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What is occlusal trauma? What are the clinical signs and symptoms of occlusal trauma? Describe the types of occlusal trauma. Which system do you use to classify mobility? What is fremitus? Is there a relationship between mobile teeth and success of periodontal treatment? What are the indications and contraindications of splinting mobile teeth?

1. Miller, S.C. Textbook of Periodontia, Blakiston Co., 1950, p. 125.
2. Laster L. An evaluation of clinical tooth mobility measurements.J Periodontol 46:603-607, 1975.
3. RosenbergD, Quirynen M, et al. A method for assessing the damping characteristics of periodontal tissues: Goals and limitations. Quintessence Int 26:191-197,1995.
4. NeiderudAM, Ericsson I, Lindhe J. Probing pocket depth at mobile/nonmobile teeth.J Clin Periodontol 1992; 19:754-759.
5. PerrierM, Polson A. The effect of progressive and increasing tooth hypermobility on reduced but healthy periodontal supporting tissues. J. Periodontol. 53:152-157, 1982.
6. KerryGJ, et al. Effect of periodontal treatment on tooth mobility.J. Periodontol. 53:635-638, 1982.
7. Fleszar TJ, Knowles JW, et al. Tooth mobility and periodontal therapy. J Clin Periodontol.7:495-505, 1980.
8. GallerC, Selipsky H, Phillips C, Ammons WF Jr. The effect of splinting on tooth mobility. (2) After osseous surgery. J Clin Periodontol. 1979 Oct;6(5):317-33.
9. Lemmerman, K. Rationale for stabilization: J Periodontol 1976;47:405-11
10. Lindhe J, Ericsson I. Influence of trauma from occlusion on reduced but healthy periodontal tissues in dogs. J. Clin. Periodontol. 3:110-122, 1976.
11. Glickman I, et al. The effect of occlusal forces on healing following mucogingival surgery. J. Periodontol. 37:319-325, 1966.
12. Polson AM, et al. Osseous repair in the presence of active tooth hypermobility.J Clin Periodontol. 10:370-379, 1983.
13. Schulz A, Hilgers RD, Neidermeier W. The effect of splinting of teeth in combination with reconstructive periodontal surgery in humans. Clin Oral Invest 4:98-105,2000.
14. Harrel SK. Occlusal forces as a risk factor for periodontal disease. Periodontol 2000 2003;32:111-7.

Describe the different theories of occlusion and its relationship to the periodontium. Do teeth with occlusal contacts in excursive positions exhibit any greater severity of periodontitis? Do occlusal discrepancies affect gingival recession?

1. Waerhaug J. The angular bone defect and its relationship to trauma from occlusion and downgrowth of subgingival plaque. J. Clin. Periodontol. 6:61-82, 1979.
2. Yuodelis RA, Mann WV. The prevalence and possible role of non-working contacts in periodontal disease. Periodontics. 3:219-223, 1965.
3. Shefter, G, McFall, W, Occlusal relationsh and periodontal status in human adults. J Periodontol 1984:55:368-374
4. Pihlstrom B, Anderson K, Aeppli D, Schaffer E. Association between signs of trauma from occlusion and periodontitis. J. Periodontol. 57:1-6, 1986.
5. NunnM, Harrel SK. The effect of occlusal discrepancies on treated and untreated periodontitis, part I: relationship of initial occlusal discrepancies to initial clinical parameters. J Periodontol 2001;72(4):485-94.
6. HarrelS, Nunn M. The effect of occlusal discrepancies on periodontitis, part II: relationship of occlusal treatment to the progression of periodontal disease. J Periodontol 2001;72(4):495-505.

What are the histological findings from trauma from occlusion?

1. Glickman I, Smulow JB. Alterations in the pathway of gingival inflammation into the underlying tissues induced by excessive occlusal forces. J Periodontol 33:7-13, 1962.
2. Glickman I, Smulow J. The combined effects of inflammation and trauma from occlusion in periodontitis. Int Dent J 1969;19(3):393-407
3. Waerhaug J. Pathogenesis of pocket formation in traumatic occlusion. J Periodontol 26:107-118, 1955.
4. Comar MD, et al. Local irritation and occlusal trauma as co-factors in the periodontal disease process. J. Periodontol. 40:193-200, 1969.
5. Lindhe J, Svanberg G. Influence of trauma from occlusion on progressive experimental periodontitis in the beagle dog. J. Clin. Periodontol. 1:3-14, 1974.
6. Ericsson I, Lindhe J. Lack of effect of trauma from occlusion on the recurrence of periodontitis. J. Clin. Periodontol. 4:115-127, 1977.
7. Nyman S, Lindhe J, Ericsson I. The effect of progressive tooth mobility on destructive periodontitis in the dog. J. Clin. Periodontol. 5:213-225, 1978.
8. Ericsson I, Lindhe J. Effect of longstanding jiggling on experimental marginal periodontitis in the beagle dog. J. Clin. Periodontol. 1982; 9: 497-503
9. Ericsson I, Lindhe J. Lack of significance of increased tooth mobility in experimental periodontitis. J. Periodontol. 55:447-452, 1984.
10. Polson AM, et al. Trauma and progression of marginal periodontitis in squirrel monkeys. III. Adaptation of interproximal alveolar bone to repetitive injury. J Periodontal Res 11:279-289, 1976.
11. Polson AM, et al. Trauma and progression of marginal periodontitis in squirrel monkeys. IV. Reversibility of bone loss due to trauma alone and trauma superimposed on periodontitis. J. Periodontal Res. 11:290-298, 1976.
12. Polson AM. Interelationship of inflammation and tooth mobility (trauma) in pathogenesis of periodontal disease. J. Clin. Periodontol. 7:351-360, 1980.
13. Pihlstrom B, Ramfjord SP. Periodontal effect of non-function in monkeys. J. Periodontol. 42:748-756, 1971.

Reviews

1. Ramfjord SP, Ash MM Jr. Significance of occlusion in the etiology and treatment of early, moderate and advanced periodontitis. J Periodontol. 52: 511-517, 1981. (review)
2. Gher ME. Non-surgical pocket therapy: Dental occlusion. Ann Periodontol 1:567-580, 1996. (Occlusion portion only) (review)
3. SerioFG, Hawley CE. Periodontal trauma and mobility – Diagnosis and treatment planning. Dent Clin NA 43:37-44,1999. (review)
4. HallmonWW. Occlusal Trauma. Texas Dental J. 118:956-960,2001. (review)

What is occlusal trauma? What are the clinical signs and symptoms of occlusal trauma? Describe the types of occlusal trauma. Which system do you use to classify mobility? What is fremitus? Is there a relationship between mobile teeth and success of periodontal treatment? What are the indications and contraindications of splinting mobile teeth?

Laster, 1975            ARTICLE
P: To evaluate the reliability and reproducibility of the modified Miller Index of teeth mobility.
M+M: Two diagonal quadrants (max right/mand left or max left/mandib right) were selected to measure horizontal tooth mobility on random basis using two methods:Periodontometer(O’Leary and Rudd, modified by Friedman and Cohen) and Miller Index(activate tooth with 2 instruments and moving side to side, 1-first sign of movement more than normal, 2-mobility as much as 1mm in B/L direction, 3- crown move more than 1 m in B/L or depressed into socket) modification that half scores were used. 5 subjects (22-65 yrs old), a total of 50 teeth measured- with each patient having horizontal mobility of 10 teeth measured five times.
R:There was a high positive correlation between the periodontists’ assessment of clinical tooth mobility and the measurements of the periodontometer. 3 periodontists were highly accurate in their ability to rank teeth in order of their mobility as determined by the periodontomenter. They were not as consistent when comparing teeth with the Miller Index across different subjects. The periodontists did not accurately utilize the Miller Index as it was originally described. They consistently scored a 2 mobility on a tooth that moved approximately 0.5mm, not 1.0mm as described by Miller.
BL: The modified Miller Index provides an efficacious system to clinically evaluate horizontal tooth mobility for large population. For individual teeth, it may not off the required degree of sensitivity.

Rosenberg, 1995            ARTICLE
BG:
Damping: to decrease the magnitude of an electrical or mechanical wave
Periotest: an objective, noninvasive clinical diagnostic method. It is a dynamic procedure that measures the resistance of the periodontium to a defined impact load. It was developed to produce a reproducible percussive force to apply defined and reproducible impacts. According to Schulte and Lukas, the Periotest value depends to some extent on tooth mobility, but mainly on the damping characteristics of the periodontium. The real meaning of the measurements and the limitations of the Periotest measuring principle seem to be poorly understood.
P:To determine the relationship between damping characteristics of periodontal tissues and tooth mobility.
M&M:58 maxillary anterior teeth from 11 periodontally healthy patients and 54 maxillary anterior teeth from patients seeking perio tx with some degree of mobility were used.10 teeth exhibited degree I mobility, 27 teeth degree II mobility and 17 teeth with degree III mobility. To assess mobility, a Muhlemann Periodontometer was used to measure the amount of mobility in a labial-palatal direction against forces of .5N, 1.0N, 2.0N, and 5.0N. Damping characteristics were assessed by a Periotest device. Two examiners performed the Periodontometer and Periotest measurements twice on each tooth.
R:The best correlations between tooth deflection and periotest values were found for teeth showing a degree of clinical mobility. Correlation was lower with healthy subjects. The better correlation found for forces > 1.0N indicates damping characteristics found with Periotest are related to secondary tooth movement (distortion of the alveolar plate).
BL:The Periotest method has proved to be objective and highly reproducible for measurement of damping characteristics of healthy teeth. However, it has certain limitations that can give different interpretation of the values.

Neiderud 1992            ARTICLE
Purpose:To induce increased tooth mobility and to study the resistance offered by the periodontal tissue to probing.
Materials and methods: 6 beagle dogs, 9 months old. Throughout the period of observation animals were fed a soft pellet diet. One month prior to the initiation of the experiment the teeth of the animals were scaled polished once a week and exposed to careful toothbrushing 3 times a week. On Day 0 the mandibular molars and premolars were free from plaque accumulation and exhibited minimal gingival inflammation. Mobility was determined using the Periotest.
Grooves were prepared 2mm from the gingival margin and pins were anchored in them in buccal and lingual side of the teeth. An orthodontic elastic was activated and positioned on the buccal side of the test teeth and in 3 days it was removed and placed on the lingual side. The position of the elastic was changed twice a week during a 3-month period.

The dogs were 3 times a week exposed to meticulous toothbrushing. Tooth mobility measurements were performed on Day 0 and Day 90.
At that day, clinical examination assessing plaque and gingivitis was performed and standardized wooden probe (0.50N, groove was prepared) was inserted in the sulcus and block biopsies were taken.
Height and width of free gingival margin, volume fractions occupied by oral epithelium (OE), junctional epithelium (JE) and connective tissue (CT), fibroblasts, collagen, vascular structures and residual tissues were assessed.
Distances from gingival margin to the apical portion of the probe, CEJ to alveolar crest, probe to bone crest and gingival margin to apical end of connective tissue were also assessed.
Results:At Day 90 all teeth surfaces were plaque free and no or minimal signs of inflammation were present. Perio test values were similar on Day 0 for test and control teeth and on Day 90 significantly higher for test teeth (30 vs 5.6). Average height and width of free gingival margin were also comparable.
CEJ-BC distance was significantly larger at test teeth.
Histological PD at test sites was almost twice as great as observed at the controls.
Apical extension of CT was comparable between the two groups, but the height of supracrestal CT located between BC and the probe was significantly greater at the test teeth.
Morphometric measurements showed the free gingival unit had similar composition in both groups (about 40% epithelium and 60% connective tissue).
The supracrestal CT at the test teeth had less collagen and more vascular structures compared to controls.
Conclusion:Tissue alterations (marginal bone loss, less collagen, more vascular elements) which occur at mobile teeth with clinically healthy gingivae and normal height of connective tissue attachment, may reduce the resistance offered by the tissues to clinical probing leading to increased probing depths.

Perrier, 1982            ARTICLE
Purpose:to assess the effect of progressive and increasing tooth hypermobility upon a periodontium reduced by marginal periodontitis, but in which the inflammatory lesion had been resolved.
Materials and methods

• 4 monkeys, marginal periodontitis was induced with silk ligature. Ten weeks after ligatures were removed and OH instituted
• After 10 weeks of OH the interproximal periodontium was subjected to repeated trauma by jiggling the teeth mesio distally
• Animals sacrificed at 10 weeks after initiation of jiggling forces.
• Control side induction of periodontitis, then 10 weeks of OH
• Mobility and inflammation were assessed, histology was performed

Results

• The mobility of the teeth increased progressively throughout the period of jiggling and at the conclusion of the study there was mobility in mesio distal, buccal and vertical directions.
• The clinical appearance of the gingival tissues had not changed during the period of tooth jiggling.
• The coronal PDL in the compressed areas was narrow, there’s vascular obstruction and acellular .In the area under tensional force, and the PDL was widened, highly cellular and had dilated blood vessels.
• Alveolar bone of experimental group had islands of osseous tissue surrounded by CT of the marrow spaces & PDL.
• A significant reduction in the % of alveolar bone had occurred subsequent to the mesio-distal jiggling forces, but the height was not significantly reduced

BL:Teeth w/ reduced but stable periodontal tissues continually accommodate increasing multidirectional forces by alterations independent of alterations in the connective tissue attachment.

Kerry, 1982            ARTICLE
P:Todetermine the effect of periodontal treatment on tooth mobility.
M&M:Retrospective eval: 93 pts (2421 teeth) w/ moderate to severe p-itis. Mobility was determined at baseline, 1 month after SRP+ occlusal adjustment, 1 month after perio tx, l year after perio tx and 2 years after completion of tx. Perio treatment was either: 1) pocket elimination 2) subgingival curettage 3) MWF 4) SRP. Patients were in 3 month recall.
R– NSSD was found b/w any of the treatment groups at 1 month post-op. At 1 month there was significant increase in proportion of teeth w/ zero mobility. At 2 years a SS decrease in moderate mobility proportions with MWF and SC. Other treatments showed NSSD at 2 yrs.
BL:Mobility decreased after phase 1 therapy (SRP/OHI/ occlusal adjustment). Mobility was NOT significantly altered by phase II treatment (scaling, subg curretage or MWF). Mobility increased 1 month after pocket elimination surgery, but returned to pre-surgical level 1 year later.Teeth with higher initial mobility tended to improve more than teeth with lower initial mobility

Fleszar, 1980   mobility and wound healing
P: To determine whether any relationship exists between tooth mobility and clinically measurable responses to conventional periodontal treatment.
M&M:  82 pts completed at least the 1^st year recall and scoring (total of 1974 teeth), 72 patients 5 years, and 43 pt 8 years.  PD, AL, Mobility were measured.  SRP, OHI, occlusal adjustment was provided and then one of three treatments: 1) Subg curettage, 2) MWF, 3) pocket elimination Sx. 3 month recalls and divided into groups to mild (1-3mm), moderate (4-6mm) and severe (7-12mm) periodontitis based on initial pocket depth. Mobility was measured as M0 = firm tooth, Ml = slight increase in mobility,  M2=definite increase in mobility but no impairment of function, M3= extreme mobility, uncomfortable in function.
R:
 

• Groups with PD 1-3 mm showed CAL with treatment and this is increased with increased mobility. M2-3 ~1mm CAL by the 2^nd year.
•  Groups with PD 4-6mm showed sites with limited mobility M0-M1 reveals gain in attachment, M2 do not appear to gain attachment, and might show loss, and M3 lose attachment within 2 years.
• Groups with PD 7-12mm had more CAL gain, with the most gain in M0 group and ~0.5 mm less in each group and grade of mobility increases. Stability of attachment occurred after the second year in all disease levels.

 
BL: Increased tooth mobility can detrimentally affect healing. Pockets of clinically mobile teeth do not respond as well to periodontal treatment as firm teeth showing same initial dz severity.  The effect stabilizes after 2 years and clinically mobile teeth can be treated and maintained.

Galler 1979,            ARTICLE
P:Determine if splinting the teeth after osseous surgery has positive effects regarding tooth mobility, bone level, attachment level over unsplinted teeth.
MM:Following phase I therapy, osseous surgery was performed to 10 healthy patients, with bilateral bone loss and at least 2 maxillary teeth with mobility. One segment was splinted and the other unsplinted. Tooth mobility was measured one week before and then at 3,6,12 and 24 weeks after surgery by the periodontomer with a 500g force. Sulcus bleeding and gingival attachmentwere measured with a pressure-sensitive modified Michigan “0” probe calibrated to 5g force before surgery and at 24 weeks. Bleeding was measured 5 seconds after insertion of the probe. Bone index were recorded with the Michigan “0” probe with the flap open pre and post osseous and bone sounding at 24 weeks. Before measurement splints were removed. Prophylaxis and OHI were given every 3 weeks. Occlusion was adjusted as needed.
R:Splinting didn’t show positive effects over unsplinted teeth in any of the above parameters. Tooth mobility increased 3 weeks after surgery and then gradually decreased (as showed in other studies). An average of 0.6mm of bone was removed post-osseous, NSD was found of this with tooth mobility post surgery.
BL: Fixed splinting the teeth after osseous surgery have no positive effect on tooth mobility, bone level, attachment level, nor bleeding. Its use for this purpose is unjustified. Increase mobility is expected after surgery with a gradual decrease to pre- surgical values after 24 weeks.

Lemmerman, 1976            ARTICLE
P:To review rationales for stabilization and to discuss its use in periodontics with supporting evidence.
Rationales for Stabilization: Reasons for splinting in normal periodontium are to prevent mobility from acute trauma or occlusal therapy for the treatment of bruxism. Another reason to splint in normal Periodontium is to prevent drifting of the dentition. Reasons for splinting in a diseased periodontium would be to promote patient function and allow for tissue repair during periodontal treatment. Splinting would also be used for the prevention of drifting dentition as seen in the normal periodontium.
Discussion:A review of the literature on stabilization reveals that much of the confusion that comes from whether to splint or not in periodontal treatment arises from differences in semantics. Authors generally use the same terminology but their meanings vary. There are many reasons that contribute to tooth mobility but there is no agreement in the literature over what is “physiologic mobility.” As a result it is difficult to determine which teeth should be stabilized. Not all visible tooth mobility should be considered abnormal and there for not all mobile teeth require splinting. Mobility must be evaluated after taking into consideration health of the periodontium, occlusion, functional considerations, as well as other clinical factors.
Another area of confusion is correlating occlusion, trauma from occlusion, and periodontitis. The literature generally agrees that trauma from occlusion does not cause periodontitis but literature on the effect of trauma of occlusion on existing periodontitis is still unclear. If trauma from occlusion and periodontitis are believed to be related then splinting would be important. If these two factors are determined to be unrelated then splinting becomes less important in the treatment of periodontitis. Lindhe published an animal study where he found that after 6 months, teeth with periodontitis that were subjected to trauma from occlusion had more apical epithelial proliferation and angular bone loss than the control. This would suggest that trauma from occlusion and periodontitis have a correlation.
Lemmerman suggests that because mobility, in the absence of local factors, does not lead to periodontitis, the terms “pathologic mobility” and secondary trauma from occlusion should not be used interchangeably. Lemmerman prefers the terms reversible and irreversible mobility, the latter being an indication for splinting.
Splinting should be considered especially to promote “functional stability” rather than preventing progression of periodontitis. Lemmerman points out that just because a tooth is splinted does not mean that it is free from trauma from occlusion. Furthermore a study by Glickman, Stein, and Smulow showed excessive forces on a splinted tooth caused comparable damage to the all teeth that are splinted.
There are several objections to splinting. Chayes believed that ridged splinting would result in reduced circulation to the periapical areas of splinted teeth but this was refuted by Amsterdam. Others believe that splinting results in a higher potential for gingival inflammation and poor oral hygiene. A third objection is that splinting practices are abused and should be avoided whenever possible. Lastly, there is a lack of research on the clinical efficacy of splinting.
Conclusion:Diseased Periodontium and normal Periodontium should be treated equally in regards to splinting except for in the case of secondary trauma from occlusion. Valid reasons for splinting are to prevent mobility, prevent drifting, and to treat secondary trauma from occlusion. Temporary splinting in periodontal treatment should be avoided because mobility in itself does not impair healing, except in cases of secondary trauma from occlusion. More research should be done to determine the relationship between trauma and periodontitis and the efficacy of splinting.

Lindhe, Ericsson, 1976            ARTICLE
P:To study influence of occlusal trauma (OT) on periodontal breakdown once inflammation has been removed.
M&M:Experimental periodontitis was induced on 5 beagle dogs. During a pre-experimental period the teeth were scaled and polished. At Day 0 none of the dogs presented gingivitis. Throughout the study the dogs were fed a diet which allows gross plaque formation. On days 0, 180, 280 and 370, gingival inflammation, plaque (Loe and Silness), tooth mobility and bone levels using standardized radiographs were assessed.

• Day 0: Inflammation was induced, narrow infrabony pockets, 1mm deep were prepared on mesial and distal aspects of lower premolars. A copper band was cemented in order to prevent reattachment of periodontal tissues. The copper bands were removed 21 days later and cotton ligatures were placed.
• Day 180: Trauma from occlusion (TFO) was produced with cap splints on both sides of maxilla and bar devices.
• Day 280: MWF was performed and traumatic occlusion eliminated on one side(control teeth). A notch was made to the bottom of the clinical infrabony pocket. Good OH was maintained until sacrifice at day 370. Histological examination was then done.

R: At the start of the study the gingiva around test and control teeth were normal and no plaque could be detected. At days 180 and 280 the gingiva exhibited signs of severe chronic inflammation. Following scaling, pocket elimination and daily tooth cleanings the clinical signs of gingivitis almost disappeared.Mobilityincreased during the experimental periodontitis period and had a more pronounced increase after induction of occlusal trauma (OT). Removal of OT at day 280 resulted in a decrease in mobility in the control teeth.In the test teeth, however, there was a further increase in mobility towards the end of the study. Bone:Apical movement of alveolar bone during induced periodontitis with widening of the PDL as result of jiggling forces. Reestablishment of narrow PDL and marginal bone in the control side occurred after removal of OT and inflammation. Radiographs from test teeth at the end of the study showed an even and rather distinct outline of marginal bone, PDL still appeared markedly widened. Histology: PDL on pressure side of test teeth showed a greater number of vascular units when OT was present. In the control side, the crest was located at the level of the apical border of the notch, while on the test side the crest was apical to the notch. No signs of inflammatory cells in the supraalveolar CT or in the PDL of both, experimental and control.
BL:Jiggling type OT and hypermobility alone were not factors that affected periodontal healing. Provided plaque and inflamed periodontal tissues were removed and a proper OH regimen was established, healing also occurred in cases where jiggling forced were acting on hypemobile teeth. Microbial plaque is the main causative factor in the progressive lesion where TFO may act as co-destructive component.

Glickman, 1966            ARTICLE
P:To determine if post-surgical healing is affected by altered occlusal forces.
M+M:9 dogs were divided into 3 groups. Group I: unaltered occlusion (2 animals), Group II: hyperfunction (3 animals), Group III: hypofunction (3 animals). One animal served as unoperated control. Hyperfunctionwas created using a cast gold overcontoured splint cemented on the mandibular anterior teeth to increase the vertical dimension and create excessive apico-labial forces. Hypofunctionwas created by extraction of the mandibular incisors. Mucogingival surgery was performed in the maxillary anterior region at the time the occlusion was altered. The maxillary anterior region was divided into two areas. On the right side resected gingival flap was performed (periosteum intact) and on left side on labial surface, a mucoperiosteal flap was reflected and then replaced and sutured at the level of the bone. The palatal marginal gingiva was removed with gingivectomy on both sides. Dogs were sacrificed at 3 months and histological analysis was done.
R: Group I: The gingiva was healed with the sulcus restored at the level of CEJ. There was a slight reduction in the height of labial bone and the periodontal ligament was intact with dense fiber bundles perpendicular to the bone and to the tooth.
Group II: The healing was the same except widened PDL, longer gingival attachment, thinned coronal labial plate and thickened in the apical half.
Group III: The fibers of PDL were reduced in number and in some areas were disoriented and parallel to the tooth.The gingival portion of the labial plate was thinned and tapered while the apical half was thickened.
Thealtered occlusion did not cause reduction in bone height beyond that produced by surgical procedures. In all operated animals the reduction in labial bone height was greater with the repositioned flap.
BL:Extreme and abrupt alterations in occlusion can affect healingof surgical wounds.

Polson, 1983            ARTICLE
P:To evaluate the periodontal response after resolution of inflammation in continued presence of active, continued tooth hypermobility.
M+M:Periodontitis induced unilaterally around mandibular 2^ndand 3^rdpremolars by tying silk ligatures at ginigival margins in 4 squirrel monkeys. Mesial-distal jiggling forces between premolars begun at 5 weeks and continued for 20 weeks. Ligatures removed 10 weeks after initiating jiggling, and regular OH regimen begun (3x/wk). Jiggling forces continued during OH.
Animals sacrificed 10 wks after OH begun.
Controls- on contralateral side of each mandible. Periodontitis and trauma produced but timed so that the 10 weeks of jiggling forces/ligatures would correspond to 10 weeks of good hygiene on experimental side.
Marginal inflammation and tooth mobility assessed. Mandibles evaluated histologically.
R:Clinical: Prior to experiment there was no gingival inflammation and no clinical mobility. 5 weeks after periodontitis induced, premolars had gingival inflammation and increased mobility. During first 10 weeks of jiggling, inflamed gingival tissues did not change, but mobility increased. After ligatures removed,OH of 10 weeks led to resolution of gingival inflammation and decrease of tooth mobility although the teeth were still subjected to active jiggling forces. At conclusion of study, mobility still present slightly, but was much improved from mobility associated with induced periodontitis.
Histological: In the presence of jiggling forces but 10wks after OH was initiated (experimental group), accumulation of inflammatory cells adjacent to epithelium was 19.2% of supracrestal CT fibers. In control group, jiggling forces with periodontitis, 57.6% accumulation inflammatory cells of supracrestal fibers. No difference in levels of connective tissue attachment or alveolar bone between both sides. Significant bone repair occurred in experimental group once periodontitis resolved even though jiggling force remained.
D:If residual tooth hypermobility, which remains after resolution of marginal inflammation associated with periodontitis, is without effect upon CT attachment levels it indicates that there is no scientific basis for considering that this mobility should be reduced in order to preserve periodontal health. Since there was no coronal gain in bone or CT levels after resolution of inflammation, the decrease in mobility was most likely due to the increase in bone density.
BL:Osseous repair can occur in the presence of active, continued hypermobility if resolution of inflammation is achieved. Continued tooth hypermobility after resolving inflammation did not lead to further loss of CT attachment. Mobility will decrease if inflammation is resolved, regardless of continued forces. Some mobility will remain, compared to no mobility prior to experiment.

Schulz 2000            ARTICLE
Purpose:To evaluate the effect of splinting on the result of periodontal reconstructive surgery using a specific bone replacement graft (BRG) material (natural coralline calcium carbonate).
Materials and methods:45 patients underwent periodontal surgery that included surgical debridement of osseous defects and if required placement of an alloplastic BRG. They were randomly assigned to one of 4 treatments: BRG and presplint teeth (18 teeth), BRG with postsplint (16 teeth, one week post-op), BRG with nonsplint (17 teeth) and debridement alone with non-splint (19 teeth). Clindamycin was administered for 6 days post-op. Splints were not removed until 8 months after surgery, and periodontal condition (PD, AL, mobility) of all teeth was recorded during a period of 0-48 weeks. Measurements were standardized and mobility was evaluated by desmodontometry and the use of periotest. Statistical analysis was performed.
Results:Significant decrease between the 4 Tx groups after 48 weeks comparing to baseline was observed for PD, AL and mobility.
PD: reduction was significantly greater in splinted teeth comparing to non-splint. Debridement alone lead to a decrease similar to presplint and postsplint.

AL: The maximum increase was seen in presplint (5.1mm) and postsplint (3.5mm) teeth. In nonsplint teeth it was significantly smaller (1.7mm), as well as in the debridement alone group (0.6mm).
Mobility: Decrease in periotest values of presplint teeth was significantly greated to all other groups. Quasistatic mobility showed significant decrease in postsplint and presplint groups comparing to the other two.
Conclusion:1. Presurgical splinting appears to have the greatest positive impact on the results of reconstructive periodontal surgery.
2. BRG + splinting resulted in greater clinical improvement comparing to nonsplinting and debridement alone in teeth with deep infrabony pockets.
3. In nonsplinted teeth the use of BRG showed nearly the same results as surgical debridement alone.

Harrel 2003            ARTICLE
Purpose: Review on occlusal forces as a risk factor for periodontal disease
Discussion
Historical Perspective: Several authors indicated that occlusal forces played a significant role in the initiation and progression of periodontal destruction. At the end of the 1930’s it was still felt that excessive occlusal forces were a major cause of periodontal disease and occlusal adjustment should be a part of periodontal treatment. In the 50’s and 60s studies in animals could not support the concept that excessive occlusal forces were a primary causative agent of periodontal destruction. During this period Glickman and Coworkers performed a series of studies in human autopsy material.Glickman’s theory of Co-Destruction continued to hold to the thesis that occlusion was, in concert with bacterial plaque, a causative factor in periodontal attachment loss and bony destruction. Glickman’s concept believes that occlusion directly changed the disease process and was thereby, in the presence of bacterial plaque, a causative agent for periodontal destruction.
Animal studies: Mainly on squirrel monkeys (Polsol) and beagle dogs (Lindhe), in these animal models, occlusion had an effect on the periodontium in the form of bone rarefaction (loss of density), which resulted in the clinical manifestation of mobility. However, these studies also found that bacterial plaque must be present to cause a loss of attachment. The author warns that it is unlikely that these animal studies give us significant information about the pathophysiology that may occur when excessive occlusal forces are present in humans who may be genetically prone to periodontal destruction and who may also have additional risk factors for periodontal disease beyond occlusal forces and bacterial plaque.
Human studies:While there are many apparently contradictory findings from human studies, there appears to be a trend toward evidence that excessive occlusal forces may play a role in periodontal destruction and the response of the periodontium to periodontal treatment. However, the 1999 International Workshop for Classification of Diseases and Conditions indicated that there was no clear evidence that occlusal forces were a factor in plaque-induced gingival disease or connective tissue loss. Since the 1999 Workshop, studies have shown that occlusal interferences have a negative effect on the periodontium and tend to cause more rapid pocket formation and poorer prognosis when compared to teeth that do not have occlusal interference. There is also recent evidence that treatment of the occlusion to minimize interferences in addition to other forms of periodontal treatment, may positively affect periodontal destruction.

Waerhaug, 1979            ARTICLE
P:To re-evaluate the scientific basis for the hypothesis that angular bone defects and infrabony pockets are the result of occlusal trauma (OT) in combination with gingival inflammation.
M & M: Histologic study of 64 sets of teeth from victims of violent death in 1944-5. Bite analysis was carried out before the jaws were fixed. Impressions & X-rays were taken.
R:Before any attachment loss, the level of the interproximal septum is determined by the location of CEJ of neighboring teeth (confirms Ritchey & Orban 1953). It is also determined by the level of subgingival plaque (The height of bone is established no closer than 1 mm to the CEJ).

• The distance from the apical border of the plaque to the nearest PDL fibers ranged from 0.2-1.8 mm (average 0.96 mm). Distance from Alveolar Crest to subgingival plaque (zone of destruction) ranged from 0.5-2.7 mm (average 1.63 mm).
• Angular bony defects occurred equally often adjacent to non-traumatized as adjacent to traumatized teeth. No correlation between angular defects and OT. Inflammation (and infrabony pockets) are associated with downgrowth of plaque.

BL: Bacterial plaque in conjunction with variation in local anatomy is the primary cause of intrabony defect formation and not trauma from occlusion. No evidence that traumatic forces are co-factors in causing angular defects.

Yuodelis, Mann, 1965                        No ARTICLE
P:To determine the prevalence of nonworking contacts in patients with periodontal disease and the possible effects of non-working contactson the periodontium.
M&M:Retrospective study. Information regarding mobility, PD, septal bone loss, and the presence or absence of non-working contacts were taken from the charts of 54 patients under treatment for periodontal disease at the University of Washington. 413 molar teeth were studied. Bone loss was measured with ruler on non-standardized radiographs. Nonworking contacts determined in lateral excursions, study models used for evidence of faceting
R:53% of molars had nonworking contacts noted by either wear facets on study models or notes in charting. SSD in mobility, bone loss, and PD in groups with nonworking interferences. NSSD between mesial and septal bone loss for maxillary and mandibular groups. Mobility, bone loss, and PD were significantly higher in teeth with nonworking contacts. Nonworking contacts showed no significant effect on patterns of bone loss around molar teeth.
BL: Bone loss, mobility, & PDs all significantly increased in the group with nonworking contacts.
Critique:

1. Retrospective study of charts, models and non standardized radiographs
2. Mean increase of PD around teeth with facets was 0.4 mm
3. All patients had periodontal disease, no healthy controls

Shefter, McFall 1984                        ARTICLE
P: To obtain data on both occlusion and periodontal status in a group of human adults in order to evaluate the relationship.
M+M: 66 subjects (33 M, 33F, 15-62 yrs old) in good health. Pts had to have 28 teeth and no hx of occlusal adjustment by selective grinding. Presence or absence of periodontal disease not a criterion. Recorded plaque score, mobility, PDs (grouped into 3 Ramfjord categories) and examined occlusion (classification of malocclusion, analysis of centric displacement, excursive movements, tooth contacts, and wear facets). Radiographs taken.
R: Angle’s classification:Class I> Class II> Class III= end to end

Functional analysis:Group function>Canine function

Nonfunctional contacts:Mostly in max and mand 2^ndmolars

PDs and Type of contacts: NSSD b/w PDs and nonworking contacts

Mobility, wear and radiographic features: NSSD in mobility found b/w teeth with wear facets and nonfaceted teeth. Teeth w/ wear facets did not show radiographic signs of occlusal trauma.

BL: NSSD b/w PDs and nonworking contacts. Mobility was not significantly influenced by nonfunctional contacts. NSSD in mobility found b/w teeth with wear facets and nonfaceted teeth. Only 4% of teeth with wear facets and nonfaceted teeth demonstrated radiographic signs of occlusal trauma. Suggest a minimal role for occlusal factors in the progression of periodontal disease.
CR: Why group the PDs into the 3 Ramfjord categories of 1-3mm, 4-6mm, and >7mm? A 4 mm PD and a 6 mm PD are significantly different.

Pihlstrom, 1986            ARTICLE
P:To evaluate the association of possible signs of trauma from occlusion (TFO), with both severity of periodontitis & radiographic record of bone support.
M&M:Maxillary first molars of 300 individuals (2040 years old) independently evaluated for PD, CAL, rec, mobility (both bidigital and functional), plaque, calculus, wear facets, uneven marginal ridges, pattern of occlusal contacts (centric, working, nonworking, protrusive) by 2 examiners. Radiographic findings recorded by third examiner without knowledge of clinical exam: widened PDL, root resorption, hypercementosis, root fracture, thickened lamina dura, presence of calculus on mesial surface. Bone loss was evaluated using bjorn technique on mesial aspect only.
Teeth categorized as not having signs of trauma from occlusion required agreement by both clinical examiners and judgement by the radiographic examiner that a normal PDL space was present. All three independent examiners (2 clinical and 1 rx) also had to be in agreement to classify the teeth as displaying signs of trauma from occlusion. These restrictions limited the number of teeth of the total sample to only 14 having signs of occlusal trauma. A total of 319 teeth were classified as not having signs of occlusal trauma.
R:Max 1^stmolars: 22% had thickened lamina dura, 19% widened PDL and 19% had radiographically visible calculus. Teeth with wear facets or a thickened lamina dura had less CALoss and more osseous support that teeth without these findings.
BL: from information concerning max 1^stmolars in pts 20-40 yrs old:
1. Teeth with bi-digital mobility, functional mobility, a widened PDL space or the presence of radiographically visible calculus had deeper PD, more CALoss and less % radiographic osseous supportthan teeth without these findings.
2. Teeth with occlusal contacts in CR, working, nonworking or protrusivepositions did notexhibit any greater severity of periodontitis than teeth without these contacts.
3. Teeth with both functional mobility and radiographic widened PDL space had deeper PD, more clinical ALoss and less radiographic evidence of osseous supportthan teeth without these findings.
4. Given equal clinical attachment levels, teeth with evidence of functional mobility and a widened PDL space had lessosseous support than teeth without these findings.
Cr:319 healthy tth vs 14 tth with occlusal trauma

Nunn 2001            ARTICLE
Purpose:To investigate the relationship of occlusal trauma to the severity of periodontal disease as reflected in clinical parameters and possible effects of occlusal treatment on the progression of periodontal disease.
Materials and methods: Retrospective epidemiological study, data were obtained from the clinical records from 24 years of practice. A complete perio exam was performed initially and patients had another complete exam at least 12 months after the initial. Examinations and data collection were performed by the same examiner. Occlusal analysis included notation of initial contact, discrepancies between initial contact and centric relation, centric occlusion and working and balancing contacts in lateral and protrusive movements.
Two groups were created, an untreated group that had none of recommended periodontal treatment performed between the 2 examinations and a partially treated group that had completed the non-surgical portions of the surgery but not the surgical. Control group included 41 patients that had completed all the recommended periodontal treatment at least 12 months prior to final examination. All data were recorded and a database was created and designed so that the data could be evaluated for the effect of presenting factors, non-treatment, partial treatment and complete treatment on the progression and/or resolution of periodontal disease.
Results:Data from 89 patients were collected. 41 pts completed all treatment recommended (control group), 18 pts in the partially treated group and 30 refused any treatment. 17/41 pts in the control group and 9/18 in the partially treated group received occlusal adjustment. 30 patients had occlusal discrepancies but were not treated for these (5 in partially treated and 25 in the untreated group).
It was found the patients with occlusal discrepancies were statistically significantly younger than patients without occlusal discrepancies.
Teeth with occlusal discrepancies were found to have significantly deeper initial PDs, worse initial prognoses and greater mobility than teeth without initial occlusal discrepancies. No significant differences in initial bifurcation involvement.
On average teeth with an initial occlusal discrepancy will have approximately 1mm greater PD when compared to teeth without an initial occlusal discrepancy even when adjusted for significant confounders, such as smoking, gender, and oral hygiene status.
Initial occlusal discrepancies were found to be the only significant predictor of initial PD.
Parafunctional habits were not found to be associated with initial PD, mobility, furc involvement or prognosis.

Harrel, 2001            ARTICLE
Purpose:to evaluate the effect of occlusal adjustment on the progression of treated and untreated periodontal disease.
Materials and Methods

• Data from private practice, patients had complete periodontal examination, occlusal analysis. All patients had non surgical and surgical periodontal treatment, and a second examination 12 months after.
• 3 groups, 89 patients total. Control (41pts, all treatments done), Untreated (30 pts, No treatment between exams) and Partially treated (18 pts, Non surgical only)

Results

• Of the 59 treated fully or partially, 26 received some for of occlusal adjustment.
• Teeth w/ no occlusal discrepancies or those with treated discrepancies were 60% less likely to have a downgrade in prognosis as those w/ no occlusal treatment.
• Teeth with no occlusal treatment were shown to have a significantly greater increase in PD per year than either teeth w/o initial discrepancies or teeth w/ treatment.
• Teeth without initial discrepancies and treated had no significant increase in probing depth per year
• Teeth with no initial discrepancies were significantly less likely to worsen in mobility compared to treated or untreated occlusal discrepancies.
• NSSD when worsening of furcations among any of the occlusal treatment group.

BL: this study provides evidence of an association between untreated occlusal discrepancies and the progression of periodontal disease. Occlusal treatment significantly reduces the progression of periodontal disease over time.