Significance of in the Etiology and Treatment of Early, Moderate and Advanced Periodontitis

Sigurd P. Ramfjord* and Major M. Ash, Jr.*

Concepts describing occlusion as a factor in the initi- odontitis in a co-destructive inves- 51 relationship26'28'30,59 ation, progress, and treatment of tigators41, using a monkey model-system were not able have a long and varied history.1"8 Although the proposed to demonstrate a loss of connective tissue attachment. interactions between occlusal stress and Periodontitis However, they did find that jiggling trauma caused some have usually involved the lesion of trauma from occlu- loss of height of crestal bone and a loss of the overall sion, occlusal relationships which interfere with plaque volume of alveolar bone.41, 51 Other investigators using elimination, and/or injure the surface of the gingiva also a beagle dog model47 reported a deepening of experi- have been postulated as etiologic factors. Thus malocclu- mentally induced periodontal pockets and an accelera- sion, irregularity of teeth, crowding, tipping, nonfunc- tion of bone résorption by progressive traumatic occlu- tion, and faulty marginal ridges have been considered sion. A number of reasons for the different results of the important in clinical periodontics. The present assess- two model systems have been speculated upon. ment of the role of occlusion in the etiology and treat- The spread of gingival inflammation into the peri- a of ment of Periodontitis will draw upon number inves- odontal membrane in association with trauma from oc- tigations and epidemological surveys of possible relation- clusion has not been found consistently in animals, in 69 ships between occlusion and periodontal disease. human biopsy or in autopsy material.32, 42' Although the biological reactions appear to be similar between SIGNIFICANCE OF TRAUMA FROM OCCLUSION humans and experimental animals, there may be signifi- TO PERIODONTAL DISEASE cant differences between animals as well as between animals and man with to the role of trauma from Injury to the periodontal tissues as a result of occlusal respect occlusion in the of disease. forces has been defined as the lesion of trauma from pathogenesis periodontal On the basis of evidence from on animals, occlusion.31'61 Furthermore, any excessive force which experiments trauma from occlusion does not initiate or results in sufficient displacement of a tooth also can or accelerate the of to produce a traumatic lesion with similar histologie fea- Periodontitis change gingivitis Whether or not trauma from occlusion will tures. However, it is not customary to describe such Periodontitis. accelerate the of formation or forces (viz. orthodontic as occlusal forces or to progress pocket signifi- forces) influence the attachment level is still controversial. speak of the lesions as being a response to trauma from cantly occlusion. Histologie characteristics of the lesions of trauma from with or without bone is occlusion have been well documented.29' 55' 60' 73' 75' 78'79 Increased tooth mobility, loss, often used as the clinical indicator for trauma from In only a few instances has the apical movement of the only occlusion. However, does not been related to trauma from occlu- hypermobility necessarily 78 indicate trauma from it be due to bone sion;8' 47' 71' in most well controlled studies, occlusion,79 may pocket loss.53 In the absence of additional and formation has not developed with trauma from occlu- signs symptoms, 74 it is a mistake to tooth with trauma sion.11, 61' An unverified for failure of equate hypermobility explanation from occlusion. The of trauma from occlusion trauma from occlusion to initiate periodontal pockets is diagnosis is difficult if not impossible to make on the basis of a the presence of the supracrestal fibers which act as a examination inasmuch as the barrier to the downgrowth of the junctional single diagnosis requires 11 epithelium.55' that be demonstrated. Move- Bone changes in the as a result oftrauma ongoing progressive injury ment of and will often from occlusion without an inflammation are teeth, repair compensatory change existing eliminate the occlusal factors the trauma and reversible34,56'52 when the forces are discontinued. producing also eliminate the clinical evidence. Thus the trauma When considering trauma from occlusion and peri- from occlusion may be self-limiting. A clinical diagnosis of trauma from occlusion requires evidence of active * Professor of , University of Michigan, Ann Arbor, MI injury. 48109. Both physiologic adaptation to function and patholog- S. Periodontol. 512 Ramfjord, A sh September, 1981 ical response to excessive function are seen clinically as been lost. This does not suggest that age itself is a increased tooth mobility, and to separate the two requires significant deterrent; orthodontic treatment can be car- more information than tooth hypermobility. The diag- ried out successfully at any age with controlled ortho- nosis is made on the basis of continued or increasing dontic procedures. Orthodontic tilting of teeth in dogs persistent discomfort or tenderness, and has shown that the response with loss of hypermobility, periodontal 17 radiographie evidence of bone and/or root résorption. attachment can occur with plaque-infected teeth.16' Hypermobility in the absence of bone loss due to peri- The transient trauma associated with orthodontics is not odontal disease may be a helpful finding but increased a significant etiologic factor with adequate periodontal mobility may not relate directly to the severity of peri- care. odontal disease.52 Both primary and secondary trauma from occlusion The presence in radiographs of a widened periodontal may be caused by . The periodontal significance space does not necessarily indicate hypermobility due to of bruxism increases with a decrease in periodontal trauma from occlusion. It may mean that a process of support. Although bruxism tends to lead to compensa- physiologic adaptation is present or that trauma from tory hypertrophy, the presence of bruxism must be con- occlusion has occurred in the past, but has become self- sidered in the prognosis and treatment of Periodontitis. limiting, or that trauma is present at the time. Additional Faulty dental procedures and restorations may be a historical evidence of past tenderness or subsequent pro- significant iatrogenic source of trauma from occlusion. gressive changes may be ofvalue in making the diagnosis For example, marginal ridge relationships and plunger of ongoing injury to the supporting structures. cusps have been considered to be etiologic factors in 12 Hypermobility of individual teeth may persist after periodontal disease.44' Although clinical observations of periodontal treatment, occlusal have supported the importance of marginal ridge rela- completion including 9 adjustment. The nature of such mobility and what should tions,38' 24' 58' controlled research on the correlation be done about it, if anything, is a controversial issue. between pocket depth and marginal ridge discrepancy Even so, there has been considerably reduced emphasis has not supported these observations. A recent study43 on splinting in the last decade. Splinting and occlusal found that marginal ridge relations in general are far less adjustment will be discussed later. important than other local factors such as plaque. Un- Hypermobility of individual teeth or groups of teeth equal marginal ridge height may not be directly related usually does not increase as a consequence ofperiodontal to food impaction or to periodontal destruction. treatment alone, but may decrease or remain the same.46, The periodontal destruction caused by continuous 64165 Also in the case of a reduced, but healthy periodon- trauma to abutment teeth can be due to faulty design of tium after periodontal therapy, increased mobility does partial dentures.60 In the presence of faulty types of not usually lead to further loss of periodontal support.45 frame work, clasps and tissue base support, extraction However, it is difficult to dismiss the clinical observation forces on the teeth and gingival irritation may cause an that the degree of hypermobility of some teeth (viz. accelerated loss of the abutment teeth. bicuspids) is more significant under certain conditions Habits such as biting on pencils or foreign objects can (viz. abutment for a clasped partial denture) than it result in localized destruction of supporting structures.67 would be for other teeth with the same degree of hyper- mobility but under different conditions. The presence of Trauma from Occlusion and Pathogenesis of traumatic rocking forces resulting in progressive injury Periodontal Disease and increasing mobility may disturb masticatory func- The role of trauma from occlusion in the pathogenesis tion and cause discomfort for the Such patient. hyper- of periodontal disease is not fully understood, but some mobility is not acceptable. provisional conclusions can be drawn from the evidence Increased mobility may be self-limiting, i.e., reach a available at this time. (1) Trauma from occlusion does of no increase in Such is often the case in point mobility. not initiate or aggravate marginal gingivitis or initiate the mandibular incisor where a nontraumatic region periodontal pockets; (2) it can cause increased tooth balance between forces and periodontal adaptation de- mobility; (3) active trauma tends to accelerate bone loss and comfort are a velops and function not problem. and pocket formation depending on the presence of local Trauma from occlusion has been listed as a possible irritants and inflammation; trauma be 25, 33' 70,80 (4) may perpetu- cause of ;14, however, reces- ated by bruxism; and (5) it plays a minor role, if any, in sion appears to be more related to plaque than to tooth the pathogenesis of early to moderate Periodontitis. hypermobility5'6 or malocclusion.76 SIGNIFICANCE OF TOOTH POSITION Orthodontics, Bruxism and Restorative Dentistry Although orthodontic treatment may lead to root ré- The relationship of occlusion to periodontal disease sorption without apparent reason, root résorption is more involves not only trauma from occlusion but also the likely to occur with the use of heavy forces,64 and is of potential effect of tooth position and irregularity and more significance where periodontal support has already crowding of teeth on periodontal disease. Volume 52 Number 9 Significance of Occlusion 513 There does not appear to be any significant correlation no significant direct relationship between malocclusion between malocclusion in terms of a classification (viz. (on the basis of Angle's classification) and the severity of Angle3) and periodontal disease.20 However, when some periodontal disease but malocclusion may indirectly af- features of malocclusion are considered separately, the fect periodontal health when it is severe enough to 13, 19' evidence for a positive relationship is conflicting.7' interfere with plaque removal; (2) malocclusion, as with as, 48, so, es, 7o The potential 0f direct trauma to the gingiva impinging overbite, can cause trauma to the gingiva; and associated with irregularly placed teeth along with a (3) severely malposed individual teeth may affect peri- predisposition to plaque accumulation has led to the odontal health. that such teeth are more to concept likely develop peri- PART odontal disease than teeth in alignment. Except for OCCLUSAL THERAPY AS A OF good PERIODONTAL TREATMENT cases of direct trauma to the gingival tissues, orthodontic treatment to reduce the likelihood of periodontal disease Since some aspects of the relationship between occlu- in later life10 has little support.35 sion and the etiology of Periodontitis are not entirely Several investigators have found a positive relation- clear, there is no agreement on requisites for occlusal ship between crowding or malalignment of the teeth and treatment in One reason for the lack of 57 periodontics. the amount of plaque present,2'7> and between crowd- agreement arises from the remaining controversy about ing and loss of attachment.1 Another investigator re- the importance of trauma from occlusion as an etiologic ported that the gingival pockets of overlapping teeth factor in Periodontitis. Another problem is the lack of were deeper than those of normally positioned teeth.72 established criteria for identifying periodontal trauma However, other investigators found that malalignment from occlusion. An additional difficulty is the paucity of of the teeth had little or no relationship to gingivitis or data on the beneficial effects of the various 39 longitudinal Periodontitis.4, 21, The determining factor for the se- forms of occlusal therapy. Despite these problems and verity of gingivitis, whether teeth are crowded or not, is disagreements, however, current concepts concerning the amount of plaque present. Thus malposed teeth are trauma from occlusion do provide guidance for the role not a significant periodontal problem in persons with of occlusal therapy in the treatment of periodontal dis- that excellent good .1'2 It has been suggested ease. can as well be found in the with the hygiene just patient General worst malocclusion as with the best occlusion.68 Principles When there is marked protrusion of maxillary anterior A general principle for the initial treatment of early, teeth, the hp seal may be obstructed which can lead to moderate and advanced Periodontitis in which the etio- mouthbreathing and predispose to gingivitis.15 The most logic factors are both bacterial plaque and occlusal fac- significant factor is not the crowding of the maxillary tors is to eliminate and control first the plaque and then anterior teeth but the presence of mouth breathing.40 the occlusal factors, except where delay may unfavorably It has been suggested that drifted teeth or those with influence later treatment, or cause discomfort to the abnormal proximal inclinations are related to poor oral patient. In such instances simultaneous, palliative treat- hygiene and thus such positions are detrimental to peri- ment may be indicated. 23' 27' 37' 49, 62, 66 factors odontal health.19' One study22 found a A general principle for the control of occlusal consistent correlation between periodontal destruction is to establish a stable occlusion with the least interfer- and mesially inclined molars, but gingival inflammation ence to plaque control and periodontal maintenance. tooth was not influenced by either abnormal tooth inclination A general principle for treating persistent hyper- occlusal or tooth drift. Also it was found that mesial inclination mobility following periodontal treatment and determined oral and predisposes to a shghtly increased incidence of tooth adjustment is to maintain hygiene mobility. Another investigation4 showed no correlation professional periodontal care, and to splint only when between the severity of periodontal disease in young such mobility interferes with the health and comfort of patients and tooth irregularities on the basis of changes the patient and/or is progressively increasing. in axial inclination, displacement, and rotation of teeth. Periodontal trauma from occlusion represents a lesion Progressive tipping associated with continuous trauma in the periodontium originating in dysfunctional occlusal from occlusion can accelerate periodontal breakdown.59 relations which have to be eliminated to restore peri- odontal health. A periodontist or another dentist who Tooth Position and Pathogenesis of Periodontal ignores occlusal therapy under those circum- Disease completely stances will fail to attain complete periodontal health for The role of crowding, rotation, tilting, and other spe- the patient, although he may succeed in eliminating cific features of malocclusion in the pathogenesis of gingival inflammation. periodontal disease has not been studied extensively Occlusal therapy may also help to reduce periodontal where objective methods of evaluating plaque have been pockets for tipped teeth and restore functional capacity utilized. Although data from longitudinal human studies to teeth with progressive mobility and trauma from are not available, current evidence indicates: (1) there is occlusion. Obviously occlusal therapy, in itself, cannot J. Periodontol. 514 Ramfjord, Ash September, 1981 cure gingivitis or Periodontitis caused by bacterial activ- The alleged value of temporary splinting with regard to ity, but it may facilitate plaque control and management promotion of healing and regeneration of periodontal of patients with periodontal disease. structures has not been substantiated by research find- The following modalities of occlusal therapy may be ings. Mobility of teeth may be decreased by reduction of applicable as part of periodontal treatment: (1) Ortho- inflammation, both with and without splinting, and the dontic treatment. (2) Temporary splinting. (3) Bite value of temporary splinting in periodontal treatment planes. (4) Occlusal adjustment. (5) Restorative dentistry. has not been established beyond facilitating scaling and (6) Splinting, long term. occlusal adjustment. A recent has reported that the response Orthodontic Treatment investigation18 1 year after periodontal treatment was more favorable Since there is no significant correlation between mal- with regard to gain of attachment in teeth having little occlusion (Angle's classification) and severity of peri- or no increase in mobility than in teeth with definite or odontal disease, orthodontic treatment of malocclusion high increases in mobility. During 7 years of subsequent should not be considered a routine preventive or thera- maintenance care there was no effect on attachment level peutic procedure in periodontics. However, there are a and pocket depth attributable to higher than normal number of more specific aspects of combined malocclu- mobility. It would therefore be interesting to see if tem- sion and periodontal disease in which orthodontic treat- porary splinting prior to periodontal therapy would lead ment may augment or even be essential to optimal results to a more favorable result of the periodontal treatment of periodontal therapy. than in nonsplinted teeth with equal elevation ofmobility a. Impinging overbite or shearing occlusion with levels. Such experiments are underway. trauma to gingival tissues usually requires ortho- Temporary splints using bonding techniques are effec- dontic treatment, or in extreme cases a combination tive and easy to use. They are also used for temporary of orthodontic and surgical procedures, often aug- replacement of lost teeth until the periodontal treatment mented by occlusal adjustment and restorative den- is completed. Indications are that temporary splints re- tistry. duce tooth mobility only as long as they are in place. b. Lack of lip seal and mouth breather's gingivitis When such splints are removed, the presplinting degree may indicate the need for orthodontic treatment. of mobility will return. c. Functional anterior crossbite often is accompanied Bite Planes by an unstable jiggling type of occlusion which seems to aggravate Periodontitis; in addition, at- Bite-planes have become increasingly popular in many taining functional comfort often will require ortho- aspects of occlusal therapy. For patients needing peri- dontic treatment. odontal treatment, they are used to ehminate trauma d. Uprighting tipped teeth may reduce periodontal from occlusion, bruxism, and temporomandibular joint pocket depth and will facilitate restorative dentistry or muscle pain, as well as to stabilize mobile teeth and and plaque control. prevent hypereruption of teeth without antagonists. A e. Correction severe of malposition ofteeth in relation bite-plane is commonly used following orthodontic re- to the is needed to secure a long positioning of teeth with advanced bone loss when the term favorable prognosis. patient for some reason cannot have permanent splint- f. Malposition of teeth in gingival fibromatosis often ing. The best type is the maxillary bite-plane with flat requires orthodontic treatment for optimal esthetic occlusal surface, centric stops for all opposing teeth, and and functional results. a cuspid rise area for posterior disclusion in lateral and g. Extensive open bite with contacts only on the last protrusive excursions. This appliance will decrease the molars often has associated periodontal problems occlusal load for single teeth, and also decrease the total and orthodontic treatment may be beneficial. muscle activity. h. Extruded anterior teeth with advanced periodontal disease and mobility may be positioned orthodont- Occlusal Adjustment ically into the alveolar process and subsequently The ultimate value of occlusal adjustment as part of treated by reattachment procedures. Forced erup- periodontal treatment has not been established in clinical tion of teeth with intrabony pockets may also re- trials. However, periodontal trauma from occlusion rep- duce the pocket depth. resents a lesion which should be eliminated in order to Orthodontic treatment should always be done after have a healthy masticatory system. Occlusal adjustment complete scaling and instruction in plaque control, but is one modality of therapy for elimination of such prior to periodontal surgery or restorative procedures. trauma. An occlusal adjustment does contribute to oc- clusal Other modalities also be Temporary Splinting stability.74 may needed, but if the trauma can be eliminated and the occlusion The purpose of a temporary splint is to reduce occlusal stabilized by occlusal adjustment, this is usually the forces and stabilize teeth for a hmited period of time. method of choice for either primary and secondary Volume 52 Number 9 Signiflcance of Occlusion 515 trauma from occlusion. Occlusal adjustment may also elusion is an essential part of complete periodontal ther- eliminate food impaction and gingival impingement in apy and restoration of health in the masticatory system some instances. for such patients. This can be achieved by orthodontic The need for adjustment should be based on a definite treatment, temporary splinting, bite-planes, occlusal ad- diagnosis of the presence of a traumatic lesion rather justment and permanent splinting of teeth. Occlusal than the location of some occlusal interferences, which therapy may be required during periodontal treatment may be of no significance. Only a few patients with early for trauma from occlusion and to enhance occlusal sta- and moderate Periodontitis have trauma from occlusion bility at any stage of Periodontitis, but is most often justifying occlusal adjustment. In advanced Periodontitis needed in advanced Periodontitis. Splinting of hyper- with extensive loss of periodontal support one may en- mobility of self-hmiting trauma from occlusion is not counter increased mobility of the teeth with or without indicated. Splinting may be required in addition to oc- actual evidence of trauma. If there are signs and symp- clusal adjustment in moderate to severe Periodontitis toms of trauma, occlusal adjustment should be consid- when trauma from occlusion is progressive. ered. 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Abstracts

Adenoid Cystic Carcinoma of the Nose, Paranasal Sinuses, multiprofessional basis which included dental, psychiatric and physi- and Palate ologic characteristics. Questions asked the patients were history of oral of what Miller, R. H., and Calcaterra, T. C. symptoms, oral habits, their personal opinion cause, they reactions to nondental examiners. Arch. Otolarynol. 106: 424, July, 1980. expected of treatment, daily stress, All the answers were related to psychiatric categorization, which was of cases In a study 18 of adenoid cystic carcinoma in patients ages the capacity for interpersonal contact (CIC). Patients with severe CIC 13 to 78 involved the years, seven cases maxillary antrum, seven reported strong pain and an unstable occlusion. Patients with good on the and four were tumors of the nasal originated palate, primary CIC reported restriction of mandibular mobility and moderate pain on cavities. Initial were a mass or or nasal obstruc- symptoms lump, pain, function. All patients reported fear of dislocation of the jaw. Most of tion. Decreased visual found in with activity was patients sinus lesions. the palpative findings by the dentist showed reports of pain with no Only one patient had cervical node metastasis and radiographie evi- differences found in oral habits. One third of the patients reported dence of pulmonary involvement. Surgery as the sole means of therapy being in stress while being examined by the dentist and a great was performed on nine patients and radiation therapy alone was proportion of the patients reported positively to nondental physiother- utilized as the initial mode of treatment in two with antral patients apy. As a result of the study it was concluded that patients with tumors. Combined therapy was used for seven patients. Follow up was complex MPD syndrome should be treated by specialists or on a extended up to 10 years, and prognosis was shown to be poor. The multiprofessional basis by the dentist and psychiatrist. Bite (occlusal) poorest prognosis was for tumors of the minor salivary glands. Depart- instability and fear ofjaw dislocation should be checked for the MPD ment of Otorhinolaryngology and Communicative Sciences, 1200 Mour- syndrome. Institute of Community Dentistry, Dental Faculty, Blindern, sund, Houston, TX. 77030. Dr. John Vrotsos Oslo 3, Norway. Dr. Rafael Diaz-Mendez Ultrastructure of the Conjunctiva, Skin, and Gingiva The Histopathologic Features Which Follow Repeated Messer, G., Harel, S., Erlich, ., Navon, R., Nemet, P., Sarnat, H., Tobacco Tar to Rat Lip Mucosa Shomrat, R., and Legum, C. Applications of Arch. Pathol. Lab. Med. 104: 123, March, 1980. Bastiaan, R. J. and Reade, P. C. Oral 49: 435, 1980. A case of Sandhoff s disease with clinical symptoms typical of Surg., May, gangliosidosis was described in a child with multiple developmental To study and evaluate the histologie changes in rat lip mucosa disabilities including blindness and psychomotor retardation. Biochem- exposed to repeated tobacco tar applications, 119 Sprague-Dawley rats ical analysis included biopsy of the gingival papillae which were red were used. Two forms of tobacco tar were used, Tar A and Tar B, and hypertrophie. Both hexosaminidase A and hexosaminidase which had basic differences in concentration. Heat was also used in activities were deficient in the leukocytes and serum. Ultrastructural two forms; dry heat and a thermostatically controlled water bath. The analysis of the conjunctiva, skin and gingiva as an aid for the diagnosis rats were divided into six groups, three experimental and three control of Sandhoffs disease was recommended along with biochemical ex- groups. After a designated period the rats were killed and histologie amination. Sandhoff s disease is a generalized lysosomal storage dis- sections were made of lungs and lip mucosa. Nodules were examined ease. Laboratory ofElectron Microscopy, Municipal Governmental Med- in the lung tissue, and the lip mucosa was studied for keratinization, ical Center, 6 Weizman Street, Tel Aviv, Israel 7065. Dr. John Vrotsos granular cell layer thickening, acanthosis, epithelial atypia, and inflam- nodules in the A Multiprofessional Study of Patients With Myofascial matory cells. The results showed that appearing lungs Pain-Dysfunction Syndrome. II were inflammatory in nature. The histologie sections showed a general irritational hyperplasia in from the tar with additional and A. N. Helöe, B., Heiberg, irritation caused by the heat. No capacity to initiate neoplastic activity Acta Odontol. Scand. 38: 119, Number 2, 1980. was found. Department of Dental Medicine and Surgery, University of To improve diagnostic procedures and treatment planning for my- Melbourne, 711 Elizabeth Street, Melbourne, Victoria, 3000, ofascial pain dysfunction syndrome, 108 patients were tested using a Australia. Dr. Rafael Diaz-Mendez