Title	In Patients With Progressing Periodontal Disease, Occlusal Adjustments Do Not Contribute Significantly to Treatment Outcomes
Clinical Question	In patients with periodontal disease, do occlusal adjustments as part of periodontal therapy, compared to periodontal therapy alone, result in additional benefit to the treatment outcome?
Clinical Bottom Line	Evidence is insufficient to conclude that occlusal adjustment is necessary to treat the progression of periodontal disease. This is supported by a systematic review of several clinical and randomized clinical trials. Each case must be evaluated individually to evaluate if actual occlusal trauma is present, and treatment should be accomplished based on patient comfort and provider clinical judgment.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 11338302 Harrel/2001 89 patients: 2,147 teeth Retrospective cohort study Key results Patients were separated into 3 groups- untreated, non-surgical treatment, and surgical treatment. 56 of 89 total patients (62.9%) and 307 of 2,147 teeth (13.35%) had occlusal discrepancies, which were defined as a vertical slide greater than 1mm from a premature contact and balancing contacts in lateral movement. In surgically treated patients with an occlusal discrepancy, pocket depths were approximately 1mm deeper than teeth without occlusal discrepancy (P ≤ .0001, statistically significant). These teeth also had statistically greater mobility. Conclusion: Teeth with treated occlusal discrepancies showed improvement in pocket depth over time. 17012717 Deas/2006 N/A Narrative review Key results Traumatic occlusion does not always result in attachment loss. Inflammation must be present for attachment loss to occur, in addition to occlusal trauma. The prevalence of non-working contacts ranges from 50-70% in the population, and the effects of these non-working contacts and periodontitis is unclear. Conclusion: Most occlusal discrepancies do not cause occlusal trauma, so completing occlusal adjustments is not justified. 22982113 Foz/2012 200 patients in 4 studies Systematic review of non-randomized trials Key results Four studies were included in the review; three clinical trials and one randomized parallel trial. Outcomes measured included clinical attachment level (CAL), probing depth (PD), mobility, sulcular fluid flow, collagenase activity in sulcular flow, and protein content in sulcular flow. Patients who had occlusal adjustments attained greater gains in clinical attachment, but no changes in probing depths were noted. Untreated occlusal discrepancies resulted in “worse periodontal response” in terms of PD, prognosis, mobility, and furcation involvement. The impact of occlusal adjustment with periodontal therapy should be investigated further. Sulcular fluid flow was unaltered, but protein content and collagenase activity decreased, and these factors are related to the progression of periodontal disease. Conclusion: the evidence included in this systematic review is insufficient to indicate the influence of occlusal adjustments associated with periodontal therapy.
Evidence Search	occlusal[All Fields] AND ("injuries"[Subheading] OR "injuries"[All Fields] OR "trauma"[All Fields] OR "wounds and injuries"[MeSH Terms] OR ("wounds"[All Fields] AND "injuries"[All Fields]) OR "wounds and injuries"[All Fields]) AND periodontal[All Fields] AND ("disease progression"[MeSH Terms] OR ("disease"[All Fields] AND "progression"[All Fields]) OR "disease progression"[All Fields] OR "progression"[All Fields])Evidence Search
Comments on The Evidence	Validity: In the study by Harrel and Nunn, the study was retrospective, rather than a double-blinded prospective study. Patient oral hygiene and maintenance were not standardized. Occlusal trauma was not diagnosed histologically, which would require extraction, nor using parameters such as tooth wear or mobility. Instead, occlusal trauma was defined as any slide between centric relation and centric occlusion, lateral working and balancing contacts, or protrusive contacts. Deas/2006 was a narrative review, so its conclusions are not supported by specific results. In the Foz/2012 systematic review, none of the included studies indicated how the occlusal adjustments were accomplished. Methodologies and statistical analysis techniques differed and resulted in different conclusions. Neither plaque index nor gingival indexes were reported when examining differences in probing depths. Patients included were those who had moderate to advanced periodontal disease, but not necessarily with occlusal discrepancies. Follow-up times were sometimes insufficient, as in one study that only followed up for 28 days. Perspective: Insufficient studies have been completed to fully identify the impact of occlusal adjustments on the improvement in treating periodontal disease. Due to ethical reasons, no studies can be done in which periodontal disease is left untreated in order to evaluate the results of occlusal adjustment alone. Traumatic occlusion, in the presence of inflammation, is a factor to consider in treating periodontal disease. Occlusal adjustments are not justified in treatment of every patient; instead, each case must be treated on an individual basis if signs and symptoms of occlusal trauma are present.
Applicability	Many factors influence the initiation and progression of periodontal disease. Occlusion should be evaluated in all patients, including patients with periodontal disease. It is important to identify occlusal interferences and adjust them as indicated according to clinical judgment, patient comfort, and dental function. Occlusal adjustments are not expensive or time consuming but should not be done arbitrarily.
Specialty	(General Dentistry) (Periodontics)
Keywords	Occlusal trauma, periodontal disease
ID#	3277
Date of submission	12/11/2017
E-mail	hyer@uthscsa.edu
Author	Jenna Hyer
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Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available