Melissa Fellman, RDH, BS

Pharmacology and Periodontal Disease:

Implications and Future Options
Introduction
Periodontal disease is a complex inflammatory disease characterized by bacterial infection, host response and patient behavior. The debridement of plaque biofilm and adequate home care are essential elements of a patients periodontal treatment. Antibiotics, antimicrobials, herbs, antivirals and vaccines may also be beneficial when combined with scaling and root planing. There is research both in support of and against the use of supplemental therapy to traditional biofilm removal.1 When considering the use of adjunctive therapy it is always important to do a detailed medical health history with your patient to rule out any known contraindications. There are many systemic antibiotics on the market. The most commonly used include tetracycline, ciprofloxacin, metronidazole and the penicillins, including amoxicillin and amoxicillin/clavulanate acid (Augmentin). Tetracycline is bacteriostatic, targets both gram positive and gram negative organisms, and has become bacterial resistant. Ciprofloxacin is bactericidal, targets gram negative rods, and may cause gastrointestinal discomfort. Amoxicillin and Augmentin are both bactericidal, with Augmentin targeting a more narrow spectrum than amoxicillin. Augmentin was developed due to amoxicillins bacterial resistance from penicillinase enzyme sensitivity.1 Of the many systemic antibiotics available, there is no consensus as to an ideal dose and duration. The choice of antibiotic should be made on an individual basis. In addition to serious adverse effects, like anaphylactic shock, microbial resistance is a growing concern.4 Other issues with oral antibiotic administration are patient adherence and adequate absorption from the gastrointestinal tract. Understanding that the periodontal disease process may be initiated by bacteria but the individuals host response was critical to the progression of this disease led to the FDA approval of doxycycline at a sub-antimicrobial dose (20mg twice daily). When administered at this low dose, doxycycline does not cause the long term side effects seen with other systemic antibiotics. Randomized double blind placebo controlled trials demonstrated reduction in probing depths, improvement in clinical attachment levels and decreased bleeding on probing when used as an adjunct with scaling and root planing.5

Antibiotics
The physical removal of biofilm has proven to be the most effective method for treating periodontal disease. The use of adjunctive antibiotic therapy, either systemic or topical, is controversial. Some studies show superior results with antibiotic use while others show no clinical difference. There is a general consensus that antibiotics should not be used as a monotherapy in the treatment of periodontal disease. Antibiotics as a stand-alone treatment are ineffective at diminishing intact subgingival biofilms.2 The American Academy of Periodontology has offered guidelines for systemic and topical antibiotic use in treating periodontal disease.3 These guidelines suggest that aggressive types of periodontitis and acute periodontal infections should be treated with systemic antibiotics while chronic infections should be treated with topical therapy. Antibiotic therapy is generally used as a follow up treatment after conventional mechanical therapy. Aggressive periodontitis may use systemic antibiotics as an adjunctive therapy.

Macrolides* (Includes Erythromycin, Azithromycin, Clarithromycin) Metronidazole

A recent review evaluating non-surgical chemotherapeutic strategies for the management of periodontal disease determined that systemic antibiotics reach the periodontal tissues by transuduction across serum, then cross the crevicular and junctional epithelia to enter the gingival sulcus.1 By the time the systemic antibiotic reaches the gingival sulcus it no longer has an adequate concentraClassification of Antibiotic Agents That Can Affect Periodontal Microbes tion to achieve the desired antimicrobial effect. This supports BACTERICIDAL BACTERIOSTATIC the fact that the mechanical disruption of biofilm must be Cephalosporins (Includes Keflex, Ceclor) Clindamycin* included in the treatment of periodontal disease.
Macrolides* (Includes Erythromycin, Azithromycin, Clarithromycin)

Topical Antibiotic Therapy

Topical (local) antibiotic/antimicrobial therapy (LAA) was the natural progression from systemic administration. It was thought that LAAs would solve the risk to benefit ratio of systemic antibiotics.5 Although there are some studies supporting the use of topicals, most fail to demonstrate a significant difference between scaling and root planing alone.
Continued on Page 10

Tetracyclines (Includes Doxycycline, Minocycline)

Penicillins (Includes Ampicillin, Amoxicillin, Augmentin, Penicillin VK) Quinolones (Includes Ciprofloxacin) *Bactericidal against some organisms at high blood levels Table modified from: Haveles, E. B. (2011). Applied Pharmacology for the Dental Hygienist. (6th ed.). Maryland Heights, MO: Mosby Elsevier, p. 77-78.

CDHA Journal Summer 2010

Investigations do show benefits for high risk patients, such as smokers, who do not respond to mechanical therapy.6-7 Recent studies have demonstrated that the use of LAAs resulted in an overall reduction of the bacterial bioburden with reduced cardiovascular event risks.8-9 The first locally administered antibiotic for periodontal disease was Actisite, made up of nonabsorbable fibers filled with tetracycline. Although Actisite was found to be effective in many cases, placement and patient follow-up for fiber removal were challenging issues.1 A bioabsorbable local delivery device called PerioChip was then developed. It was comprised of 34% chlorhexidine gluconate, about 5mm round and 1mm thick. It is the only LAA that is not an antibiotic. Atridox is a 10% doxycyline hyclate gel and is prepared by mixing powder and liquid from two syringes. The antibiotic is administered into the gingival sulcus through a cannula. Absorption lasts up to 21 days, while therapeutic drug levels in the gingival crevicular fluid start to decline at 7 days. The most notable drawback is the high level of clinician skill needed to deliver this therapy as the material tends to come out of the pocket as the syringe is being pulled out of the sulcus. The majority of the time, more than one site can be treated depending on the depth and size of the pockets.1 Arestin is comprised of spheres embedded with 2% minocycline HCl that is slowly released and holds the therapeutic dose in the gingival crivicular fluid for 14-21 days. The most notable drawback for Arestin is the delivery dose. The syringe holds pre-set doses that may not be sufficient for every site. This results in the need to reapply in the same pocket. Currently, resorbable antibiotics such as Atridox and Arestin are the topical antibiotics of choice. The American Academy of Periodontology (AAP) supports that local adjuncts, when compared with scaling and root planing alone, provide limited improvement.10 Locally administered antibiotics still require a strict health history review to verify there are no known allergies. Even though these medications are applied topically, as opposed to oral administration, the same precautions apply.
Antibiotic 10% Doxycyline 2% Minocycline HCl microspheres Brand Name Atridox Arestin Delivery Fluid mixed in a syringe, Multisite Solid dose applies with a syringe, Single site Absorption 21 days 14-21 days

rinse. This term refers to the adherent qualities of a mouthwash and its ability to be retained. Saliva has a natural flushing property making it difficult to maintain an antimicrobial effect. Research shows a significant antibacterial effect up to 7 hours after mouthrinses with high a substantivity property.11 First generation antimicrobials include phenolic, sanguinarine, quaternary compounds. Listerine and its generics are phenolics which possess the only ADA Seal of Acceptance among the first generation antimicrobials. Listerine contains 26.9% alcohol, alters the bacterial cell wall, and has 36% gingivitis reduction.1 Cepacol and Scope, quaternary ammonium compounds, contain 14% and 18.9% alcohol respectively, increase bacterial cell wall permeability causing cell lysis, and reduces gingivitis approximately 15%.1 Second generation antimicrobials include cetylpyridinium chloride (CPC) and chlorhexidine (CHX). A commercial name for CPC is Crest Pro-Health, which contains 0.07% CPC. Bacteria cells are killed by cellular pressure, resulting in a similar efficacy as Listerine. Chlorhexidine has many commercial products including the availability of a nonalcoholic version by Sunstar Americas, Inc. Peridex by 3M Espe and Periogard by Colgate Professional are two examples of popular chlorhexidine-based products. Their active ingredient is 0.12% chlorhexidine. Cell death results from altered osmotic equilibrium. CHX efficacy in the reduction of certain aerobic and anaerobic bacteria has been shown to be as high as 97% after 6 months of use. CHX has 29% gingivitis reduction. The gingivitis reduction percents listed above for both first and second generation antimicrobials are based on efficacy data published by manufacturers.1 Other antimicrobials include oxygenating, chlorine dioxide, and zinc chloride agents. Peroxyl is an oxygenating agent with the active ingredient of hydrogen peroxide. It has anti-inflammatory properties as well as a bubbling action to clean and alleviate discomfort. Short term studies have produced controversial findings. Oxyfresh, a 1% chlorine dioxide agent, has minimal plaque reduction. It is a stable, free radical and an oxidant with algicidal, bactericidal, cysticidal, fungicidal, sporicidal, and viricidal properties. Oxyfresh is primarily used for the treatment of halitosis. Breath Rx is a zinc chloride agent designed to odorize sulfhydryl groups with zinc ions. It claims to be a scientific bad breath treatment specifically designed to help treat the causes of bad breath and the symptoms.1 Antimicrobial mouth rinses have been linked to several side effects; some more serious than others. First generation compounds like Listerine can cause a burning sensation and bitter taste. Chlorhexidine can cause supragingival calculus build-up and staining. Research has demonstrated permanent damage to enamel through erosive pH levels and abrasive antimicrobial toothpastes.1 Carcinogenic changes have been linked to the use of oxygenating agents and mouth rinses containing alcohol.1

Antiseptics
Unlike topical controlled-released antibiotics, oral rinses do not penetrate deep into the gingival sulcus. Despite this limitation they do show benefit when used adjunctively for gingival inflammation. Oral rinses are also of great value in post surgical healing. Substantivity is a crucial component when considering the effectiveness of a mouth
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CDHA Journal Vol. 25 No. 2

Nutraceuticals
As antibiotic resistance becomes more of a concern, health care providers looking for alternate adjunctive periodontal therapies for their patients. Some examples of nutraceuticals include herbal and nutritional supplements and the future of this type of therapy is promising. There are approximately 500,000 plant species, with only 1% having been photochemically investigated. Herbal plant extracts have been shown to reduce the level of biofilms influencing the level of bacterial adhesion. This has shown results with the reduction of periodontal disease. Some herbs such as Coptidis rhizome extract and Hamamelis virginiana, are used as bactericidal agents against oral bacteria while others such as cranberry, Polygonum cuspidatum and Mikania are used to inhibit adhesion.12 The use of probiotics in the control of periodontal pathogens is emerging. Probiotics are live microorganisms, which when administered in adequate amounts confer a health benefit on the host.13 Simply put, they are healthy bacteria that displace unhealthy or pathogenic bacteria. A reduction in gingivitis and dental plaque has been shown with the administration of L. reuteri Prodentis gum chewed twice daily in patients with moderate to severe gingivitis.14 GUM PerioBalance, marketed by Sunstar Americas, is a once daily lozenge with L. reuteri Prodentis that claims a reduction in moderate to severe plaque and bad breath.15 EvoraPlus from Oragenics, Inc. is another new probiotic for oral health and is used once daily. This supplement contains a combination of three bacterial strains Streptococcus uberis KJ2, S. oralis KJ3, and S. rattus JH145, and claims a reduction in periopathogens within the periodontal pocket.16

have been identified as antigenic targets.19 More research is needed in this field before it is widely accepted as an alternative to antibiotic or antimicrobial therapy.

Conclusion
All drug sensitivities and allergies should be reviewed prior to incorporating pharmacological agents into a patients treatment regimen. The future is promising in the areas of nutraceuticals and vaccines but more research is needed. The future of public health can be greatly affected by the scientific breakthroughs becoming made in dentistry. Long time traditional regimens of antibiotics and antimicrobials have served our profession well and assisted hygienists to achieve optimal patient results.

About the Author

Melissa Fellman, RDH, BS, is the Program Coordinator and Evaluation Specialist for the Nevada State Oral Health Program. In addition, she is an instructor in the dental hygiene program at Truckee Meadows Community College (TMCC) in Reno, NV where she teaches pharmacology. Melissa is in the process of completing a Masters degree in public health at the University of Nevada, Reno where her graduate research includes conducting a dental hygiene needs assessment on HIV outpatients and developing a coalition to increase access to dental hygiene care for HIV positive individuals in northern NV. Melissa can be reached at mfellman@tmcc.edu

References
1. Krayer JW, Leite RS, Kirkwood KL. Non-surgical chemotherapeutic treatment strategies for the management of periodontal diseases. Dent Clin N Am. 2010; 54: 13-33. 2. Schaudinn C, Gorur A, Keller D, Sedghizadeh PP, Costerton JW. Periodontitis: an archetypical biofilm disease. JADA. 2009;140: 978-86. 3. The American Academy of Periodontology (AAP). J. Periodontol. 2004;75: 1553-65. 4. Heitz-Mayfield LJA. Systemic antibiotics in periodontal therapy. Aus Dent J. 2009;54(1 Suppl): S96-S101. 5. Cortelli JR, Aquino DR, Cortillo SC, Carvalho-Filho J, Roman-Torres CVG, Costa FO. A double-blinded randomized clinical trial of subgingival minocycline for chronic periodontitis. J Oral Sci. 2009;50(3): 259-65. 6. Goodson JM, Gunsolley JC, Grossi SG, Bland PS, Otomo-Corgel J, Doherty F, Comiskey J. Minocycline HCl microspheres reduce red-complex bacteria in periodontal disease therapy. J Periodontol. 2007;78: 1568-79. 7. Machion L, Andia DC, Lecio G, Nociti FH Jr, Casati MZ, Sallum AW, Sallum EA. Locally delivered doxycylcline as an adjunctive therapy to scaling and root planing in the treatment of smokers: a two-year follow-up. J Periodontol. 2006;77(4): 606-13. 8. DAiuto F, Parkar M, Nibali L, Suvan J, Lessem J, Tonetti MS. Periodontal infections cause changes in traditional and novel cardiovascular risk factors: results from a randomized controlled clinical trial. Am Heart J. 2006;151(5): 977-84.

Antivirals
A new area of research when evaluating periodontal disease is the use of antivirals. The Epstein-Barr (EBV) virus has been associated with recurrent periodontal disease. Since bacterial disease may be secondary to viral infections, antiviral treatment decreases EBV and improves the periodontal condition.17 The Human Cytomegalovirus (HCMV) has also been linked to periodontal disease. The HCMV can cause infections in immune-compromised individuals like organ transplant patients or patients with acquired immune deficiency syndrome (AIDS). Periodontal lesions can exhibit great amounts of EBV and HCMV. Anti-herpesvirus chemotherapy can decrease salivary viral loads resulting in the improvement if secondary bacterial periodontal infections exist.18

Vaccines
Vaccine therapy in the fight against periodontal disease is also a new and exciting option. As discussed earlier, antibiotic resistance is a growing worldwide problem. Vaccines offer a solution to the overuse of antibiotics in dentistry. Vaccine development is based on the identification of virulence factors that stimulate the induction of salivary immunoglobulin A antibody response. When used for periodontal disease, Porphyromonas gingivalis and Aggregatibacter actinobacillus
CDHA Journal Summer 2010

References continued on Page 25

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InnovationSavvy

Cathy Draper, RDH, MS

Advances in Technology and Periodontal Therapy

Treatment of periodontal disease has changed tremendously in the last 60 years. The basic principles of periodontal surgery as described by Shluger in 1949 called on periodontists to eliminate the periodontal pocket, create a harmonious gingival form and recontour the alveolar bone in order to prevent the progression or recurrence of periodontal pocketing.1 The traditional treatment modalities were based on the repair model of care. The clinicians goal was to diagnose the disease and provide treatment without any consideration of risk factors or host susceptibility. Hygienists who practiced in the 1960s and 70s will remember referring most patients with 5 to 6 millimeter pockets to the periodontist for evaluation and surgery. It was not until the 1980s when well-designed clinical trials compared scaling and root planing therapy, to periodontal surgery, that the outcomes of the various treatments were systematically reviewed.2 Clinical trials carried out over a period of five years demonstrated that thorough debridement was often as effective as periodontal surgery in preventing the progression of alveolar bone loss in patients with chronic periodontitis.2 These results led to a paradigm shift in the treatment of periodontal disease still practiced today and periodontal research continues to focus on non-surgical methods to prevent attachment loss. The new frontier in periodontal research is in the application of new technologies including lasers, gene therapy, growth factors, drug delivery systems and implants to restore lost tissue and function. While the role of periodontal therapy in the prevention or reduction of systemic disease has not been proven by randomized controlled trials, new research with improved study designs is ongoing.3 Dental hygienists today have a variety of tests available to identify patients risk factors and to treat and manage disease tissues. When evaluating any new technique or technology, remember to make decisions based on the best evidence supporting the treatment or technology along with clinical experience and the specific needs of the patient.

Risk Assessment and Diagnostics

PreViser Oral Health Information Suite www.previser.com Described as a user-friendly Internet based technology, the Oral Health Information Suite (OHIS) compiles, analyzes and quantifies information about an individuals current oral health status, the necessary interventions for wellness and the outcomes of any treatment performed. The OHIS features quantitative risk assessment tools and places quantitative values on changes in periodontal status over time. The Periodontal Assessment Tool (PAT) analyses the input of 23 items taken from a routine periodontal examination and provides clinicians and patients with objective measurements of the outcomes and the effectiveness of therapeutic interventions based on the wellness model of dental care. PreViser can now be used with Dentrix practice management software for seamless integration into your patient assessment data. DIAGNOdent Perio Probe KaVo Dental Corporation www.kavousa.com This periodontal probe utilizes the laser fluorescence properties of subgingival calculus to quantify the amount of residual calculus on the root surfaces following scaling and root planing. The device utilizes the DIAGNOdent caries detection classic or pen model handpiece. The thin, perio tip insert attaches to the handpiece and detects calculus, elicits an audible tone and gives a measurable value in pocket depths up to 9 mm. The unit has been shown to register readings in areas where only slight amounts of residual calculus remain or in difficult access areas such as furcations and deep line angles. The audible tone and detection values can also prove beneficial in patient acceptance and compliance with periodontal treatment recommendations. MyPerioPath MyPerioID PST OralDNA Labs Inc. www.oraldna.com Designed to be fundamental elements of a patients wellness plan, these salivary diagnostic tests measure periodontal disease infection and genetic risk factors for periodontal disease. MyPerioPath offers genomic DNA testing that

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InnovationSavvy
identifies the type and concentration of 13 specific periodontal pathogens found in a saliva sample. Saliva samples are mailed to the laboratory and a detailed analysis is conducted, with a quantification of the specific pathogens and their risk factors. Additional clinical and medical risk factors are included as well as treatment considerations and reassessment recommendations. MyPerioID PST identifies an individuals genetic susceptibility to periodontal disease by testing for the presence of two interleukin-1 polymorphisms. Both tests can be used as part of the baseline data for any patient at increased risk for periodontal infections as well as for patients who are unresponsive to their current treatment. ZEN Prophy Cordless Handpiece Discus Dental, LLC www.discusdental.com The ZEN Phophy Cordless Handpiece has total maneuverability, eliminates cord-catching, and causes less stress and user fatigue. The wireless connection between the foot pedal and the handpiece enhances portability, allows flexibility of movement, enables movement from operatory to operatory without limitations, and improves control of speed and power with a rheostat foot pedal. The ZEN has a non-slip grip for better handling as well as a light-weight and balanced design to reduce clinician fatigue and wrist strain. A latex-free autoclavable shell slips over the handpiece to ensure the highest level of infection control between each appointment. The unit has a high powered lithium battery for extended use and a discrete compact charger base for counter or wall mount. SWERV3 Magnetostrictive Ultrasonic Scaler Hu-Friedy Manufacturing Company, Inc. www.hu-friedy.com The SWERV3 magnetostrictive power scaler offers finely tuned electronics and delivers a full range of power with a color-coded lighted display. A user-friendly touch pad and dual power modes within the scaler simplify use and ensure proper power adjustment. It is compatible with inserts produced by all major magnetostrictive scaling unit manufacturers. The handpiece features a comfort zone grip that reduces muscle strain and enhances clinician comfort. InSight LED Ultrasonic Scaler Inserts Discus Dental, LLC www.discusdental.com Designed to maximize scaling efficiency and effectiveness, InSight LED ultrasonic scaler inserts provide dual-LED illumination to eliminate the need to move the overhead dental chair light, thus improving workflow and allowing the user to assume a neutral body position. The inserts smooth swivel mechanism provides comfortable, neutral wrist and shoulder positioning without cord tension or twisting. Blue Boa Suction System www.theblueboa.com This unique suction system is designed by a dental hygienist to assist clinicians with efficient water and saliva evacuation particularly while using an ultrasonic scaler.
Continued on Page 14

Innovations for Treatment

NV Microlaser Manufactured by Zap Lasers, LLC Distributed by Discus Dental, LLC www.discusdental.com The NV Microlaser delivers full power and the capabilities of the larger, desktop soft tissue diode lasers in a light-weight pen-sized package. Formerly known as the Styla MicroLaser, the NV microlaser is completely wireless. Controlled by a foot pedal, a rechargeable lithium ion battery powers the micro diode laser in continuous wave or pulsed modes. Custom features include preset procedure settings, pre-threaded disposable tips and a combination charger/sensor holder. Incorporation of the disposable tips eliminates the need for fiber management and enhances the portability of the device. Periowave Ondine Biopharma Corporation www.periowave.com The Periowave utilizes photodisinfection to target specific periodontal pathogenic bacteria. Methylene blue dye is injected into the periodontal pocket following scaling and root planing. The dye binds to the lipopolysaccharides and lipids found in the cell walls of gram positive and gram negative bacteria. Periowaves non-thermal, diode laser is then used in the pocket for 60 seconds to initiate the photodynamic chain of events. Laser energy is transferred to the photosensitive molecules bound to the subgingival biofilms by the methylene blue dye. The Periowave is designed for treating patients with 4 to 9 millimeter pockets with bleeding on probing. Retreatment is recommended at 3 to 6 weeks to prevent the biofilm from re-establishing during the healing process. FDA approval is pending for use in the United States.

CDHA Journal Summer 2010

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InnovationSavvy
One end of the tubing attaches to the high volume evacuator while the other is attached to an ergonomically designed saliva ejector. The lightweight tubing, high volume evacuation and formfitting saliva ejectors provide excellent moisture control for ultrasonic instrumentation as well as sealant placement. Hygienists using this system can have both hands free to effectively instrument all areas of the mouth. Blue Boa tubing is reusable and can be fully sterilized after each use. The manufacturers web site features a demonstration video of a dental hygienist using the system for ultrasonic debridement. Air-BUG Edge Medical Technologies, Inc. www.airbug.com The air-BUG is a patented high speed evacuation and retraction system featuring a unique one size adult design incorporating a tongue and cheek retractor to create a virtual shield from debris and fluids. The airBUG features four components: sterilizable bite springs and U-Tubes, and single use tongue shields and bite grips. The system is fully portable and does not require any additional tubing. Field isolation is made easy without compromising patient comfort. Assembly and operating instructions can be viewed on the manufacturers web site videos. Water Pik Water Flosser Water Pik, Inc. www.waterpik.com Now marketed as water flossers, Water Pik offers a full line of products that feature state of the art dental water jet technology. Units vary from countertop models to completely portable models with selfcontained water reservoirs. The units come with a variety of tips and intraoral devices designed for oral irrigation. Added product benefits include ease of use and the capability of adding oral medicaments to the irrigating solution.

About the Author

Cathy Draper RDH, MS, graduated in 1975 from Foothill College and completed her MS in dental hygiene at the University of Michigan in 1978. Her dental hygiene career has taken her many places; Croatia, Germany, China as well as her home state, California. She currently splits her time between private practice, teaching at Foothill College, presenting CE courses and volunteering as a library reference associate at Stanford Hospital.

Patient Education Software

Orasphere Orasphere Ltd. www.orasphere.com Orasphere patient education programs are available for viewing from the reception area, operatories, or from the practice website. The dental education software system is delivered via DVD, PC, Web, or iPod touch. The online subscription option allows patients requesting treatment information over the phone to be directed to a log in password page to view patient education videos. Topics in periodontics include scaling and root planing, periodontal surgery and gingival grafts.

References
1. Shluger S. Osseous resection-a basic principle in periodontal surgery. Oral Surg. 1949;70: 316-25. 2. Ramfjord SP, Cafesse RG, Morrison EC, et al. Four modalities of periodontal treatment compared over five years. J Periodont Res. 1987;22(3): 22-3. 3. Scannapieco FA, Dasanayake AP. Does periodontal therapy reduce the risk for systemic disease? Dent Clin N Am. 2010;54: 163-81.

Oral Hygiene Products

Flexcare + Philips Oral Healthcare www.sonicare.com The Sonicare FlexCare+ is specifically designed to help motivate patients to achieve consistency with their home brushing habits. The FlexCare+ offers advanced features including 1,2 and 3 minute cycles and 3 speeds or intensities. The brush head attachment slides on and off the lightweight handle making it easy to clean. The FlexCare+ features a UV light sanitizing chamber that kills 99% of selected pathogens including: E.coli, S. mutans, and Herpes simplex virus.
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CDHA Journal Vol. 25 No. 2

Heidi Emmerling, RDH, PhD Ellen Standley, RDH, BS, MA

Probing into Probes

Introduction

Measuring the Choices

Heftis History of Probes10
1887 1928 1929 GV Black used flat blade probes bent slightly to the right and left: 8 mm length; 1.5mm wide HK Box wrote a textbook, Treatment of the Periodontal Pocket, which referenced a set of six probes Sachs (German periodontist who was trained in Chicago by R. Good) Paradentometer a thin steel blade with six groove at 2mm increments Struckman (Germany) Duka Taschenmass; a set of six stainless steel probes from 3-8mm in length CHM Williams(a periodontist) developed a probe which has continued to be used and modified ; thin stainless steel 13mm length (1, 2, 3, 5, 7, 8, 9, 10 marks) regarded as the prototype for many first generation probes used today such as Merritt and University of Michigan. Additionally Goldman and Fox, as well as Nabers, have been referenced as possible modifications. Fish(Europe) round tip, tapered 10mm length ; no calibration marks WG Cross modified the Box probes (1928) using three types; made of sterling silver; 1-16 mm marks with emphasis on 2, 4, 6mm marks; instruments for right and left sides were available Schmid presented the Plast-O-Probe with metal handle and disposable plastic tip with 9mm length and 3, 6 and 9mm marks World Health Organization recommended the use of a .5mm ball tip probe with 3.5, 5.5, 8.5 and 11.5mm marks. For use with the community periodontal index of treatment needs (CPITN) as well as for individual screenings of private practice patients. Gabathuler and Hassell developed first true pressure sensitive probe consisting of a standard ZIS probe and a piezoelectric pressure sensor; used in research Armitage et al. used pressure sensitive probe holder to which any type of probe could be attached Van der Velden and de Vries Pressure Probe which allowed probing force to be adjusted; 9mm length with 1mm marks from 1-9mm with emphasis on 5mm. Jeffcoat et al. presented the first controlled force with automated detection Gibbs et al. developed the Florida Probe in response to RFP put out by NIDR Goodson and Kondon developed the Accutek probe Birek et al. and McCulloch et al. developed the Toronto automated probe; modified in 1994 Bose and Ott developed the Peri-Probe

The periodontal probe is an essential instrument in every dental hygienists armamentarium. Wilkins states the probe is the only accurate, dependable, method to locate, assess, and measure sulci and pockets.1 Probing has been referred to as the gold standard of periodontal assessment. The American Dental Hygienists Association, dental and dental hygiene textbooks, as well as clinicians all acknowledge the importance of the periodontal probe. Commonly used probes vary by markings, color, diameter, material, and angle. Furthermore, probe readings have long been a source of discussion due to the variations in operator technique, pressure, angulation, and subjective measurement and recording of the probe marks. Most clinicians use the probe they were taught in their dental hygiene education.1 Darby writes, Given the importance of the periodontal probe in the process of care and long term occupational health, dental hygienists should deliberately try several probes and choose the one that works best for them.2 The Standards of Clinical Dental Hygiene Practice were adopted in 2008 by the American Dental Hygienists Association. These standards state that a comprehensive clinical evaluation includes full mouth periodontal charting, documenting pocket depths, bleeding points, suppuration, mucogingival relationships, recession, and attachment level.3 Carranzas Clinical Periodontology states, The only accurate method of detecting and measuring periodontal pockets is careful exploration with a periodontal probe.4 Many dental hygiene textbooks include chapters on periodontal probing and the importance of assessment.5-8 Furthermore, probing is imperative in managing the legal risk since failure to accurately diagnose periodontal disease is one of the top ten reasons for dental malpractice.2

1934 1936; 1943

1946 1966

1967 1978

1971

1977 1978

Historical Perspective
Probes can be grouped into classifications according to Pihlstrom9: First Generation: Conventional manual probes Second Generation: Constant force controlled pressure probes Third Generation: Constant force plus computer assisted probes While probes are now widely used to assess individual and group populations, this has not always been the case. Russell developed the Periodontal Index (PI) in 1956 which used only a mirror, light source and explorer.10 The periodontal probe was not used because Russell believed including actual pocket depths in the index added little and proved to be a troublesome focus of examiner disagreement.11 Furthermore, studies have shown that there is difference in measurements between varying probe styles, same probe styles
CDHA Journal Summer 2010

1986 1988 1988 1987 1992

Continued on Page 16

15

The World Health Organization (WHO) endorsed the Community Periodontal Index of Treatment Needs (CPITN) in the late 1970s.13 This index uses a special probe with a ball tip and color coded markings. In referring to National Health and Nutrition Examination Survey (NHANES) III, Dye and Thornton-Evans reported, The descriptive findings from phase I (1988 to 1991) and later from the combined phases (1988-1994) represented the first reporting of probing depth, gingival recession and attachment loss in the United States.14

Probes Used in Examinations

Dental hygiene clinical examinations include probing documentation. All state clinical boards and regional testing agencies include periodontal assessment as a component of the clinical exam. Furthermore, different boards and testing agencies specify acceptable probe styles and most limit the probe to only one style (Table 1).

Other plastic probes include the PerioWise Friendly Probe by Premier Dental which has a green band at 3mm or less, red millimeter markings at 5 or 6mm and thereafter. The EasyView Probe by Paradise Dental Technology is a thermal resin probe with yellow and green bands at 3, 6, 9 and 12mm or 3, 5, 7, and 10mm.5 The Orascoptic DK is a newer version of a first generation probe. It is unique due to the incorporation of the use of disposable fiber optic fibers for ease of visibility. The DK Fiber Lite Attachment holds disposable fiber optic fibers for perio work with 3, 5 and 7mm markings to measure pocket depth. The handle is autoclavable. The Orascoptic DK kits can be ordered directly from the Orascoptic online store.

First Generation Probes

First generation probes are composed of either stainless steel or plastic. The design of the working ends of manual probes are either tapered, round, flat, or rectangular with smooth rounded ends and are calibrated in millimeters at various intervals. Probes have either straight or curved working ends. The probes with curved working ends are paired and are used for examining the topography of furcations. When the probe is too bulky or is flat, it is often difficult to insert the instrument into tight tissue; fine, sharp and thin probes pose the danger of trauma and perforation of the junctional epithelium. Thin probes are also subject to bending and damage during sterilization.5

Specialty First Generation Probes

There are several first generation probes designed for specific purposes (Table 3). Novatech: The Novatech probe incorporates a right angle plus upward bend which enhances the access to the difficult posterior areas.

Table 1: California and Regional Exam Probe Styles

California Western Regional Examining Board (WREB) 1-2-3-4-5-6-7-8-9-1011-12 PCP UNC12 (Regular or Color Coded at 5-10) (Williams style probe, regular or color coded) (Williams style probe) (Williams style probe) Southern Regional Testing Agency (SRTA) 1-2-3-5-7-8-9-10 North East Regional Board (NERB) 1-2-3-5-7-8-9-10 Central Regional Dental Testing Service (CRDTS) 1-2-3-4-5-6-7-8-9-10 Council of Interstate Testing Agencies (CITA) 3-6-9-12 PCV-12 (Hu-Friedy PH-6 Color Vue)

3-6-9-12 PCP 12 Marquis (color coded)

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Photo courtesy of Hu-Friedy

produced by different manufacturers, and even same probe styles produced by the same manufacturer in different batches. According a study, mean inaccuracies of different probe sets varied from 0.06 to 0.22mm.12 Probes from the same batch and same production line could differ by more than 0.5mm in calibration. Mean tip diameter ranged from 0.28 to 0.70mm. In 1959, Ramfjord introduced the Periodontal Disease Index (PDI) and is credited with being the first index to use a periodontal probe to measure clinical loss of attachment.11

There are many styles of probes. A few of the commonly used manual probes are shown and described in Table 2. The Marquis probe is favored by many on the west coast. A number of schools use either the traditional Marquis or the newer plastic Color Vue version. Michele Darby writes that the Color Vue probe is her favorite because the yellow provides better contrast than the traditional metal. With so many Contrast Provided by Color Vue Probe patients opting for dental implants, the dental hygienist does not have to change from a metal to a plastic probe when dental implants are present. The Color Vue probe can be used to assess signs of a failing implant. The rounded, yet tapered probe is easily angulated into tight areas, and its slight flexibility enhances patient comfort. 2

Table 2: Commonly Used Periodontal Probes

All photos are courtesy of Hu-Friedy PQO Michigan-O Style PCP 12 Marquis PCV 12 Color Vue UNC-12 (or 15) PQW Williams P26G Glickman P3/4 Cattoni PGF Goldman-Fox

Marks

3-6-9-12

Marquis (shown) Williams style UNC 12 style Yes

1-2-3-4-5-6-78-9-10-11-12 Color coded at 5-10 (UNC 15 at 5-10-15) Thin shank allows access into tight fibrotic sulci; UNC 15 is for clients with attachment loss while UNC 12 is for maintenance N/A

3-6-8 (shown) or w/ Williams markings No

1-2-3-5-7-89-10 Also available with color-code at 3-5-7-10 Spaces between 3 and 5 and between 5 and 7 minimize confusion

1-2-3-5-7-89-10 No

3-6-9-12

1-2-3-5-7-89-10 No

Color coding (Usually black bands) Advantages5

Yes

No

Easy to read; thin shank allows access into tight, fibrotic sulci

Easy to read due to contrast; thin shank allows access into tight fibrotic sulci; sterilizable; will not scratch implants Markings wear away then entire probe or tip needs to be thrown out

Thin shank allows access into tight fibrotic sulci

Spaces between 3 and 5 and between 5 and 7 minimize confusion

Difficult to read

Spaces between 3 and 5 and between 5 and 7 minimize confusion

Disadvantages5

Markings must be estimated between color bands; thin tip may penetrate junctional epithelium

Markings end at Difficult to read 8mm

Difficult to read

Difficult to read

Flat shank does not allow easy access into tight fibrotic pockets

Other features

Plastic probe offers the option of using replaceable and flexible yellow tips

Very thin UNC Round, fine 12 is for mainte- tapered, narrow nance; UNC 15 diameter is for attachment loss

Nabers: The Nabers probe has curved workings ends and a blunt tip to facilitate detection and classification of furcations, ie, degree of penetration into the furca. Although the conventional straight probes can still be used, most clinicians find the Nabers probe to be superior for furcation areas. World Health Organization (WHO): This probe has a ball tip 0.5mm in diameter. The purpose of the ball tip is to provide patient comfort and help detect calculus as well as irregular margins of restorations.

clinically meaningful.8 The second generation probes did not have electronic data collection.The technology of second generation probes was the basis of the third generation probes, which included the electronic data collection capability.

Third Generation Probes

Florida probe The Florida Probe was developed following the criteria defined by the National Institute of Dental and Craniofacial Research for overcoming limitations of conventional probing. These criteria include constant and standardized force, noninvasive, lightweight, and easy to use; easy access to any location around all teeth; a guidance system to ensure proper angulation; complete sterilization of all portions entering mouth; no biohazard from material or electric shock; and direct electronic reading and digital output.4
Continued on Page 18

Second Generation Probes

Second generation probes were developed in an effort to standardize and quantify the pressure used during probing. According to Hefti et al., some research identified a positive correlation between probing force and depth of probe penetration.10 Weinberg et al. stated that controlled force of 20 to 25 grams probes reduced examiner error and made depth changes of less than 2mm
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Table 3: Specialty First Generation Probes

All photos are courtesy of Hu-Friedy PCPNT2 Novatech PQ2N Nabers Style PCP11.5B WHO/PSR Screening

sensitivity, a fixed force setting regardless of inflammatory status, and an underestimation of deep probing depths.5 UltraSonographic Probe Designed at NASA to detect cracks in airplanes, the US Probe is an ultrasonographic instrument that integrates diagnostic medical ultrasound techniques with advanced artificial intelligence to automatically detect, US Probe map, and diagnose periodontal disease. According to McCombs and Hinders, The ultrasound probe projects a very narrow beam of high-frequency (10-15 MHz) ultrasonic waves into the gingival sulcus and then detects echoes of returning waves, which are reflected back from tissues. The ultrasound probe tip is gently placed on the gingival margin until slight blanching occurs, then swept along the entire gingival area. The ultrasound probe is able to painlessly capture a series of observations (depth measurements plus contour) across the entire subgingival area as the probe tip passes along the gingival margin, therefore yielding more information.15 In other words, there is no subgingival penetration. They conclude, The ultrasound probe may offer an important alternative to traditional manual periodontal probing because it is non-invasive, painless, less prone to examiner variability, potentially more sensitive, and may yield additional histological information. However, more research is needed to validate these claims. Issues such as the cost of research and development and the price of bringing a new product to market all play important roles in the rates of development, production, and adoption of the new ultrasound probing technology.15

Markings

Depends on style; Marquis markings are shown 3-6-9-12 Yes Adaptability in areas of limited access; more accurate readings, particularly on distobuccal and distolingual aspects of posterior teeth; smooth insertion into sulcus May feel bulky due to angulation
5

3-6-9-12

3.5-5.5-8.5-11.5

Color coding Advantages

Yes Ideal for detection of mesial and distal furcations in maxillary molars; markings are helpful

Yes Ball tip for client comfort, color coded from 3.5-5.5; easy to read markings; thin shank allows access into tight fibrotic sulci Markings at 0.5mm

Disadvantages5

May feel bulky when clinician is accustomed to using a periodontal explorer for furcation detection Curved working end, paired furcation probes, smooth, ronded for investigating furcas

Other features

Right-angle design

Marks at, round tapered fine with ball end

The system includes a probe handpiece, digital readout, foot switch, computer interface, and computer. Once the tip of the probe is inserted into the sulcus, the clinician presses the foot petal and the system automatically records pocket depth, attachment loss, bleeding, suppuration, plaque, recession, hyperplasia, mobility, furcation, and mucoginigval involvement. The probe moves through a sleeve. Next, a colored chart can be printed and used as part of the patients record or for patient education purposes. The probe measures 0.4mm and applies 15g of pressure.5
Photos courtesy of Florida Probe

Limitations
The periodontal probe presents problems of sensitivity and reproducibility. Carranza reports, The precise location of the probe tip depends on the degree of inflammationtechnique, force, size of the probe, angulation, and precision of calibration. All of these variables contribute to the large standard deviations (0.5-1.3mm) in clinical probing results.4 Electronic probes, primarily the Florida Probe, were designed to address these problems. Other electronic probes (Interprobe and Peri-Probe) provide some of the benefits of the electronic probe (constant force, computer storage of data, precise management of inflammation).4 Although not clinically
CDHA Journal Vol. 25 No. 2

The advantages include constant probing force with precise electronic measurements and computer storage of data. A problem is a lack of tactile
Florida Probe

18

Photos courtesy of US Probe

significant, these probes have reported only slightly improved reproducibility compared with conventional probing.

References
1. 2. Wilkins E. Clinical practice of the dental hygienist. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2009. Darby M. My favorite probe. Friends of Hu-Friedy [Internet]. [Cited 24 Mar 2010]. Available from: http://www.friendsofhu-friedy.com/ resources/InstrumentoftheMonth.asp Standards for Clinical Dental Hygiene Practice. American Dental Hygienists Association. [Internet] [Cited 1 June 2010]. Available from: http://adha.org/downloads/adha_standards08.pdf Newman M, Takei H, Klokkevold P , Carranza F. (2006). Carranzas clinical periodontology. 10th ed. St Louis: Saunders; 2006; 550p. Darby M, Walsh M. Dental hygiene theory and practice. 3rd ed. St. Louis: Saunders; 2010. Perry D, Beemsterboer P. (2007) Periodontology for the dental hygienist. 3rd ed. St Louis: Saunders; 2007. Nield-Gehrig J, Willmann D. Foundations of periodontics for the dental hygienist. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2008. Weinberg M, Westphal C, Froum S, Palat M, Schoor R. Comprehensive periodontics for the dental hygienist. 3rd ed. Boston: Pearson; 2010. Pihlstrom B. Measurement of attachment level in clinical trials: probing methods. J Periodontol. 1992;63(12 Suppl): 1072-7.

Conclusion
Conventional probes come in a variety of designs which offer advantages and disadvantages. In spite of identified limitations, the standard of care in dental hygiene treatment is to do a thorough periodontal assessment on all patients, which includes probe measurements and documentation. Manufacturers continue to address the concerns by developing and implementing new technology, particularly with the third generation or automated probes. It is imperative that the dental hygienist be familiar with different probe styles and be comfortable using a variety of probes due to office and examining board requirements. Educators can facilitate operator confidence by introducing students to a variety of probes. Licensed clinicians have the opportunity to familiarize themselves with probes through sales representatives, trade shows, conventions, and literature.

3.

4. 5. 6. 7. 8. 9.

About the Authors

Heidi Emmerling, RDH, PhD, is Assistant Professor of Dental Hygiene at Sacramento City College and a CODA site consultant. She is also owner of Writing Cures (www.writingcures.com), a writing and editing service, and co-author of Purple Guide: Paper Persona, a guide to preparing professional development and job search materials. Dr Emmerling can be reached at EmmerlH@scc.losrios.edu Ellen Standley, RDH, BS, MA, is Professor of Dental Hygiene at Sacramento City College and has taught in the department for over 30 years. She is a member of the California Dental Hygiene Educators Association and the American Academy of Dental Hygiene. Ms. Standley is the 2010-2011 President of the California Dental Hygienists Association. She can be reached at Standle@scc.losrios.edu

10. Hefti A. Periodontal probing. Crit Rev Oral Biol Med. 1997;8: 336-56. Russell A. A system of classification and scoring for prevalence surveys of periodontal disease. J Dent Res. 1956;35: 350-57. 11. Van der Zee E, Davies E, Newman H. Marking width, calibration from tip and tine diameter of periodontal probes. J Clin Periodontol. 1991;18(7): 516-20. 12. Rapp G, Barbosa Jr A, Mendes A, Motta A, Biao M, Garcia R. Technical assessment of WHO-621 periodontal probe made in Brazil. Brz Dent J. 2002;13(1): 61-5. 13. Dye B, Thornton-Evans G. A brief history of national surveillance efforts for periodontal disease in the United States. J Periodontol. 2007 July;78(Suppl): 1373-9. 14. McCombs G, Hinders M. The potential of the ultrasonic probe. Dimens Dent Hyg. 2006;4(4): 16-8.

CDHA Journal Summer 2010

19

Photodynamic Therapy

Catherine Fairfield, RDH

Photodisinfection Innovative Adjunctive Therapy

Treatment protocols for periodontal diseases strive to evolve and provide enhanced outcomes in conjunction with a culminating body of research that demonstrates the complexity of these diseases. The pathogenesis of periodontal diseases is not simple with bacteria and host immune responses working together.1 The primary etiology of these diseases consists of periodontal bacteria and their products that exist in multispecies biofilms.1-3 The host immune inflammatory response to this microbial challenge leads to tissue destruction, periodontal pocket formation, damage to the alveolar bone, and possible tooth loss.1,3-4 Likewise, peri-implant inflammatory lesions resemble periodontal diseases with similar periodontal pathogens, host immune responses and inflammatory reactions.5-7 Eradication of periodontal pathogens plays a key role in the treatment of periodontal and periimplant diseases.4-7 Scaling and root planing (SRP) have long been considered the gold standard of non-surgical treatment for periodontal diseases by diminishing plaque and calculus deposits, subsequently altering the subgingival microbial load.3,8 Individuals who do not respond as favorably to standard scaling and root planing often require additional treatment modalities such as systemic antibiotics and locally delivered antimicrobials.9 Studies report improved gains in clinical attachment levels, reduction in probing depths, and decreased bleeding on probing following scaling and root planing therapy when combined with adjunctive antimicrobial use.9-10 However, limitations such as re-colonization of subgingival sites and bacterial resistance exist with current adjunctive therapies. Photodisinfection (PD), an emerging technology, shows promise as a locally delivered antimicrobial (LDA) adjunct in the treatment of both periodontal and peri-implant diseases.11 Particular bacterial species existing in intricate biofilms play a key role in the initiation and progression of periodontal diseases.3 This list includes gram-negative anaerobes such as Porphymonas gingivalis, Prevotella intermedia, Treponema denticola and Tannerella forsythensis as well as the facultative anaerobe Aggregatibacter actinomycetemcomitans.12 Each of these bacteria has virulence factors that act locally to enhance destruction within the sulcular tissues.13 Studies indicate virulence factors will continue to exert adverse effects on host tissues after the infecting pathogen is eliminated with an antibiotic regimen.14 Virulence factors, including lipopolysaccharides and proteolytic enzymes, are not eliminated with antibiotic therapy.14-15 Specific periodontal pathogens have also been shown to invade oral epithelial cells perhaps enhancing their ability to further evade eradication following standard treatment protocols including systemic antibiotic therapy.16-17 The use of adjunctive antimicrobials has been shown to improve clinical outcomes and suppress bacterial loads as compared to scaling and root planing alone.9-10,18 Most studies indicate that no single instru20

mentation technique is totally effective in eliminating all bacteria from the subgingival tooth surfaces.19 It has been stated that improved treatment outcomes could be achieved with full mouth disinfection or anti-infective therapy that includes both mechanical and chemotherapeutic approaches to reduce or eliminate the microbial biofilm.20 Dental implants face equal challenges with colonization of pathogenic bacterial species.6-7 Consequently, dental implant maintenance requires routine monitoring of the peri-implant soft and hard tissues, combined with mechanical debridement of the biofilm and adjunctive therapies as needed.21-22 However, the reductions of subgingival pathogenic bacteria associated with adjunctive antimicrobials are not permanent with most studies indicating suppressions for terms of 3 to 18 months.23-24 Short-term pathogen reductions followed by re-colonization by the same species is consistent among full-mouth disinfection studies, leading researchers to investigate possible re-colonization from sources outside the treated periodontal pocket or from pathogens which have invaded epithelial cells.24-26 It has been established that P. gingivalis was able to recolonize subgingival sites in which it had been earlier suppressed shortly after active periodontal treatment.25 In addition, it has been demonstrated that pathogenic bacteria were able to colonize pristine peri-implant sites in mixed dentitions, indicating that healthy periimplant sites may be threatened by periodontal pathogens existing in other areas of the oral cavity.27 These findings support the theory that previously treated subgingival areas, natural dentition or dental implant, may demonstrate recolonization due to extracrevicular sources such as active periodontal disease in separate periodontal defects despite comprehensive periodontal therapy.25 Current antimicrobial treatment modalities are based primarily on antibiotic therapies, both locally and systemically delivered. Two distinct drawbacks with antibiotics exist: the inability to neutralize virulence factors and the formation of bacterial resistance. Virulence factors contribute to a pathogens success at initiating and progressing host tissue destruction.13 A common known limitation to antibiotic therapy is the inability to neutralize or eliminate virulence factors.14-15 Bacterial resistance is increasing due to the heightened use of broad spectrum antibiotics and the evolution of bacteria and biofilm to acquire new mechanisms needed for resistance.9, 28 In subjects with chronic periodontitis who received SRP alone or with systemically administered azithromycin, metronidazole or a sub-antimicrobial dose of doxycycline, a percentage of resistant isolates increased in plaque samples in all adjunctive treatment groups, peaking at the end of administration.29 Although no resistant isolates remained permanently, bacterial resistance had occurred. Further, intracellular bacterial invasion research demonstrated resistant strains of intracellular P. gingivalis to select antibiotics capable of entering eurkaryotic cells.10
CDHA Journal Vol. 25 No. 2

Limitations exist with current adjunctive treatment modalities due likely to numerous factors such as evasive periodontal pathogens, their damaging virulence factors and increasing bacterial resistance to antibiotic regimens.27, 29-31 Photodisinfection presents a novel antimicrobial therapeutic approach for periodontal and peri-implant diseases. The science of photodisinfection began over 100 years ago when the combination of harmless dyes and visible light in vitro resulted in the killing of microorganisms.32 Prior treatment of bacteria with a chemical photosensitizing agent was found to sensitize targeted bacteria to killing by light emitted from low-power non-thermal lasers. Research led to the introduction of photodisinfection for the treatment of cancers, disinfection of blood products and drinking water.32-35 A rise in resistant strains of bacteria appearing more readily sparked interest in the use of photodisinfection for the treatment of infectious diseases.35-36 As early as 1992, researchers proposed that lethal photosensitization could be an effective means of eliminating peridontopathogenic bacteria from dental plaque.36 The non-antibiotic technology of photodisinfection targets and eliminates microbes including bacteria, viruses, fungi and protazoa.37-38 Designated photosensitizing agents on the cell membrane of targeted pathogens are activated by light of a specific wavelength.38-39 This excitation generates localized singlet oxygen and free radicals that directly attack the targeted plasma membrane resulting in cell membrane disruption.39 Bacterial cell death via loss of membrane integrity, lipid peroxidation and the inactivation of essential enzymes follows.39 Photodisinfection for the treatment of periodontal and peri-implant diseases consists of a simple two-step clinical procedure.40 The first step is thorough irrigation of the affected site with the photosensitizing solution that selectively binds to gram-negative bacteria. (Figure 1) The second step consists of illuminating the site with the light-diffusing tip from a non-thermal diode laser of the appropriate and constant wavelength for a set time. (Figure 2)

occurring in-vivo and resulted in decreased bone loss in rats.44 Formation of bacterial resistance is a key concern with antibiotic therapies, however bacteria are not likely to develop resistance to photodisinfection.38,45 Resistance in the target bacteria would be unlikely as the killing is achieved in very short periods of time. In addition, multi-antibiotic resistant strains have been eradicated by photodisinfection. It has also been demonstrated the in-vivo killing of epidemic methicillin-resistant Staphylococcus aureus (EMRSA-16) strain in two mouse wound models utilizing methylene blue as the photosensitizing agent.46 Potential problems with photodisinfection do exist. The process has a possible cytotoxic effect on surrounding tissues and produces heat during illumination. This cytotoxicity destroys bacteria, however the reactive oxygen species may inadvertently cause damage to host tissues.47 Heat is produced by red light illumination, which if excessive may lead to delayed healing or tissue necrosis. Biopsies have been examined in a recent study following treatment with methylene blue and red light illumination and did not reveal any tissue necrosis after 24 hours.46 In spite of these concerns, lethal photosensitization for periodontal and peri-implant diseases is considered safe.32,43 The low concentrations of non- toxic photosensitizing solutions, such as methylene blue, when combined with low intensity red light energy have been shown to eliminate the infecting organisms and the related virulence factors without causing damage to the adjacent host tissues.32,48 The greatest level of killing occurred with exposure to laser light in conjunction with methylene blue as a photosensitizing agent.48 A recent study utilized methylene blue and demonstrated the effectiveness of photodisinfection as an adjunct to SRP.40 These in vivo results showed increases in clinical attachment levels, reductions in probing depth and decreases in bleeding on probing as compared to SRP alone. Periimplant diseases have a similar etiology to periodontal diseases.5-6 Thus, photodisinfection has been identified as a non-invasive adjunctive therapy that could reduce microorganisms and related virulence factors in periimplant diseases.11, 49

Figure 1: Step one Irrigation

Photodisinfection has certain advantages over other Research continues to unfold the complex nature of antimicrobial treatment modalities. Unlike antibiotic periodontal and peri-implant diseases further identifytherapy, photodisinfection is capable of neutralizing ing the limitations of current non-surgical treatment virulence factors, including both lipopolysaccharides and protocols. The need for novel adjunctive therapies that Figure 2: Step two Illumination enzymes, thus preventing further damage to the sur15, 41-42 eliminate or reduce the current limitations to treatAlthough bacterial biofilms rounding host tissues. ment modalities is clear. The role of photodisinfection protect the pathogenic organisms from immune system as an adjunctive antimicrobial in the clinical treatment of periodontal clearance and increase resistance to phagocytosis and antibiotics, a and peri-implant diseases warrants further investigation and shows study has confirmed that light in the presence of a photosensitizing 28,43 much promise. agent can kill substantial numbers of oral bacteria. Further, research has reported lethal photosensitization of P. gingivalis
Continued on Page 22

CDHA Journal Summer 2010

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About the Author

Catherine Fairfield, RDH, graduated from the dental hygiene program at the University of Alberta in 1989. She has 21 years of experience in private periodontal practices in Calgary, Alberta and is currently practicing in both periodontal and prosthodontic disciplines. Catherine contributed as a part-time clinical educator and guest lecturer in the Graduate Periodontal program at the University of British Columbia for 6 years. She currently provides educational seminars in non-surgical periodontal therapy, adjunctive therapies for the treatment of periodontal and peri-implant diseases, dental implant maintenance therapy, and hands-on advanced instrumentation workshops. Catherine continues to provide consulting services and lectures on behalf of various companies in the dental industry and has just completed 7 years as a member of the Competence Committee for the College of Registered Dental Hygienists of Alberta. Catherine can be reached at catherinefairfield@gmail.com

20. Drisko CH. Nonsurgical periodontal therapy. Periodontol. 2000. 2001;25: 77-88. 21. Lang NP, Nyman SR. Supportive maintenance care for patients with implants and advanced restorative therapy. Periodontology. 2000. 1994;4: 119-26. 22. Mombelli A, Lang NP. The diagnosis and treatment of peri-implantitis. Periodontol. 2000. 1998; 17: 63-76. 23. Ehmke B, Moter A, Beikler T, et al. Adjunctive antimicrobial therapy of periodontitis: long-term effects on disease progression and oral colonization. J Periodontol. 2005;76: 74959. 24. Feres M, Haffajee AD, Allard K, et al. Change in subgingival microbial profiles in adult periodontitis subjects receiving either systemically-administered amoxicillin or metronidazole. J Clin Periodontol. 2001;28: 597609. 25. Fujise O, Miura M, Hamachi, et al. Risk of Porphyromonas gingivalis recolonization during the early period of periodontal maintenance in initially severe periodontitis sites. J Periodontol. 2006;77: 13339. 26. Bollen CM, Mongardini C, Papaioannou W, et al. The effect of a one-stage full-mouth disinfection on different intra-oral niches. Clinical and microbiological observations. J Clin Periodontol. 1998;25: 5666. 27. Quirynen M, Vogels R, Pauwels M, et al. Initial subgingival colonization of pristine pockets. J Dent Res. 2005;84: 3404. 28. Sharma M, Visai L, Bragheri F, Cristiani I, Gupta PK, Speziale P. Toludine blue-mediated photodynamic effects of staphylococcal biofilms. Antimicrob Agents Chemother. 2008;52(1): 299-305. 29. Haffajee AD, Patel M, Socransky SS. Microbiological changes associated with four different periodontal therapies for the treatment of chronic periodontitis. Oral Microbiol Immunol. 2008;23(2): 148-57. 30. Johnson JD, Chen R, Lenton PA, Zhang G, Hinrichs JE, Rudney JD. Persistence of extracrevicular bacterial reservoirs after treatment of aggressive periodontitis. J Periodontol. 2008;79(12): 2305-12. 31. Bonito AJ, Lux L, Lohr KN. Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review. J Periodontol. 2005;76(8): 1227-36. Review. Erratum in: J Periodontol. 2006;77(2): 326. 32. Wilson M. Bactericidal effect of laser light and its potential use in the treatment of plaque-related diseases. Int Dent J. 1994;44(2): 181-9. 33. Wainright, M. Pathogen inactivation in blood products. Curr Med Chem. 2002;9: 127-43. 34. Kuznetsova N, Makarov D, Kaliya O, Vorozhtsov G. Photosensitized oxidation by dioxygen as the base for drinking water disinfection. J Hazard Mater. 2007;31;146: 487-91. 35. Dai T, Huang YY, Hamblin MR. Photodynamic therapy for localized infections state of the art. Photodiagnosis Photodyn Ther. 2009; 6(3-4): 170-88. 36. Dobson J, Wilson M. Sensitization of oral bacteria in biofilms to filling by light from a low-power laser. Arch Oral Biol. 1992 Nov;37(11): 883-7. 37. Wainright, M. Photoinactivation of viruses. Photochem Photobiol Sci. 2004;3: 406-11. 38. Wilson M. Lethal photosensitisation of oral bacteria and its potential application in the photodynamic therapy of oral infections. Photochem Photobiol Sci. 2004;3: 412-8. 39. Omar GS, Wilson M, Nair SP. Lethal photosensitization of wound-associated microbes using indocyanine green and near-infrared light. BMC Microbiol. 2008;8:111120. 40. Andersen R, Loebel N, Hammond D, Wilson M. Treatment of periodontal disease by photodisinfection compared to scaling and root planing. J Clin Dent. 2007;18: 348. 41. Komerik N, Wilson M, Poole S. The effect of photodynamic action on two virulence factors of gram-negative bacteria. Photochem Photobiol. 2000;72(5): 676-80. 42. Packer S, Bhatti M, Burns T, Wilson M. Inactivation of Proteolytic Enzymes from Porphyromonas gingivalis using light-activated agents. Lasers Med Sci. 2000;15: 2430. 43. ONeill JF, Hope CK, Wilson M. Oral bacteria in multi-species biofilms can be killed by red light in the presence of toluidine blue. Lasers Surg. 2002;31: 8690. 44. Komerik N, Nakanishi H, MacRobert AJ, et al. In vivo killing of Porphyromonas gingivalis by toluidine blue-mediated photosensititzation in an animal model. Antimicrob Agents Chemother. 2003;47(3): 932-40. 45. Jori G, Fabris C, Soncin M, et al. Photodynamic therapy in the treatment of microbial infections: basic principles and perspective applications. Lasers Surg Med. 2006;38: 46881. 46. Zolfaghari PS, Packer S, Singer M, et al. In vivo killing of Staphylococcus aureus using a lightactivated antimicrobial agent. BMC Microbiol. 2009;9: 27. 47. Lambrechts SA, Demidova TN, Aalders MC, Hasan T, Hamblin MR. Photodynamic therapy for Staphylococcus aureus infected burn wounds in mice. Photochem Photobiol Sci. 2005;4: 5039. 48. Chan Y, Lai CH. Bactericidal effects of different laser wavelengths on periodontopathic germs in photodynamic therapy. Lasers Med Sci. 2003;18(1): 51-5. 49. Shibli JA, Martins MC, Theodoro LH, Lotufo RF, Garcia VG, Marcantonio EJ. Lethal photosensitization in microbiological treatment of ligature-induced peri-implantitis: a preliminary study in dogs. J Oral Sci. 2003;45(1): 17 -23.

References
1. Offenbacher S. Periodontal diseases: pathogenesis. Ann Periodontol. 1996;1: 82178. 2. Haffajee AD, Socransky SS. Microbial etiological agents of destructive periodontal diseases. Periodontol. 2000. 1994;5: 78111. 3. Cobb CM. Microbes, inflammation, scaling and root planing, and the periodontal condition. J Dent Hyg. 2008; 82(3): 4-9. 4. Teles RP, Patel M, Socransky SS, Haffajee AD. Disease progression in periodontally healthy and maintenace subjects. J Periodontol. 2008 May;70(5):784-94. 5. Haanaes HR. Implants and infection with special reference to oral bacteria. J Clin Periodontol. 1990;17: 516-24. 6. Hultin M, Gustafsson A, Hallstrom H, et al. Microbiological findings and host response in patients with peri-implantitis. Clin Oral Impl Res. 2002;13: 349-58. 7. Mombelli A, Lang NP. The diagnosis and treatment of peri-implantitis. Periodontol. 2000. 1998; 17: 63-76. 8. Cobb CM. Clinical significance of non-surgical periodontal therapy: an evidence-based perspective of scaling and root planing. J Clin Periodontol. 2002 May;29 Suppl 2:6-16. 9. Walker CB, Karpinia K, Baehni P. Chemotherapeutics: antibiotics and other antimicrobials. Periodontol. 2000. 2004;36: 146-65. 10. Eick S, Pfister W. Efficacy of antibiotics against periodontopathogenic bacteria within epithelial cells: an in vitro study. J Periodontol. 2004;75: 1327-34. 11. Hayek RR, Araujo NS, Gioso MA, et al. Comparative study between the effects of photodynamic therapy and conventional therapy on microbial reduction in ligature-induced peri-implantitis in dogs. J Periodontology. 2005;76(8): 1275-81. 12. Wolff LF, Aeppli DM, Pihlstrom B, et al. Natural distribution of 5 bacteria associated with periodontal disease. J Clin Periodontol. 1993;20: 699706. 13. Fives-Taylor PM, Meyer DH, Mintz KP, et al. Virulence factors of Actinobacillus actinomycetemcomitans. Periodontol. 2000. 1999;20: 13667. 14. Komerik N, Wilson M, Poole S. The effect of photodynamic action on two virulence factors of gramnegative bacteria. Photochem Photobiol. 2000;72(5): 676-80. 15. Wilson M. Lethal photosensitisation of oral bacteria and its potential application in the photodynamic therapy of oral infections. Photochem Photobiol Sci. 2004;3: 412-8. 16. Andrian E, Grenier D, Rouabhia M. In vitro models of tissue penetration and destruction by Porphyromonas gingivalis. Infect Immun. 2004;72: 468998. 17. Saglie R, Newman MG, Carranza FA, et al. Bacterial invasion of gingiva in advanced periodontitis in humans. J Periodontol. 1982;53: 21722. 18. Walker C, Karpinia K Rationale for use of antibiotics in periodontics. J Periodontol. 2002;73(10): 1188-96. 19. Adriaens PA, Edwards Ca, De Boever Ja, Loesche WJ. Ultrastructural observations on bacterial invasion in cementum and radicular dentin of periodontally diseased human teeth. J Periodontol. 1988;59: 493-503.

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CDHA Journal Vol. 25 No. 2

LifeLongLearning
Home Study Correspondence Course

2 CE Units (Category I)

Read the following articles and answer the questions: Pharmacology and Periodontal Disease Advances in Technology and Periodontal Therapy Probing into Probes Photodisinfection-Innovative Antimicrobial Adjunctive Therapy
2 CE Units Member $25, Potential member $35
Circle the correct answer for questions 1-10

1. Of the many systemic antibiotics available to treat periodontal disease, there is no consensus as to the ideal dose and duration of treatment required. a. True b. False 2. All of the following antibiotic agents are bactericidal EXCEPT: a. amoxicillin. c. metronidazole. b. cephalosporin. d. tetracycline. 3. First generation antimicrobial antiseptics include all of the following EXCEPT: a. chlorhexidine. c. sanguinarine. b. phenolics. d. quarternary compounds. 4 5 The therapuetic drug levels of locally delivered antimicrobials in the gingivial crevicular fluid, begin to decline in: a. 3-5 days. c. 10-21 days. b. 7-14 days. d. after 30 days. Technology that allows for risk assessment for periodontal disease is the: a. DIAGNOdent Perio Probe. c. PreViser. b. MyPerioPath. d. Orasphere.

7. The periodontal probe favored by many on the west coast is the: a. ColorVue probe. c. Williams probe. b. Marquis probe. d. UNC-12 probe. 8. An advantage of the Florida probe includes: a. constant probing force. c. it is non-invasive. b. increased tactile sensitivity. d. painless probing. 9. Photodisinfection technique includes: a. one step, illuminating the affected site with a non-thermal diode laser. b. two steps, including irrigation of the affected site with a photosensitizing solution and illumination of the site with a non-thermal diode laser. c. three steps, including irrigation of the affected site with a photosensitizing solution, placement of a locally delivered antimicrobial, and illumination of the site with a non-thermal diode laser. d. four steps, including irrigation of the the affected site with a photosensitizing solution, placement of a locally delivered antimicrobial, illumination of the site with a non-thermal diode laser and rinsing with a hydrogen peroxide rinse for one minute following the procedure. 10. The advantages of photodisinfection include all of the following EXCEPT: a. capable of neutralizing virulence factors. b. less bacterial resistance. c. increased healing due to heat production. d. multi-antibiotic resistant strains can be eradicated.

6. New innovations for treatment of periodontal disease include all of the following EXCEPT: a. InSight LED ultrasonic scaler insert. b. NV Microlaser. c. Blue Boa. d. Swerv3 magnetostrictive ultrasonic scaler.

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CDHA Journal Summer 2010 23