Tagged: occlusal trauma

A Plethora of Dental Problems Causing a Periodontal Abscess

Update below.

I have recently had an email exchange with a German colleague in which I had tried to correct certain misconceptions about Scandinavian Dentistry and its self-proclaimed superiority as compared to that of the “American”, “British” or “German” profession. Dental textbooks with “The Scandinavian Way” as a subtitle have fortunately vanished in the meantime. Maybe Scandinavians have understood (or were told) that “Am deutschen Wesen …” was a really bad example and did imply in fact frank racism.

A whole generation of, in particular, German periodontists has long been influenced by Scandinavian teachers and scientists such as Sigurd Ramfjord and Jan Lindhe, who had frequently visited the country, made friends with many colleagues and had an enormous impact on the development of modern Periodontology in Germany. I take pride of being a member of this generation and I have always tried to convey the messages by these and other Scandinavian giants in my discipline to contemporary students of Dentistry.

I remember vivid dicussions in the early 1980s in self-proclaimed dental elites like the Neue Gruppe, which was eager to invite both outstanding Scandinavian and American colleagues as speakers for their annual meetings, about whether the “Scandinavian approach”, which was allegedly “determined biologic”, should be favored when compared to the “determined mechanistic” treatment practiced by German dentists and, in particular “gnathologists”, who considered themselves a bit like “dental engineers”. “Biologic” more or less meant cause-related, and was mainly based on emerging scientific revelations from oral microbiology and immunology, oral physiology and biochemistry. The “mechanistic approach” on the other hand was mainly based on occlusion and a strive for improving “fit, form and function” of restorations which comprised nearly 100% of dental work in dental practice.

The truth lies somewhere in between, as usual. I am grateful for a profound education in occlusal concepts during both undergraduate and postgraduate education. Since, as a specialist, I used to treat patients who could usually not be treated by other colleagues, I was from the very beginning prepared to expand knowledge and skills to definitely restore periodontally mutilated dentitions with the necessary precision. Although being a specialist in Perio, comprehensive dental care has always been at the center of my treatment, the main reason why I had recently joined two dental schools which apparently favored respective concepts in dental education. I had not expected what I would encounter on a daily basis: bad dentistry.

The following case (and I want to warn the unprepared reader, graphic imagery may be disturbing) is in no way special and how it was treated before I was involved (and probably afterwards) is typical.

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Mounting Cast Models of Hypermobile Teeth

I have noted that clinical instructors at IKO’s student clinic at the University in Tromsø (now called “The Arctic University of Norway”) do not pay too much attention to occlusion and occlusal discrepancies in students’ patients. The reason for that is not really clear to me. Trauma from occlusion does not only affect periodontal tissues but can have deleterious effects on the pulp-dentin complex, the occlusal surfaces of the teeth (usually aggravating the problem with time), the temporomandibular joints and the neuromuscular system. In my lectures I can only address periodontal problems, which had long been considered minor, based on animal experiments. Recent retrospective studies in humans, however, have told us different lessons. In order to get what you should get after non-surgical and surgical periodontal treatment, it may be justified to better remove any balancing contacts and harmonize working side contacts (apart from establishing proper oral hygiene). It is interesting to remember that, without hard evidence, many dentists’s observations, i.e. clinical experience, has suggested that for almost a century. Excesses by so-called gnathologists exempted.

Since the advent of evidence-based medicine in Dentistry about 20 years ago, we know that animal experiments do not provide hard evidence. They may be used in order to formulate a hypothesis which has to be tested in randomized clinical trials in humans. Moreover, if one has a close look again at the mechanical apparatuses which had been installed in beagle dogs in Gothenburg, Sweden, in the 1970s and 1980s in order to simulate occlusal trauma (a supracontact in an artificial crown on a upper premolar which leads to a violent forward-push of a lower premolar whenever the dog closes its mouth, while a lingual bar with a spring wire attached to that particular lower premolar which pulls back the tooth whenever it opens), one instantly doubts whether this actually fits the purpose. In addition, a dog tormented in that way may experience tremendous stress, may even lose any hope and just want to die. This kind of distress has been shown in the meantime to be an important risk factor for periodontal disease in itself. So, claims by the research group in Gothenburg, that all other factors were controlled for while only dental plaque and occlusal forces combined had an influence on the integrity of periodontal tissues may seriously be questioned.

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