ROLE OF OCCLUSION IN PERIODONTAL DISEASE

GUIDED BY: PRESENTED BY:DR. AMIT GOEL DR. VIRSHALI GUPTA PG 2ND YEAR

CONTENTS INTRODUCTION DEFINITION OF OCCLUSION CLASSIFICATION BIOLOGICAL BASIS OF OCCLUSAL FUNCTION RELATIONSHIP OF OCCLUSAL DISHARMONY TO PERIODONTAL DISEASE HYPERFUNCTION : OCCLUSAL TRAUMA & TFO HYPOFUNCTION PARAFUNCTION : BRUXISM AND PERIODONTAL DISEASE CLINICAL DIAGNOSIS TREATMENT PLANING CONCLUSION REFERENCES

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INTRODUCTION Periodontal disease is a multifactorial disease that affects only a limited number

of people within a population.

Occlusal discrepancies do not cause periodontal disease but may be a significant risk factor in their progression.

Removing the risk factor of occlusal discrepancies through selective grinding and/or occlusal appliances during periodontal therapy has been shown to produce significant changes in the progression of the disease and improve the results of treatment of the inflammatory component of the disease.

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HISTORY Karolyi (1901) : Linked trauma from occlusion to periodontal disease.

Weinmann (1941) : No relationship between occlusal forces and periodontal destruction. Gingival Inflammation extending into the supporting bone was the cause of periodontal destruction.

Glickman et al (1954): No initiation of periodontal disease by occlusal trauma.

Waerhaug (1979): considered that excessive occlusal forces resulted in changes distinct from periodontitis and that there was little or no relation between occlusal trauma and the

changes associated with inflammatory plaque associated periodontitis.

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DEFINITION OF OCCLUSION Functional relationship between the components of the masticatory system,

including the teeth, supporting tissues, neuromuscular system, TMJ and craniofacial skeleton.

CLASSIFICATION OF OCCLUSION Physiologic occlusion: occlusion of the teeth in harmony with the functions of the

masticatory system.

Non- physiologic occlusion: Associated with dysfunction or disease due to tissue injury and treatment may be indicated.

The signs and symptoms of non-physiologic occlusion include damaged teeth and restorations, abnormal mobility, fremitus, a widened PDL, pain and a subjective sense of a bite discomfort.

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BIOLOGICAL BASIS OF OCCLUSAL FUNCTION

The masticatory apparatus is a dynamic system with a considerable total capacity to adapt through a wide range of functional requirements.

There is constant turnover and adjustment of supporting bone and the connective tissue elements of the periodontium to maintain a balanced relationship where the total adaptive capacity of masticatory system is exceeded, breakdown of any of the individual tissue involved may result.

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RELATIONSHIP OF OCCLUSAL DISHARMONY TO PERIODONTAL DISEASEHYPERFUNCTION

CHANGES ARE PRODUCED SUCH AS:Polson and Zander 1983 found that a single episode of trauma results in damage to the periodontium: Necrosis Hemorrhage Thrombosis Undermining resorption.

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OCCLUSAL TRAUMA Injury to the periodontium resulting from occlusal forces which exceed the reparative

capacity of the attachment apparatus.

CLASSIFICATION OF OCCLUSAL TRAUMA

Primary occlusal trauma Secondary occlusal trauma

Injury resulting in tissue changes from Injury resulting in tissue changes from normal excessive occlusal forces applied to or excessive occlusal forces applied to a tooth or teeth with normal support. tooth or teeth with reduced support.

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Primary occlusal trauma: Can cause migration and transient or permanent loosening of teeth, but it cannot

produce gingivitis, pocket formation, apical migration of the epithelial cuff or gingival hyperplasia.

Secondary occlusal trauma: may facilitate the deeper spread of the inflammatory process. may be a cause of vertical bone resorption and compound pocket formation.

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OCCLUSAL TRAUMA AND PLAQUE-INDUCED INFLAMMATORY PERIODONTITIS

Excessive occlusal forces placed on a non infected periodontium do not initiate gingival connective tissue attachment loss or pocket formation.

When occlusal trauma is superimposed on plaque-induced inflammatory periodontitis, vascularity and osteoclastic activity increases, and tooth mobility and PDL width increases.

enhanced loss of alveolar bone height and volume as compared with inflammatory periodontitis alone.

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CURRENT CONCEPTS OF TRAUMA FROM OCCLUSION

Transient TFO will not initiate nor aggravate marginal gingivitis, nor will it initiate formation of periodontal pockets.

Contribute to increase tooth mobility, progressive TFO without self- limiting features tends to accelerate pocket formation and bone loss.

Periodontal significance of TFO in patients with periodontitis also depends on the magnitude of the irritants in pockets.

TFO plays a minor role, in the pathogenesis of early to moderate periodontitis.

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TYPES OF FORCES APPLIED TO THE TOOTH Jiggling force : the direction of forces are multidirectional and the bony area of breakdown will be "funnel" shaped as the periodontal ligament widens on both sides of the tooth.

Orthodontic force:unilateral force that results in deflection of the tooth away from the force.

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HYPOFUNCTION Anneroth and Ericsson 1967, have stated the present generally accepted view on

the changes associated with hypofunction which was formulated by Goldman et al. 1991.

The changes usually include: Loss of alveolar proper, entirely missing supporting bone. PDL is thin and consists of principally indifferent fibers. Most of the principle fibers

having been lost. Decreased osteoblastic and cementoblastic activity, Cribiform plate is completely missing, bone marrow will occupy the space

previously occupied by periodontal ligament. Collagen fibers are few in number.

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PARAFUNCTIONHabits performed at a subconscious reflex level and the patient may be unaware of their existence. Habits of significance have been classified by Sorrin into 3 main groups: Neurosis Occupational habits Miscellaneous habits

Neurosis such as HABIT RESULT

Cheek biting and lip biting parafunctional position of the mandible

Tongue thrusting and abnormal swallowing anterior open bite or tilting of anterior teeth Biting of pencils or finger nails dysfunction and occlusal trauma

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BRUXISM AND PERIODONTAL DISEASE Bruxism does not initiate gingivitis or pocket formation. The most frequent results of bruxism in a normal mouth are compensatory

hypertrophy of the periodontal structures and increase in width of the periodontal membrane.

Where there is pre -existing gingival inflammation and particularly where there is some loss of tooth support, the weight of evidence suggests that bruxism probably accelerates the destructive process, as does any other form of secondary occlusal trauma.

Y Ono et al 2008 suggested that bruxism affects both periodontal sensation and tooth displacement.

OCCUPATIONAL HABITS: holding of nails in the mouth e.g. cobblers.MISCELLANOEUS HABITS: pipe or cigarette smoking, tobacco chewing, incorrect methods of tooth brushing.

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CLINICAL EVALUATION AND DIAGNOSISDIAGNOSIS OF BRUXISM:

Number of signs help in diagnosis: Advanced attrition Increased tooth mobility not present with the amount of attachment loss or

degree of inflammation. Widened PDL spaces seen in radiographs. Hypertonicity of muscles of mastication which can be diagnosed with

electromyography.

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TMJ SCREENING EXAMINATION:

Maximal interincisal opening Opening – closing pathway Auscultation for TMJ sounds Palpation for TMJ tenderness Palpation for muscle tenderness

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DIAGNOSIS OF OCCLUSAL TRAUMA Increasing tooth mobility, migration or drifting. Wear facets Fremitus Persistent discomfort on eating Fractured tooth/teeth. Thermal sensitivity.

RADIOGRAPHIC SIGNS: Discontinuity and thickening of lamina dura. Widening of periodontal ligament space (funneling/saucerisation) Radiolucency and condensation of alveolar bone or root resorption. “Vertical” rather than “Horizontal” destruction of the interdental septum.

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DEVELOPMENT OF TREATMENT PLANNINGOCCLUSAL THERAPY The purpose of occlusal therapy is to establish stable functional relationships favorable to the oral health of the patient, including periodontium. A variety of procedures can be done. Occlusal adjustment Restorative procedures Inter occlusal appliance Orthodontic tooth movement Orthognathic therapy

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OCCLUSAL ADJUSTMENTCORONOPLASTY

Retrusive prematurities are eliminated. Adjust ICP to achieve stable, simultaneous contacts. Test for excessive occlusal contact on the incisors in ICP. Elimination of posterior protrusive contacts. Reduce mediotrusive prematurities Laterotrusive prematurities Gross occlusal disharmonies Recheck Contact relationship Polish all depressed surfaces to make the patient feel comfortable, the occlusal

surfaces are smoothened and polished.

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Burgett et al, 1992: occlusal adjustment to reduce tooth mobility before conventional periodontal

treatment leads to probing attachment gain after therapy.

current view is that, if occlusal adjustment is needed, it should be carried out after treatment.

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World workshop in periodontics’ guidelines for situations when occlusal equilibration may be indicated: When there are occlusal contact relationships that cause trauma to the

periodontium, joints, muscles or soft tissue. When there are interferences that aggravate parafunction. As an aid to splint therapy.

All these stages may be necessary before equilibration of the patient’s teeth can be completed: Successful stabilization-splint therapy. Study models mounted to centric relation on a semi-adjustable articulator. Mock equilibration on duplicated study models.

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SPLINTING‘World workshop in periodontics’ indications:

To stabilize teeth with increasing mobility that have not responded to occlusal adjustment and periodontal treatment.

To prevent tipping or drifting and the over-eruption of unopposed teeth. To stabilize teeth after orthodontic treatment. To stabilize teeth following acute trauma.

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HOW TO DECIDE WHAT MODE OF TREATMENT IS REQUIRED?CLINICAL FEATURES RADIOGRAPHIC

FEATURESTREATMENT REQUIRED

TREATMENT OUTCOME

INCREASED mobility. INCREASE width of PDL with NORMAL bone height.

Periodontal therapy and occlusal equilibration.

Normalizes PDL width.

Increased mobility. INCREASE width of PDL with REDUCE bone height.

Periodontal therapy and occlusal equilibration.

Bone fill of angular defect, bone level stabilized, normal PDL width.

Increased mobility, patient NOT functioning comfortably.

NORMAL width of PDL with REDUCED bone height.

Periodontal therapy, occlusal equilibration ± splinting.

Patient’s comfort and function may improve.

Increased mobility, patient functioning comfortably.

NORMAL width of PDL, REDUCED bone height.

Periodontal therapy alone. No occlusal adjustment required.

No further deterioration

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CONCLUSION

Evaluation and management of the periodontal patient must include a thorough examination of the masticatory system, including a TMD screening exam and functional evaluation of occlusion. Occlusal interventions should be considered an adjunct to periodontal therapy, reversible when possible and planned in the context of the restorative needs.

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REFERENCES

Etiology and Pathogenesis of Periodontal Disease, Alexandrina L. Dumitrescu. Occlusal considerations in periodontics British dental journal, volume 191, no. 11,

December 8 2000. Occlusal forces as a risk factor for periodontal disease. Periodontology 2000 vol

32, 2003, 111-117. Occlusion and periodontal health., J. De Boever, A. De Boeve. Textbook of clinical periodontology, Carranza 9th edition. PERIODONTICS MEDICINE, SURGERY, and IMPLANTS ,Louis F. Rose, DDS, MD .

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