JIACD
The Journal of Implant & Advanced Clinical Dentistry
What is the current thought on occlusion in the routine treatment of periodontitis?
Thu, 12/04/2008 - 14:35 — HerndonDDS
Lack of mobility is a fundamental in wound healing. I am interested in a consensus of thought in the periodontal community on how they manage this, or if they do, in the usual course of traditional osseous and mucogingival surgery and following scaling and root planing. I am also interested in the degree of importance that is placed on this within the treatment planning process. I hope many of you reading this will comment! Thanks.
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I adjust occlusion
Controversial subject. I adjust. Patients like it when their "bite feels more even" and I have seen improvement in non-surgical outcomes when occlusal adjustment added. Again, a controversial subject, so no one is going to agree with everything.
Occlusion. A controversial subject.
Perio + Occlusion is a very controversial subject. Personally, I side with the Gothenburg group of studies. In my opinion, these studies by Lindhe, Ericsson, Svenberg, etc. were a better design than the Eastman studies due to use of buccal/lingual forces (more realistic than mesial distal forces as were used in the Eastman studies) and the evaluation times went out to one year.
1996 Yamamoto study noted that when Human PDL cells are subjected to prolonged or excessive stress or hydrostatic pressure, they produce elevated cytokines such as IL-6, IL-8, and RANKL.
Youdellis/Mann 1965, Burgett 1992, Nunn/Harrell 2001 showed that it was better to treat occlusal discrepencies.
There are many studies to argue the contrary, but these are some of the studies that I use to support adjusting occlusion. Additionally, most of my patients always comment that their bite feels much better after occlusal adjustment and I have never had anyone complain.
Anectdotally, I can say that my non-surgical results do seem much better when I adjust occlusion.
As for bone grafting, elimination of mobility is a must in my opinion. Mellonig likes to quote a study by Hjorting-Hansen noting that as little as 20 micrometers of movement during the early stages of ossesous healing is enough to shift differentiation of mesenchymal cells from osteoblasts to fibroblasts. Also, in some personal conversations I have had with Dr. Bowers, he states that lack of mobility is key when attempting regeneration.
Occlusion....no clear answers
I think occlusion is something we all talk about from the ivory pillars of academia, but when the rubber meets the road it is very difficult to truly control occlusion in every situation.
For me control of occlusion becomes increasingly important in cases with more advanced bone loss. In mild to moderate periodontitis I don't generally spend much time on occlusion unless there is alot of tooth mobility. I believe that if there is no tooth mobility, than the forces the patient has placed on their teeth have not exceeded the adaptive capacity of their periodontium. Also Reinhardt found that at 60% or more bone loss it only takes 1/3 the force to create injury to the bone and periodontal ligament. When tooth mobility is present...or potential for it after surgical incision then control of occlusion as part of initial therapy is important. Gillespie showed that as bone loss increases post-incision mobility increases exponentailly and may become an issue.
In these cases I prefer to adjust any gross interference, then put the patient into an occlusal orthotic device. Studies by Attenasio show that as much as 70% of parafunction occurs at night, so this is the time when occlusal control is most important. Occlusal adjustment is (in my experience) rarely accomplish-able to ideal occlusion without removing significant amounts of tooth structure, therefore use of a reversible device is a more conservative approach. Compliance is the disadvantage here, however, but then again occlusally adjusted teeth can also shift over time into interference again, so what is the therapeutic endpoint???
Regenerative therapy.....less mobility is better, but studies by Trejo show that CAL gains are achieveable with DFDBA/GTR grafting up to class 2 mobility, but these studies do not evaluate bone fill, which I believe is worse with mobility.
Ccclusion for Dr. Shumaker
Nick, you mean it has been over 2 years?? Time is passing to quick! But then you are a young guy and have not experienced that yet, right!! Ha.. An interesting side line to this is immediately following sugical treatment, and I mean at the same appointment, check the occlusion immediately post op. I think you will find as I do that mobility has increased and interferences are more obvious. I do one side surgery, check the occlusion, adjust until there are no contacts and at the next week post op, everything is back into occlusion and more moderate adjustment is done at that time. Etc., as time goes on and through out their career as a patient. Mostly, BULL adjustment (not meaning bovine stuff..). Again, as we all know but sometimes forget, the tooth is one of the walls of the defect..
Occlusion...remember the basics
Had a referral recently for "periodontal disease". The patient had "Loose teeth" but no pocket depths, no bleeding on probing, and good oral hygiene. The patient did, however, have widened PDLs, plenty of mobility, and tons of interfering contacts.
Did a full mouth occlusal adjustment. Patient was happy with her improved bite, and said she felt better by the one week follow up visit. Within a few months, much of the mobility had disappeared.
Remember the basics folks.
Occlusion...remember the basics
Had a referral recently for "periodontal disease". The patient had "Loose teeth" but no pocket depths, no bleeding on probing, and good oral hygiene. The patient did, however, have widened PDLs, plenty of mobility, and tons of interfering contacts.
Did a full mouth occlusal adjustment. Patient was happy with her improved bite, and said she felt better by the one week follow up visit. Within a few months, much of the mobility had disappeared.
Remember the basics folks.