masseter muscles.
  • Abfraction: A wedge-shaped defect at the Cemento-Enamel Junction (CEJ) thought to be caused by tooth flexure resulting from excessive occlusal forces.
  • Fremitus: Palpable or visible movement of a tooth when subjected to occlusal force. It can indicate past disease, adaptation, or ongoing pathology.

Diagnosis and Clinical Presentation

Diagnostic Indicators and Symptoms

Diagnostic Protocol18

Diagnosing trauma from occlusion requires:

  • Detailed history
  • Examination of the TMJ, teeth, pulp, and periodontium
    • Examination of the TMJ for clicking or deviation
    • Assessment of muscles (e.g., masseter) for tenderness, which may indicate Myofascial Dysfunction Syndrome
  • Radiographic analysis

Note: Histological diagnosis is not clinically feasible.

Impact of Traumatic Occlusal Forces19

Beyond the periodontium, traumatic forces can harm:

  • Temporomandibular Joint (TMJ)
  • Masticatory muscles
  • Pulp tissue
  • Tooth structure

Clinical and Radiographic Indicators20

  1. Fremitus

Fremitus Procedure

Wet a gloved finger and place it on the maxillary teeth (covering lateral to lateral). Ask the patient to bite into maximum intercuspation. Vibration indicates a positive result.

Note: In normal occlusion, there should be a gap between the palatal surface of maxillary anteriors and the incisal edge of mandibular anteriors. If they hit, fremitus is positive.

  1. Mobility
  2. Occlusal discrepancies
  3. Wear facets
  4. Tooth migration
  5. Fractured tooth
  6. Thermal sensitivity
  7. Discomfort/pain on chewing
  8. Widened PDL space
  9. Root resorption
  10. Cemental tear
  11. Angular bone loss

Clinical Observations21

  • Increased Tooth Mobility: Can be physiologic and adaptive. It occurs as a result of adaptation to increased occlusal force and can be reversed.
  • Localized Indicators: Isolated bone loss and recession should raise suspicion for occlusal trauma.
    • If recession or bone loss is found on only one or two teeth (e.g., lower anteriors) without a pocket, suspect trauma from occlusion.

Pathological Tooth Mobility22

Pathologic Mobility23

Progressively increasing tooth mobility is a true diagnostic sign of trauma from occlusion, though it can be caused by other conditions. - Etiology includes bone loss, inflammation, and overloading.

  • Assessment: Requires repetitive assessments to determine gradual increases in mobility (or other indicators like tooth movement).
  • Mechanism: Occurs when force exceeds the adaptive capability of the PDL, leading to increased PDL width.
  • Interaction with Periodontitis: If active periodontitis is present, trauma may aggravate the condition, potentially resulting in permanent attachment loss.

Angular Bone Defects

The presence of angular bone defects cannot, by itself, be regarded as an exclusive symptom of trauma from occlusion.

It is important to remember that not all tooth mobility is caused by occlusal trauma.

Research Evidence and Historical Theories

Initiation and Progression of Periodontitis24

Can traumatic occlusal forces initiate or aggravate inflammation in the periodontium?

Historical Theories on Initiation and Progression25

Proponents of Occlusal Trauma as a Primary Cause

  • Karolyu (1901)
  • Stones (1938): Based on animal models
  • Carranza (1939): Based on cadaver studies

The Glickman Concept Based on human autopsy findings, Glickman believed occlusal trauma was directly related to:

  • Development of angular and infrabony defects
  • Deepening of periodontal pockets

Theories Opposing Occlusal Trauma as a Primary Cause26

Research Evidence

  • Bhaskar & Orban (1955): Animal model (dogs)
  • Ewen et al. (1962): Animal model (dogs)
  • Polson et al. (1974): Animal model (monkeys)

The Waerhaug Concept Based on autopsy material, Waerhaug concluded:

  • Without the presence of plaque, occlusal trauma did not cause periodontitis or angular bone defects.
    • Research (including animal studies) indicates that without plaque, occlusal trauma does not cause periodontitis or pocket formation.
  • Angular bone defects occurred at sites not affected by occlusal trauma.

Tissue Adaptation and Aggravation27

  • Changes in the periodontium are reversible and can be repaired if offending forces are removed.
  • Persistent trauma results in a funnel-shaped widening of the crestal portion of the periodontal ligament and resorption of adjacent bone.
  • These changes may result in an angular bony crest, representing an adaptation to “cushion” increased forces; however, this may weaken tooth support and increase mobility.
  • When combined with inflammation, Trauma From Occlusion (TFO) may aggravate bone destruction, resulting in bizarre bone patterns.
  • If plaque is present, occlusal trauma aggravates the inflammatory response and increases the rate of periodontal destruction and bone loss.

Clinical Assessment of Tooth Mobility

Measurement Devices and Ranges

  • Physiological Mobility: Limited normal movement of the crown in horizontal, vertical, and rotational directions.
  • Measurement Tools:
    • Periodontometer
    • Periotest: Measures the reaction of the periodontium to percussion forces; used in both clinical and research settings.
    • T-Scan: A software used to assess occlusal forces (though its accuracy has been debated).

Periotest Ranges

  • -8 to +9: Clinically firm tooth
  • 10–19: Palpable mobility
  • 20–29: Visible mobility
  • 30–50: Mobility in response to lip and tongue movements

Physiological Versus Pathological Mobility

Physiological Tooth Mobility28

Each tooth has a physiologic mobility in horizontal, vertical, and rotational directions. This varies among healthy individuals and follows a 24-hour cycle, with teeth typically being more mobile in the morning than in the evening.

Mobility depends on the root surface area available for the insertion of Sharpey’s fibers, specifically:

  • Number of roots
  • Length of roots
  • Diameter of roots

Normal Mobility Ranges by Tooth Type

TeethMobility Range (mm/100mm)
Incisors10–12
Canines5–9
Premolars8–10
Molars4–8

Degrees of Clinical Mobility29

Miller’s Classification

The degrees of clinical mobility described below are commonly referred to as Miller’s Classification.

  • Degree 0: Physiological mobility measured at the crown level. The tooth is mobile within the alveolus to approximately 0.1–0.2 mm in a horizontal direction.
  • Degree 1: Increased mobility of the crown to a maximum of 1 mm in a horizontal direction.
  • Degree 2: Increased mobility exceeding 1 mm in a horizontal direction.
  • Degree 3: Severe mobility in both horizontal and vertical directions, impinging on tooth function.
    • In Grade 3 mobility, the tooth can be depressed into the socket.

Etiology of Increased Mobility

Factors Contributing to Increased Mobility30

  1. Advanced bone loss (periodontal disease)
  2. Inflammation of the periodontal ligament (periodontal or periapical origin)
  3. Systemic causes (e.g., pregnancy)
  4. Destruction of surrounding alveolar bone (e.g., osteomyelitis or jaw tumors)
  5. Overloading of teeth and occlusal trauma
  6. Immediate post-operative period following periodontal surgery
  7. Root resorption
  8. Root fractures

Special Considerations in Occlusion

Pathological Tooth Migration

Clinical Indicators31

Pathological tooth migration often manifests as the labial migration of the upper central incisors.

  • Excessive forces can lead to labial flaring or migration, particularly in the upper centrals.

Effects of Orthodontic Forces

Periodontal Considerations in Orthodontics32

  • Plaque Control: Clinical studies show that with good plaque control, teeth with a reduced periodontium can undergo successful orthodontic treatment without injury.
  • Orthodontic treatment involves continuous force.
  • Risks of Uncontrolled Force: Non-controlled forces can injure the periodontium, causing root resorption, pulp disorders, and bone loss.

Force Application Speed

Forces must be applied slowly; excessive speed in tooth movement can lead to tooth loss.

  • Inflammation: Plaque control is more difficult during treatment, often leading to increased gingivitis. If periodontitis exists, orthodontic treatment may aggravate the disease.
  • If plaque control is poor, orthodontic forces can lead to rapid destruction.
  • Mobility: Transient mobility is common during the remodeling of alveolar bone, gingivae, and the periodontium.
  • Retention: Long-term retainers or fiberotomy may be used to prevent relapse post-treatment.

Trauma in Healthy Versus Diseased Periodontium

Reversibility in Healthy Periodontium33

Physiological Adaptation to Jiggling Forces34

  • Increased mobility and a wider Periodontal Ligament (PDL) space are results of physiological adaptation to altered functional demands.
  • Occlusal adjustment can eliminate excess force, leading to bone deposition.
  • Alveolar bone loss resulting solely from trauma from occlusion is considered reversible.

Jiggling forces

Reduced Periodontium and Occlusal Adjustment35

Increased mobility resulting from occlusal trauma in teeth with a reduced but healthy periodontium is reversible. Bone apposition to pre-trauma levels occurs following the removal of the traumatic force.

Experimental Observations of Jiggling Forces36

Radiographic evidence from studies (e.g., Lindhe & Svanberg 1974) comparing test teeth (T) subjected to jiggling trauma and induced periodontitis against control teeth (C) shows:

  • Significant angular bone loss around the roots of teeth subjected to both trauma and plaque-induced inflammation.
  • Absence of such defects in control teeth without traumatic forces.

Interactions with Active Periodontitis

Effects of Jiggling Forces in Periodontitis37

  • Trauma from occlusion in a periodontitis patient causes increased mobility and widening of the PDL space.
  • In most cases, no further loss of attachment occurs due to trauma alone; occlusal adjustment should return mobility to pre-trauma levels.
  • In the presence of plaque-associated disease, trauma enhances the progression of periodontitis.
  • It is essential to treat the plaque-associated periodontitis concurrently.
  • Some evidence suggests that mobile teeth may heal less effectively following periodontal treatment.

Evidence Regarding Abfraction and Attachment Loss

2017 World Workshop Findings (Fan & Caton)38

Abfraction

  • Defined as wedge-shaped defects at the cemento-enamel junction attributed to tooth flexure and fatigue.
  • Current evidence does not support the existence of abfraction as a clinical entity.

Clinical Perspective on Abfraction

The lecturer notes that while some evidence is limited, clinical experience suggests a link to trauma.

Gingival Recession

  • Observational studies indicate that occlusal forces do not cause gingival recession.
  • Studies are conflicting on whether traumatic forces directly cause recession, though isolated recession is often a clinical indicator.

Impact of Traumatic Occlusal Forces39

  • Attachment Loss: There is no evidence that traumatic occlusal force or occlusal trauma causes periodontal attachment loss in humans.
  • Periodontal Inflammation: Limited evidence from human and animal studies suggests traumatic occlusal forces can cause inflammation within the periodontal ligament.
  • Progression of Periodontitis:
    • Observational studies suggest traumatic forces may be associated with the severity of periodontitis.
    • Animal models indicate these forces may increase alveolar bone loss.
    • There is no evidence that traumatic occlusal forces accelerate the progression of periodontitis in humans.

Treatment and Management

Impact of Occlusal Adjustment on Healing

Clinical Outcomes of Occlusal Therapy40

  • One randomized clinical trial suggests that reducing tooth mobility may improve periodontal treatment outcomes.

  • Overall, there is insufficient clinical evidence to definitively evaluate how eliminating signs of traumatic occlusal forces impacts the response to periodontal treatment.

  • Key researchers in this area include Rosling et al. (1976) and Pihlstrom et al. (1986).

  • Addressing the cause is essential; if the etiology (trauma) is not corrected, the periodontal problem will not be solved.

  • Methods of correction include:

    • Enameloplasty: Selective grinding or reshaping of the natural tooth (e.g., incisal edges of lower anteriors) to eliminate high points or fremitus.
    • Bite Raising: Increasing the vertical dimension in the posterior area to create space in the anterior.
    • Prosthetic Correction: Changing a crown or restoration if it has a high point.

Animal Study Findings41

  • Reduced Healthy Periodontium: Similar to other findings, no loss of attachment occurs with occlusal overload in a healthy but reduced periodontium.
  • Plaque-Associated Disease: Results are conflicting.
    • Jiggling forces of a magnitude exceeding adaptation can lead to permanent injury, inflammation, angular bone destruction, and apical migration of the junctional epithelium.
    • Tissue destruction was observed in dog studies.
    • Monkey studies showed no migration of connective tissue attachment.

Clinical Trials and Mixed Conclusions

Human Clinical Trial Data42

  • Increased tooth mobility is a primary sign of occlusal trauma.
  • Data regarding the relationship between periodontal condition and occlusal trauma remains conflicting.
  • Some evidence supports the concept that trauma from occlusion has a detrimental effect on the periodontium.

Summary of Mixed Conclusions43

  • Reduced Response to Treatment: Pockets of mobile teeth may not respond as well to periodontal treatment (Fleszar et al. 1980, Burgett et al. 1992, Nunn and Harrel 2001).
  • Equivalent Healing: Some studies showed that multiple intrabony defects in advanced periodontitis patients healed similarly in hypermobile teeth compared to firm teeth (Rosling et al. 1976).
  • Probing Depth: Beagle dog studies indicated that probe tips penetrated approximately 0.5mm deeper at mobile teeth (Neiderud et al. 1992).

Conclusion and Summary4445

Summary of Research Findings46

Animal and human studies have concluded the following:

  • Unilateral or jiggling forces in a healthy periodontium do not result in attachment loss.
  • Trauma from occlusion can result in alveolar bone resorption leading to tooth mobility, which may be transient or permanent.
  • Trauma from occlusion does not initiate periodontitis but acts as a co-destructive factor when plaque is present.
  • Radiographic widening of the PDL space changes the "hourglass" shape to a "funnel" shape.
  • Bone pathology from trauma typically takes 6 to 8 months to become detectable on a radiograph, requiring approximately 20-21% bone mineral loss to be visible.

Treatment Modalities and Splinting

Clinical Approaches to Tooth Mobility47

Treatment of increased tooth mobility is primarily performed for patient comfort and involves the following strategies:

  • Inflammation Control: Prioritize the control of inflammation and the exclusion of other etiological factors.
  • Occlusal Surface Correction: Modify the anatomy of the occlusal surface through new restorations or selective occlusal adjustment.
  • Orthodontic Intervention: Utilize orthodontic movement to correct the position of the teeth
  • Grade 1 mobility is often treated with enameloplasty or bite adjustment.
    • Grade 2 mobility may require splinting if the tooth does not stabilize after 3-4 weeks of adjusting the occlusion.
  • Support and Protection: Provide posterior support and utilize mouthguards or occlusal splints.

Splinting Modalities

Teeth may be stabilized using various splinting methods:

  1. Joined composite fillings or fibers
  • Extracoronal Splinting: Using a wire and composite on the lingual/palatal surfaces to hold teeth together.
  1. Orthodontic wires
  2. Fixed bridges
  • Joint Crowns: Connecting a mobile tooth to a stable, root-canal-treated tooth via a bridge or joined crowns.
  1. Cross-arch splints designed with balanced contact for all excursive movements
  2. Occlusal Splints (Night Guards):
    • Hard Splints: Recommended for bruxism to protect teeth and muscles.
    • Soft Splints: Not recommended for bruxers as they may chew them like "bubble gum," potentially worsening the habit.

THANK YOU

Footnotes

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