# The role of occlusion in periodontal therapy Dr Hughes & Dr Pradeep   Presented by Dr. Hughes & Dr. Pradeep Labelled diagram (A) showing a dental occlusal guard or splint over an upper molar. The image illustrates the periodontal status with red and yellow coloring around the tooth root indicating inflammation or bone loss, and blue areas at the base representing healthy tissue or bone support. Labelled diagram (B) showing a similar setup to A but with a different occlusal guard design or positioning. It also depicts periodontal conditions with color-coded zones (red/yellow for inflammation, blue for healthy tissue), likely demonstrating a comparative scenario related to occlusion in periodontal therapy as per the title. **Reading Resources** 2017 WORLD WORKSHOP Occlusal trauma and excessive occlusal forces: Narrative review, case definitions, and diagnostic considerations Jingyuan Fan | Jack G. Caton 2017 WORLD WORKSHOP 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 Søren Jepsen¹ | Jack G. Caton² | Jasim M. Albendar³ | Nabil F. Bissada⁴ | Philippe Bouchard⁵ | Pierpaolo Cortellini⁶ | Korkud Demirel⁷ | Massimo de Sanctis⁸ | #### 2017 World Workshop Publications - **Occlusal trauma and excessive occlusal forces: Narrative review, case definitions, and diagnostic considerations** - 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 Reading resources ### Lindhe's Clinical Periodontology and Implant Dentistry - Seventh Edition **TWO-VOLUME SET** Edited by **Tord Berglundh**, **William V. Giannobile**, **Niklaus P. Lang**, and **Mariano Sanz** Published by **WILEY Blackwell** ### Newman and Carranza's Clinical Periodontology and Implantology - 14th Edition Published by **NBB (No specific author names listed in OCR)** #### Section VI: Occlusion #### Chapter 32 **Periodontal Response to External Forces** Authors: **Flavia Q. Pinh**, **Paulo M. Camargo**, **Henry H. Takei**, **Fernim A. Carranza**    #### Core Textbooks - **Lindhe's Clinical Periodontology and Implant Dentistry (Seventh Edition)** - 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)** - 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 Book cover image of 'Lindhe's Clinical Periodontology and Implant Dentistry - Seventh Edition'. The cover displays the title, editor names (Tord Berglundh, William V. Giannobile, Niklaus P. Lang, Mariano Sanz), publisher (Wiley Blackwell), and a small collage of four clinical images at the bottom showing histological sections and dental procedures. Book cover image of 'Newman and Carranza's Clinical Periodontology and Implantology - 14th Edition'. The cover displays the title, author names (Newman, Klokkevold, Elangovan, Kapila, Carranza, Takei), publisher info, and a collage of four clinical images at the bottom showing teeth, bacteria, and dental procedures. Figure from Chapter 32 of Section VI: Occlusion in Newman and Carranza's text. The figure is titled 'Periodontal Response to External Forces' and lists authors Flavia Q. Pinh, Paulo M. Camargo, Henry H. Takei, Fernim A. Carranza. It appears to be a visual illustration or diagram related to periodontal response to forces. # Aim of the lecture *The University of Western Australia* * To define occlusal trauma—PRIMARY, SECONDARY, ACUTE AND CHRONIC and its 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 how, why and when to treat. #### Lecture Objectives - 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. **Function of the periodontal ligament in occlusion** - Viscoelastic cushioning effect, absorbing occlusal forces, and adapting to variations in forces  The periodontal ligament provides a viscoelastic cushioning effect, absorbing occlusal forces and adapting to variations in those forces. Labelled diagram illustrating the types of periodontal ligament fibers and their functions. The image shows two teeth with various fiber groups labeled: Trans-septal (between teeth), Alveolo-gingival (root to gum), Inter-radicular (between roots), Oblique (angled root support), Apical (tip of root), Dentino-gingival (crown to gum), Circumferential (around tooth neck), Alveolar crest (top bone level), and Horizontal (across root width). The text above describes the viscoelastic cushioning effect of these fibers in occlusion. **ADAPTATIVE CAPACITY OF THE PERIODONTIUM TO OCCLUSAL FORCES** explained before we define trauma from occlusion * Mechanoreceptors and cells of the periodontium respond to variations of forces on the dentition * Pdl fibres are best able to **tolerate forces 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 * Changes occur in the pdl space and surrounding alveolar bone depending on the type of force-adaptive hypermobility-**widening of pdl space but no pocketing** * Constant forces, lateral or rotational forces are more injurious than intermittent forces <img>Dental X-ray diagram with handwritten notes indicating "Widening of PDL space" and "Ligament transformation"<img> *A book icon next to the text:* Pockets without bone loss could be due to trauma from occlusion!  #### Physiological Response to Force - Mechanoreceptors and cells of the periodontium respond to variations of forces on the dentition. - 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. Dental radiograph (X-ray) showing tooth roots with handwritten red annotations. The text 'Widening of PDL space' points to the periodontal ligament area between the root and bone. Below that, a hand-drawn diagram illustrates 'Ligament transformation', showing a transition from a normal bone structure to a widened or altered shape. # Case definitions-2017 WORLD WORKSHOP ## OCCLUSAL TRAUMA AND TRAUMATIC OCCLUSAL FORCES **The group defined excessive occlusal force and renamed it *traumatic occlusal force*. *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* is a term used to describe the injury to the periodontal attachment apparatus, and is a histologic term. Nevertheless, the clinical presentation of the presence of occlusal trauma can be exhibited clinically as described in the case definition.** --- ### 2017 WORLD WORKSHOP **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** Søren Jepsen<sup>1</sup> | Jack G. Caton<sup>2</sup> | Jasim M. Albandar<sup>3</sup> | Nabil F. Bitadjeu<sup>4</sup> | Philippe Bouchard<sup>5</sup> | Pierpaolo Cortellini<sup>6</sup> | Korkut Demirel<sup>7</sup> | Massimo De Sanctis<sup>8</sup> | Carlo Ercoli<sup>9</sup> | Jingnan Fan<sup>10</sup> | Nicolaas C. Geurs<sup>11</sup> | Francis J. Hughes<sup>12</sup> | Lijian Ju<sup>13</sup> | Aloysius Kontarakis<sup>14</sup> | Emmanuele Marconcini<sup>15</sup> | Debora Mattox<sup>16</sup> | Michael K. McGavin<sup>17</sup> | Michael P. Mills<sup>18</sup> | Philip M. Preshaw<sup>19</sup> | Mark A. Reynolds<sup>20</sup> | Antim Seiberlich<sup>21</sup> | Cristiano Sigmund<sup>22</sup> | Nicola X. West<sup>23</sup> | Kazuhisa Yamazaki<sup>24</sup> THE UNIVERSITY OF WESTERN AUSTRALIA #### Traumatic Occlusal Force 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). TRAUMA FROM OCCLUSION Trauma from occlusion is **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* **red**) Excessive occlusal forces is defined as an occlusal force that exceeds the reparative capacity of the periodontal attachment apparatus which results in occlusal trauma and/or causes excessive tooth wear and other injuries  #### Definitions of Injury and Force - **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. Anatomical diagram illustrating 'TRAUMA FROM OCCLUSION'. It depicts a cross-section of two teeth and surrounding periodontium. A red arrow labeled 'Force' points downwards onto the occlusal surface. Dashed black arrows show force distribution into the bone. Callouts identify 'Host-parasite reaction' (grey circles) and 'Trauma from occlusion' (black arrow pointing to the alveolar bone). Types of Occlusive Forces * Physiological force- 5N or less, chewing, swallowing, roughly and intermittently 5 minutes a day (Max bite forces-=250-850N, age, jaw shape, tooth type and sex dependent) * Impact force- high but short period. If exceeds buffer capacity of the PDL- fracture of the tooth /bone * Continuous forces- eg orthodontic tooth movement * Jiggling forces- forces in 2 directions- eg high filling-widened PDL and mobility * Traumatizing forces may act on one or more teeth, may be through a premature contact, bruxism or alteration of tooth position #### Classification of Forces - **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. #### Mechanisms of Trauma Traumatizing forces may act on one or more teeth through premature contact, bruxism, or alteration of tooth position. HISTOLOGICAL DESCRIPTION OF OCCLUSAL TRAUMA-animal studies - The only accurate way of diagnosing TFO is histologically-diagrams showing orthodontic movements - Distinct zones of **pressure** and **tension** within the periodontium- illustrated here as controlled orthodontic tooth movements - **Pressure side**- mild inflammation. increased vascularization, haemorrhage, thrombois in the pdl, bone resorption , sometimes root resorption, cemental tears - Higher magnitude of force, pdl necrosis, decomposition of cells, vessels, matrix and fibers. - Indirect bone resorption - **Tension side** – elongation of the pdl fibres, bone and cementum formation  #### Histological Diagnosis 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. - Indirect bone resorption. #### Tension Side Characteristics - Elongation of the PDL fibres. - Bone and cementum formation. Labeled diagram illustrating orthodontic tooth movements and periodontal stress zones. The image contains two panels: (a) 'Tipping movement' showing a tooth shifting with pressure (P) on the top-right and bottom-left, and tension (T) on the top-left and bottom-right; (b) 'Bodily movement' showing uniform pressure (P) along the left side and tension (T) along the right side. Grey shaded areas indicate tissue compression or deformation. Arrows show direction of force application. TRAUMA FROM OCCLUSION –J Jiggling forces ANIMAL STUDIES **JIGGLING TRAUMA** Forces directed alternatively in one and another direction * Combination of pressure and tension sites all along the root * Mild inflammatory changes occur in the ligament causing **active bone resorption** * Increased width of periodontal ligament on both sides * **Increasing mobility** * Force compensated by tooth hypermobility but no longer progressive- ➝ adaptation * In a **non-inflamed periodontium**, supra-alveolar connective tissue remains healthy, no loss of attachment occurs, mobility remains stable  #### Characteristics of Jiggling Trauma 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. Anatomical cross-section diagram illustrating 'Jiggling Trauma'. The image shows two teeth with their roots embedded in the alveolar bone. Arrows at the top indicate forces directed alternatively in different directions (one pushing left, one right), demonstrating how pressure and tension sites are created along the root surface. This visual supports the text description of jiggling trauma causing inflammation and bone resorption. Jiggling forces on a normal healthy periodontium-hypermobility but no LOA   Jiggling forces on a normal healthy periodontium result in hypermobility but no loss of attachment (LOA). Anatomical diagram illustrating 'Jiggling forces on a normal healthy periodontium'. The image shows two side-by-side panels of a tooth root within the alveolar bone. The left panel depicts a static state, while the right panel demonstrates movement indicated by arrows, representing hypermobility. Shaded areas highlight the periodontal ligament space. A caption '(a)' is visible at the bottom. A supplementary anatomical illustration showing two adjacent teeth roots with attached gingiva and periodontal ligaments. Arrows indicate rotational or jiggling movement, demonstrating mobility without loss of attachment (LOA) in a healthy context. **TEXT INJURIES ASSOCIATED WITH TRAUMA- PRIMARY OCCLUSAL TRAUMA** **Is injury resulting in tissue changes from excessive occlusal forces applied to a** **tooth or teeth with normal periodontal support** Examples include - High filling - Orthodontic treatment - Prosthetic replacement high spot - Extrusion of the tooth eg overeruption - Bruxism  #### Primary Occlusal Trauma Definition Primary occlusal trauma is injury resulting in tissue changes from excessive occlusal forces applied to a tooth or teeth with normal periodontal support. #### Common Examples - High filling - Orthodontic treatment - High spots on prosthetic replacements - Extrusion of the tooth (e.g., overeruption) - Bruxism Labelled diagram illustrating 'Primary Occlusal Trauma'. Shows a cross-section of a tooth within the jawbone. A red arrow points to the occlusal surface of the crown, indicating excessive force application. Inside the root structure, a red dot is labeled 'Center of Rotation', demonstrating how the tooth pivots around this point during trauma. <b>**SECONDARY OCCLUSAL TRAUMA**> **SECONDARY OCCLUSAL TRAUMA** Is injury resulting in tissue damage from normal or excessive occlusal forces applied to a tooth / teeth with reduced periodontal support – periodontium may be healthy or diseased, force may be normal or reduced but **exceeding the adaptive capacity of the periodontium.**  #### Secondary Occlusal Trauma Definition 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. Labelled diagram of a tooth illustrating 'Secondary Occlusal Trauma'. The image shows a cross-section of a tooth with a red arrow indicating occlusal force applied to the crown. A red dot marks the 'Center of Rotation' within the root structure. Handwritten red annotations label the bone loss area as 'boneless' and point to the alveolar bone surrounding the tooth. > **Causes of primary and secondary occlusal trauma** Figure 15-3 Traumatic forces can occur on A, normal periodontium with normal height of bone; B, normal periodontium with reduced height of bone; or C, marginal periodontitis with reduced height of bone.  #### Clinical Scenarios of Traumatic Forces 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. Labelled anatomical diagram (Figure 15-3) illustrating three scenarios of occlusal trauma: A shows normal periodontium with normal bone height; B shows normal periodontium with reduced bone height; C shows marginal periodontitis with reduced bone height. # **ACUTE AND CHRONIC TRAUMA DEFINITIONS** **Acute trauma** Result from abrupt occlusal impact on produced by bitting or a hard object Symptoms may include tooth pain, sensitivity to percussion, increased tooth mobility 3 main outcomes-healing, pulp/perio inflammation, acute injury becomes chronic +/- drifting **Chronic trauma** More common and significant than acute Results in gradual changes Tooth wear Drifting Widened PDL space seen radiographically Commonly caused by parafunction like bruxism and clenching An occlusion is traumatic if produces periodontal injury **Tx.** based on **assesses periodontal status** #### Acute Trauma Acute trauma results from abrupt occlusal impact, such as biting on a hard object. - **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. - **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. # MORE DEFINITIONS * **Bruxism or tooth grinding** is a habit of grinding, clenching or clamping the teeth. **THE FORCE GENERATED MAY DAMAGE THE TOOTH AND ATTACHMENT APPARATUS** * ( The duration of the night grinding can be 5 to 38 minutes, 66% of that is generated by the masseters) * **Abfraction-** -a wedge shaped defect at the CEJ thought to be caused by flexure in this area as a result of excessive occlusal forces * **Fremitus** – is palpable or visible movement of a tooth when subjected to an occlusal force( can indicate past disease or adaptation or an ongoing pathology) #### Parafunction and Structural Defects - **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. **Diagnosing trauma from occlusion** - Detailed History - Examination - TMJ, teeth, pulp, perio, radiographs - Unfortunately, not histology! #### Diagnostic Protocol Diagnosing trauma from occlusion requires: - Detailed history - Examination of the TMJ, teeth, pulp, and periodontium - Radiographic analysis Note: Histological diagnosis is not clinically feasible. **Traumatic occlusal forces** **... Besides trauma to the periodontium, they** **can harm .....** **TMJ** **Masticatory muscles** **Pulp tissue** **Tooth structure** #### Impact of Traumatic Occlusal Forces Beyond the periodontium, traumatic forces can harm: - Temporomandibular Joint (TMJ) - Masticatory muscles - Pulp tissue - Tooth structure Signs and symptoms of occlusal trauma **TABLE 1** Proposed clinical and radiographic indicators of occlusal trauma 1. Fremitus 2. Mobility 3. Occlusal discrepancies 4. Wear facets 5. Tooth migration 6. Fractured tooth 7. Thermal sensitivity 8. Discomfort/pain on chewing 9. Widened PDL space 10. Root resorption 11. Cemental tear PDL, periodontal ligament.  #### Clinical and Radiographic Indicators 1. Fremitus 2. Mobility 3. Occlusal discrepancies 4. Wear facets 5. Tooth migration 6. Fractured tooth 7. Thermal sensitivity 8. Discomfort/pain on chewing 9. Widened PDL space 10. Root resorption 11. Cemental tear Table 1: Proposed clinical and radiographic indicators of occlusal trauma. The table lists 11 numbered indicators in two columns. Left column includes: Fremitus, Mobility, Occlusal discrepancies, Wear facets, Tooth migration, Fractured tooth. Right column includes: Thermal sensitivity, Discomfort/pain on chewing, Widened PDL space, Root resorption, Cemental tear. A footnote defines 'PDL' as periodontal ligament. Clinical signs and symptoms of trauma from occlusion Increased tooth mobility (Physiologic and adaptive) Occurs as a result of adaptation to the increased occlusal force Can be reversed Isolated bone loss and recession should raise suspicion for occlusal trauma    #### Clinical Observations - **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. Anatomical line diagram illustrating two adjacent teeth with arrows indicating horizontal mobility. The illustration depicts the periodontal ligament space and alveolar bone supporting the roots. Dental radiograph (X-ray) showing a section of posterior teeth. It visualizes the root structures and surrounding bone density. Clinical photograph of anterior teeth displaying gingival recession and isolated vertical bone loss at the crestal level, consistent with occlusal trauma. **Progressively increasing tooth mobility (pathologic) - true diagnostic sign of trauma from occlusion** but can be caused by other conditions **requires repetitive assessments** to determine gradual increases in mobility which is difficult (or use other indicators such as movement of teeth) force exceeds adaptive capability of the Pdl width of periodontal ligament increases if there is active periodontitis this may be aggravated with resultant permanent attachment loss (some evidence) **angular bone defects?** presence of angular bone defects **cannot** per-se be regarded as an exclusive symptom of trauma from occlusion #### Pathologic Mobility Progressively increasing tooth mobility is a true diagnostic sign of trauma from occlusion, though it can be caused by other conditions. - **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. - **But remember that not all tooth mobility is caused by occlusal trauma** It is important to remember that not all tooth mobility is caused by occlusal trauma. Can traumatic occlusal forces initiate or aggravate inflammation in the periodontium?? **The University of Western Australia** Can traumatic occlusal forces initiate or aggravate inflammation in the periodontium? # Historical theories of the role occlusal trauma in initiation and progression of periodontitis ### Yes occlusal trauma can initiate / cause periodontitis camp * Karolyu, 1901, * Stones 1938 in animal model * Carranza 1939 in cadavers **Glickman concept** (human autopsys) Believed occlusal trauma was related to the development of angular / infrabony defects and deepening of periodontal pocket #### Historical Theories on Initiation and Progression **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 # NO IT DOESN’T CAMP - Bhaskar & Orban 1955 – animal model (dogs) - Ewen et al 1962 – animal model (dogs) - Polson et al 1974 – animal model (monkeys) - **Waerhaug concept/theory** (autopsy material) - Concluded that without plaque, occlusal trauma did not cause periodontitis or angular bone defects - Angular bone defects occured at sites not affected by occlusal trauma #### Theories Opposing Occlusal Trauma as a Primary Cause **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. - Angular bone defects occurred at sites not affected by occlusal trauma. • These changes are reversible in that they can be repaired if the offending forces are removed. • However, persistent trauma from occlusion results in **funnel-shaped widening of the crestal portion** of the periodontal ligament with resorption of the adjacent bone. • These changes, which may cause the bony crest to have an **angular shape**, represent adaptation of the periodontal tissues aimed at “cushioning” increased occlusal forces; however, the modified bone shape may weaken tooth support and cause tooth mobility. • When it is combined with inflammation, **TFO may aggravate the bone destruction** caused by the inflammation and results in **bizarre bone patterns** #### Tissue Adaptation and Aggravation - 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. # TOOTH MOBILITY-information - Physiological mobility-limited normal movement of the crown in horizontal, vertical and rotational directions - Periodontometer - Periotest measures reaction to the periodontium to percussion forces - Used in clinic and research settings ## Everyday clinical settings- * Device to cheek mobility **Periotest** * **RANGES:** * **-8 to +9:** Clinically firm tooth * **10-19:** Palpable mobility * **20-29:** Visible mobility * **30-50:** Mobility in response to lip & tongue movements  #### Clinical Assessment of Tooth Mobility - **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. #### 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 Product photograph of a Periotest device (a digital instrument used to measure tooth mobility) resting on its charging stand. NORMAL TOOTH MOBILITY Each tooth has a physiologic mobility in horizontal, vertical and rotational direction. It varies among healthy persons. It varies also within 24-hour cycle, the teeth are more mobile in the morning than in the evening. The mobility depends on Root surface area available for the insertion of Sharpey’s fibers: - Number of roots - Length of roots - Diameter of roots Normal tooth mobility varies between different types of teeth: | Teeth | Mobility Range (mm/100mm) | |---------------|---------------------------| | Incisors | 10-12 | | Canines | 5-9 | | Premolars | 8-10 | | Molars | 4-8 |  #### Physiological Tooth Mobility 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 | Teeth | Mobility Range (mm/100mm) | | :--- | :--- | | Incisors | 10–12 | | Canines | 5–9 | | Premolars | 8–10 | | Molars | 4–8 | Table titled 'Normal tooth mobility varies between different types teeth:' listing four categories of teeth (Incisors, Canines, Premolars, Molars) with corresponding mobility ranges in mm/100mm. Values are: Incisors 10-12, Canines 5-9, Premolars 8-10, Molars 4-8. > 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 of the tooth to at the most 1 mm in a horizontal direction. > Degree 2: increased mobility of the tooth exceeding 1 mm in a horizontal direction. > Degree 3: severe mobility of the crown of the tooth both in horizontal and vertical directions impinging on the function of the tooth. #### Degrees of Clinical Mobility - **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. **Mobility** **Aetiology:** 1. Advanced bone loss (periodontal disease), 2. Inflammation of the periodontal ligament of periodontal or periapical origin, 3. Some systemic causes (e.g., pregnancy), 4. The destruction of surrounding alveolar bone, such as occurs with osteomyelitis or jaw tumours, 5. Overloading of teeth and occlusal trauma, 6. Increased Immediately following periodontal surgery. 7. Root resorption 8. Root fractures #### Factors Contributing to Increased Mobility 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 # Other signs of occlusal trauma ## Pathological Tooth Migration Labial Migration of Upper central incisors   #### Clinical Indicators Pathological tooth migration often manifests as the labial migration of the upper central incisors. Clinical photograph (Panel A) showing the anterior maxillary dentition. It demonstrates significant spacing between the upper central incisors and a noticeable forward movement of these teeth relative to the lower incisors, illustrating labial migration. Close-up clinical photograph (Panel B) focusing on the upper right lateral incisor and canine. The image highlights severe crowding and the mesial inclination of the tooth, demonstrating pathological displacement in the dental arch. **EFFECTS OF ORTHODONTIC FORCES ON THE PERIODONTIUM** * Clinical studies have shown **with good plaque control teeth with reduced periodontium can undergo successful orthdontic treatment without injury** * However a non-controlled orthodontic force **can injure** the periodontium and cause root resortion, pulp disorders and bone loss * Long term effects of orthodontic forces on the periodontium has been controversial. * Plaque control more difficult during orthodontic treatment- more gingivitis * **Transient mobility common while the alveolar bone,gingivae and periodontium are being remodelled** * If there is existing periodontitis orthodontic treatment may aggravate the disease * Longterm retainers / fiberotomy to prevent relapse post- ortho   #### Periodontal Considerations in Orthodontics - **Plaque Control:** Clinical studies show that with good plaque control, teeth with a reduced periodontium can undergo successful orthodontic treatment without injury. - **Risks of Uncontrolled Force:** Non-controlled forces can injure the periodontium, causing root resorption, pulp disorders, and bone loss. - **Inflammation:** Plaque control is more difficult during treatment, often leading to increased gingivitis. If periodontitis exists, orthodontic treatment may aggravate the disease. - **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. Clinical photo of the anterior dentition with fixed orthodontic appliances (braces). The image demonstrates a patient undergoing treatment, serving as a visual example for the text's discussion on orthodontic forces and periodontal health. The teeth show brackets bonded to the enamel surfaces. Clinical photo of the anterior dentition with fixed orthodontic appliances (braces), similar to the first image but showing a slightly different stage or perspective of the treatment. This image reinforces the context of orthodontic treatment discussed in the OCR text regarding plaque control and gingivitis. OCCLUSAL TRAUMA CAUSING INCREASED MOBILITY AND WIDTH OF THE PDL IN A **HEALTHY PERIODONTIUM**-JIGGLING FORCES * Mobility and wider pdl are a result of physiological adaptation to the altered functional demands. * Occlusal adjustment will eliminate the excess force * Bone deposition occurred * Hence alveolar bone loss as a result from trauma from occlusion is reversible <a href="https://ddragon.leagueoflegends.com/cdn/13.1.1/img/champion/Ahri.png" target="_blank"><img src="https://ddragon.leagueoflegends.com/cdn/13.1.1/img/champion/Ahri.png" alt="Image"></a>Dental illustration showing adjacent teeth, PDL (Periodontal Ligament) spaces, and alveolar bone (JIGGLING FORCES)  #### Physiological Adaptation to Jiggling Forces - 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. Four-panel dental diagram illustrating the physiological adaptation of a healthy periodontium to occlusal trauma (jiggling forces). The sequence shows: (a) initial healthy state; (b) application of jiggling forces causing widened PDL and mobility; (c) bone deposition occurring at the base of the socket in response to force; and (d) final stable state with bone filling the widened area. Labels include '(a)', '(b)', '(c)', '(d)', arrows indicating movement/forces, and visual representations of teeth, PDL spaces, and alveolar bone. # Jiggling forces  Jiggling forces Labeled diagram illustrating 'Jiggling forces' on a tooth. The image is split into two panels: the left panel shows horizontal arrows indicating lateral movement of the tooth within its socket, while the right panel adds downward arrows to indicate vertical displacement. Both panels depict anatomical structures including the tooth root, surrounding bone (cortical and cancellous), and periodontal ligament fibers. **Jiggling forces on a healthy but reduced periodontium- before and after occlusal adjustment** - Increased mobility as a result of occlusal trauma in teeth with a reduced periodontiuin is also **reversible**- bone apposition to pre- trauma level occurs  #### Reduced Periodontium and Occlusal Adjustment 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. Medical diagram illustrating the effect of occlusal trauma on a tooth with reduced periodontium. The figure is divided into two panels labeled (a) and (b). Panel (a) shows a tooth with widened periodontal ligament space (indicated by brown areas) and increased mobility arrows, representing excessive horizontal forces. Panel (b) shows the same tooth after reduction of forces, demonstrating bone apposition where the ligament space has returned to pre-trauma levels. A caption below describes the process of stabilization following elimination of excessive forces. C T **Fig. 13-7** Radiographic appearance of one test tooth (T) and one control tooth (C) at the termination of an experiment in which periodontitis was induced by ligature placement and plaque accumulation, and in which trauma of the jigging type was induced. Note the angular bone loss particularly around the mesial root of the mandibular premolar (T) and the absence of such a defect at the mandibular premolar (C). (Source: Lindhe & Svanberg 1974. Reproduced with permission from John Wiley & Sons.)  #### Experimental Observations of Jiggling Forces 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. Radiographic comparison figure (Fig. 13-7) showing two dental X-rays side-by-side: left panel labeled 'C' (control tooth), right panel labeled 'T' (test tooth). Both images display mandibular premolars with ligatures and plaque accumulation. The test tooth (T) exhibits angular bone loss around the mesial root, while the control tooth (C) shows no such defect. Caption below confirms experimental induction of periodontitis and jigging-type trauma. ## **Jiggling forces in a periodontitis patient** * The trauma from occlusion will cause increased mobility and width of pdl space. * In **most cases** no further loss of attachment occurs- occlusal adjustment should result in decreased mobility to pre-trauma level * It is vital to treat the plaque associated periodontitis as well * Some evidence to show mobile teeth heal less well after perio treatment  #### Effects of Jiggling Forces in Periodontitis - 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. - It is essential to treat the plaque-associated periodontitis concurrently. - Some evidence suggests that mobile teeth may heal less effectively following periodontal treatment. Four-panel labeled diagram illustrating the effects of trauma from occlusion on periodontal health. Panel 'a' shows normal teeth with narrow pink PDL spaces and yellow bone. Panel 'b' depicts increased mobility with widened PDL spaces (indicated by arrows) and loss of attachment due to trauma. Panel 'c' demonstrates decreased mobility after occlusal adjustment, returning PDL width to pre-trauma levels. Panel 'd' shows the addition of green plaque accumulation on the tooth surfaces, indicating that treating associated periodontitis is vital for healing. 2017 WORLD WORKSHOP WILEY **Occlusal trauma and excessive occlusal forces: Narrative review, case definitions, and diagnostic considerations** Jingyuan Fan | Jack G. Caton **What is the evidence that abfraction exists?** Abfraction, a term used to define a wedge-shaped defect that occurs at the cemento-enamel junction of affected teeth, has been claimed to be the result of flexure and fatigue of enamel and dentin. The existence of abfraction is not supported by current evidence. **Can traumatic occlusal forces cause gingival recession?** There is evidence from observational studies that occlusal forces do not cause gingival recession.<sup>37, 38</sup> #### 2017 World Workshop Findings (Fan & Caton) **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. **Gingival Recession** - Observational studies indicate that occlusal forces do not cause gingival recession. Does traumatic occlusal force or occlusal trauma cause periodontal attachment loss in humans? There is no evidence that traumatic occlusal force or occlusal trauma causes periodontal attachment loss in humans. Can traumatic occlusal force cause periodontal inflammation? There is limited evidence from human and animal studies that traumatic occlusal forces can cause inflammation in the periodontal ligament.**3** Does traumatic occlusal force accelerate the progression of periodontitis? There is evidence from observational studies that traumatic occlusal forces may be associated with the severity of periodontitis.**34** Evidence from *animal* models indicate that traumatic occlusal forces may increase alveolar bone loss.**35, 36** However, there is no evidence that traumatic occlusal forces can accelerate the progression of periodontitis *in humans*. #### Impact of Traumatic Occlusal Forces - **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. The University of Western Australia Does the elimination of the signs of traumatic occlusal forces improve the response to treatment of periodontitis? There is evidence from one randomized clinical trial that reducing tooth mobility may improve periodontal treatment outcomes.43 There is insufficient clinical evidence evaluating the impact of eliminating signs of traumatic occlusal forces on response to periodontal treatment. Rosling et al 1976 Pihlstrom et al 1986 #### Clinical Outcomes of Occlusal Therapy - 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). # Trauma from occlusion in the presence of periodontal disease ## ANIMAL STUDIES * **Reduced healthy periodontium** similar results as previous- no loss of attachment with occlusal overload * **Plaque associated** periodontal disease- conflicting results * Jiggling forces of magnitude and direction where pressure and tension areas exceed adaptation, areas of permanent injury, inflammation, angular bone destruction and apical migration of junctional epithelium seen * In dog studies- **tissue destruction seen** * In monkey studies, no migration of connective tissue attachment #### Animal Study Findings - **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. TRAUMA FROM OCCLUSION AND PERIODONTAL DISEASE **HUMAN** CLINICAL TRIALS • Increased tooth mobility a sign of occlusal trauma • **conflicting data** regarding periodontal condition and occlusal trauma • some support the concept that trauma from occlusion has detrimental effect on periodontium #### Human Clinical Trial Data - 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. # Clinical trials- mixed conclusions - Pockets of mobile teeth do not respond as well to periodontal treatment- Fleszar et al 1980, Burgett et al 1992, Nunn and Harrel ( 2001) - Multiple intrabony defects in patients with advanced periodontitis exhibited the same healing at hypermobile teeth compared with firm teeth after periodontal treatment -Rosling et al 1976 - Beagle dog studies showed probe tip penetrated deeper ( 0.5mm) at mobile teeth ( Neiderud et al 1992)  #### Summary of Mixed Conclusions - **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). Decorative graphic element consisting of five overlapping circles in light purple and white colors positioned behind the title text 'Clinical trials- mixed conclusions'. This visual serves as a design accent rather than a data visualization. CONCLUSION ANIMAL AND HUMAN STUDIES CONCLUDED Unilateral or jiggling forces in a healthy periodontium does not result in attachment loss Trauma from occlusion can result in alveolar bone resorption leading to tooth mobility, which may be transient or permanent  #### Summary of Research Findings 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. Labelled diagram of two adjacent teeth showing the periodontium. The image depicts the tooth roots embedded in alveolar bone with attached gingiva and periodontal ligament fibers. Red arrows point towards the occlusal surfaces or contacts of the teeth, indicating areas of force application or trauma from occlusion as discussed in the text.  Institutional logo for The University of Western Australia, featuring a shield with a bird emblem and text identifying the university. # Treatment of increased tooth mobility mostly for patient comfort * **Control inflammation / exclude other etiological factors.** * Correction of anatomy of occlusal surface- new restoration or selective occlusal adjustment * **Splinting teeth** - splint can be 1. Joined composite filling/ fibres 2. Orthodontic wires 3. Fixed bridges 4. Cross arch splint with balanced contact for all excursive movements * Orthodontic movement to correct position of teeth * Mouthguard/occlusal splint * Provide posterior support      #### Clinical Approaches to Tooth Mobility 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. - **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 2. Orthodontic wires 3. Fixed bridges 4. Cross-arch splints designed with balanced contact for all excursive movements Clinical photo showing a close-up view of the anterior maxillary dentition with increased mobility. The teeth appear to be loose and are held in place by a pink acrylic splint or retainer. Clinical photo of a patient's occlusion demonstrating severe generalized tooth mobility. Multiple teeth show significant gingival recession and periodontal pocketing. A composite figure containing multiple periapical radiographs (X-rays) of posterior teeth. The images demonstrate various stages of periodontal bone loss and root morphology associated with increased tooth mobility. Clinical photo of a clear plastic mouthguard/occlusal splint designed to cover the mandibular teeth. This device is used for posterior support and stabilization of mobile teeth. Clinical photo of a yellowish acrylic occlusal splint covering the upper dental arch. The appliance provides balanced contact for all excursive movements to stabilize mobile teeth. 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