Periodontology has some good studies and evidence base – but what is the current thinking in the role of occlusion/parafunction in the aetiology and progress of periodontal diseases?
I am joined by Specialist Periodontist, London-based Dr Richard Horwitz to discuss exactly the correlation and link between occlusion and periodontitis.
This episode’s Protrusive Dental Pearl I picked up from Dr Dipesh Parmar on his fantastic Composite course Mini Smile Makeover – it is to use a sectional posterior matrix band (like the B100 from Garrison or Tor VM) in a vertical fashion to create perfect mesial and distal contours for your anterior composite restorations such as Class IVs.
I had a really fun chat with Richard which included so much:
- When and why would you consider occlusal adjustment/equilibration in a periodontally compromised patient, perhaps to reduce occlusal trauma?
- Can Periodontal splinting help in these parafunctional patients?
- How can you check for fremitus?
- What role can appliances have in the stabilised periodontal patient?
- Listen to how I ruined Richard’s canine guidance!
If you enjoyed this episode, you will like my episode with Endodontist Kreena Patel on Cracked Teeth!
Click below for full episode transcript:Opening Snippet: I'm checking the occlusion as part of your periodontal examination is a must, is something which is often left. And it is really important and valid. Just because I don't feel it's the primary cause of periodontitis doesn't mean to say I find it any less important in the progression of periodontitis and it has to be addressed, especially when I show you those cases where they were in part exacerbated by a trauma from occlusion. If you don't treat the trauma from occlusion, when it's exacerbated a periodontal problem, it's never going to be treated. So it's really important...
Jaz’s Introduction: I am getting very nervous and very anxious. Why? Because it’s been so many episodes, since I talked about something occlusion related. So when this happens, I get very nervous. So let’s focus back in, let’s pull it back into occlusion. Can we? Today is all about perio and occlusion. I’m joined by my good friend, specialist, periodontist, Richard Horwitz, and we’re gonna sort of do some myth busting or perhaps some changing of perceptions, can occlusion cause perio? I’m about to say can perio cause occlusion? That would be stupid. Can occlusion? And what I mean by occlusion is Can someone with a dodgy bite, are they more susceptible to perio? Is that a thing like you know, occlusal trauma, we know that occlusal trauma exists. But what role does occlusion actually play in periodontal bone loss? So that’s the kind of stuff we’re covering today. So welcome, everyone to Episode 47 of the Protrusive Dental podcast. Now another massive thank you is due for everyone. around about a month ago now something pretty awesome happened. We crossed and I say we because you know, you guys are like family to me now. A lot of you on the Protrusive Dental community Facebook group. And I love seeing you guys there. We crossed 50,000 downloads, right. And this is pretty big, right? A lot of podcasts that get created. It’s like businesses like nine out of 10 new businesses will fail in the next five years or something like that, it’s a famous quote, right? So a lot of podcasts started and they never reach 50,000 downloads. And so I am so, so thankful to you all for giving up your time to listen in your commutes while you’re chopping onions while you’re gardening, that sort of stuff. And you know, it’s amazing. So thank you community, Which reminds me, I need to change your name and I need your help. If you can think of a better name for the people, the good people who listen to the podcast from something else other than family would really, what will be a good name for you guys, right? Help me out. I’m gonna post on the Protrusive Dental Podcast Community Facebook group as well. And hopefully we can get some good ideas you can Instagram me as well as @jazzygulati. But before we get to the episode, of course, I owe you a Protrusive Dental pearl. This episode’s Protrusive Dental pearl is when you’re doing anterior composites, and you want to get a very nice contact point, which we all do, obviously, the choice is often twofold, okay, and this could also be applying to resin veneers, you could either do the mylar pull technique, or you can do and I’ve talked about that once before, some episodes go in like a little mini episode. But I want to focus in on the other technique, which is actually using a matrix band. And the matrix band of choice. And I’m sure many of you know this already, is to use a posterior sectional matrix band. But use it vertically. Okay, anteriorly, I’ll see if I can get a photo of this here, of me doing this. Now, one of the places where I saw this being demonstrated in the best way and showing both of those techniques, ie using a matrix band on its side vertically, such as the Garrison B100, or the Tor VM soft one that can be used as well, compared to using the mylar pull technique and the nuances around that was the Mini Smile makeover course. By Dipesh Parmar, he really went over a lot of in so many cases and stunning case after case after case. And he really goes over several indications. So you know, hat tip to Dipesh Parmar, amazing, talented clinician that he is. And so the tip is to use a posterior sectional matrix band vertically and that could be you can use many but the B 100 seems to be quite popular for that and garrison, I tend to use, the Tor VM which is like a Russian brand, you can get that from Incidental Limited. So I hope you enjoyed that little tip next time when you’re doing a class four you can just put the matrix band in, a bit of a wedge and then this is once you build up your palatal walls. So you build up your palatal wall and then two handle the interproximal. To get the nice contour, these curved bands can be quite good to get the right contour mesially or distally, for example, so I hope that little tip helped. Before we dive into the episode, I want to discuss one more thing that we discussed in a previous episode with Shaz Memon, we talked about personal branding for Dentists. So if you haven’t heard this episode already, do check it out. And my pearl then was to check out this review collecting platform for dentists called doctify, which I quite like. I get quite a lot of reviews from patients and some of my patients come from there, it’s a great way to collect genuine reviews from your patients. And it looks really nice. When you type in a dentists’ name on Google that it comes up. Now the feedback I’ve had from a lot of people is that hey, you know, my I’m an associate. And when I told my principal, that I want to start collecting reviews for me myself, they’re a bit funny about it. Which is a real shame. I think, like putting myself in the shoes of a principal, I get it like you don’t want your associate to be taking their own review because one day, what if they go then all those reviews go with them. But that’s kind of the point that associates self employed, okay. But think of it as a good thing, like its associates getting good reviews, and getting patients coming through the door for the associate, then they’re doing their own marketing, right. It’s a great thing. So I think there is a win-win to be found in that. So for those people who are still reluctant, Alex from doctify very kindly, he came up to me and said, Hey, for anyone who listens to Protrusive Dental podcast, he can do you guys a favor, he’s willing to do 50% of her first four months. That way you can test if this is something that works for you, if you’re able to collect reviews at a decent enough pace, and you will be if you prompt your patients, there’ll be happy to review usually, so 50% off for four months. And so check it out. All you have to do is when you sort of are discussing with doctify about signing up, they’ll ask you, hey, how’d you hear about us, you say protrusive dental podcast I want the 50% off for four months. And just give it a go, you know, give it a go four months, see what you think. And then the more reviews you collect, the more you get out of it really. And then you’ll be able to see the response that you get from that. So I hope that helps you guys were sitting on the fence. And I’m hoping that even the principals who want to get doctify for their practice will be able to benefit from that. Anyway, let’s learn all about perio and occlusion.
Richard Horwitz, it’s great to have you on the Protrusive Dental podcast. Thanks so much for coming on. [Richard]
Thank you for having me. Really grateful for you inviting me. [Jaz]
No, you’re a friend of mine. We went to uni a few years above me at the time. And I then went on to, after qualifying, I met you on a tube. And that’s when I found out I think you were commuting to Eastman at the time to do your perio training. And then next time, next thing you know we’re at an Indian restaurant, we’re at Regency we’re having lamb chops and whatnot. So again, over zoom. Who was locked down been for you. [Richard]
It’s been good. It’s been tough, but I always like to, you know, find the silver lining and be positive. And for me, it’s been a bit of a paternity leave as I think it has been for you as well. So it’s been great spend time with my daughter who’s 11 months. And yeah, seeing her crawl for the first time, putting herself up on bits of furniture, gnawing bits of furniture while she’s teething. So it’s no it’s been really lovely. And I would never have had that. At the same time, I’m excited to go back to work so yeah [Jaz]
I’m the same. Absolutely. So the same exact journey as you seeing the crawling development, standing or the mischief and stuff. So it’s been great. So yeah, my son’s 10 months, 10 in a bit months and Sophie’s obviously 11 months so it’s I think we’ve shared something special over the last few months but yes, we’re both a keen to go back to work. And for me, it’s going to be Friday, supposed to be tomorrow. For those listening by time this episodes published are hopefully going to be in the swing of things and not dressed as spacesuits anymore. I mean, I’ve got my hood now, so I will be dressed as a space alien. You’re gonna be going for a mask? [Richard]
I think so. Yeah. It means I can’t do my [designer stubble], but yeah. [Jaz]
But for those who don’t know who you are, Richard, please tell us about yourself and what you do day in day out, your speciality and what we’re gonna be talking about today. [Richard]
Okay. I’ll start at the beginning. I’m born in London. So grew up in London, went up to Sheffield and had my fantastic years there. Met yourself in Sheffield. And yeah, it was a great experience people that are so warm and friendly. And I always have a soft spot for Sheffield and I do miss it. Friends and family’s in London. So I came back to London and did my foundation training. I found that what I liked and didn’t like in that year. That was a really important year for me. Every time I found a case which I wasn’t so sure about and I wanted to refer I wanted to see what the specialist was doing that was so special. I want to be able to see what could be done that I couldn’t do or didn’t understand how to do? So that was a great learning curve for me. I also found out what I really didn’t like as well. We’re chatting before I’m so happy to see your last podcast with Mark Bishop. He’s fantastic tutor, he taught me confidentially. He was a brilliant teacher. He’s a brilliant teacher. In that in those first years, when I was a general dentist, I found out what I wasn’t good at. And just to put this in perspective, I made a denture for a patient in practice working out in Dunstable outside Luton. It was a great practice I made this denture. It was one of these [Ivory] style because I was into perio I thought I knew I know I wanted to Perio and I want to make it cleansible. I made this [ivory] style denture for [Jaz]
spoon denture [Richard]
Spoon denture. It’s pretty much with two [inaudible] Okay? It was not something to be proud of, but I made it. I don’t know why I forgot about this denture, obviously, because I don’t keep a recollection of every denture I make. I go to do my training, at Eastman, my three year specialty training in perio. Enjoying it. It’s great. In our final year, they send us out on this outreach program to work in specialist clinics in the community. And I work in this place in Bedford. And I see this patient of mine in Bedford, he recognized me. I didn’t recognize the patient. I looked at this denture and I thought, God that is a bad denture. I didn’t say anything. Well, I just said When did you have your denture made? Because I think you need a new one. He said you made it for me. [Jaz]
He said Really? Sorry. Really? Sorry. [Richard]
I think I was thinking I’m really sorry. Moving on. Yeah, so it’s a bit of a long story, but it’s just an I’d say in finding perios my specialty. I found things I didn’t like in general dentistry. I was never, I didn’t want to. I felt like I really want to excel in things I loved and perio, surgery, implants were the subjects which I really wanted to master. And [Jaz]
So that was a DF1 year where you decided in your journey? [Richard]
I’d say the end of the DF1 and DF2. Yes. [Jaz]
And did you do any shadowing of specialist and if you don’t mind me asking how many specialists did you shadow for how long? Because I something I advocate for young denstists, DF1s is just go out there and shadow to get the maximum exposure. How was your journey in relation to shadowing and mentorship? [Richard]
So I shadowed an orthodontist, endodontist, prosthodontist, periodontist. I shadowed really every specialist, I could find. Anyone who I’d refer to, I’d ask if I could shadow. So I could see the journey of my patient. Patient was fantastic, which I am carrying and interested in them. But it’s a great thing to do to see your patient through the journey. And then you get to learn what the specialist does, which is great. And you find out I mean, actually in Sheffield, I loved endo, and I was I want to be an endodontist. Right? Okay, so and then I got into foundation year and I thought I really I find I’m stressing like every time I do an endo I get stressed, I get heart palpitations, I’m just go home. What a stressful day. Every time I was doing Perio, First of all, I was thinking God, there’s so much I don’t know. And even through my course I remember the first few weeks was hand scaling. We did like a hand scaling masterclass. I had no idea about these hand instruments. I just didn’t, there was so much to learn. [Jaz]
There’s so many nuances, right? of every instrument that a manufacturer, which angle to hold it at, which part’s cutting, which part’s non cutting. The various little things which we know we just think we just picked this up and we just started scraping, but really, there’s a way to do it and there’s, you know, you can actually be doing a lot of damage or doing something completely ineffectively if you’re doing it wrong. [Richard]
Absolutely. And what I felt was that within my journey, there were so many new things which I just didn’t know which I was thirsty to learn about. So that’s why I kind of fell on to perio. And yes, mentors are really important. I had, I mean I shadowed Jonathan [Lac] is a periodontist who I shadowed a lot and he encouraged me he was teaching at the time at Eastern encouraged me not to go forth with periodontal training. [Jaz]
So in a moment, am I right that you work in, Wimpole street or Hollis England? [Richard]
So I’m in Wimpole street and Hampstead between two and I do lots of lecturing for the CPD department at Eastman on aesthetic dentistry course and other courses. [Jaz]
Excellent. We now know a little bit more about you Richard. Let’s get into the main topic for today, which is the main reason why I had this lovely pink background for you reflects Perio I’ve never gone for pink before so [Richard]
I’m the loving the pink. First of all what I have a lecture title which I call thinking pink. So that’s all over it. But yeah, it’s like you’ve got the lighter stipple pink at the top of health and then the purple disease at the bottom. I love it. With contrast is I mean my computer is too old to be able to produce a background like [Jaz]
Brillian. Thank you so much. Well, the thing I wanted to talk about is something that you know we were talking on Instagram and stuff something you know, you know, I’m already have an interest in it’s occlusion, it’s parafunction, it’s bruxism. So I know that in perio there are some very good long term studies now, you know, way more than I do about this entire subject, but I think of studies like is it [Axel or Axelsen?] like those sorts of studies where they’re in private practice over many decades, they follow up patients and they show that wow, we can really keep teeth with we know with good periodontal treatment and good oral hygiene regime. So I know that perio is quite rich in literature and some of it is actually very good. How much is there in relation to the role of bruxism and parafunction and Perio? [Richard]
So short answer, not a lot. But I’ll go into in a little bit more detail. It was really the 70s where we had most of the studies which we now come to look to when we’re treatment planning, when we are looking at occlusion in perio and occlusion is a big part of my examination. Now, various periodontist will have different levels of importance put on occlusion, and people will go with different schools of thought. I think it’s incredibly important. And it’s a little bit of chicken the egg, which came first when it comes to perio or occlusion. But I think perio is all about removing causes, controlling the etiology. And whilst not to give the game away, whilst trauma from occlusion is not the cause of periodontal destruction. It’s an exacerbating factor. And like all modifying exacerbating factors, risk factors, they need to be controlled if there can be. So it’s important. And I’ll talk to you when we chat more really about why I’ve come to that conclusion as well. [Jaz]
But Richard, if you want to study something on that it’s almost impossible to study, for example, if we’re going to design a randomized control trial, looking at parafunction bruxism, there’s so many variables, how long the teeth are in contact for? To what force? The size of the masseters? What kind of parafunction? Is it clenching? Is it excursive?, and also, all the myriad of inflammatory factors of blood tests, vitamin D, is just too many practice to be able to come up with such a study. So really, we might never know the truth. But we You sound like we have some good ideas. So tell me a little bit more where your, what your current thinking is. But I also want to know, as a periodontist, what is it that you look for in an occlusal exam, which may be different to I look for? Or maybe it might be the same? [Richard]
I think it will be similar, but we’ll see. I mean, I would look for guidance, I’d look for anterior guidance, I look for lateral excursions, I’d see if there’s parameters in any teeth, I’d look to see incisor relationship and is there an anterior open bite, which may have further implications on the posterior dentition? I would look for wear facets, I’d look for non working side interferences and all these things that can influence bone loss. And because we do know, I mean, when you look at these studies, now the human bones aren’t many, because how can you design a study? And when they do have them, they read the original historical ones that cadavers, which had tooth wear, and then you can’t really it’s difficult. So they have these hypotheses, like you have our hypotheses and Glickman, which shows that there’s zones of CO destruction and but I think when further studies were done on on Beagle dogs, they managed to see histologically what’s going on when you apply a certain force on a tooth and if that, if there’s periodontitis, with the trauma from occlusion, or if it’s in a reduced periodontium, or if it’s in a healthy periodontium so all these things are measured. And all of these are important in forming an overall idea of the [role]. So and what we know from those studies is that we know that if you are a periodontally healthy dog, okay? Or human, you can infer that you’ll get no further periodontal destruction. You’re getting sorry, you’ll get no further pocket depth increase, if there is no inflammation, if there’s no periodontitis. What you will get is bone loss. Okay? You’ll get a widening of periodontal ligaments, you’ll get mobility increase, but you won’t get pocket increasing, you won’t get clinical attachment loss. Okay? [Jaz]
But surely by bone loss that inverse clinical attachment loss. [Richard]
No. So you because you would still have the connective tissue attachment and the junction epithelium so you won’t lose any attachment, but radiographically you’ll see changes. But the relation is bi-directional, because if you have that to then let’s say this is a Bruxist, who doesn’t have any periodontal disease, and lets you treat them with a splint, Splint therapy, and it works really well. Once that trauma from occlusion is address, you will find radiographic infill of the either bony defects or widen periodontal ligament. So that is reversible if there’s no inflammation. [Jaz]
Let me just hone in on that. Let me just hone in on that point. What you just suggested is that if you have someone who through your therapy, you’ve managed to control that oral hygiene, you remove any sort of factors contributing to inflammation. And now the the other piece of the jigsaw puzzle is controlling the forces which you’ve suggested with a splint, for example, right? And that as a package, so one without the other, you know, you can’t let inflammation continue but as a package that has helped to see radiographic healing, am I right in what I’ve been further? [Richard]
So you were talking about someone with periodontal disease, this can be in someone without periodontal disease, you’ll still see widening periodontal ligament and bony defects if they have torn from occlusion, but they won’t have increased pocket depths [Jaz]
A new type of bone loss that I’ve classically described it radiographically is a funneling, [Richard]
Yes, because you get that movement within the periodontal ligament. But what you’re doing, you stretch the periodontal ligament, you stretch the attachment, you’ll will get bone loss, but you won’t get pocket reduction unless of course there is inflammation. So inflammation is the key here. If there’s inflammation, you will exacerbate the amount of bone loss and the progression of the periodontal disease. So we know that from both the North American Studies and the Swedish and the European studies we have. [Jaz]
So the next question I asked you is when and also we can talk about the how but or do you even consider the role of occlusal adjustment and equilibration when we’re, when you’re carrying out your periodontal therapy or post periodontal therapy to make sure that all the factors are controlled, so the forces being one factor, which may exacerbate the issue. So do you subscribe to school of thought whereby occlusal adjustments and a calibration are part of your practice? Is that make sense? [Richard]
Absolutely. So as I’m not a prosthodontist, and I’m not a general dentist with occlusion as my subspecialty I very much leave it to the experts in a sense to adjust the occlusion as they see fit. Whether that be by taking occlusal records mounting and simply adjust articulator and finding out what the consequences of adjustment is, whether that’s creating a splint in Michigan or any other time is up to them in a sense. My view is it can’t be left. So if I was, if I had a patient with trauma from occlusion, I would definitely discuss it with the dentist and say, I would recommend either an occlusal adjustment or a splint therapy as you see fit. Because I can guarantee if you had 10 dentists in a room that all say different ways of treating trauma from occlusion and some will be splint therapy is the only way and some will be adjustment’s the only way and each of them would think the other one what they’re suggesting is complete the outrageous so I think really my view is both work adjusting and using splint. So whatever, at least you address it and you don’t ignore the problem. I think the issue is yes, without inflammation, it won’t progress. But if you have a patient with periodontitis, they’re prone to inflect inflammation. And when you keep them a three months, the recall you always see sometimes, okay, but all the pockets under four millimeters, you have some control but something will pop up every so often. And it’s important not to leave an exacerbating factor there which can cause further deterioration. So I think it’s always something that needs to be addressed might not be the primary cause, but it can certainly make things worse for the patient. [Jaz]
Brilliant. Now, when we read these texts of like Dawson, and if you subscribe to some of the what Pankey teaches that actually in a patient who is parafunctional or exhibits bruxism that you may be more likely to see a recession, is there any, because sometimes I see a patient and I know they’re known bruxism, they’ve got their large masseters, they’ve got cracked teeth, and occasionally you see some teeth with recession now, recession is multifold, multifactorial, we know there’s the bio type that’s in play, we notice their brushing habit, which is very, very heavily implicated, how much bone they have all those sorts of things. But what do we know about recession defects? Stemming primarily, potentially from power function? Is there any causal link there? [Richard]
Personally, I think there’s too many factors. For one to pinpoint occlusion as being the cause of recession. More often than not, it’s to do with over brushing, under brushing, aberrant frenum biotypes, things like that. It’s a difficult one. Because yes, if you have trauma from occlusion, you can get, what trauma from occlusion you won’t get attachment loss. So you will only get recession if there’s inflammation. So if someone is not brushing, because they’ve got an aberrant frenum on the lowered central incisor, it’s really hard to clean. Also, that lower incisor is in fremitus. Okay? And it’s just wobbling and it’s highly mobile, has a lot of guidance concentrated on that one tooth, probably going to exacerbate the recession. So it definitely has a role. I don’t think I’m going to factor. So it’s totally fine. [Jaz]
Yeah, a lot of it is and you know, like we said that the right at the beginning, we will never be able to prove exactly, there’s too many variables. But what we do know so far is exactly what we said, these factors are contributory, they play a role, but they’re probably not the main big player here. There’s other things, you know, like inflammation might be, you know, brushing habits we need to consider. Now I’m very aware that some students have started to listen to my podcast and some young dentist. So just explain fremitus, What is it? How did I mean, we’re going back to basics here. what is it? How do you look for it? [Richard]
You need to look at their static [equilibration] when they’re biting together what the relationship is, and when they’re moving in left and right lateral excursions and anterior guidance, what movement there is on the teeth. With fremitus, if unnatural excursions, the teeth are mobile, and there is a heavy contact on that tooth. And then that’s something which you need to be aware of and mark it down. You need to mark it down because it can have an adverse impact on the health of that tooth. [Jaz]
I think you’re right about checking parameters in static, the simple way I like to explain to young dentists that when people bite together, you shouldn’t see that teeth move like piano keys, you know how they just flick out. And the other thing that you could do is if you put your fingers on their teeth, you know you’re indexing, so your actual fingers on their teeth. And when they bite together, there might be the odd tooth where you feel excessive movement in the PDL. And that’s a good way to check as well, because sometimes not always visual, it is by how you feel it as well. [Richard]
Absolutely, that’s a really good I mean, using your finger is really the best way I use finger and ask them to bite together and that’s when you’ll feel the tooth move. So here I’ll just show you a couple of cases. [*shares the screen] Okay can you see? [Jaz]
Yeah beautifully. [Richard]
Okay great so this is a patient it’s difficult to tell here but complete wear facets on posterior dentition. This guy is 35 years old okay? Anterior open bite okay and here [Jaz]
So that’s what i mean it’s good you mentioned that because there’s a lot of people who believe that by someone who has an AOB that their posteriors are “overloaded” and therefore you may see some more periodontal destruction so i think based on our chat so far, it may play a factor but we also need to be mindful of inflammation and all the other bits but we can take care of this so it’d be interesting to see how you manage this post in terms of the periodontal, the pink stuff but then also the forces. So please I’m keen. [Richard]
So pink stuff, control of the inflammation you go through basics, you have your systemic phase you check the medical history, you check the roles of diabetes, you check the roles of any medical systemic influences, you go to the initial phase which is your non-surgical therapy this is also all things which we do in general practice which we’re all very good at. And then we have a residual pocket on this lower left five we have a residual pocket with bleeding it’s eight millimeters in depth it’s not going to respond to further non-surgical therapy because of this defect there’s a local factor stopping the closure of this pocket. So what is going on well it’s not just the inflammation that’s caused the bone loss, the bone loss has been exacerbated by a occlusal problem so yes i can treat the inflammation surgically okay but before i treat it surgically to try and regenerate this area the occlusion needs to be addressed. Now no amount of occlusal adjustment on a patient with an anterior open bite is going to reestablish the anterior open bite so splint therapy is i think personally if i’m wrong but vital in this kind of patient unless you want to send them to the maxillofacial surgeon. [Jaz]
Yeah if someone’s got a you know skeletal AOB that’s quite gross like that then yeah splint is a reversible way to give them a more desirable distribution of forces which will then help the situation [Richard]
So once you have that then we need to look at surgically what I do. I’ll just show you that so here this case was we use guided tissue regeneration. We preserve the papilla so this little bit of a papilla here we preserve and we suture back together over a graft material this is a bovine derived caldera bone graft and then we have a collagen membrane which is supported by the bone graft and we suture together and then we reduce it from an eight millimeter pocket to a four and we have radiographic infill. Now if we weren’t to adjust the occlusion or if we weren’t to address the occlusion I should say, it’s very likely that any inflammation in that site will lead to further bone loss and reestablishment of the injured bony defect so it’s really important now you’ve noticed that there is a rather bulky but there is a composite splint holding these teeth together ultimately i mean do you want me to talk about the splinting or when? [Jaz]
Yes. So i’m going to ask about splinting but just worth mentioning for anyone watching this right now, some people listening obviously, but what we can see here is which has shown is guided tissue regeneration very nicely. It looks very neat surgery, we can see the wear facets, as you mentioned, quite flat on that molar and premolar and in this case, the bone, the bony healing looks fantastic. And we see a thick composite splint the front which we’re gonna talk about in a minute, but the reason it’s thick is because trust me, if it’s thin it will break, you’ll have a cohesive fracture. So it’s sort of happening. I’m sure we learn through trial and error. But these things have to be thicky. You made that mistake once and he learned you make is because you can get away with. [Richard]
It’s more trial and error, believe me. [Jaz]
Absolutely. So I mean, before we come on to the role of splinting generally for mobile teeth, where we suspect maybe occlusal, or not in a role, I want to touch on why, you know, I’m not expecting you know the answer to this, because I think no one knows the answer to this. But why do some people with OABs go throughout life without any issues at all? and others have these sorts of issues? Why are some of them having cracked teeth? And while others do not want? Why are some having periodontal breakdown? while others are not? It’s, you know, we just don’t know, it’s just one of those things. Now, I have theories, right? My theory is that those who are producing a lot of forces, I mean, yes, they have their AOB, but unless they actually at nighttime, if there’s 17 and a half minute chewer. And their teeth are touching, you know, 17 and a half mins a day, then they’re not much forced. And you know, the teeth aren’t taking that much force. But at nocturnally during parafunction, we can produce four times as many forces as we can, when we weren’t aware of it. So if you tally up the fact that we have a parafunctional patient with AOB versus a less parafunctional, patient or non parafunctional, which are rare nowadays, with an AOB, then that may have one role. The other theory that I subscribe to, is that there’s perhaps a weak point. So if we look at their teeth, if we look at their periodontium, and we look at their, you know, TMJ, for example, then one of these, they may, you know, naturally have potentially a weak point, whichever is the weakest link or suffer. So for example, if the bio type of their periodontium is hard, and you know what I mean, the type that I’ve got exostoses that are never going to get perio because they’ve got surplus of bone. If they smoked 50 a day, they don’t brush but you know, they don’t have any perio because they’re almost genetically immune in a way to Perio right? So they got really fantastic periodontium but then they’re getting cracked teeth because the parafunction is actually overloading the teeth, but not overloading the threshold of perio. That’s a theory. What do you think about that? [Richard]
I think you hit the nail on the head when we said genetic, we know whatever Health Survey you look at, whether it be the adult dental health survey the [NHIS] in North America. If you look to the initial studies on periodontitis in populations in Sri Lanka, it’s all the same. 50% of people have periodontitis. 10% have severe periodontitis, their roundabout is pretty much the same wherever you go. Now. So even in untreated populations, treated populations, Western civilization, third world, it’s all the same, which means there’s a massive genetic part to play. Yes, there are risk factors. You’ve got the smoking risk factor. You’ve got diabetes as a risk factor, which have strong links to periodontitis. But it’s all to do with susceptibility. And this is what I tell patients all the time. I’ll say that if I’ve diagnosed them with periodontitis was for periodontitis, I say unfortunately, you are highly susceptible to something called periodontitis. Okay. Whilst I mean, whilst 90% of people, as you said, could have brux to their heart’s content or could not brush so their heart’s content and not have perio disease. Okay, the 10%. If they just look at pluck up for a second, they’ve got periodontal disease. And so I think shifting the blame away from you’re not brushing your teeth, to you’re susceptible to it. So you really need to, it’s a difference. And patients respond a lot better to it, because they are empowered by the fact that they know that they have something which is that which they are susceptible to. And that can be managed. And I think it’s really I think I’ve gone off on a massive tangent. [Jaz]
No, no, I think what you said was great. [Richard]
Back, yeah, current back to the tangent. Why do some people with AOB don’t have that bone loss? Because 90% of individuals aren’t susceptible to severe periodontal disease. If they are in that 10% they’re gonna get it. [Jaz]
And do you find that your patients with AOB now this is an interesting question, because I just thought of it now wasn’t scripted or anything. So those patients with AOBs that are susceptible to perio, are they also having the same bone defects around their anterior teeth? [Richard]
It depends. There are lots of Okay, if they are smokers, they’ll get defects anteriorly because by virtue of where they hold the cigarette, you get a local vasoconstriction as a general as well, but more localized to the front but or if their mouth breathers and it’s hard to brush up you get great inflammation and theory. So there’s lots of factors. But it’s often I’ll see posterior bony defects around patients without to recognize, [Jaz]
So Richard, what I want to know you showed that Thick composites splint, obviously, and we discussed here why that may be necessary. So tell us about the role of using splints, for example, some dentists may believe, and I believe the work from what I was taught that actually splinting is more for patient comfort, it won’t necessarily prevent them from losing their teeth or whatever. But I feel like the evidence base is Harris. Am I right, Harris? Harris? Is that a name? Okay. These are just names. [overlapping conversation] In Harris, a legend. But anyway, so I believe the literature suggests that splinting has its role, but it won’t, you know, if you just splint everything, their Perio won’t magically stop. But what about those teeth were you, What about those cases where you believe there’s an occlusal role, where the splints come into that? And what I mean by splint is actually sticking teeth together, not the sort of appliance to wear, which we’ll surely touched on [Richard]
Yes, which can get confusing, especially when talking to about it. Where’s the role? You’re right. The only benefits of splinting teeth is patient comfort. However, there are other roles when you do need to splint teeth together. One of them I showed you before, if you’re doing any regenerative surgery, what you rely on is wound stability. So if you need wound stability, you mustn’t have any mobility in the teeth. So for the six months healing, you need to splint to be to enable that bone to grow in the area in a undisturbed sight so it’s important splint. Then why are composite really whatever it is, is just has to be rigid. It has to be splinted. Now, you mentioned it needs to be a thick so a composite doesn’t break. That’s exactly true. But also, if you’re not making any occlusal adjustments, and you’re not removing the cause of the trauma from occlusion, that splint will break. Because if the patient’s a bruxist, they will just break through it. So the cause of the trauma from occlusion needs to be adjusted there with adjustment. So there is definitely a role for occlusal adjustment in that sense, in the isolated tooth sense. [Richard]
I can actually show you a little example of that as well [Jaz]
Yeah please let’s have a look [Richard]
Okay let’s have. Okay so this case and another case which i use guided tissue regeneration on but this she was 30 years old and she had a really it was quite localizer periodontitis to this upper left 4 now there are local risk factors including a root groove and a furcation involvement. Now fortunately when i raised the flap and looked around the tooth there isn’t a vacation involvement yet but there often are roots, you often have two roots on a premolar you often have a root groove but also this patient did have a high contact on the upper left 4 that tooth was in fremitus and also on lateral excursions, it was in group function on left lateral. Left lateral excursions, it was in group function so if we’re going to treat this tooth regeneratively and we’re going to splint this tooth, if we splint it and don’t adjust the occlusion and in group function they’re going to break that splint every time they chew. So that needs to be addressed. Now whether it’s addressed by an adjustment of the premolar or adding composite to the upper left canine, we’re adding restoration to the upper left canine to [Jaz]
canine riser [Richard]
Yeah if it has a canine riser whatever it is, it’s really down to the dentist to decide what’s more appropriate and i think really in this case taking some cast seeing how much adjustment you’d have to do compared to using a canine riser will tell you a lot and so if it’s just a small adjustment then it might be just better off to make that small adjustment. If you’d have to really cut into your dentine to stop the lateral excursion contact then you’re better off looking at a canine riser. So i think that whichever approach you take it doesn’t matter but it needs to be done before Splinting. Now this was just a very simple adjustment which was done and it was splintered. [Jaz]
I think we can see from the clinical photo, but would you say that the cuspal inclines of this patient were very steep, would you say? [Richard]
Yeah, I mean, it’s hard to tell from that photo. Yes, it was. [Jaz]
So it’s, you know, it’s interesting because when I think of his most patients, most people are actually in group function. You know, as much as we think canine guidance is important. Most people actually in group function, especially if you’re with any force, if you think if someone’s in canine guidance, you get them to press together really hard, as if the parafunction and then go incursions, they are quite usually in group function. So it’s good to mention here that some schools of thought suggest that actually, more than anything, having it to make sure there’s freedom from centric, so that when patients do have produced an excursion, that it’s smooth, and if you imagine a sort of steep cuspal incline, and if patients now moving their mandible as almost like knocking and hitting against that premolar it could be that rather than just pure group function, we will never know exactly, but this is just the sort of theory is why some people would group function and why certain teeth and when so it’s all a very interesting area, which will never really have the answers to but I just think it’s another thing to consider that maybe it could be that to it because of the fact it had a steep cuspal incline. And there was a lack of freedom from centric ie teeth are knocking [Richard]
Yes, no, absolutely. What I’m going to be looking at is when I see this back, is whenever anyone talks about occlusion I don’t know if this is just me. It will be terribly embarrassing. I do notice it. Whenever you talk about inclines and guidance. I’m doing this [*Richard clenching] I’m checking my own, and I can’t help it. And I’m gonna look back at this video and I’m gonna see myself doing it and be like, oh, but I hope you guys out there watching this or doing the same thing as me and I’m not the only crazy person. Okay? [Jaz]
I think many people are. Absolutely. [Richard]
I can’t help it. With more [lateral] excursions that, am I my group function? Am I canine guidance? [Jaz]
What do you think you are? What do you, before we had this chat, what did you think you were at? [Richard]
I was canine guidance, but I’m very aware that I’ve got big canine facets. [Jaz]
Okay, now if you actually press together really hard now we can do it live now, you’re going to press together really hard and you’re going to go to one side you feel your posterior teeth touching? [Richard]
I don’t want to admit it, because I feel like I’m admitting defeat. But yes, I do. [Jaz]
It’s food for thought. It’s just that this is why I love this area so much because it’s so fascinating. Sorry, the day the day I broke Richard’s canine guidance. I’m sorry. [Richard]
It’s okay. It’s alright. Don’t worry, I’m over. [Jaz]
You’re less superior human from when before we started this podcast. [Richard]
Now the secret’s out. It’s out for everyone to see. [Jaz]
We’ve discussed a few things, we discussed some controversial topics. Okay? And you know what, Richard? The truth is, some people will listen to this, right? And they will say, they will completely disagree with you. And it’s true, right? Because that’s a school of thought, that’s a background they have. But I think where we have as evidence based conditions, we have to follow the evidence, okay? And right now, it’s very much strongly in the favor that occlusion and parafunction, bruxism has a role, but it’s not the primary role. Now, some clinicians get very upset about this, because actually, they placed the role of occlusion as a way higher, in particularly in terms of and we can talk about this if you don’t mind is particularly in implant failure. Some clinicians suggests that actually, one reason why implants may be failing could be more to do with forces than any other factor. What was the evidence say? What do you think about that? On the same topic of forces and in a periodontal disruption, tell us about implants cuz obviously, they don’t have any PDL. They don’t have the sort of proprioception. [Richard]
Some mechanical failures, definitely, no doubt about it, and they need to be managed really carefully. And implants are a they’re a treatment modalities for choice. It’s like a denture or like a bridge, whatever it is, you need to have the occlusion in mind. So any restoration, you need to consider the occlusion, if they are bruxists, you need to address it before you start with your implant restorations and planning. So that’s without saying biological failures. It’s very much an inflammatory process. And I feel the general consensus is that it’s inflammatory process. You have factors which can increase the risk. I mean, there are when I present on periodontitis, there are so many risk factors. I mean, you’ve got all the ones you’ve got with Perio. So all the systemic ones are Perio, pretty much with diabetes, and smoking, etc. You’ve got then local factors, like the implant design, okay, you’ve got things like the angle from the implant platform to the contact point. So recently, I was randomized control trials showing increased angle with more than 30%, higher incidence of bone loss. You’ve got implant surfaces, [polish collars, or a one stage implant versus with soft tissue component versus a bone level, so many different things. How many times you change your [button]? And that’s another debate, if you keep changing the route, does that. So I feel Yes, occlusion has a role, but there are so many others. And I think if you focus on occlusion as the bane of all problems, I don’t think it’s right. But yes, with mechanical screw loosening. And then if that screw loosening, will lead to an abutment loosening lead to micro gap with [ ? ], yes, it could cause bone loss. I don’t think it’s occlusion straight to failure of implant. Some kinda get sorry, I’m going to, sometimes get an initial failure through overloading it too early. That’s different scenario in itself. [Jaz]
Yeah, I see a point that and I know that I think the, you know, the answer is somewhere where, you know, there are too many unknown unknowns. But you know, what it’s good practice at the moment is not to, yeah look for everything, your patient as a whole, all the factors involved. And like you said, it definitely has a huge, definite role in mechanical failure, screw loose things and whatnot, whereas the biological from what we understand at the moment is mostly inflammatory. And that’s, you know, it’s cool that you have that stance, and I respect it. And that is the main stance, you know, that is the body at the moment, that’s the evidence body at the moment, and any periodontist would back you up. But, you know, there are people who choose, who are not guided by the evidence and have these theories, and that’s all there is, but we have to sort of, you know, it’s everything is in balance, and you have to reflect on it. [Richard]
I mean, evidence is based on testing theories. So it’s not a bad thing to have different theories and different opinions. I think that’s what drives us and makes us better dentists. So that’s fine. But we I mean, that’s why I say that checking the occlusion as part of your periodontal examination is a must, is something which is often left. And it is really important and valid. Just because I don’t feel it’s the primary cause of periodontitis doesn’t mean to say I find it any less important in progression of periodontitis. And it has to be addressed, especially when I show you those cases where they were in part exacerbated by a trauma from occlusion. If you don’t treat the trauma from occlusion, when it’s exacerbated a periodontal problem, it’s never going to be treated. So it’s really important. [Jaz]
Thank you so much for coming on. If anyone wants to reach out to you, because I know you do a bit of teaching at Eastman. Maybe they work locally to you and they want to refer your patient, How can they reach out to you? [Jaz]
That’s very kind Thank you. So reach out to me. Well, I have an Instagram account, london_periodontist, my email richardhorwitz.co.uk and any questions on trauma from occlusion or anything else, I’m happy to help. [Jaz]
Richard’s a very helpful guy. If you ever messaged him, he’ll always be willing to help you out. So I would you know young dentists who want maybe some mentorship on Perio, implant that sort of stuff, you know, Richard’s a great guy to reach out to. So buddy, I’m wary the fact that Sophie will probably waking up soon and so as well as Ishaan. So thank you so much for coming on, mate. It was discussing something very controversial with you.
Jaz’s Outro: So there we are, we covered lots of different points. And essentially, it is something that I hope most of us knew already that as far as we know, a bad bite or occlusion or even parafunction just by itself won’t cause Perio, but for that susceptible patient, it’s one more aggravating factor that can lead to trauma, that can exacerbate existing plop in periodontal disease. So hope you found that interesting. Thanks so much, Richard, for coming and sharing all that specialist information with us. I’m so sorry, Richard, for ruining your canine guidance. Okay? That one’s on me. I apologize. Okay? So, thank you so much for listening all the way to the end, guys, and I’ll catch you in the next episode.