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 patient’s 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 amoxicillin’s 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 individual’s 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

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Oral rinses are also of great value in post surgical healing. while therapeutic drug levels in the gingival crevicular fluid start to decline at 7 days.10 Locally administered antibiotics still require a strict health history review to verify there are no known allergies. Their active ingredient is 0. sporicidal. has minimal plaque reduction. Peridex® by 3M Espe and Periogard® by Colgate® Professional are two examples of popular chlorhexidine-based products. alters the bacterial cell wall.1 Cepacol® and Scope®.1 Carcinogenic changes have been linked to the use of oxygenating agents and mouth rinses containing alcohol. bactericidal. quaternary ammonium compounds. The American Academy of Periodontology (AAP) supports that local adjuncts.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. The gingivitis reduction percents listed above for both first and second generation antimicrobials are based on efficacy data published by manufacturers. Cell death results from altered osmotic equilibrium. 2 . Despite this limitation they do show benefit when used adjunctively for gingival inflammation. First generation compounds like Listerine can cause a burning sensation and bitter taste. Research shows a significant antibacterial effect up to 7 hours after mouthrinses with high a substantivity property. The majority of the time.1 Antimicrobial mouth rinses have been linked to several side effects. and has 36% gingivitis reduction. It is a stable.9% alcohol respectively. Bacteria cells are killed by cellular pressure.07% CPC. such as smokers. a 1% chlorine dioxide agent. resulting in a similar efficacy as Listerine. 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. quaternary compounds. contain 14% and 18. Currently. increase bacterial cell wall permeability causing cell lysis. cysticidal. as opposed to oral administration. Atridox® is a 10% doxycyline hyclate gel and is prepared by mixing powder and liquid from two syringes.1 Antiseptics Unlike topical controlled-released antibiotics. Substantivity is a crucial component when considering the effectiveness of a mouth 10 CDHA Journal Vol. and viricidal properties. which contains 0.1 A bioabsorbable local delivery device called PerioChip® was then developed. Saliva has a natural flushing property making it difficult to maintain an antimicrobial effect. Absorption lasts up to 21 days. It was comprised of 34% chlorhexidine gluconate. Single site Absorption 21 days 14-21 days rinse. sanguinarine. Listerine contains 26. fungicidal. The most notable drawback for Arestin is the delivery dose.11 First generation antimicrobials include phenolic. The syringe holds pre-set doses that may not be sufficient for every site.1 Second generation antimicrobials include cetylpyridinium chloride (CPC) and chlorhexidine (CHX). This term refers to the adherent qualities of a mouthwash and its ability to be retained. free radical and an oxidant with algicidal. Oxyfresh is primarily used for the treatment of halitosis. 25 No. A commercial name for CPC is Crest® Pro-Health®. some more serious than others. Inc. Multisite Solid dose applies with a syringe. Although Actisite was found to be effective in many cases.1 Other antimicrobials include oxygenating. Even though these medications are applied topically. about 5mm round and 1mm thick. Chlorhexidine can cause supragingival calculus build-up and staining. chlorine dioxide. and zinc chloride agents. who do not respond to mechanical therapy. 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. It is the only LAA that is not an antibiotic. Oxyfresh®. Breath Rx® is a zinc chloride agent designed to odorize sulfhydryl groups with zinc ions. Listerine® and its generics are phenolics which possess the only ADA Seal of Acceptance among the first generation antimicrobials.12% chlorhexidine. more than one site can be treated depending on the depth and size of the pockets. This results in the need to reapply in the same pocket. and reduces gingivitis approximately 15%. when compared with scaling and root planing alone. placement and patient follow-up for fiber removal were challenging issues. resorbable antibiotics such as Atridox® and Arestin® are the topical antibiotics of choice. the same precautions apply.8-9 The first locally administered antibiotic for periodontal disease was Actisite®. made up of nonabsorbable fibers filled with tetracycline.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. Research has demonstrated permanent damage to enamel through erosive pH levels and abrasive antimicrobial toothpastes. Peroxyl® is an oxygenating agent with the active ingredient of hydrogen peroxide. Short term studies have produced controversial findings. It claims to be a scientific bad breath treatment specifically designed to help treat the causes of bad breath and the symptoms.Investigations do show benefits for high risk patients. CHX has 29% gingivitis reduction. It has anti-inflammatory properties as well as a bubbling action to clean and alleviate discomfort.9% alcohol. Chlorhexidine has many commercial products including the availability of a nonalcoholic version by Sunstar Americas. The antibiotic is administered into the gingival sulcus through a cannula. Antibiotic 10% Doxycyline 2% Minocycline HCl microspheres Brand Name Atridox® Arestin® Delivery Fluid mixed in a syringe. provide limited improvement. oral rinses do not penetrate deep into the gingival sulcus.

Some herbs such as Coptidis rhizome extract and Hamamelis virginiana. Melissa is in the process of completing a Master’s degree in public health at the University of Nevada. 54: 13-33. Am Heart J. Vaccines offer a solution to the overuse of antibiotics in dentistry. 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. Parkar M. Schaudinn C. Keller D. is another new probiotic for oral health and is used once daily. Comiskey J. When used for periodontal disease. Aus Dent J. 6. Gunsolley JC. she is an instructor in the dental hygiene program at Truckee Meadows Community College (TMCC) in Reno. J Periodontol.78: 1568-79. Andia DC. 8.77(4): 606-13. Kirkwood KL. Aquino DR. 2007. Porphyromonas gingivalis and Aggregatibacter actinobacillus CDHA Journal – Summer 2010 References continued on Page 25 11 . are used as bactericidal agents against oral bacteria while others such as cranberry. A double-blinded randomized clinical trial of subgingival minocycline for chronic periodontitis. 2006. This has shown results with the reduction of periodontal disease. Doherty F. they are healthy bacteria that displace unhealthy or pathogenic bacteria. Dent Clin N Am. antiviral treatment decreases EBV and improves the periodontal condition. reuteri Prodentis® gum chewed twice daily in patients with moderate to severe gingivitis. Periodontal lesions can exhibit great amounts of EBV and HCMV. JADA. Some examples of nutraceuticals include herbal and nutritional supplements and the future of this type of therapy is promising. 3.140: 978-86.54(1 Suppl): S96-S101. Cortelli JR.edu References 1. Antivirals A new area of research when evaluating periodontal disease is the use of antivirals. The American Academy of Periodontology (AAP). Tonetti MS. Probiotics are “live microorganisms. BS. J. marketed by Sunstar Americas. Minocycline HCl microspheres reduce red-complex bacteria in periodontal disease therapy. Cortillo SC. Periodontal infections cause changes in traditional and novel cardiovascular risk factors: results from a randomized controlled clinical trial. Systemic antibiotics in periodontal therapy.17 The Human Cytomegalovirus (HCMV) has also been linked to periodontal disease. rattus JH145. and S. 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.15 EvoraPlus™ from Oragenics. 5. D’Aiuto F.16 have been identified as antigenic targets. Sallum AW. This supplement contains a combination of three bacterial strains Streptococcus uberis KJ2. Carvalho-Filho J. which when administered in adequate amounts confer a health benefit on the host. Conclusion All drug sensitivities and allergies should be reviewed prior to incorporating pharmacological agents into a patient’s treatment regimen. As discussed earlier.50(3): 259-65. Otomo-Corgel J. reuteri Prodentis® that claims a reduction in moderate to severe plaque and bad breath. Machion L. Heitz-Mayfield LJA. 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.75: 1553-65. Suvan J. is the Program Coordinator and Evaluation Specialist for the Nevada State Oral Health Program. 2006. J Periodontol. 2010.Nutraceuticals As antibiotic resistance becomes more of a concern. J Oral Sci. 2009. 2009.”13 Simply put. Lecio G. Melissa can be reached at mfellman@tmcc. 2. The future of public health can be greatly affected by the scientific breakthroughs becoming made in dentistry. Inc. There are approximately 500. Sedghizadeh PP. Bland PS.18 Vaccines Vaccine therapy in the fight against periodontal disease is also a new and exciting option. NV where she teaches pharmacology. is a once daily lozenge with L. Anti-herpesvirus chemotherapy can decrease salivary viral loads resulting in the improvement if secondary bacterial periodontal infections exist.14 GUM® PerioBalance®.19 More research is needed in this field before it is widely accepted as an alternative to antibiotic or antimicrobial therapy. Nociti FH Jr. Leite RS. The future is promising in the areas of nutraceuticals and vaccines but more research is needed. Nibali L. Costerton JW. 4. S. Periodontitis: an archetypical biofilm disease. Non-surgical chemotherapeutic treatment strategies for the management of periodontal diseases. RDH. The Epstein-Barr (EBV) virus has been associated with recurrent periodontal disease. Lessem J. Roman-Torres CVG. 2009. In addition.151(5): 977-84. Gorur A. Costa FO. 2004. 7. health care providers looking for alternate adjunctive periodontal therapies for their patients. A reduction in gingivitis and dental plaque has been shown with the administration of L. Locally delivered doxycylcline as an adjunctive therapy to scaling and root planing in the treatment of smokers: a two-year follow-up. Vaccine development is based on the identification of virulence factors that stimulate the induction of salivary immunoglobulin A antibody response. Periodontol. Sallum EA. Goodson JM.12 The use of probiotics in the control of periodontal pathogens is emerging. Polygonum cuspidatum and Mikania are used to inhibit adhesion. antibiotic resistance is a growing worldwide problem. Since bacterial disease may be secondary to viral infections.000 plant species. Krayer JW. Grossi SG. Casati MZ. The HCMV can cause infections in immune-compromised individuals like organ transplant patients or patients with acquired immune deficiency syndrome (AIDS). and claims a reduction in periopathogens within the periodontal pocket. oralis KJ3.

that the outcomes of the various treatments were systematically reviewed. The clinician’s goal was to diagnose the disease and provide treatment without any consideration of risk factors or host susceptibility. gene therapy.com Described as a user-friendly Internet based technology.com Designed to be fundamental elements of a patient’s wellness plan. The thin.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.3 Dental hygienists today have a variety of tests available to identify patient’s risk factors and to treat and manage disease tissues. The audible tone and detection values can also prove beneficial in patient acceptance and compliance with periodontal treatment recommendations. the Oral Health Information Suite (OHIS) compiles.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. elicits an audible tone and gives a measurable value in pocket depths up to 9 mm. Risk Assessment and Diagnostics PreViser™ Oral Health Information Suite www. The OHIS features quantitative risk assessment tools and places quantitative values on changes in periodontal status over time. these salivary diagnostic tests measure periodontal disease infection and genetic risk factors for periodontal disease. 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. It was not until the 1980’s when well-designed clinical trials compared scaling and root planing therapy. Hygienists who practiced in the 1960’s and 70’s will remember referring most patients with 5 to 6 millimeter pockets to the periodontist for evaluation and surgery. The basic principles of periodontal surgery as described by Shluger in 1949 called on periodontists to eliminate the periodontal pocket.previser. The new frontier in periodontal research is in the application of new technologies including lasers. www. DIAGNOdent® Perio Probe KaVo Dental Corporation www. 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. MS Advances in Technology and Periodontal Therapy Treatment of periodontal disease has changed tremendously in the last 60 years. analyzes and quantifies information about an individual’s current oral health status. The device utilizes the DIAGNOdent caries detection classic or pen model handpiece. growth factors.InnovationSavvy Cathy Draper. MyPerioPath® offers genomic DNA testing that 12 CDHA Journal Vol. While the role of periodontal therapy in the prevention or reduction of systemic disease has not been proven by randomized controlled trials. 25 No. PreViser can now be used with Dentrix practice management software for seamless integration into your patient assessment data. RDH. new research with improved study designs is ongoing.oraldna. the necessary interventions for wellness and the outcomes of any treatment performed.kavousa. to periodontal surgery. When evaluating any new technique or technology. drug delivery systems and implants to restore lost tissue and function. 2 . 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. MyPerioPath® MyPerioID® PST® OralDNA Labs® Inc. 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.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. perio tip insert attaches to the handpiece and detects calculus.

pre-threaded disposable tips and a combination charger/sensor holder.discusdental. InSight™ LED Ultrasonic Scaler Inserts Discus Dental. 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. Inc. The Periowave is designed for treating patients with 4 to 9 millimeter pockets with bleeding on probing. Controlled by a foot pedal. Custom features include preset procedure settings. with a quantification of the specific pathogens and their risk factors.periowave.com The SWERV3™ magnetostrictive power scaler offers finely tuned electronics and delivers a full range of power with a color-coded lighted display. Laser energy is transferred to the photosensitive molecules bound to the subgingival biofilms by the methylene blue dye.hu-friedy. enables movement from operatory to operatory without limitations. InSight™ LED ultrasonic scaler inserts provide dual-LED illumination to eliminate the need to move the overhead dental chair light. A user-friendly touch pad and dual power modes within the scaler simplify use and ensure proper power adjustment. allows flexibility of movement.com The Periowave™ utilizes photodisinfection to target specific periodontal pathogenic bacteria. Incorporation of the disposable tips eliminates the need for fiber management and enhances the portability of the device.InnovationSavvy identifies the type and concentration of 13 specific periodontal pathogens found in a saliva sample. ZEN™ Prophy Cordless Handpiece Discus Dental. The inserts’ smooth swivel mechanism provides comfortable. FDA approval is pending for use in the United States. 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. and causes less stress and user fatigue.discusdental. The handpiece features a comfort zone grip that reduces muscle strain and enhances clinician comfort.com Designed to maximize scaling efficiency and effectiveness. The unit has a high powered lithium battery for extended use and a discrete compact charger base for counter or wall mount. the NV microlaser is completely wireless. neutral wrist and shoulder positioning without cord tension or twisting.com The NV Microlaser™ delivers full power and the capabilities of the larger.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. SWERV3™ Magnetostrictive Ultrasonic Scaler Hu-Friedy Manufacturing Company. Blue Boa® Suction System www. LLC Distributed by Discus Dental. LLC www.discusdental. desktop soft tissue diode lasers in a light-weight pen-sized package. Retreatment is recommended at 3 to 6 weeks to prevent the biofilm from re-establishing during the healing process. LLC www. eliminates cord-catching. thus improving workflow and allowing the user to assume a neutral body position. a rechargeable lithium ion battery powers the micro diode laser in continuous wave or pulsed modes. www. diode laser is then used in the pocket for 60 seconds to initiate the photodynamic chain of events. Continued on Page 14 Innovations for Treatment NV Microlaser™ Manufactured by Zap Lasers. Methylene blue dye is injected into the periodontal pocket following scaling and root planing. Additional clinical and medical risk factors are included as well as treatment considerations and reassessment recommendations. Saliva samples are mailed to the laboratory and a detailed analysis is conducted. The wireless connection between the foot pedal and the handpiece enhances portability.theblueboa. A latex-free autoclavable shell slips over the handpiece to ensure the highest level of infection control between each appointment. MyPerioID® PST® identifies an individuals genetic susceptibility to periodontal disease by testing for the presence of two interleukin-1 polymorphisms. and improves control of speed and power with a rheostat foot pedal. Formerly known as the Styla MicroLaser. Periowave™ Ondine Biopharma Corporation www. CDHA Journal – Summer 2010 13 . It is compatible with inserts produced by all major magnetostrictive scaling unit manufacturers. Periowave’s non-thermal. LLC www.com The ZEN™ Phophy Cordless Handpiece has total maneuverability. The dye binds to the lipopolysaccharides and lipids found in the cell walls of gram positive and gram negative bacteria.

The units come with a variety of tips and intraoral devices designed for oral irrigation. Web. Germany. The brush head attachment slides on and off the lightweight handle making it easy to clean. 25 No. www. Topics in periodontics include scaling and root planing. et al. 1949.sonicare.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. Dasanayake AP. Hygienists using this system can have both hands free to effectively instrument all areas of the mouth. www. 2010. PC. graduated in 1975 from Foothill College and completed her MS in dental hygiene at the University of Michigan in 1978. operatories. “Does periodontal therapy reduce the risk for systemic disease?” Dent Clin N Am. or from the practice website.54: 163-81. mutans. Shluger S. presenting CE courses and volunteering as a library reference associate at Stanford Hospital. Inc. 2 . China as well as her home state. The FlexCare+ offers advanced features including 1. and single use tongue shields and bite grips. Added product benefits include ease of use and the capability of adding oral medicaments to the irrigating solution. www. 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. The system is fully portable and does not require any additional tubing. Inc. J Periodont Res. or iPod touch. About the Author Cathy Draper RDH. Air-BUG™ Edge Medical Technologies.70: 316-25.InnovationSavvy One end of the tubing attaches to the high volume evacuator while the other is attached to an ergonomically designed saliva ejector. Croatia. Cafesse RG. The dental education software system is delivered via DVD. and Herpes simplex virus. Oral Hygiene Products Flexcare + Philips Oral Healthcare www.2 and 3 minute cycles and 3 speeds or intensities. S. Morrison EC.waterpik. teaching at Foothill College. 1987. high volume evacuation and formfitting saliva ejectors provide excellent moisture control for ultrasonic instrumentation as well as sealant placement. periodontal surgery and gingival grafts. 2.orasphere.airbug. Her dental hygiene career has taken her many places. The FlexCare+ features a UV light sanitizing chamber that kills 99% of selected pathogens including: E.coli. Assembly and operating instructions can be viewed on the manufacturer’s web site videos. MS. 3. Water Pik® Water Flosser Water Pik. Osseous resection-a basic principle in periodontal surgery. The manufacturer’s web site features a demonstration video of a dental hygienist using the system for ultrasonic debridement.com Now marketed as water flossers. Water Pik® offers a full line of products that feature state of the art dental water jet technology.com The Sonicare FlexCare+ is specifically designed to help motivate patients to achieve consistency with their home brushing habits. Units vary from countertop models to completely portable models with selfcontained water reservoirs. She currently splits her time between private practice. Four modalities of periodontal treatment compared over five years. The lightweight tubing. The airBUG™ features four components: sterilizable bite springs and U-Tubes.com Orasphere patient education programs are available for viewing from the reception area. Blue Boa® tubing is reusable and can be fully sterilized after each use. References 1. California. Ramfjord SP. Patient Education Software Orasphere® Orasphere Ltd. Oral Surg. Scannapieco FA. Field isolation is made easy without compromising patient comfort. 14 CDHA Journal Vol.22(3): 22-3.

dental and dental hygiene textbooks. Gabathuler and Hassell developed first true pressure sensitive probe consisting of a standard ZIS probe and a piezoelectric pressure sensor. documenting pocket depths. and measure sulci and pockets. probe readings have long been a source of discussion due to the variations in operator technique. Russell developed the Periodontal Index (PI) in 1956 which used only a mirror. 5. 6 and 9mm marks World Health Organization recommended the use of a . 9. 4. no calibration marks WG Cross modified the Box probes (1928) using three types. 8. method to locate. 10 marks) regarded as the prototype for many first generation probes used today such as Merritt and University of Michigan. mucogingival relationships. BS. same probe styles CDHA Journal – Summer 2010 1986 1988 1988 1987 1992 Continued on Page 16 15 . and angle. developed the Florida Probe in response to RFP put out by NIDR Goodson and Kondon developed the Accutek probe Birek et al. assess.1 Darby writes. angulation. Most clinicians use the probe they were taught in their dental hygiene education. RDH. RDH. 2. pressure. For use with the community periodontal index of treatment needs (CPITN) as well as for individual screenings of private practice patients. 5. 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. These standards state that a comprehensive clinical evaluation includes full mouth periodontal charting. which referenced a set of six probes Sachs (German periodontist who was trained in Chicago by R. 1. this has not always been the case. presented the first controlled force with automated detection Gibbs et al. have been referenced as possible modifications. Jeffcoat et al. 7. Additionally Goldman and Fox. made of sterling silver. light source and explorer. dental hygienists should deliberately try several probes and choose the one that works best for them. studies have shown that there is difference in measurements between varying probe styles. 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.5 and 11. recession. 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. “Given the importance of the periodontal probe in the process of care and long term occupational health.5.”1 Probing has been referred to as the gold standard of periodontal assessment.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.2 1934 1936. color. Commonly used probes vary by markings. material. tapered 10mm length . and subjective measurement and recording of the probe marks. 1-16 mm marks with emphasis on 2. PhD Ellen Standley. bleeding points. Wilkins states the probe is “the only accurate. Treatment of the Periodontal Pocket. modified in 1994 Bose and Ott developed the Peri-Probe The periodontal probe is an essential instrument in every dental hygienist’s armamentarium. dependable. 9mm length with 1mm marks from 1-9mm with emphasis on 5mm. 3.”2 The Standards of Clinical Dental Hygiene Practice were adopted in 2008 by the American Dental Hygienists’ Association.5-8 Furthermore.5mm marks. 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. diameter. as well as clinicians all acknowledge the importance of the periodontal probe.5. “The only accurate method of detecting and measuring periodontal pockets is careful exploration with a periodontal probe. 6mm marks. suppuration.”11 Furthermore. and attachment level. Good) “Paradentometer” a thin steel blade with six groove at 2mm increments Struckman (Germany) Duka Taschenmass.3 Carranza’s Clinical Periodontology states.5mm wide HK Box wrote a textbook. 8. Furthermore. MA Probing into Probes Introduction Measuring the Choices Hefti’s History of Probes10 1887 1928 1929 GV Black used flat blade probes bent slightly to the right and left: 8 mm length.Heidi Emmerling. as well as Nabers. used in research Armitage et al. thin stainless steel 13mm length (1.”4 Many dental hygiene textbooks include chapters on periodontal probing and the importance of assessment. developed the Toronto automated probe. and McCulloch et al. The American Dental Hygienists’ Association.5mm ball tip probe with 3. Fish(Europe) round tip. 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 .

The DK Fiber Lite Attachment holds disposable fiber optic fibers for perio work with 3. and 10mm. The EasyView Probe by Paradise Dental Technology is a thermal resin probe with yellow and green bands at 3. red millimeter markings at 5 or 6mm and thereafter. 25 No. In referring to National Health and Nutrition Examination Survey (NHANES) III. When the probe is too bulky or is flat.”14 Probes Used in Examinations Dental hygiene clinical examinations include probing documentation.” 2 .13 This index uses a special probe with a ball tip and color coded markings. sharp and thin probes pose the danger of trauma and perforation of the junctional epithelium. 7.The World Health Organization (WHO) endorsed the Community Periodontal Index of Treatment Needs (CPITN) in the late 1970s. Thin probes are also subject to bending and damage during sterilization.12 Probes from the same batch and same production line could differ by more than 0.06 to 0.5mm in calibration. In 1959. the dental hygienist does not have to change from a metal to a plastic probe when dental implants are present. 6. The design of the working ends of manual probes are either tapered. All state clinical boards and regional testing agencies include periodontal assessment as a component of the clinical exam. fine. and even same probe styles produced by the same manufacturer in different batches. According a study. 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) 16 CDHA Journal Vol. A number of schools use either the traditional Marquis or the newer plastic Color Vue version. gingival recession and attachment loss in the United States. The Marquis probe is favored by many on the west coast. The handle is autoclavable. 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. 9 and 12mm or 3. or rectangular with smooth rounded ends and are calibrated in millimeters at various intervals. Furthermore. and its slight flexibility enhances patient comfort. The Orascoptic DK kits can be ordered directly from the Orascoptic online store. mean inaccuracies of different probe sets varied from 0.5 Specialty First Generation Probes There are several first generation probes designed for specific purposes (Table 3). It is unique due to the incorporation of the use of disposable fiber optic fibers for ease of visibility.70mm. • Novatech: The Novatech probe incorporates a right angle plus upward bend which enhances the access to the difficult posterior areas. 5 and 7mm markings to measure pocket depth. The probes with curved working ends are paired and are used for examining the topography of furcations. Michele Darby writes that the Color Vue probe is her favorite because the yellow provides better contrast than the traditional metal. First Generation Probes First generation probes are composed of either stainless steel or plastic. The rounded. flat.28 to 0. “With so many Contrast Provided by Color Vue Probe patients opting for dental implants. Probes have either straight or curved working ends. it is often difficult to insert the instrument into tight tissue.5 The Orascoptic DK is a newer version of a first generation probe. Dye and Thornton-Evans reported. round. Other plastic probes include the PerioWise Friendly Probe by Premier Dental which has a green band at 3mm or less. yet tapered probe is easily angulated into tight areas. 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. 5.11 There are many styles of probes. Mean tip diameter ranged from 0. The Color Vue probe can be used to assess signs of a failing implant. different boards and testing agencies specify acceptable probe styles and most limit the probe to only one style (Table 1). “The descriptive findings from phase I (1988 to 1991) and later from the combined phases (1988-1994) represented the first reporting of probing depth.22mm. A few of the commonly used manual probes are shown and described in Table 2. 2 Photo courtesy of Hu-Friedy produced by different manufacturers.

fine 12 is for mainte. no biohazard from material or electric shock.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. clinically meaningful. degree of penetration into the furca. narrow nance. 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. which included the electronic data collection capability.tapered. easy access to any location around all teeth. most clinicians find the Nabers probe to be superior for furcation areas. some research “identified a positive correlation between probing force and depth of probe penetration. 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. noninvasive. ie. sterilizable.5mm in diameter. and direct electronic reading and digital output.The technology of second generation probes was the basis of the third generation probes.”10 Weinberg et al. thin shank allows access into tight fibrotic sulci.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. stated that controlled force of 20 to 25 grams probes reduced examiner error and made depth changes of less than 2mm CDHA Journal – Summer 2010 17 . The purpose of the ball tip is to provide patient comfort and help detect calculus as well as irregular margins of restorations. a guidance system to ensure proper angulation. Although the conventional straight probes can still be used. fibrotic sulci Easy to read due to contrast. These criteria include constant and standardized force. lightweight.. 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. thin shank allows access into tight. complete sterilization of all portions entering mouth. and easy to use. 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.8 The second generation probes did not have electronic data collection. 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. According to Hefti et al. • World Health Organization (WHO): This probe has a ball tip 0.

thin shank allows access into tight fibrotic sulci Markings at 0. therefore yielding more information.5mm Disadvantages5 May feel bulky when clinician is accustomed to using a periodontal explorer for furcation detection Curved working end. smooth insertion into sulcus May feel bulky due to angulation 5 3-6-9-12 3. Once the tip of the probe is inserted into the sulcus. and an underestimation of deep probing depths. “The ultrasound probe may offer an important alternative to traditional manual periodontal probing because it is non-invasive.”4 Electronic probes. then swept along the entire gingival area. paired furcation probes. primarily the Florida Probe. mobility. The probe measures 0. According to McCombs and Hinders. Other electronic probes (Interprobe and Peri-Probe) provide some of the benefits of the electronic probe (constant force. precise management of inflammation). particularly on distobuccal and distolingual aspects of posterior teeth. “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. computer interface. All of these variables contribute to the large standard deviations (0. recession. there is no subgingival penetration.3mm) in clinical probing results. The ultrasound probe tip is gently placed on the gingival margin until slight blanching occurs. and diagnose periodontal disease. “The precise location of the probe tip depends on the degree of inflammation…technique.5 UltraSonographic Probe Designed at NASA to detect cracks in airplanes. round tapered fine with ball end The system includes a probe handpiece. However. painless. 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. A problem is a lack of tactile Florida Probe 18 Photos courtesy of US Probe .4mm and applies 15g of pressure. size of the probe. 25 No. Carranza reports. ronded for investigating furcas Other features Right-angle design Marks at.”15 In other words. more accurate readings. angulation. smooth. a fixed force setting regardless of inflammatory status. The probe moves through a sleeve. the US Probe is an ultrasonographic instrument that integrates diagnostic medical ultrasound techniques with advanced artificial intelligence to automatically detect. production.5-1. and mucoginigval involvement.5 Photos courtesy of Florida Probe Limitations The periodontal probe presents problems of sensitivity and reproducibility. They conclude. easy to read markings. and may yield additional histological information. 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. a colored chart can be printed and used as part of the patient’s record or for patient education purposes. less prone to examiner variability. and adoption of the new ultrasound probing technology. furcation. markings are helpful Yes Ball tip for client comfort. computer storage of data. foot switch. color coded from 3.4 Although not clinically CDHA Journal Vol.5-8. attachment loss. plaque.5 Color coding Advantages Yes Ideal for detection of mesial and distal furcations in maxillary molars.5-11. Marquis markings are shown 3-6-9-12 Yes Adaptability in areas of limited access. more research is needed to validate these claims. and precision of calibration. the clinician presses the foot petal and the system automatically records pocket depth. Next. force.Table 3: Specialty First Generation Probes All photos are courtesy of Hu-Friedy PCPNT2 Novatech PQ2N Nabers Style PCP11. hyperplasia. suppuration. and computer. which are reflected back from tissues….5. potentially more sensitive.5B WHO/PSR Screening sensitivity.5-5. were designed to address these problems. 2 The advantages include constant probing force with precise electronic measurements and computer storage of data. bleeding. US Probe map.”15 Markings Depends on style.5-5. digital readout.

asp Standards for Clinical Dental Hygiene Practice.pdf Newman M. is Professor of Dental Hygiene at Sacramento City College and has taught in the department for over 30 years. 3rd ed. which includes probe measurements and documentation. 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. Perry D. Nield-Gehrig J. these probes have reported only slightly improved reproducibility compared with conventional probing. Thornton-Evans G. Technical assessment of WHO-621 periodontal probe made in Brazil. 13. Pihlstrom B. 2010. 1992. (2006). She is also owner of Writing Cures (www. 3rd ed.org/downloads/adha_standards08. Darby M. 5. a writing and editing service. Van der Zee E. [Cited 24 Mar 2010]. Periodontal probing. Available from: http://adha. 4. 10th ed. Willmann D.18(7): 516-20. Barbosa Jr A. 2. Davies E. Biao M. Takei H. 12. 2007.edu Ellen Standley. particularly with the third generation or automated probes. J Periodontol. Brz Dent J. Marking width. Schoor R.writingcures. Klokkevold P . PhD. Manufacturers continue to address the concerns by developing and implementing new technology. is Assistant Professor of Dental Hygiene at Sacramento City College and a CODA site consultant. Standley is the 2010-2011 President of the California Dental Hygienists’ Association. Louis: Saunders. MA. American Dental Hygienists’ Association. RDH. the standard of care in dental hygiene treatment is to do a thorough periodontal assessment on all patients. Froum S. St. a guide to preparing professional development and job search materials. St Louis: Saunders. She is a member of the California Dental Hygiene Educator’s Association and the American Academy of Dental Hygiene.losrios.78(Suppl): 1373-9. Wilkins E. conventions. BS. Conclusion Conventional probes come in a variety of designs which offer advantages and disadvantages. Garcia R. Dye B. 1991. Philadelphia: Lippincott Williams & Wilkins. St Louis: Saunders. About the Authors Heidi Emmerling. A brief history of national surveillance efforts for periodontal disease in the United States. 6. My favorite probe. 11. RDH. 14. Comprehensive periodontics for the dental hygienist. Rapp G.edu 10. J Dent Res. Russell A. 2nd ed. 1956. and co-author of Purple Guide: Paper Persona. Licensed clinicians have the opportunity to familiarize themselves with probes through sales representatives.4(4): 16-8. 7.8: 336-56. Dr Emmerling can be reached at EmmerlH@scc. 1997. 2007 July. McCombs G. Dental hygiene theory and practice. J Clin Periodontol.com). Hefti A. Boston: Pearson. 10th ed. 2010. Walsh M. CDHA Journal – Summer 2010 19 . Mendes A. Ms. Educators can facilitate operator confidence by introducing students to a variety of probes. (2007) Periodontology for the dental hygienist. 9.friendsofhu-friedy. A system of classification and scoring for prevalence surveys of periodontal disease. Clinical practice of the dental hygienist. 8. Dimens Dent Hyg. Available from: http://www. 2008. Carranza’s clinical periodontology.com/ resources/InstrumentoftheMonth.13(1): 61-5.63(12 Suppl): 1072-7. Philadelphia: Lippincott Williams and Wilkins. Friends of Hu-Friedy [Internet]. Beemsterboer P. trade shows. Motta A. 2002. 3rd ed. Westphal C. and literature. Hinders M. Newman H. 3. The potential of the ultrasonic probe.significant. In spite of identified limitations. Measurement of attachment level in clinical trials: probing methods. 2006.35: 350-57. 550p. Darby M.losrios. Crit Rev Oral Biol Med. Palat M. 2009. Carranza F. calibration from tip and tine diameter of periodontal probes. [Internet] [Cited 1 June 2010]. 2006. She can be reached at Standle@scc. Foundations of periodontics for the dental hygienist. J Periodontol. References 1. Weinberg M.

a percentage of resistant isolates increased in plaque samples in all adjunctive treatment groups. Prevotella intermedia. 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. and decreased bleeding on probing following scaling and root planing therapy when combined with adjunctive antimicrobial use. damage to the alveolar bone. peri-implant inflammatory lesions resemble periodontal diseases with similar periodontal pathogens.9. host immune responses and inflammatory reactions. Treponema denticola and Tannerella forsythensis as well as the facultative anaerobe Aggregatibacter actinomycetemcomitans. periodontal pocket formation.20 Dental implants face equal challenges with colonization of pathogenic bacterial species.29 Although no resistant isolates remained permanently. intracellular bacterial invasion research demonstrated resistant strains of intracellular P.13 Studies indicate virulence factors will continue to exert adverse effects on host tissues after the infecting pathogen is eliminated with an antibiotic regimen. bacterial resistance had occurred. gingivalis to select antibiotics capable of entering eurkaryotic cells. shows promise as a locally delivered antimicrobial (LDA) adjunct in the treatment of both periodontal and peri-implant diseases.25 Current antimicrobial treatment modalities are based primarily on antibiotic therapies.3-4 Likewise. Photodisinfection (PD). 25 No.25 In addition. limitations such as re-colonization of subgingival sites and bacterial resistance exist with current adjunctive therapies.11 Particular bacterial species existing in intricate biofilms play a key role in the initiation and progression of periodontal diseases.Photodynamic Therapy Catherine Fairfield. reduction in probing depths. natural dentition or dental implant.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.12 Each of these bacteria has virulence factors that act locally to enhance destruction within the sulcular tissues. Two distinct drawbacks with antibiotics exist: the inability to neutralize virulence factors and the formation of bacterial resistance. leading researchers to investigate possible re-colonization from sources outside the treated periodontal pocket or from pathogens which have invaded epithelial cells. peaking at the end of administration.27 These findings support the theory that previously treated subgingival areas.23-24 Short-term pathogen reductions followed by re-colonization by the same species is consistent among full-mouth disinfection studies.1 The primary etiology of these diseases consists of periodontal bacteria and their products that exist in multispecies biofilms. The pathogenesis of periodontal diseases is not simple with bacteria and host immune responses working together.9-10. Virulence factors contribute to a pathogens success at initiating and progressing host tissue destruction. 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.3. indicating that healthy periimplant sites may be threatened by periodontal pathogens existing in other areas of the oral cavity. including lipopolysaccharides and proteolytic enzymes.10 CDHA Journal Vol. metronidazole or a sub-antimicrobial dose of doxycycline.18 Most studies indicate that no single instru20 mentation technique is totally effective in eliminating all bacteria from the subgingival tooth surfaces.9-10 However. it has been demonstrated that pathogenic bacteria were able to colonize ‘pristine’ peri-implant sites in mixed dentitions.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.1-3 The host immune inflammatory response to this microbial challenge leads to tissue destruction.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. dental implant maintenance requires routine monitoring of the peri-implant soft and hard tissues. subsequently altering the subgingival microbial load. combined with mechanical debridement of the biofilm and adjunctive therapies as needed.9 Studies report improved gains in clinical attachment levels. Further.13 A common known limitation to antibiotic therapy is the inability to neutralize or eliminate virulence factors.21-22 However.5-7 Eradication of periodontal pathogens plays a key role in the treatment of periodontal and periimplant diseases. and possible tooth loss. both locally and systemically delivered.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.3 This list includes gram-negative anaerobes such as Porphymonas gingivalis.6-7 Consequently.1. 28 In subjects with chronic periodontitis who received SRP alone or with systemically administered azithromycin. 2 .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. are not eliminated with antibiotic therapy.14 Virulence factors.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.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. may demonstrate recolonization due to extracrevicular sources such as active periodontal disease in separate periodontal defects despite comprehensive periodontal therapy. an emerging technology.

Further.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. agent can kill substantial numbers of oral bacteria. however bacteria are not likely to develop resistance to photodisinfection. research has reported lethal photosensitization of P.36 The non-antibiotic technology of photodisinfection targets and eliminates microbes including bacteria.39 Photodisinfection for the treatment of periodontal and peri-implant diseases consists of a simple two-step clinical procedure. ment modalities is clear. The process has a possible cytotoxic effect on surrounding tissues and produces heat during illumination. disinfection of blood products and drinking water. 41-42 eliminate or reduce the current limitations to treatAlthough bacterial biofilms rounding host tissues.32. researchers proposed that lethal photosensitization could be an effective means of eliminating peridontopathogenic bacteria from dental plaque.toxic photosensitizing solutions. 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. such as methylene blue. photodisinfection is capable of neutralizing ing the limitations of current non-surgical treatment virulence factors.43 much promise.11. In addition.5-6 Thus. 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.46 Potential problems with photodisinfection do exist. Periimplant diseases have a similar etiology to periodontal diseases. lethal photosensitization for periodontal and peri-implant diseases is considered safe.37-38 Designated photosensitizing agents on the cell membrane of targeted pathogens are activated by light of a specific wavelength. gingivalis Continued on Page 22 CDHA Journal – Summer 2010 21 . however the reactive oxygen species may inadvertently cause damage to host tissues. thus preventing further damage to the sur15.40 The first step is thorough irrigation of the affected site with the photosensitizing solution that selectively binds to gram-negative bacteria.43 The low concentrations of non.39 Bacterial cell death via loss of membrane integrity.27.40 These in vivo results showed increases in clinical attachment levels. a and peri-implant diseases warrants further investigation and shows study has confirmed that light in the presence of a photosensitizing 28. multi-antibiotic resistant strains have been eradicated by photodisinfection. photodisinfection has been identified as a non-invasive adjunctive therapy that could reduce microorganisms and related virulence factors in periimplant diseases.47 Heat is produced by red light illumination. 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.Limitations exist with current adjunctive treatment modalities due likely to numerous factors such as evasive periodontal pathogens. 29-31 Photodisinfection presents a novel antimicrobial therapeutic approach for periodontal and peri-implant diseases.46 In spite of these concerns. The need for novel adjunctive therapies that Figure 2: Step two – Illumination enzymes. which if excessive may lead to delayed healing or tissue necrosis. 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. 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. (Figure 2) occurring in-vivo and resulted in decreased bone loss in rats.35-36 As early as 1992. lipid peroxidation and the inactivation of essential enzymes follows.38-39 This excitation generates localized singlet oxygen and free radicals that directly attack the targeted plasma membrane resulting in cell membrane disruption.38. fungi and protazoa.48 A recent study utilized methylene blue and demonstrated the effectiveness of photodisinfection as an adjunct to SRP. Research led to the introduction of photodisinfection for the treatment of cancers.48 The greatest level of killing occurred with exposure to laser light in conjunction with methylene blue as a photosensitizing agent.32. their damaging virulence factors and increasing bacterial resistance to antibiotic regimens. (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. Unlike antibiotic periodontal and peri-implant diseases further identifytherapy.45 Resistance in the target bacteria would be unlikely as the killing is achieved in very short periods of time. This cytotoxicity destroys bacteria.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. 49 Figure 1: Step one – Irrigation Photodisinfection has certain advantages over other Research continues to unfold the complex nature of antimicrobial treatment modalities. viruses.44 Formation of bacterial resistance is a key concern with antibiotic therapies. including both lipopolysaccharides and protocols. reductions in probing depth and decreases in bleeding on probing as compared to SRP alone.

2004.17: 516-24. 2005.77(2): 326. Virulence factors of Actinobacillus actinomycetemcomitans. Makarov D. 2009. Packer S.4: 119-26.52(1): 299-305. Rouabhia M. Burns T. Ehmke B. Wilson M. 26. J Periodontol.36: 146-65. She has 21 years of experience in private periodontal practices in Calgary.44(2): 181-9. 48. Komerik N.3: 412-8. J Hazard Mater. 38. 1990. Periodontol. Marcantonio EJ. Meyer DH. 1994. In vivo killing of Porphyromonas gingivalis by toluidine blue-mediated photosensititzation in an animal model.72(5): 676-80. 1982. Zolfaghari PS. 2008. Microbial etiological agents of destructive periodontal diseases. Papaioannou W. The effect of photodynamic action on two virulence factors of gram-negative bacteria. et al. RDH. Miura M. 2000. Lethal photosensitization in microbiological treatment of ligature-induced peri-implantitis: a preliminary study in dogs. Lambrechts SA. adjunctive therapies for the treatment of periodontal and peri-implant diseases. J Periodontology. Baehni P. Catherine can be reached at catherinefairfield@gmail. Andrian E. 45.13: 349-58. Bactericidal effect of laser light and its potential use in the treatment of plaque-related diseases. Periodontal diseases: pathogenesis. 1993. Initial subgingival colonization of ‘pristine’ pockets. 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. J Clin Periodontol. J Dent Res. J Periodontol. 1998. The effect of photodynamic action on two virulence factors of gramnegative bacteria.76(8): 1227-36.25: 77-88. Comparative study between the effects of photodynamic therapy and conventional therapy on microbial reduction in ligature-induced peri-implantitis in dogs. J Clin Dent. 29. Shibli JA. Haanaes HR. et al. 14. 2009. 2000. 2006. et al. Sharma M. Poole S. Haffajee AD. dental implant maintenance therapy. Hasan T. Cobb CM. 34.20: 699–706. Hope CK.77: 1333–9. Risk of Porphyromonas gingivalis recolonization during the early period of periodontal maintenance in initially severe periodontitis sites. 2002.18(1): 51-5. 2000. Toludine blue-mediated photodynamic effects of staphylococcal biofilms. BMC Microbiol. Loesche WJ.53: 217–22. Hammond D. 30. O’Neill JF. Nyman SR. Soncin M. J Periodontol. Loebel N. Johnson JD. Bactericidal effects of different laser wavelengths on periodontopathic germs in photodynamic therapy. Bragheri F. Carranza FA. 39. J Clin Periodontol. et al. 2 . 3. Lotufo RF. J Clin Periodontol. 17. Hallstrom H.146: 487-91. Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review. Grenier D. 2004. Natural distribution of 5 bacteria associated with periodontal disease. Fabris C. Karpinia K. 1994. Wilson M. 43. 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. Disease progression in periodontally healthy and maintenace subjects. 37. M. Lasers Surg. Lethal photosensitisation of oral bacteria and its potential application in the photodynamic therapy of oral infections. Hinrichs JE. Packer S. Cristiani I. Wainright. Inactivation of Proteolytic Enzymes from Porphyromonas gingivalis using light-activated agents. Jori G. Lethal photosensitization of wound-associated microbes using indocyanine green and near-infrared light. Moter A.76: 749–59. 2000. Microbes. Photosensitized oxidation by dioxygen as the base for drinking water disinfection. Microbiological changes associated with four different periodontal therapies for the treatment of chronic periodontitis. 2008. Offenbacher S. Chemotherapeutics: antibiotics and other antimicrobials. BMC Microbiol. Lang NP. 1996. graduated from the dental hygiene program at the University of Alberta in 1989. Lai CH. Persistence of extracrevicular bacterial reservoirs after treatment of aggressive periodontitis. Haffajee AD. Haffajee AD. Change in subgingival microbial profiles in adult periodontitis subjects receiving either systemically-administered amoxicillin or metronidazole. Vorozhtsov G. Mombelli A. Bacterial invasion of gingiva in advanced periodontitis in humans.About the Author Catherine Fairfield. Supportive maintenance care for patients with implants and advanced restorative therapy. and hands-on advanced instrumentation workshops. Patel M. Periodontol. 2000. Theodoro LH. 24.3: 406-11. scaling and root planing. MacRobert AJ. Feres M. Adjunctive antimicrobial therapy of periodontitis: long-term effects on disease progression and oral colonization. 2002 May. Photoinactivation of viruses. 1994. 2. et al.3: 412-8. 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CA 91203 CDHA Journal – Summer 2010 23 . Potential member $35 Circle the correct answer for questions 1-10 1. 10-21 days. d. d. UNC-12 probe. Brand Blvd. one step. Please allow 4 .6 weeks to receive your certificate. The advantages of photodisinfection include all of the following EXCEPT: a. less bacterial resistance. d. b. 8. Williams probe. c. including irrigation of the affected site with a photosensitizing solution. constant probing force. 9. All of the following antibiotic agents are bactericidal EXCEPT: a. False 2. c. Technology that allows for risk assessment for periodontal disease is the: a. The following information is needed to process your CE certificate. An advantage of the Florida probe includes: a. Please print clearly: ADHA Membership ID#: ________________________ Expiration:___________ ❑ I am not a member Name: _____________________________________________________ License #: ___________________ Mailing Address: __________________________________________________________________________ Phone: ______________________ Email: __________________________ Fax: ______________________ Signature: ______________________________________________________________________________ Please mail photocopy of completed Post-test and completed information with your check payable to CDHA: 130 N. c. painless probing. Orasphere. d. Photodisinfection technique includes: a. MyPerioPath. PreViser. ColorVue probe. d. a. multi-antibiotic resistant strains can be eradicated. Swerv3™ magnetostrictive ultrasonic scaler. First generation antimicrobial antiseptics include all of the following EXCEPT: a. b. d. begin to decline in: a. illumination of the site with a non-thermal diode laser and rinsing with a hydrogen peroxide rinse for one minute following the procedure. b. Suite 301. 3. 4 5 The therapuetic drug levels of locally delivered antimicrobials in the gingivial crevicular fluid. Of the many systemic antibiotics available to treat periodontal disease. b. b. four steps. sanguinarine. 3-5 days. 7. 6. d. New innovations for treatment of periodontal disease include all of the following EXCEPT: a. there is no consensus as to the ideal dose and duration of treatment required. d. it is non-invasive. increased healing due to heat production. 10. c. two steps. Glendale. phenolics. b. metronidazole. True b. c. b. quarternary compounds.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. c. NV Microlaser™. cephalosporin. c. Blue Boa®. three steps. tetracycline. including irrigation of the affected site with a photosensitizing solution and illumination of the site with a non-thermal diode laser. InSight™ LED ultrasonic scaler insert. and illumination of the site with a non-thermal diode laser. DIAGNOdent Perio Probe. b. Marquis probe. 7-14 days. including irrigation of the the affected site with a photosensitizing solution. c. increased tactile sensitivity. placement of a locally delivered antimicrobial. b. illuminating the affected site with a non-thermal diode laser. The periodontal probe favored by many on the west coast is the: a. capable of neutralizing virulence factors. c. chlorhexidine. placement of a locally delivered antimicrobial. amoxicillin. d. after 30 days.