ORIGINAL RESEARCH


https://doi.org/10.5005/jp-journals-10015-2220
World Journal of Dentistry
Volume 14 | Issue 4 | Year 2023

Comparing Clinical Parameters with Occlusion in Health and Periodontal Disease Using T-Scan III Software: A Cross-sectional Study


Iram R Pawane1, Sankari Malaiappan2

1,2Department of Periodontics, Saveetha Dental College & Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS) (Deemed to be University), Chennai, Tamil Nadu, India

Corresponding Author: Iram R Pawane, Department of Periodontics, Saveetha Dental College & Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS) (Deemed to be University), Chennai, Tamil Nadu, India, Phone: +91 9619245546, e-mail: iramrafique2396@gmail.com

Received on: 04 March 2023; Accepted on: 05 April 2023; Published on: 02 June 2023

ABSTRACT

Aim: The aim of this study was to compare clinical and occlusal patterns in patients with and without periodontitis using the T-scan software.

Materials and methods: A total of 30 healthy subjects and 30 subjects with periodontal disease were recruited for this study. A T-scan analysis was done for all these patients before any intervention, and the force distribution on each side, first contact, maximum biting force, forces at maximum intercuspation, and time taken for occlusion and disocclusion were recorded for all patients. Clinical parameters, such as pocket depth, clinical attachment level, and gingival index, were also recorded.

Results: Chi-squared tests reveal no significant relationship between occlusal stresses and pocket depth or clinical attachment levels (p > 0.05). The relationship between occlusal force and tooth type was statistically significant (p = 0.04). The maxillary posteriors had the highest occlusal forces, followed by the mandibular posteriors. There was no significant difference between right and left force distribution between healthy and periodontitis groups (p > 0.05); however, a significant difference was observed in occlusion and disocclusion time (p = 0.042 and 0.000, respectively).

Conclusion: T-scan system is useful in the diagnosis, progression, and severity of periodontal disease, the distribution of deleterious eccentric forces that lead to periodontal destruction. The correlation of these forces to the location and type of tooth was seen to be of clinical significance.

Clinical significance: The physiologically occurring repair and remodeling of forces directed onto the masticatory system components is critical, as disruptions in the physiological functioning of the masticatory system can cause periodontitis, which can lead to tooth loss. T-Scan is a software that analyzes occlusion in various aspects such as bite forces, force distribution, and time is taken for disocclusion; these readings can be taken in centric, protrusive, and laterotrusive contact in real-time, aiding the clinician in analyzing eccentric deleterious forces and treatment planning.

How to cite this article: Pawane IR, Malaiappan S. Comparing Clinical Parameters with Occlusion in Health and Periodontal Disease Using T-Scan III Software: A Cross-sectional Study. World J Dent 2023;14(4):308-312.

Source of support: Nil

Conflict of interest: None

Keywords: Occlusion, Periodontitis, Trauma from occlusion, T-scan

INTRODUCTION

To investigate any disharmony in occlusion, it is necessary to study both normal and deleterious forces. To detect them, biting forces must be studied, as the human occlusal system is extremely complicated and difficult to assess.1 Occlusion is a term used to describe a phenomenon in which ”the incising or occlusal surfaces of maxillary or mandibular teeth or tooth analogs have a static relationship. The occlusion must be stable and stress-free.”2 Occlusion is more than just morphological contact interactions between teeth. It includes all masticatory system constituents, such as teeth, periodontal tissues, the neuromuscular system, the temporomandibular joint, and craniofacial bones, in their dynamic morphofunctional interactions.2

The periodontium is able to adjust to occlusal stress; however, when these forces go beyond this adaptive capability, the etiology of occlusal trauma should be explored.3 However, periodontitis may worsen the disease’s severity. Occlusal modifications in the teeth were indicated for premature contact or interference. The frequency, amount, direction, and duration of deleterious occlusal forces impact the periodontium and may result in periodontal weakening and, perhaps, a further increase in occlusal disharmony.4 In subjects with chronic periodontitis, premature occlusal contacts are frequently found and are highly connected with their severity. Occlusal trauma linked with periodontal diseases, as well as temporomandibular disorders, may increase the risk of further periodic breakdown, particularly in individuals with untreated chronic periodontitis.5,6

To analyze occlusion, T-scan has recently been widely used to detect and study occlusal contact force using a paper sensory disposable sensor as a reliable and easy-to-use clinical diagnostic device. Maness et al. published the prototype of a digital occlusal analysis equipment (T-scan system; Sentek Crop, Boston, Massachusetts, United States of America) in 1987.5 T-scan has over 25 years of history and has become a highly essential diagnostic tool for the optimal occlusal pattern, producing high-quality findings that were not before accomplished. Prematurity, high points, force distribution, first contact, maximum biting force, forces at maximum intercuspation, and time taken for occlusion and disocclusion may all be determined quickly with the T-scan computerized system.2 It can be used to analyze forces of occlusion, which the pressure-mapping sensor captures intraorally. It includes a sensor with a handle, a mount, the computer software that has to be installed, and a printer. The sensor is the most important component. The T-scan quantifies occlusal contact information by capturing characteristics such as tooth contact timing and storing the data in time for data analytics on a disc. T-scan sensors come in two sizes—small and big. A big sensor with a width of up to 66 mm fits 1,370 sensors, whereas a small sensor with a width of 58 mm can accommodate 1,122 sensors. The role of occlusion in the progression of periodontal disease is well established; however, identifying these deleterious forces that occur during mastication has been a challenge, and literature evidence to correlate the forces of occlusion and periodontal destruction is insufficient. Therefore, the aim of this cross-sectional study was to compare the clinical and occlusal patterns in patients with and without generalized chronic periodontitis using the T-scan software.

MATERIALS AND METHODS

Study Sample

From October 2020 to June 2021, 60 individuals were divided into two groups, groups I and II. Group I consisted of 30 subjects (17 males and 13 females) with stage III grade B periodontitis, and group II of 30 subjects with clinically healthy gingiva ranging in age from 21 to 50 years, were recruited from the Department of Periodontics, Saveetha Dental College and Hospitals, Chennai, Tamil Nadu, India. The ethical committee of the institution gave its approval to the study methodology, and all subjects provided written and video informed consent to participate in the study before the trial. The sample size was calculated to be 30 based on the standard deviation values of prior research (G power 3.0 software).7 The inclusion criteria were as follows:

For group I—subjects with periodontitis, at least six teeth with pocket depths of ≥ 6 mm, a clinical attachment loss (CAL) of ≥ 6 mm, the presence of the first or second molar in each quadrant, and no >3 teeth missing in the upper or lower jaw), with no prior history of periodontal intervention.

For group II—clinically healthy gingiva with probing depth (PD) <3 mm and without any tooth exfoliation/extraction, with the exception of disimpaction surgery of third molars.

Exclusion criteria were the presence of any type of prosthesis (dental implants, crowns, bridges, etc.), any history of occlusal adjustments or orthodontic treatment/orthognathic surgery, and restoration of carious/fractured teeth.

Clinical parameters recorded were PD, CAL, Miller’s tooth mobility index, and occlusal examination using the T-scan software.

Clinical Procedure

After recording clinical parameters, the sensor strip of the T-scan apparatus (T-scan III, software version 8.0.1, Tekscan, Inc. Boston, Massachusetts, United States of America) was inserted into the patient’s mouth. The observed occlusal force, occlusion time, and disocclusion time were all recorded and evaluated by the software. To prepare for the analysis, each person was instructed to bite on the sensor strip twice for practice. Patients were instructed to bite in centric relation with a clenching force. The proportion of teeth with higher occlusal forces was determined in various occlusal locations. A single examiner performed all of the T-scan recordings.

Statistical Analysis

The periodontal parameters were expressed in terms of mean and standard deviation. Chi-squared tests were used to determine the relationship between occlusal forces and the following factors—(1) tooth type (maxillary posteriors and mandibular posteriors), which bear the majority of the occlusal load, (2) pocket depth, (3) CAL, (4) tooth mobility, (5) time taken for occlusion, (6) disocclusion in patients with chronic periodontitis and healthy subjects, (7) comparing the force distribution between both groups. An independent t-test was carried out to compare right and left force distribution, occlusion, and disocclusion time in patients with and without periodontal disease. Statistical Package for the Social Sciences (SPSS) version 23.0 was used for all statistical analyses (SPSS). p < 0.05 was deemed statistically significant.

RESULTS

Role of Occlusion

No significant relationship was observed between occlusal forces, PD, or CAL (p > 0.05); however, the relationship between occlusal load and position of the tooth was statistically significant (p = 0.04) (Fig. 1).

Fig. 1: Correlation between occlusal force and tooth type

The highest occlusal forces were seen to be in the mandibular posteriors, followed by the maxillary posteriors. There was a significant correlation between the occlusal forces and tooth mobility (p = 0.03). As a result, teeth with high occlusal forces exhibited grade III mobility, while teeth with low occlusal forces exhibited grade I mobility, mandibular posteriors had the highest occlusal forces, followed by mandibular anterior, maxillary posteriors, and maxillary anterior (Fig. 2).

Fig. 2: The occlusal load and tooth mobility interrelationship

Force Distribution

In this study, it was observed that there was no significant difference between right and left side force distribution in patients of either group (Fig. 3). According to independent t-tests conducted, there was a statistically significant difference between occluding and disoccluding timings between subjects in both groups (p = 0.04 centric to maximum intercuspation) (p = 0.00 maximum intercuspation to centric or disocclusion) (Fig. 4).

Figs 3A and B: Comparison of (A) right and (B) left side forces between subjects with and without periodontal disease

Figs 4A and B: Comparison of time taken for (A) occlusion and (B) disocclusion between patients with and without periodontal disease

Comparing Health and Periodontal Disease

On comparing healthy and periodontal disease groups, a delay in occlusion and disocclusion is seen in periodontitis subjects. Several areas marked in red and pink suggested trauma from occlusion and clinically correlated with tooth mobility, increased PD, and alveolar bone loss (Fig. 5A). Readings in the anterior aspects of the upper and lower arcs suggest trauma from occlusion and excessive occlusal forces. The red and pink readings in the posterior upper and lower arcs suggest high occlusal forces clinically correlated with mobility and alveolar bone loss. The delayed time for occlusion and disocclusion is more in the healthy group (Fig. 5B).

Figs 5A and B: T-scan of two patients (A) with periodontitis and (B) without periodontitis

DISCUSSION

The early research on the impact of occlusion on the development of periodontal disease was primarily focused on a cause-and-effect relationship. According to Stillman et al., the etiology of periodontal disease is excessive occlusal forces, and treating these occlusal contacts is the key technique for successful therapy.7 Research in the etiologies of periodontal disease concluded malocclusion as a cause of certain types of periodontal disease.8 Occlusion, in combination with bacterial plaque, was a cause of CAL and osseous degeneration; according to Glickman’s codestruction theory, alternative pathways of destruction were identified, which were through pathways of occlusal force and bacterial plaque.9,10

The effect of occlusal stresses on the cellular level structure of the periodontal attachment was studied in squirrel monkeys and Beagles.11 Occlusion in the form of bone rarefaction had an effect on the periodontium in these experiments, resulting in mobility. In an attempt to define an operational mechanism to generate a particular morphology for attachment and bone loss, he identified alternative pathways of destruction, which were bound to arise from a codestructive action of occlusal stresses and bacterial plaque. The concept of occlusion persisted in the rerouted destruction path. It was also clear that periodontal damage and attachment loss did not occur in the animal models unless there were excessive occlusal stresses present.11,12 Only in Beagles did attachment loss occur, and only when excessive occlusal forces and bacterial plaque were present.13-15

Although animal studies have provided us with a thorough understanding of the effect of high occlusal stresses on the animal periodontium, it is important to remember that these studies were conducted on animals that have little or no proclivity for periodontal destruction in natural conditions.14 These animal studies are unlikely to provide us with meaningful data about the pathogenesis and progression that may occur when elevated occlusal forces are prevalent in patients who may be predisposed to periodontal destruction and who may also be at risk for chronic periodontitis apart from occlusal and bacterial plaques.

Research done on human subjects has evaluated the function of high occlusal stresses in the development of periodontal disease in subjects predisposed to it. While evidence suggests that elevated occlusal force plays a role in periodontal damage and treatment response, human research has produced a slew of seemingly contradictory results. At the 1999 International Workshop on Classification of Diseases and Conditions, no clear evidence that occlusal strength is a factor in plaque-induced gingival disease or connective tissue loss was presented, despite available data suggesting a link between excessive occlusal forces and periodontal disease progression.16 Since then, occlusal etiologies have been shown in studies to have a negative effect on the periodontium, causing rapid pocket development and an even worse prognosis than teeth with no occlusal interference.

Occlusal trauma compromises periodontal health and complicates therapy. Periodontal degradation has been associated with occlusal discrepancies, particularly balance interferences. Teeth with excessive occlusal loads had a significantly greater PD and a poor prognosis. Periodontal therapy includes treating these teeth with coronoplasty and/or occlusal stents as constituents of the overall treatment plan. Older software of the T-scan system (1847–2015) has given occlusion analysis a new meaning. The ”T-scan I” was developed around 25 years ago, and since then, the entire system and software have undergone hardware, sensor, and user interface upgrades, resulting in today’s ”T-scan III” system (version 7.0) being significantly improved over previous systems.2

This is the first study in an Indian population to show a clinical and occlusal correlation between periodontal disease and occlusal force measured by T-scan in healthy and periodontitis patients. The current findings show that high occlusal forces are primarily observed in the posterior teeth. This result was similar to that of Zhou et al.’s research, where the teeth observed that had high occlusal forces were molars with high PD values and higher frequency of bleeding on probing than those without high occlusal forces.6 Takeuchi and Yamamoto investigated the relationship between biting force and periodontal health and found that occlusal force is associated with attachment loss; a multiple stepwise regression analysis demonstrated that total biting force and occlusal contact area were positively associated with the number of present teeth and negatively associated with female gender, mean CAL and mean probing pocket depth. Biting pressure was positively associated with CAL. Our findings, which found no link between occlusal pressures and CAL, contradicted this.

Occlusal forces and tooth mobility were found to be linked in the current study. This observation was also reported in a study where they observed the tooth level relationship between various occlusal contacts and PD, as well as the thickness of keratinized gingiva, and found that protrusive contacts on front teeth are usually not as deleterious.4 Although the protrusive contacts in their sample may differ from the high occlusal forces detected by the T-scan III device in our study, more research is needed to determine the precise impact of occlusal force on periodontal diseases in anterior teeth.

In this study, it was observed that high occlusal forces are distributed more on the mandibular posterior teeth. T-scan can reliably assess the distribution of occlusal contact in maximum intercuspation.5 In this study, it has been observed that there are no significant differences seen between right and left side force distribution between subjects with and without periodontitis. We observed that in participants without periodontal disease, centric relation to maximum intercuspation and from maximum intercuspation to disocclusion takes a relatively longer time than that in patients with periodontal disease due to factors such as high occlusal points, extrusion due to bone loss or missing teeth and mobility.

The limitations of this study include the high cost of the equipment, sensor sheet, and software maintenance. The procedure to record the occlusal forces is highly technique sensitive and patient-centered; hence, the results may not be accurate, and the whole procedure should be repeated to ensure correct placement and occlusion. Future research could identify the correlation between the presence of angular defects at sites with high occlusal forces, resolution of inflammation, and occlusal load after periodontal treatment and occlusal corrections.

CONCLUSION

The role of occlusion in the progression of periodontal disease is an important etiological factor correlated to clinical parameters. The T-scan system is useful in the diagnosis, progression, and severity of periodontal disease, the distribution of deleterious eccentric forces that lead to periodontal destruction. The correlation of these forces to the location and type of tooth was seen to be of clinical significance.

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