journal of dentistry 40 (2012) 10251035

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Review

Occlusal adjustment associated with periodontal therapyA systematic review

Adriana M. Foz, Hilana P.C. Artese, Anna Carolina R.T. Horliana, Claudio M. Pannuti, Giuseppe A. Romito *
Department of Periodontics, Dental School, University of Sa o Paulo, Brazil

article info
Article history: Received 13 March 2012 Received in revised form 5 September 2012 Accepted 7 September 2012

abstract
Objectives: Occlusal adjustment as part of periodontal therapy has been controversial for years, mostly because the literature does not provide enough evidence regarding the inuence of trauma from occlusion (TfO) on periodontitis. The need for occlusal adjustment in periodontal therapy is considered uncertain and requires investigation. The aim of this systematic review was to identify and analyse those studies that investigated the effects of occlusal adjustment, associated with periodontal therapy, on periodontal parameters. Data: A protocol was developed that included all aspects of a systematic review: search

Keywords: Occlusal adjustment Dental occlusion Traumatic Periodontal disease Periodontal debridement

strategy, selection criteria, selection methods, data collection and data extraction. Sources: A literature search was conducted using MEDLINE via PubMed, the Cochrane Central Register of Controlled Trials, and EMBASE. Study selection: Three reviewers screened the titles and abstracts of articles according to the established criteria. Every article that indicated a possible match, or could not be excluded based on the information given in the title or abstract, was considered and evaluated. On nal selection, four articles were included. Conclusions: Although the selected studies suggest an association between occlusal adjustment and an improvement in periodontal parameters, their methodological issues (explored in this review) suggest the need for new trials of a higher quality. There is insufcient evidence at present to presume that occlusal adjustment is necessary to reduce the progression of periodontal disease. Clinical signicance: Although it is still not possible to determine the role of occlusal adjustment in periodontal treatment, adverse effects have not been related to occlusal adjustment. This means that the decision made by clinicians whether or not to use occlusal adjustment in conjunction with periodontal therapy hinges upon clinical evaluation, patient comfort, and tooth function. # 2012 Elsevier Ltd. All rights reserved.

ria, CEP 05508-900, Sa * Corresponding author at: Av. Prof. Lineu Prestes, 2227, Cidade Univerista o Paulo, Brazil. Tel.: +55 11 3091 7833; fax: +55 11 3091 7833. E-mail address: garomito@usp.br (G.A. Romito). 0300-5712/$ see front matter # 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jdent.2012.09.002

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1.

Introduction

The relationship between trauma from occlusion (TfO) and periodontal disease has been discussed for more than a century. Periodontal disease is characterized by gingival inammation, periodontal pocket formation, bone loss and clinical attachment loss (CAL).1 Conversely, TfO has been dened as an injury resulting in tissue changes within the attachment apparatus as a result of occlusal force(s).2 Nowadays, it is well known that subgingival biolm plays a major role in the pathogenesis of periodontal disease,3,4 stimulating an immune response that can lead to periodontal breakdown.5,6 Susceptibility to periodontal disease, its severity and progression are all inuenced by environmental factors, besides genetic and acquired risk factors that can modify the host response.79 Nevertheless, prior to this insight, it was believed that TfO could be the main cause of alveolar bone loss, since Karolyis pioneering work10 had indicated a possible relationship between excessive occlusal forces and periodontal breakdown. Subsequent decades saw a great number of contributions from different authors, but their conclusions were still based on histological studies from human autopsies and animal experiments.1116 Until the early 80s, animal studies helped to identify subgingival biolm as the main risk factor for periodontitis, but it was still believed that TfO could inuence the severity and progression of periodontitis.1426 Despite their conclusions, some studies presented histological evidence from human biopsies that suggested only a weak association between TfO and periodontal breakdown.13,27,28 A few observational studies reported a positive relationship between TfO and CAL, and demonstrated that periodontally compromised teeth presenting TfO had less bone support29,30 and greater pocket probing depth (PD).2934 Based on those animal and epidemiological studies, if TfO had any relationship to the progression of periodontitis, then its elimination could also enhance clinical periodontal conditions.14 Occlusal adjustment, dened as reshaping the occluding surfaces of teeth by grinding, to create harmonious contact relationships between the upper and lower teeth,2 aims to remove any present occlusal trauma. Occlusal adjustment, which was routinely conducted during an initial preparation phase as part of the preliminary procedures to control periodontal disease,3538 has been considered part of periodontal therapy by many authors in several elds of study. Still, its importance and indication have not been established, since the literature does not prove any inuence of TfO on periodontitis. It has been related that occlusal adjustment could be benecial at both tooth and periodontal level,39 although much of the existing research does not provide valuable information regarding the potential for this therapy to contribute towards the elimination of periodontal disease.4042 In a recent systematic review,43 the authors stated that the evidence available was inconclusive, although their search was limited to randomized clinical trials (RCTs) with a follow-up period of at least three months. This restricted their analysis to just one study. Even though RCTs represent

the highest quality of evidence, a wider look at all the available data is needed, since the present conclusions remain ambiguous and do not represent the compilation of a great deal of evidence. Nonetheless, the information obtained from the existing interventional studies may advance our knowledge and might help us to design future investigations. In short, occlusal adjustment in periodontal therapy is of unknown benet, and its indication and importance ought to be evaluated.

2.

Aim

The main question of this systematic review is: In periodontally compromised patients, is there any scientic evidence that occlusal adjustment as part of periodontal therapy provides additional benet on periodontal parameters, when compared to periodontal therapy alone? Therefore, the aim of this study is to identify and analyse all the existing studies that have sought answers to this question, and also to perform a meta-analysis, if such an analysis can be reliably or meaningfully performed.

3.
3.1.

Materials and methods

Protocol development

A protocol was developed to answer the main question of this study, and includes all aspects of a systematic review: selection criteria, search strategy, selection methods, data collection, data extraction, and assessment of the risk of bias.

3.2. 3.2.1.

Criteria for considering studies for this review Types of studies

Only interventional studies were eligible for inclusion in this systematic review.

3.2.2.

Types of interventions

Eligible interventions were conducted in order to eliminate periodontal disease. Occlusal adjustment by grinding was the additional treatment for all test groups, compared with periodontal therapy alone.

3.2.3.

Types of participants

Studies that included the following participants were eligible for this systematic review: 1. Study population was all adults (25 years or older). 2. Study population had a clinical diagnosis of periodontal disease.

3.2.4.

Types of outcome measures

Studies presenting any of the following outcomes were eligible for this systematic review: 1. Periodontal clinical parameters (such as CAL, PD, and tooth mobility).

journal of dentistry 40 (2012) 10251035

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2. Laboratorial parameters related to periodontal disease.

4.

Results

3.2.5.

Inclusion criteria
Our search strategy identied 376 references, of which 234 were considered irrelevant for this review, due to the fact that their titles did not match the inclusion criteria. Abstracts from 142 potentially relevant articles were assessed (rst selection), and 133 of them were discarded because they had already failed to meet all of the proper inclusion criteria (second selection). Finally, the full texts of nine articles were read, ve of which did not meet the eligibility criteria and were excluded. The nal selection for this systematic review was four articles, all of which had their data extracted for further evaluation. Fig. 1 presents a ow chart of the selection process.

Studies that presented the following interventions and analysis were eligible for this systematic review: 1. Periodontal treatment. 2. Occlusal adjustment by grinding. 3. Relationship between occlusal adjustment and periodontal response.

3.2.6.

Exclusion criteria

The following types of studies were not eligible for this systematic review: casecontrol studies, cross-sectional studies, case series and case report, analytical and narrative reviews and animal studies.

4.1. 4.1.1.

Study characteristics Types of selected studies

3.2.7.

Search strategy

A literature search was conducted using MEDLINE via PubMed, the Cochrane Central Register of Controlled Trials, and EMBASE. Manual searches from some important journals were also conducted (the Journal of Periodontology, the Journal of Periodontal Research, and the Journal of Clinical Periodontology), along with a search for unpublished studies. Reference lists of main articles related to the theme were also assessed to guarantee that all evidence available was found and revised. A search strategy for databases was performed to nd studies that matched the following terms: Occlusal Adjustment [Mesh], Dental Occlusion, Traumatic [Majr], Periodontitis [Mesh], Periodontal Diseases [Mesh] (for MEDLINE via PubMed), and Occlusal Adjustment, Traumatic dental occlusion, Periodontal Disease and Periodontitis (for Cochrane Central Register of Controlled Trials and EMBASE).

Four studies were selected for this review.4548 Three of them were clinical trials,45,46,48 but only Burgett et al.48 conducted a randomized parallel trial. Hakkarainen45,46 conducted two cross-over trials. Harrel and Nunn47 presented a retrospective study, analysing data obtained from the clinical records of a private practice over 24 years. Characteristics of the included studies are described in Table 1.

4.1.2.

Population characteristics

3.2.8.

Search limits

Databases were searched up to April 2011, with no limits on the year of publication. The only limits included in the search strategy were: 1. Human studies. 2. Adult patients. 3. English language.

All the studies that were included in this review provided information about the number of participants; 200 patients were evaluated in total. One of the studies48 classied its population (n = 50) as having moderate to severe periodontal disease, with an average age of 44.2 years (range: 2569 years). In her rst study,45 Hakkarainen included 47 adult patients (mean age was 49 years, ranging from 33 to 76 years), suffering from localized advanced periodontitis. In a later study,46 the authors observed 14 adult patients (mean age of 49 years, ranging from 35 to 65 years), with localized advanced periodontitis. Harrel and Nunn47 evaluated a population that had moderate to severe periodontal disease (n = 89), whose ages varied between 25 and 88 years. The diagnostic criteria for periodontitis were not cited in neither of the included studies.

4.1.3. 3.2.9. Selection methods

Initially, three independent reviewers (AF, AH and HA) screened the titles and abstracts of articles according to the limits mentioned above. Every article that indicated a possible match, or could not be excluded based on the information given in the title or abstract, was considered and evaluated. Finally, the studies selected for this systematic review were submitted for validation and data extraction. Any disagreement regarding inclusion was resolved through discussion with two other review authors (CMP and GAR).

Duration characteristics (time of study)

3.2.10.

Qualitative analysis

Burgett et al.48 followed up on their patients condition over two years; during this period, the patients were maintained with prophylaxis every three months. Reexamination visits took place at one year and again at two years. The follow-up time for both studies conducted by Hakkarainen45,46 was 28 days, when results were assessed 14 days after each treatment (treatment appointments were conducted on day 0 and day 14, when patients received both an examination and treatment, and another examination appointment was conducted on day 28). Harrel and Nunn47 extracted data from patients who returned for a new periodontal exam at least one year after the rst exam. The maximum follow-up period was 14.5 years.

In order to evaluate their quality, the articles included in this systematic review were evaluated for any risk of bias, as described in the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0.44

4.1.4.

Types of interventions

The following types of interventions were observed in the included studies:

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journal of dentistry 40 (2012) 10251035

Fig. 1 Selection process.

1. Scaling and root planing. 2. Modied Widman ap surgery. 3. Hygiene phase treatment: scaling and root planing, polishing of teeth, smoothing of restorations, uoride treatment. 4. Oral hygiene instructions. 5. Osseous surgery, osseous regenerative procedure, soft tissue grafting. 6. Occlusal adjustment by grinding. Burgett et al.48 performed a clinical trial in which patients received periodontal treatment consisting of two different therapies assigned randomly for each side of the mouth: (1) scaling and root planing (2) and modied Widman ap surgery. Some of these individuals (test group; 22 participants) were randomly assigned to receive occlusal adjustment within their periodontal therapy programme. Harrel and Nunn47 analysed data from clinical records of a private practice, and divided all 89 included patients into three groups based on their treatment: fully treated patients,

partially treated patients (who completed the non-surgical part of the treatment but had not completed the recommended surgical therapy) and non-treated patients (patients who had received none of the recommended treatments between initial and nal exams). Among 89 patients, 56 presented with occlusal discrepancies. Occlusal adjustment was recommended to those 56 patients in association with periodontal therapy. Nevertheless, only 26 of these 56 individuals received occlusal adjustment (17 fully treated patients and nine partially treated patients).

4.1.5.

Types of outcome measures

The following types of outcome measures were observed in the included studies: 1. 2. 3. 4. CAL PD Mobility Sulcular uid ow

Table 1 Included studies. Study/design

Hakkarainnen, 198645/ clinical trial

Main objectives
To evaluate gingival crevicular uid ow in teeth with occlusal discrepancies, before and after occlusal adjustment and scaling and root planing.

Population/periodontal diagnosis
47 individuals with localized, advanced periodontitis assigned to either Group A (n = 24) or Group B (n = 23)

Inclusion criteria
Non diabetic nor pregnant patients, presenting one pre molar or anterior tooth with PD ! 5 mm, mobility and occlusal interference.

Occlusal analysis
Occlusal interference either in centric relation, protrusion or lateral excursions

Periodontal treatment
Group A: on day 0 test tooth received scaling and root planing, and on day 14 same tooth received occlusal adjustment. Group B: on day 0 test tooth received occlusal adjustment, and on day 14 same tooth received scaling and root planing. Group A: on day 0 test tooth received scaling and root planing, and on day 14 same tooth received occlusal adjustment. Group B: on day 0 test tooth received occlusal adjustment, and on day 14 same tooth received scaling and root planing. After hygienic phase, test group received OA, and control group had no OA. After OA on test group, all patients received a split mouth periodontal treatment, randomly assigned: one side of the mouth received surgical therapy and other side received scaling and root planing only. Untreated group: had a periodontal treatment recommended, but did not come back to the clinic for one year; partially treated group: had completed nonsurgical phase of therapy, but did not have surgical treatment performed; fully treated group had completed all non-surgical and surgical phases of treatment.

Follow-up time
28 days

Hakkarainnen et al., 198846/ clinical trial

To evaluate collagenase activity and protein content of sulcular uid after scaling and occlusal adjustment of teeth with periodontal pockets.

14 individuals with localized, advanced periodontitis, assigned to either Group A (n = 7) or Group B (n = 7)

Non diabetic nor pregnant patients, presenting one anterior tooth with PD ! 5 mm, mobility and occlusal interference. Participants could not have had antibiotics in the last 5 months. Adults diagnosed with moderate to advanced periodontitis who had agreed to participate in the trial, including maintenance care and rescoring visits.

Occlusal interference either in centric relation, protrusion or lateral excursions

28 days journal of dentistry 40 (2012) 10251035

Burgett et al., 199248/ clinical trial

To test the inuence of occlusal adjustment in association with periodontal therapy on attachment levels, pocket depth, and tooth mobility and whether OA was of greater signicance in nonsurgically treated periodontal defects.

50 participants with moderate to advanced periodontitis randomly assigned to OA or no OA (test group = 22; control group: n = 28)

Occlusal interferences in centric relation, eccentric mandibular motion, and balancing side interferences

2 years

Harrel and Nunn, 200147/ retrospective

To evaluate the effects of occlusal adjustment on the progression of treated or untreated periodontitis.

89 participants with moderate to advanced periodontitis

Patients who had undergone two complete periodontal exams (within at least one year difference between them) and who received a periodontal treatment plan after rst exam.

Initial contacts, discrepancies in centric relations or lateral excursions

At least one year, maximum 14.5 years

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5. Collagenase activity in sulcular uid 6. Protein content in sulcular uid

4.1.6.

Excluded studies characteristics

Three hundred and seventy-two studies were excluded because they did not match the inclusion criteria for this review. Although a strict search strategy was conducted to look for all available evidence, most of the search results were not related to the question purposed in this systematic review, nor had a study design that would allow being included in this review. The reasons for these exclusions were: no evaluation of the relationship between periodontal treatment and occlusal adjustment; no assessment of periodontal responses to both treatments; population studies were neither adult nor periodontally compromised. Table 2 describes the characteristics of ve studies that were excluded after full text assessment, as well as the reason for their exclusion.

4.1.7.

Qualitative analysis

Table 3 presents the individual quality criteria for each included study. The characteristics of included and excluded studies are described in Tables 1 and 2, respectively. Individual outcomes of the included studies are described in Table 4.

4.1.8.

Quantitative analysis

It was not possible to conduct a meta-analysis of the results of the included studies, since the outcomes, measurements and methodologies of these studies were not similar.

5.

Discussion

Occlusal adjustment in periodontal therapy has been controversial since its earliest use. So far, its importance in the treatment of periodontal disease has not been established, mostly because the effects of occlusal trauma on the periodontium remain unclear. The existing research regarding the relationship between TfO and periodontal disease has

produced conicting results, and while some authors believe in a plausible association,11,14,16,34,4952 many other studies13,27,28,30,5355 could not produce favourable results, which leads us to conclude that there is not enough evidence to prove the relationship. Because of the contemporary controversy, this study aimed to systematically review the available evidence on the inuence of occlusal adjustment associated with periodontal therapy. A strict methodology was applied to the search for relevant studies, and to their selection and analysis, in order to minimize bias in the results of this review. Many studies that aimed to evaluate occlusal adjustment were not included, since they did not match all the inclusion criteria. All the outcomes that could be related to periodontitis were taken into consideration, which allowed those studies that did not present any clinical parameters as primary outcomes to be included in this review.45,46 Within the included studies, only one48 was a randomized clinical trial that aimed to evaluate the inuence of occlusal adjustment in association with periodontal therapy on periodontal clinical parameters (CAL, PD and tooth mobility). This trial had shown that patients who received occlusal adjustment associated with periodontal therapy had obtained greater gains in clinical attachment on both sides of the mouth during the follow-up period (examinations at one year and at two years). On the other hand, occlusal adjustment did not appear to have any inuence on PD during the two-year follow-up. It is important to observe, however, that this study poses some methodological problems that could introduce bias to the outcomes obtained. First of all, differences in PD could be due to inadequate oral hygiene, since the plaque index and gingival index were neither assessed nor reported during the reexamination visits. Another important issue is that the participants enrolled in this study had to be adults who had been diagnosed with moderate to advanced periodontitis, but were not necessarily found to have occlusal discrepancies, which could mean that not all patients would actually need an occlusal adjustment.

Table 2 Excluded studies. Study

Haddad et al., 1974
40

Reasons for exclusion

Did not evaluate the effects of OA in periodontal parameters

Design
Cohort

Main objectives
To evaluate chewing time; to observe duration of intervals between occlusal contacts during function; and to evaluate effects of occlusal adjustment on chewing contacts To determine whether tooth mobility decreases after OA; to determine whether OA can inuence marginal gingivitis To determine whether tooth mobility inuences results on periodontal treatment To compare tooth mobility following two methods of eliminating occlusal discrepancies

Vollmer and Rateitschak, 197541 Fleszar et al., 198059

Did not perform periodontal treatment (scaling and root planing) in association with OA Did not evaluate the effects of OA on periodontal parameters Did not perform periodontal treatment (scaling and root planing) in association with OA; patients were periodontally healthy Did not evaluate the effects of OA in comparison to no OA during periodontal therapy

Clinical trial

Cohort

Moozeh and Bissada, 1981

Clinical trial

39

Kerry et al., 198258

Clinical trial

To compare tooth mobility at different time periods during periodontal treatment and to relate changes in mobility to each method of treatment

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Table 3 Quality assessment. Study

Random sequence generation Allocation concealment Blinding of participants and personnel Blinding of outcome assessment Complete outcome data addressed Other biases

Hakkarainnen, 198645
Yes No No No No Yes

Hakkarainnen et al., 198846

No No No No No Yes

Burgett et al., 199248

Yes Unclear No Unclear Yes Yes

Harrel and Nunn, 200147

No No No No Yes No

Yes indicates a low risk of bias, No indicates a high risk of bias, and Unclear indicates either lack of information or uncertainty over the potential for bias.

In a retrospective study,47 an analysis was conducted of data obtained from 24 years of a private practice to evaluate the effects of occlusal adjustment in association with periodontal therapy. Although the study did not follow a trial methodology, it contained enough information to be included in this review. Statistical analyses were performed at the tooth level instead of the individual level, when groups were divided as described: teeth with untreated occlusal discrepancies, teeth with treated occlusal discrepancies, and teeth with no occlusal discrepancies. Therefore, it has been demonstrated that teeth with untreated occlusal discrepancies had worse periodontal responses related to PD, prognosis, tooth mobility and furcation involvement compared to teeth with treated occlusal discrepancies and teeth with no occlusal discrepancies. It was concluded that the impact of occlusal adjustment in association with periodontal therapy is signicant and should be investigated further. These ndings should be interpreted with care, since the study protocol does not t an adequate design, which reduces the quality of the study. It is not possible to ensure that all teeth gathered in the same statistical analysis group received the same treatments, especially within the same period of time. If a treatment protocol is not followed, bias in the outcomes is possible. The positive inuence of occlusal adjustment on tooth mobility was also observed in one of the studies conducted by Hakkarainen,45,46 although the author, among with her coworkers, could not observe any changes in a later study.46 In the earlier study, although a modest improvement in the mobility of teeth with excessive occlusal contacts could be seen 28 days after occlusal adjustment and periodontal therapy,45 sulcular uid ow (SFF) was unaltered. SFF has been related to inammation and periodontal destruction,56 and a decrease in this ow could be expected after a source of trauma was removed. On the other hand, a signicant ( p < 0.05) reduction in the rate of SFF was observed after scaling and root planing, but in teeth with occlusal interferences and also in teeth that had occlusal adjustment.45 Teeth that had their interferences adjusted did not derive any additional benet from SFF, possibly indicating that occlusal interferences do not affect this outcome. Although uid ow did not change after occlusal adjustment, the later study observed that its quality could be inuenced after this intervention.46 It was shown that occlusal adjustment performed on teeth with occlusal discrepancies reduced the protein content and collagenase activity of the sulcular uid. These factors, which can be inuenced by tooth

mobility, are also related to inammation and the progression of periodontal disease. It has been suggested that increased collagenase activity is related to the destructive phase of the progression of periodontitis.57 Yet, as observed in the other included studies, the two studies mentioned above also have methodological issues that do not facilitate any remarkable conclusion, especially because their follow-up times were only 28 days. It is important to notice that none of the included studies explained how occlusal adjustment was conducted. TfO might be related to parafunctional habits, as well as the number of remaining teeth and its insertion levels. Occlusal adjustment should be conducted in order to solve the ethiologic factors for TfO. This issue represents an important risk of bias for interpreting results of these studies. It was not possible to conduct a meta-analysis in the present study, since the results of the included studies were too different to be gathered into a single piece of analysis. Although the four studies evaluated in this review had demonstrated a possible improvement in periodontal parameters when occlusal adjustment is associated with periodontal therapy, there are still conicts between them. Burgett et al.48 could not conclude that occlusal adjustment had any inuence on PD, while a statistical analysis conducted by Harrel and Nunn47 has shown that improvement in probing depths was directly related to occlusal adjustment performed on teeth with excessive occlusal contacts. These results are probably due to differences related to methodologies and specially statistical analysis. Considering that each study had their own way to treat and analyse their data, their results should not be compared as well. Burgett et al. conducted their analysis on a patient level, while Harrel and Nunn used the method of GEE to analyse their data on a tooth level. Other studies that could not be included in this review (for reasons provided in Table 2) had also pointed to a positive effect on periodontal parameters from occlusal adjustment. Vollmer and Rateitschak41 had observed an improvement on tooth mobility 30 days after occlusal adjustment alone, with no other periodontal therapy associated. This improvement, however, could not be seen on rates of sulcular uid ow. Another clinical trial excluded from this systematic review was conducted by Kerry et al.,58 whose patients underwent a hygienic phase of treatment consisting of initial scaling, root planing and occlusal adjustment. Although it was excluded for the fact that it did not provide any information about the specic role of occlusal adjustment

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Table 4 Individual outcomes from included studies. Study PD Mean (mm) SDall teeth Group Aa
Hakkarainnen, 198645 Day 0 Day 14 Day 28 6.4 0.3 Not mentioned Not mentioned

Results Mobilityall teeth Group A

1.3 0.1 Not mentioned Not mentioned

SFF Mean (mm)test teeth Group A

2.3 1.1*** 1.1

Group Ba
7.4 0.4
**

Group B
1.4 0.1 Not mentioned Not mentioned

Group B
3.4 1.9 1.3*** journal of dentistry 40 (2012) 10251035

Not mentioned Not mentioned

Study Mobilitytest teeth Group Aa

Hakkarainnen et al., 198846 Day 0 Day 14 Day 28 1.1 0.1 Not mentioned 1.0 0.0

Results Protein content on SFFtest teeth Group A

41 9 29 7 22 5

Collagenase activity on SFFtest teeth Group A

2931 96 2031 299 1680 308

Group Ba
1.3 0.2 Not mentioned 0.9 0.1

Group B
60 13 37 7 24 6

Group B
3543 240 2815 186 1409 262

Study PD Mean (mm) SD Occlusal adjustment

Burgett et al., 199248 Baseline 3.65 (0.78)

Results CAL Mean (mm) SDb Occlusal adjustment

3.50 (0.78)

Mobility

No occlusal adjustment
3.50 (0.63)

No occlusal adjustment
3.47 (1.20) Mean mobility for all of the teeth of all patients was 0.75. Clinical attachment gain was greater when tooth mobility was <0.75 (for both groups).

1 year

2.97 (0.37)

2.88 (0.46)

0.32 (0.54)

0.07 (0.44)

2 years

2.99 (0.97)

2.96 (0.42)

0.42 (0.67)

0.02 (0.53)

Study PD Mean (mm) SD 0

Harrel and Nunn, 200147 Baseline No occlusal problem Treated occlusal problem Untreated occlusal problem 4.77 mm (1.31) 5.53 mm (1.51) 5.59 mm (1.29) 42% 34% 45%

Results Mobilitypercentage of teeth per group 1

40% 31% 39%

2
14% 28% 16%

3
journal of dentistry 40 (2012) 10251035 5% 7% <1%

Study Mean PD per year

Harrel and Nunn, 200147 Post treatment No occlusal problem Treated occlusal problem Untreated occlusal problem
a b

Results
c

Improvement
13% 16% 0%

No change
75% 63% 63%

Worsening
13% 20% 37%

0.048 mm 0.122 mm 0.066 mm

Group A: day 0 = scaling and root planing; day 14 = occlusal adjustment. Group B: day 0 = occlusal adjustment; day 14 = scaling and root planing. Negative measures mean loss of clinical attachment levels. c Negative measures mean an improvement on probing depths. ** At baseline, difference between mean PD of each group was statistically significant ( p < 0.05). *** SFF (sulcular fluid flow) diminished significantly after intervention, when compared to previous exam ( p < 0.05). Collagenase activity diminished significantly after intervention, when compared to previous exam ( p < 0.05). Difference between mean CAL of each group was statistically significant ( p < 0.05). Difference between mean PD between test and control groups ( p < 0.0001).

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journal of dentistry 40 (2012) 10251035

associated with periodontal therapy, a signicant reduction in the number of mobile teeth was observed after this initial hygienic phase.41,46 The lack of evidence in this area might be partially due to ethical considerations, since it is not possible to run a protocol on untreated periodontal disease to evaluate longitudinally the results of occlusal adjustment treatment by itself.60,61 Besides that, it has also not yet been established whether trauma from occlusion inuences periodontal breakdown. As has been discussed here, the evidence has shown that occlusal discrepancies might induce greater alveolar bone loss and CAL. If this is actually true, leaving occlusal discrepancies untreated to observe attachment loss would be considered extremely unethical. It has been stated that prospective studies on the effect of occlusal forces on the progression of periodontitis are not ethically acceptable in humans by The World Workshop in Periodontics.61 This fact hampers the development of protocols that could help to dene the role of occlusal adjustment in periodontal therapy. Even though the available evidence points to the benet of occlusal adjustment on periodontal parameters among periodontally compromised patients, studies have not been able to explain the direct inuence of occlusal adjustment in reducing probing depths and improving clinical attachment. It is still necessary to develop stricter protocols that will help to determine the role of occlusal adjustment in conjunction with periodontal treatment. It is important to state, however, that no adverse effects have been related to occlusal adjustment, which means that although its benets are not proven, it is also not detrimental. The decision made by clinicians whether or not to use occlusal adjustment in conjunction with periodontal therapy hinges upon clinical evaluation, patient comfort, and tooth function. The evidence thus far is insufcient to presume that occlusal adjustment is necessary to reduce the progression of periodontal disease.

6.

Conclusions

Within the limits of this systematic review, few studies could be analysed to reach a solid conclusion about the inuence of occlusal adjustment associated with periodontal therapy, on periodontal clinical parameters. Even though the benets of occlusal adjustment are yet to be proven, evidences so far have not shown any adverse effects associated to this therapy. However, new studies are required to answer the question of this systematic review.

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