Section 5C

Non-Surgical

Pocket

Therapy:

Dental Occlusion

Marlin E. Gher*
'Private practice, Carlsbad,

California

Question Set

1. What evidence exists that establishes a

relationship between excessive occlusal forces
and the initiation, development, and/or exacerbation ofperiodontal diseases?
2. What evidence exists that occlusal therapy can modify the progression of Periodontitis or aid in the treatment ofPeriodontitis?
3. What are the effects of occlusal forces
on wound healingfollowing various periodontal surgical procedures; e.g., guided tissue
and guided bone regeneration, mucogingival
surgery, osseous regeneration, etc?
4. What evidence exists that "preventive"
occlusal adjustment is justifiedfor the health
of the periodontium?
5. What are the future directions for clinical practice and research on occlusal therapy
in relation to periodontal health?

Ann Penodontol

1996;1:567-580.

INTRODUCTION
The effects of occlusal forces on the progression of Periodontitis have been researched and debated for decades.1 36 Early
theories implicated traumatogenic occlusion
as the etiology of Periodontitis.13 When the
role of microorganisms as causative agents
in Periodontitis became evident, emphasis
switched to the evaluation of traumatogenic
occlusion as a cofactor in the progression of
Periodontitis.417 Glickman in the early
1960s proposed that a traumatogenic occlusion could produce a lesion of occlusal
trauma which could accelerate the progression of Periodontitis and direct the inflammatory process into the periodontal ligament.47 These early papers relied on
retrospective analysis of occlusal wear pat-

terns,

mobility patterns, autopsy material,

and patterns of attachment loss and pocket

formation to develop the theories that linked
traumatogenic occlusion and Periodontitis.
Later studies by Waerhaug associated the
location and severity of attachment loss with
the location of the "plaque front" on the
tooth.1819 These studies questioned the effect of occlusal forces on the progression of
Periodontitis and suggested that the various
patterns of attachment loss and intraosseous defect formation could be explained by
the "down growth of subgingival plaque."
Controlled prospective studies were
needed to investigate this controversial issue
and substantiate the effects of occlusal
forces on the progression of Periodontitis.
Due to the ethical questions and difficulty in
designing well-controlled prospective hu-

Vol. 1, No. 1, November 1996

Girier

568

man

studies, animal models

were

developed

to study the effects of traumatogenic occlusion on periodontal attachment and bone

loss.20 35 The prominent studies of the 1970s

and 1980s were published by Poison and
Zander used squirrel monkeys as their animal model27 35 and by Lindhe, Ericsson, and
Nyman using beagle dogs as their animal
model.20 26 In these animal models, the researchers could artificially induce experimental Periodontitis and superimposing a
traumatogenic occlusion to evaluate its effects on bone and attachment loss. Studies
by both Lindhe and Ericsson21 and Perrier
and Poison32 presented clinical and histologic data which indicated that heavy occlusal forces, in the absence of Periodontitis,
led to increased tooth mobility and bone
loss. Bone loss was present principally in the
form of widened periodontal ligament spaces
and, in a few cases, horizontal loss of crestal
bone height.
These research groups differed in their
findings, however, when simulated traumatogenic occlusion was combined with Periodontitis. Studies using beagle dogs indicated
that heavy occlusal forces when combined
with plaque induced Periodontitis led to accelerated attachment loss.20'2226 Studies
conducted using squirrel monkeys also
found bone loss and increased tooth mobility associated with "jiggling forces" used to
simulate a traumatogenic occlusion.27 31 The
squirrel monkey studies, however, found little or no effect of traumatic jiggling forces on
the rate of plaque associated attachment
loss. The authors also reported that elimination of traumatic jiggling forces in the
presence of continuing Periodontitis did not
lead to bone regeneration or a reduction in
mobility.30 The resolution of inflammation in
the presence of continuing mobility29 or jiggling trauma,34 however, led to decreased
mobility and increased bone density, but no
change in attachment level or alveolar bone
level. The results of these studies led clinicians to place greater emphasis on the elimination of dental plaque, the etiologic agents
responsible for Periodontitis, and to establish maintenance programs to maintain periodontal health.28 Occlusal therapy was
deemphasized in the treatment of Periodon-

Annals

of Periodontology

titis since it appeared to have a minimal role

in maintaining the attachment level once

plaque was eliminated.28

Human research studies reported from

1986-1987 questioned the effect of occlusal
forces on the progression of Periodontitis.37 39
In a report that evaluated patients with periodontal disease and occlusal parafunction,
Houston et al. concluded that "...there is no
or only weak correlation between periodontal disease and bruxism."37 Hakkarainen
evaluated the effect of the resolution of inflammation versus the resolution of occlusal
trauma on sulcular fluid flow.38 He found a
significant decrease in sulcular fluid flow after inflammation was reduced by oral hygiene instructions and scaling procedures,
however, no significant reduction of sulcular
fluid flow was detected after the elimination
of occlusal interferences. Pihlstrom et al.
evaluated the association between occlusal
trauma, severity of Periodontitis, and radiographic bone loss.39 They concluded that
teeth with occlusal contacts in working, balancing, and non-working positions had no
greater severity of Periodontitis than teeth
without these contacts.
The subject of occlusal treatment was reviewed by the World Workshop in Clinical
Periodontics in 1989.40 After examining the
literature up to that date, the reviewer concluded that the role of occlusal trauma in
the pathogenesis of Periodontitis was controversial and the influence of occlusion on
periodontal therapy remained unresolved.
The 1989 Consensus Report, however, supported the use of occlusal adjustment,
splinting, and orthodontic treatment for a
wide variety of clinical problems faced by the
dentist. These included the use of occlusal
adjustment to reduce mobility and fremitus,
encourage repair of the periodontal attachment apparatus, treat discomfort during
function, treat parafunction, and to achieve
functional relationships in conjunction with
restorative dentistry. Splinting was found to
be indicated for the stabilization of teeth for
a variety of restorative and functional needs.
Orthodontic treatment was also found to be
appropriate for a variety of reasons including
the facilitation of occlusal and restorative
treatment, to aid in the treatment of gingival

Review:

Non-Surgical Pocket Therapy: Dental Occlusion

defects, to improve plaque conto

food impaction problems,
eliminate
trol,
and to correct root proximity problems.
and

osseous

The multitude of articles, theories, and

techniques published on dental occlusion
have spawned a number of descriptive terms
which are at times confusing and misused.
This can lead to misinterpretation of research findings and development of therapy
that may not be based on sound clinical
principles. To reduce possible ambiguity in
the evaluation of the articles being reviewed
in this paper, a glossary of pertinent terms
is included at the end of this paper.
This review follows the following outline:
randomized controlled trials; cohort or longitudinal studies; non-controlled case studies; indirect evidence, animal studies; indirect evidence, laboratory studies; summary;
future research; and glossary.
A computer search was conducted to locate articles that could be used to evaluate
the effects of occlusal forces on the progression of Periodontitis. The search included
key words such as occlusion, dental occlusion, bite force, Periodontitis, periodontal
disease, etc. The search was limited to articles published in English after 1988. From
the thousands of articles published on periodontal disease since 1988, only 96 related
occlusion or occlusal forces to periodontal
diseases. A review of these articles was conducted to eliminate reviews, and articles on
occlusal adjustment technique, discussing
philosophy of occlusion, and those which did
not provide direct clinical or research findings.4155 This reduced the initial search to 9
possibly pertinent articles. It became evident
that since 1988 research efforts have
shifted away from dental occlusion to other
areas of periodontal diagnosis and therapy.
Research in the fields of dental implants,

periodontal regeneration, periodontal plas-

tic surgery, the use of antibiotics to treat

Periodontitis, and diagnostic techniques to
identify pathogenic microorganisms and active attachment loss have drawn the interest of researchers away from dental
occlusion. A journal-by-journal review of
the major peer reviewed journals was then
conducted to identify additional pertinent
articles not found in the computer search.

569

The search also was expanded to include

articles on risk factors to determine if occlusion had been implicated as a risk factor in
these research efforts. This expanded the
bibliography to those reviewed in this paper.5678 The 12 most pertinent articles are
summarized and presented in rank order in
Table 1 56-59.72.73.76-81
Meta-analysis was considered as a method
to evaluate the articles in this review. The
proper use of meta-analysis to evaluate the
findings of articles related to a specific subject requires a large number of studies that
address the subject to be evaluated; small
differences in findings to be estimated; and
an ability to rank treatments by superiority
which will not be reversed for subgroups.
Meta-analysis was, therefore, not used for
this review due to the limited number of articles on the effect of occlusal forces on Periodontitis published since 1988 and the use
of research animal models which have in the
past resulted in conflicting results. The reviewed articles were ranked and their findings discussed according to the following
rank order, the most important at the top of
the list: 1) randomized controlled trials; 2)
cohort or longitudinal studies; 3) case-controlled studies; 4) non-controlled case studies; 5) descriptive studies; 6) indirect evidence, animal studies; and 7) indirect
evidence, laboratory studies.

RANDOMIZED CONTROLLED TRIALS

Burgett et al. reported results from a randomized clinical trial designed to test the effect of occlusal adjustment as a component
of the treatment of Periodontitis.56 Fifty patients with moderate to advanced Periodontitis were entered in the study. All patients
received initial periodontal therapy and were
randomly divided into two groups who received either occlusal adjustment or no occlusal adjustment prior to definitive periodontal therapy. The patients were then
treated, in a split mouth design, with modified Widman flap surgery or scaling and root
planing. Those patients who received occlusal adjustment had a statistically significant
mean probing attachment gain of 0.42 mm
when compared to the patients with no oc-

Vol. 1, No. 1, November 1996

Gher

570

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Non-Surgical Pocket Therapy: Dental Occlusion

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Vbi. J, No. i, November 1996

Gher

572

clusal adjustment and a mean probing attachment gain of 0.02 mm. There was no
significant effect of occlusal adjustment on
the reduction of probing depth. While the
clinical attachment gain was considered statistically significant, this difference may be
of limited clinical importance to the clinician. The authors also stated that "Surprisingly, we did not find any significant
difference in reduction of tooth mobility between the adjusted and the not adjusted

groups."
In

review of data from

previous

of Periodontology

COHORT OR LONGITUDINAL
STUDIES

ran-

domized controlled human study, Wang et

al. evaluated the influence of furcation involvement and tooth mobility on periodontal
attachment loss and tooth loss for molar
teeth.57 They reported findings gathered
from The University of Michigan longitudinal
periodontal clinical trial. The data used were
from 24 of 78 patients who had been treated
with initial periodontal treatment followed
by periodontal surgery using one of three
surgical techniques. The surgical techniques
used included pocket elimination surgery,
modified Widman flap surgery, and gingival
curettage. The 24 patients evaluated had
been professional maintained for 8 years
without missing appointments. The author
attempted to relate attachment loss and
tooth loss over the 8-year period to furcation
involvement and tooth mobility. Loss of a
tooth was artificially assigned an attachment loss of 3.5 mm to account for lost teeth
in the attachment loss data. Teeth with furcation involvement were found to have increase tooth loss and attachment loss versus
teeth without furcation involvement. Mobile
teeth were reported to have significantly
more attachment loss (-1.08 0.41) mm
during the maintenance period than nonmobile teeth (-0.48 0.25 mm). A paired t
test indicated that during the maintenance
period, molars with furcation involvement
and mobility has significantly more attachment loss than furcation involved molars
with no mobility. Several problems make it
difficult to relate these findings to the effect
of occlusal forces or mobility on Periodontitis. Occlusal adjustment was included as a
standard component of initial periodontal
treatment in the original study to minimize

Annals

the effect of occlusion on the comparison of

the surgical treatment being evaluated.36
The cause(s) of the ongoing tooth mobility
such as continuing occlusal trauma or continued plaque induced inflammation were
not reported. Due to the complexities of dental furcation anatomy, it is difficult to quantify and separate the effects of compromised
plaque control due to the inaccessibility of
the furcation from the other variables.82 89

Ismail et al. reported on the findings from

group of 165 adults, residing in Tecumseh,
MI, who were originally examined in 1959
and reexamined in 1987.58 The purpose of
the study was to evaluate the change in attachment level in a sample population of
adults over a period of years. Results of the
re-examination indicated that 10.9% (376
teeth) of the teeth present at the beginning
of the study were lost during the 28-year
evaluation period. One hundred (100) of the
3,487 teeth evaluated were mobile at the
baseline examination. Forty-five percent (45%)
of these teeth were lost by the end of the
study. Three-hundred thirteen (313) (83%)
of the teeth lost had an initial attachment
loss of 2 mm or less. The cause of tooth loss
was not identified and therefore its effect on
the attachment loss measurements could
not be determined. Of the remaining teeth
evaluated, only 13.3% of the adults examined had a mean attachment loss of 2 mm
or more from 1959 to 1987. This study identified individuals with higher levels of attachment loss as having the following risk
markers: were older; smoked; had tooth
mobility at the base line examination; had
higher levels of gingivitis, calculus, plaque,
and tooth mobility at the second examination; and had a lower education level and irregular dental attendance. Increased age,
smoking, and tooth mobility were found to
be the factors most closely related to attachment loss. Considering any of these factors
to be risk markers does not establish a
cause and effect relationship. This study did
not evaluate occlusion and did not indicate
if occlusion was an etiologic factor in the disa

Review:

ease

fied

process or in the tooth

risk factor.

Non-Surgical Pocket Therapy:

mobility identi-

as a

A retrospective study by Jin and Cao in

1992 attempted to relate clinical signs of a
traumatogenic occlusion with severity of
Periodontitis in 32 patients with moderate to
advanced chronic adult Periodontitis.59 The

complete periodontal exincluding radiographs, recording

of probing depths, gingival index, bleeding
index, clinical attachment loss, plaque index, tooth mobility, tooth wear, and an occlusal analysis. Abnormal occlusal contacts;
i.e., premature contacts in centric relation,
non-working contacts in lateral excursions,
patients received

amination

premature contacts of anterior teeth, and

posterior tooth contacts during protrusion,

identified. After analyzing the data collected, the authors concluded that there was
no significant differences in probing depth,
clinical attachment level, or loss of alveolar
bone height when comparing teeth with and
without abnormal occlusal contacts. Teeth
with significant mobility, functional mobility, or radiographically widened periodontal
ligaments were associated with deeper probing depths, more attachment loss, and
greater bone loss. This study could not determine if tooth mobility and radiographically widened periodontal ligaments were
risk factors for the progression of Periodontitis or markers of the disease process.
Other studies have attempted to identify
"risk factors" for Periodontitis,60 62 attachment loss,63 67 bone loss,68 69 and tooth loss.70
Those factors reported as risk factors, listed
from the most commonly identified to the
least commonly identified by these studies,
included: age, race, tobacco use, increased
percent of sites with plaque, the presence of
Prevotella intermedius, Bactroides forsythus,
bleeding on probing, prior attachment loss,
probing depth, lower educational attainment,

were

gender (male), calculus, Porphyromonas gingivalis, positive BANA test, gingivitis, sociolevel, diabetes mellitus, systemic
disease, mobility, early loss of the first molar, and the lack of use of dental care. These
economic

articles did not clearly distinguish which of

these factors were true risk factors and
which were disease markers and therefore
could not establish which were etiologic.

Dental Occlusion

573

None of these studies identified occlusion

as

risk factor for Periodontitis; however, occlusal analysis and mobility measurements
were rarely included in the factors being
evaluated as risk factors.
In a series of papers on prognosis, McGuire and McGuire and Nunn reported on
their ability to accurately predict future
prognosis from commonly evaluated clinical
factors.7173 Mobility and parafunctional habits were identified as two of several "prognostic factors" that correlated with tooth
loss or with a worsening individual tooth
prognosis during a 5 to 8 year maintenance
period after treatment. In "well maintained"
patients, prognostic factors associated with
a worsening prognosis for individual teeth
included: deeper initial probing depths,
more severe furcation involvement, endodontic involvement, smoking, diabetes, malposed teeth, unsatisfactory root form, and
the presence of a parafunctional habit with
no biteguard.72 Initial tooth mobility was associated with a prognosis that was unlikely
to improve but was not associated with a
a

worsening prognosis.72
Prognostic factors associated with tooth
loss during the maintenance period included
initially greater: probing depths, furcation
involvement, mobility, and bone loss

as well
poor crown-to-root ratio, poor root form,
parafunctional habits without a bite guard,
and smoking.73 Tooth loss in this study was
due to periodontal disease, restorative purposes, endodontic involvement, and caries.
Unfortunately the authors could not associate initial prognostic factors with progressive attachment loss, the gold standard for
advancing Periodontitis. The inability to associate the prognostic factors of mobility and
parafunction with advancing attachment
loss; the inclusion of teeth lost due to nonperiodontal reasons; and the inability to
separate out other prognostic factors such
as furcation involvement, bone loss, and attachment loss inhibit our ability to draw conclusions about mobility or parafunction in
relation to progressive Periodontitis. The authors also noted that these findings relate to
well maintained patients and may not apply
when evaluating poorly maintained individuals.
as

Vol. 1, No. 1, November 1996

Gher

574

NON-CONTROLLED CASE STUDIES

Non-controlled case studies are relatively
unreliable sources of information upon
which to base a philosophy of treatment.
Benefits of treatment demonstrated for one
patient may not reliably transfer to other patients and the conclusions drawn from the
results of successful therapy in a few patients under conditions where a multitude of
variables were either unrecognized or poorly
controlled may lead the clinician to incorrect
conclusions. The following case studies are,
therefore, being presented principally to illustrate points which have been previously
presented in well designed studies.
Paul et al. reported the treatment of a case

diagnosed

as

rapidly progressive Periodon-

titis with localized occlusal trauma involving

tooth #10.74 Treatment consisted of scaling
and root planing, microbiological monitoring, use of systemic antibiotics, and surgical
treatment where needed. Six weeks after initial therapy, pockets involving tooth #10
had been reduced from 8 mm to 3 mm without surgical therapy or occlusal adjustment.
However, 6 months later, tooth #10 remained mobile and radiographically apparent bone loss remained despite minimal
probing depths. Multiple occlusal adjustments over the next year resulted in "reeruption" of the tooth which reduced the
crown-root ratio, eliminated occlusal interferences, and improved function. This case
demonstrated the ability to reduce probing
depth and eliminate inflammatory periodontal disease without occlusal adjustment. The
authors, however, considered occlusal adjustment to be a valuable treatment to reduce mobility and improve clinical function
of a tooth with severe attachment loss.
Wolffe et al. documented the restorative
and surgical treatment of a patient with advanced Periodontitis.75 Six months foUowing
the placement of 4 fixed partial dentures
(FPD), one in each quadrant, the occlusion remained stable. Over the next 2 years, the patient developed a malocclusion due to a shift
of one the FPDs in response to forces generated by the patient's tongue. The authors
stated that the reduced periodontium may

Annals

of Periodontology

have contributed to the lack of stability of the

splinted teeth. Occlusal adjustments led to a
clinically stable occlusion. The periodontium
remained healthy, with no signs of bleeding,
increased sulcus depth, or mobility throughout the reported period despite the persistent
forces that caused drifting of the teeth and significant changes in the occlusion.

INDIRECT EVIDENCE, ANIMAL

STUDIES
In a beagle dog study, Ericsson et al. evaluated the effect of splinting on the progression of experimental Periodontitis.76 Five
dogs had their mandibular 2nd and 3rd premolars and mandibular 1st molars extracted. Titanium implants were then
installed in the position of the 1st molar and
3rd premolar in the right side of the mandible. After 3 months of healing, non-resilient splints were placed connecting the
dental implants to the 4th premolar on the
right side. The 4th premolar on the left side
remained unsplinted and served as a control
with persistent mobility from prior attachment loss. Experimental Periodontitis was
initiated and maintained for 180 days by
placing a ligature around the premolars. Attachment loss and down growth of plaque
were evaluated with radiographs and biopsies after the 180-day test period. The researchers found that splinting the test
premolars failed to retard attachment loss or
to inhibit the apical down growth of the microbial plaque. They concluded that increased tooth mobility at the control tooth
did not exacerbate periodontal attachment
loss in this model.
The effect of jiggling occlusal forces on
probing depths in beagle dogs with normal
periodontal tissues was evaluated by Neiderud et al.77 Six beagle dogs had their teeth
cleaned before entering the study and 3
times each week during the study. Each dog
had jiggling forces applied to a test premolar
while a contralateral tooth served as a nonjiggling control. After jiggling forces had been
applied for 90 days, a probe was inserted
into the sulcus of the test and control teeth
and stabilized in position with composite
resin. Biopsies of the sites were obtained

Review:

Non-Surgical Pocket Therapy: Dental Occlusion

and used for histometric and morphometric

measurements. The measurements revealed
that despite clinically healthy gingival tissues, the teeth which had become mobile
due to the jiggling forces had lost marginal
bone. An enlarged "supracrestal connective
tissue compartment" had also developed
which resulted in significantly greater clinical probing depth measurements. This increased probing depth was related to a decrease in collagen density and a more
vascular connective tissue that was less resistant to probing without loss of connective
tissue attachment.
In a related study, Giargia et al. reported
a reduction of probing depth and mobility after removal of plaque retaining ligatures in a
beagle dog model.78 This study evaluated the
effect of experimental Periodontitis on the
histologic appearance of the periodontal soft
tissues, alveolar bone height, and on tooth
mobility. After 120 days of experimentally
induced Periodontitis, plaque retaining ligatures were removed and a supragingival debridement was performed. Block sections,
taken at the time of ligature removal and 15
days and 3 months later, were used for histometric and morphometric evaluation. Experimental Periodontitis led to the formation
of an inflammatory lesion, extensive bone
loss, and markedly increased tooth mobility.
Removal of the dental plaque led to reduced
tooth mobility and a decrease in the inflammatory lesion, but no regeneration of lost
bone. Probing depth which increased due to
the experimental Periodontitis was reduced
after removal of the microbial plaque. The
authors suggested that the reduced probing
depth was a result of the soft tissue changes,
due to resolution of inflammation after
plaque removal and to reduced mobility of
the teeth. The authors' comments on the effect of reduced mobility on probing depth
changes appeared to be more related to their
awareness of the results of the prior Neiderud study than to the results of this study.
This study does document an increase in
mobility due to periodontal inflammation
and a decrease in that mobility as inflammation is decreased. This result appeared to
be independent of occlusal forces in this experimental model. It also documented that

575

changes in mobility may persist for several

months after etiologic factors are reduced
and inflammation is resolving.
In a study in a rat model that evaluated
the effect of experimental traumatic occlusion on periodontal blood flow, Kvinnsland
et al. reported an increase in blood flow to
both the pulp and periodontal ligament after
the initiation of heavy occlusal forces.79 In
the early stages of the study the experimental "traumatized" side had an increased
blood flow when compared to the control
side. In the later stages of the experiment,
both control and experimental sides had increased blood flow. This study did not evaluate the effects of occlusal forces on
Periodontitis but did demonstrate a physiologic response of the periodontal tissues to
occlusal forces.
INDIRECT EVIDENCE, LABORATORY
STUDIES
Photoelastic model and finite element
model studies have evaluated the transmission of occlusal forces to the periodontium.80 81 Wylie et al. used a photoelastic
model to simulate the effect of splinting a
periodontally involved tooth to one or more
sound teeth when placing a cantilevered
fixed partial denture.80 They found that optimal stress distribution occurred when
splinting the compromised tooth to 2 sound
teeth. Increasing the number of splinted
teeth, beyond two sound teeth, did not significantly decrease the stress transmitted to
the periodontium. Cross-arch splinting did
not result in a significant sharing of the occlusal forces.
Using a finite element model, Aydin et al.
evaluated the stresses induced by various
loading forces on a mandibular 3-unit fixed
partial denture using a molar and a premolar as abutments.81 Loads of 300 N to 600 N
applied in axial and nonaxial directions were
analyzed. Forces applied in non-axial directions led to an increase the level of stress delivered to the alveolar bone. The premolar
exhibited greater stress distribution to the
bone than the molar when non-axial forces
were applied. Stress levels increased, also,
when periodontal support was diminished.

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Studies like these can be used to demonstrate the mechanics of transmission of

forces from teeth to the periodontium. They
can not be used to interpolate results to
broader and more involved interactions such
as those involving occlusion and inflamma-

tory periodontal

disease.

SUMMARY

Despite decades of debate and multiple

publications that discuss the theory of occlusion, occlusal design, and equilibration
techniques, there have been few well-designed human studies that can help answer
the question "does occlusal trauma modify
the

progression of attachment loss due to in-

flammatory periodontal
cles reviewed clearly

disease." The artidemonstrate that

occlusal forces are transmitted to the periodontal attachment apparatus80'81 and those
forces can cause changes in the bone and
connective tissue.21-27'77-79 These changes can
effect tooth mobility and clinical probing
depth.23,28 74'77 While occlusal forces do not
initiate Periodontitis, results are inconclusive on the interactions between occlusion
and the progression of attachment loss due
to inflammatory periodontal disease.
While some studies found a relationship
between increased attachment loss and
tooth mobility,57-59 others found no relationship between attachment loss and abnormal
occlusal contacts.59 Tooth mobility can be a
result of a variety of factors including loss of
alveolar bone, attachment loss, disruption of
the periodontal supporting tissues by inflammation, occlusal forces which lead to
widening of the periodontal ligament (physiologic adaptation), periodontal ligament atrophy from disuse, or any process which
effects the supporting periodontal structures. Therefore, any relationship found between tooth mobility and progressing Periodontitis does not necessarily indite or defend
occlusion as a cofactor in the progression of
inflammatory periodontal disease.
Periodontitis can be treated and periodontal health maintained without occlusal adjustment and despite the obvious presence
of traumatic occlusal forces. 21,29,74,75 However, statistically greater gains in clinical

Annals

of Periodontology

periodontal attachment level have been documented when occlusal adjustment was included as a component of periodontal
therapy.56 The extent to which this is clinically meaningful in the treatment of Perio-

dontitis is unclear. The effects of normal

occlusion, parafunctional habits, and tooth
mobility on wound healing have also not
been adequately evaluated.
Once periodontal health is established,
occlusal therapy can be an aid to help reduce mobility, regain some bone lost due
to traumatic occlusal forces, and to treat a
variety of clinical problems related to occlusal instability and restorative needs.40 71
Based on the literature, it appears that a
clinician's decision whether or not to use
occlusal adjustment as a component of
periodontal therapy should be related to an
evaluation of clinical factors involving patient comfort and function and not based
on the assumption that occlusal adjustment is necessary to stop the progression
of Periodontitis.

FUTURE RESEARCH

Prospective studies on the effects of occlusal forces on the progression of Periodontitis

are not ethically acceptable in humans.
Double-blind controlled prospective human
studies to determine the effects of occlusal
forces and mobility on wound healing follow-

ing periodontal therapy are possible and are

badly needed. These studies could answer
questions concerning the effects of occlusion
and mobility on regenerative periodontal
therapy such as guided tissue regeneration

and periodontal plastic surgery.

Studies that attempt to identify risk factors for Periodontitis should also include occlusal analysis in the study parameters to
evaluate this variable. These studies are,
however, retrospective in nature and therefore may find it difficult to establish cause
and effect relationships. Animal studies
could help to define the effects of occlusal
forces on peri-implant bone loss and to determine if excessive occlusal forces can effect
the progression of plaque induced peri-im-

plantitis.

Review:

Non-Surgical Pocket Therapy: Dental Occlusion

GLOSSARY OF TERMS
Attachment

apparatus: The cementum,

periodontal ligament,

and alveolar bone

which function as a unit to support the
teeth.
Bruxism: A habit of grinding, clenching,
or clamping the teeth. The forces so generated may damage both the tooth and the attachment apparatus.
Co-factor: An aspect of personal behavior
or life-style, an environmental exposure, or
an inborn or inherited characteristic which
by itself does not cause a disease process
but which can modify the course or expression of a disease process.
Disease markers: Factors that are indicative of the disease, but that are not thought
to be etiologic or may be historical measures
of the disease or disease progression.
Fremitus: A palpable or visible movement
of a tooth when subjected to occlusal forces,
(also referred to as functional mobility)
Mobility, tooth: A visually perceptible
movement of the tooth away from its normal
position when a light force is applied. (This
movement may be within physiologic limits
or

beyond physiologic limits.)

Occlusion: The contact of opposing teeth.

Occlusal adjustment: Reshaping the occluding surfaces of teeth by grinding to create harmonious contact relationships between the upper and lower teeth or
orthodontic movement of the teeth to create
a more harmonious occlusal relationship.
Occlusal forces: Forces that are generated and transmitted to the supporting
structures of the teeth when the teeth are

brought into

contact.

inhibits the

remaining occluding surfaces

achieving

Any

contact that

stable and harmonious

con-

tacts..

Occlusal trauma: An

injury to the attach-

ment apparatus or tooth

cessive occlusal forces.

as a

result of

ex-

Occlusal traumatism: the overall process

which a traumatogenic occlusion produces injury in the periodontal attachment

by

apparatus.

Parafunction: abnormal
as in bruxism.

function,

Premature occlusal contact: A condition

of tooth contact that diverts the mandible
from a normal path of closure.
Primary occlusal trauma: Injury resulting from excessive occlusal forces applied to
a tooth or teeth with normal periodontal

support.
Secondary

occlusal trauma: Injury refrom

normal
occlusal forces applied
sulting
to a tooth or teeth with inadequate periodontal support.
Traumatogenic occlusion: Any occlusion that produces forces that cause an injury to the attachment apparatus.

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