Open access peer-reviewed chapter - ONLINE FIRST
Abstract
Periodontal diseases are prevalent worldwide, affecting individuals of all ages, including children. Despite advances in scientific knowledge, these diseases still lead to significant tooth loss. Furthermore, research has shown a close link between periodontal diseases and systemic conditions such as respiratory and cardiological issues, hormonal imbalances, pregnancy complications, and more. Preventive measures and campaigns targeting periodontal health could yield significant results if implemented widely across different regions. It is imperative to extend such initiatives to children and adolescents, considering the high prevalence of periodontal diseases globally. Introducing early education on the importance of periodontal health could further reinforce preventive efforts and contribute to better quality of life in the future. In the current context, professionals can apply minimally invasive non-surgical periodontal therapy procedures to effectively manage these diseases in their early and moderate stages, leveraging the excellent repair capacity of periodontal tissues. Emphasizing proper hygiene practices is also essential.
Keywords
- periodontal disease
- biofilm
- dental calculus
- dental scaling
- root planing
1. Introduction
Periodontal diseases have existed since the early stages of human civilization. Historical evidence suggests that periodontal disease existed as far back as 3000 years BC, among civilizations such as the Sumerians, who were known to practice dental hygiene using gold toothpicks. Similar evidence of periodontal diseases has been found in ancient Egypt, Greece, Peru [1, 2, 3], and other regions (Figures 1 and 2).
Figure 1.
Courtesy of Anton Samplonius. Jaw of an ancient Peruvian. Bone loss up to the middle third is observed in tooth 3.4. In tooth 3.5, the bone loss covers the cervical third of the root. In tooth 3.6, bone loss is observed in the mesial and distal roots and reaches the cervical third. The furcation presents a “tunnel”-type lesion that advances to the lingual surface.
Figure 2.
Courtesy of Anton Samplonius. Upper jaw of an ancient Peruvian. Tooth 2.6 shows extensive bone loss from mesial to distal, reaching the apical third. In piece 2.7, we note that the bone loss is very extensive and has reached the mesial and distal roots. In the mesial root, it affects the apical third. The furcation area of this piece shows bone resorption. The presence of calculus in the molars is also observed. In tooth 2.6 the stone reaches the apex of the mesial root.
In modern times, periodontal diseases are recognized as a universal health issue affecting populations worldwide. Scientific evidence supports the effectiveness of scaling and root planing procedures in treating periodontal disease.
The treatment of periodontal inflammatory lesions is multifaceted, with the primary goals being their control and elimination. Therapeutic approaches consider factors such as the severity of the disease, individual patient needs, and relevant risk factors. By addressing these factors systematically, healthcare providers can achieve the best possible treatment outcomes [4, 5].
Non-surgical periodontal treatment is recommended for conditions such as gingivitis, gingival enlargements, and initial or moderate periodontitis. In such cases, the primary objective is to suppress local irritating factors [6, 7, 8].
However, it is important to note that non-surgical periodontal treatment may have limitations, particularly in interproximal areas or cases of bifurcation and trifurcation compromises, deep pockets, teeth in poor position, and intrabony defects [6].
2. Etiology of periodontal disease
The transition from health to disease occurs when specific bacteria within the bacterial biofilm proliferate and produce virulence factors that exceed the person’s limit of defensive resistance. This can result from a decrease in the host’s defenses, an exaggerated inflammatory response to bacterial attack, or the characteristics of the offending bacterial species, leading to the development of gingivitis or periodontitis and subsequent periodontal tissue destruction within a multifactorial pathogenic mechanism [9, 10].
The subgingival biofilm exhibits continuous presence and poses challenges for eradication, compounded by its constant exposure to gingival crevicular fluid (GCF). During inflammation, various cells and inflammatory biomarkers (enzymes, tissue degradation products, cytokines, etc.) are released into the GCF, necessitating analysis of its protein composition for predicting, diagnosing, and monitoring periodontal tissue health [11, 12].
Gram-negative bacteria within the biofilm continually release pro-inflammatory molecules such as bacterial lipopolysaccharides (LPS), which are endotoxins, and butyric acid. These bioactive substances interact with gingival tissue, initiating and amplifying the inflammatory response. Upon contacting the gingival epithelium, they can penetrate the connective tissue and enter the systemic circulation, emphasizing the importance of physically disrupting the biofilm to stop its growth.
Based on these principles, scaling and root planing are considered the “gold standard” of periodontal therapy for patients diagnosed with gingivitis, as well as those with initial and moderate periodontitis [13, 14]. In other words, non-surgical mechanical treatment is the cornerstone of periodontal therapy and the primary method recommended for controlling periodontal infections [15, 16].
3. Biofilm control
Non-surgical periodontal treatment must begin by empowering the patient to take control of the biofilm. This involves providing the patient with all the necessary information about the significance of biofilm control and educating them on effective periodontal hygiene techniques, including the selection of an appropriate toothbrush for biofilm removal.
When inflammation is confined to the gingival tissues, the treatment procedure primarily involves the removal of the biofilm using the proper periodontal hygiene techniques.
Figures 3–5 clearly illustrate the explanation given by the professional and demonstrate the application of scientific knowledge on biofilm control by the patient. These figures highlight the relatively simple procedures patients can undertake to achieve the benefits of periodontal health.
Figure 3.
In tooth 1.3 an inflammatory process is observed in the marginal gingiva and in a part of the attached gingiva.
Figure 4.
The biofilm has taken on a greater extent in the cervical third of tooth 1.3 and in the neighboring teeth.
Figure 5.
The gingival inflammation of tooth 1.3 has been significantly reduced in just 21 days using the Modified Bass Technique.
The fundamental procedure in combating periodontal infections remains the elimination of both supragingival and subgingival bacterial deposits.
The removal of supragingival plaque is crucial, as its presence can lead to the initial formation of subgingival plaque [17]. Supragingival plaque is composed primarily of gram-positive cocci and streptococci, which are aerobic bacteria and considered nonspecific opportunistic pathogens that induce gingivitis [18, 19].
Studies have shown that meticulous control of supragingival plaque can have a significant impact on both the quantity and quality of the subgingival microbiota, as well as the clinical symptoms associated with periodontitis in adults. This is because the quantity, composition, and recolonization rate of subgingival plaque are, to some extent, dependent on the accumulation of supragingival plaque [20, 21, 22].
4. Scaling and root planning
Scaling is defined as the procedure that removes the biofilm and dental calculus from the periodontal pocket, without modifying the root surface (Figures 6 and 7).
Figure 6.
Supragingival and subgingival calculus accumulation in the anterior region of the lingual surfaces of the incisors and canines.
Figure 7.
Recovery of the gingival tissues can be seen after the removal of dental calculus from the anterior region of the lingual surfaces of the incisors and canines.
Scaling is carried out using mainly ultrasonic and manual methods.
The objective of this supragingival and subgingival mechanical debridement is to reduce the bacterial load, alter the microbial composition, and establish a flora that benefits the person’s health. These microbiological changes help reduce inflammation and promote the stability of the periodontal attachment level [23].
In this chapter, we present our experience of scaling and root planing in clinical practice to show that these two procedures are the most important and fundamental in the treatment of bacterial periodontal diseases. While choosing a form of periodontal treatment is crucial, it does not singularly determine treatment success [24].
The success of periodontal treatments depends on several factors, including meticulous actions on the root surface of the teeth, patient compliance with periodontal maintenance, and consistent periodontal hygiene practices [25, 26]. A primary goal is the complete removal of subgingival calculus and biofilm.
Research indicates a significant reduction in subgingival bacterial load and specific periodontal pathogens following scaling and root planing in periodontitis [27]. Achieving thorough debridement of subgingival areas requires proper periodontal instruments, excellent technique, and training to prevent bacterial repopulation and reinfection due to residual calculus and biofilm [28].
While scaling and root planing are remarkably effective for reducing inflammation and reaching periodontal probing depths, subgingival calculus may remain inadvertently. Therefore, professionals recognize the importance of refining scaling and root planning techniques. These procedures are often clinically complex and resemble flapless periodontal surgery, requiring tactile perception similar to that of an open flap procedure.
Based on our clinical experience, we recommend the use of Hirshfield files and diamond tips (see Figures 8 and 9), which have proven highly effective in reaching inaccessible areas.
Figure 8.
Periodontal file. Hirshfield No. 3 by Hu-Friedy.
Figure 9.
Diamondtec Mesial Curette/Hu-Friedy Distal SDCM/D7.
Preventing recurrence during periodontal requires meticulous scaling and root planing procedures and ongoing maintenance phases. Hirshfield files, particularly 3/7 (buccal and lingual) and 5/7 (mesial and distal), are very useful for non-surgical periodontal treatment. Before starting periodontal work, it is necessary to verify that the instruments have the necessary sharpness to be effective.
During treatment, the active part of the instrument must adapt to the root surface environment to remove subgingival calculus and biofilm without causing unnecessary trauma to soft tissues. Movements typically include vertical, oblique and, occasionally, horizontal motions. Every five movements, it is crucial to check for the presence of subgingival calculus and ensure its total removal [29].
When root surfaces become smoother, using a periodontal probe followed by tactile verification with a periodontal file helps identify any remaining roughness requiring further treatment. Incomplete removal of subgingival calculus can result in bacterial reservoirs, as spaces and channels within the stones allow bacterial proliferation and toxin accumulation, along with other microorganisms [30, 31].
It is worth pointing out that bacteria can reside in other areas, such as root cementum and dentin [32]. The following clinical cases illustrate the benefits of root planing supported by a careful manual technique.
In one clinical case, a 62-year-old patient presented with gingival pain, discomfort on both sides when chewing, bad breath, purulent discharge, and tooth mobility in molars 3.6 and 4.6. The patient was diagnosed with initial and moderate chronic periodontitis. In recent years, the patient had been prescribed monthly antibiotics for respiratory infections (Figures 10–12).
Figure 10.
X-ray of tooth 3.6 shows a radiolucent area in the furcation of the first molar.
After a few weeks of non-surgical periodontal treatment, the patient improved significantly and experienced complete resolution of respiratory infections. During 10 years of periodontal maintenance, the patient did not suffer any periodontal recurrence.
The x-rays of tooth 3.6 and 4.6 show evidence of bone recovery in the furcation areas (Figures 11 and 13).
Figure 11.
Ten years after treatment the furcation area has been significantly reduced and the bone has consolidated.
Figure 12.
The radiological image of the furcation of tooth 4.6 shows a radiolucent lesion.
Figure 13.
Ten years after treatment the furcation lesion has reduced, and bone tissue has been regenerated.
The second clinical case involves a 32-year-old patient, depicted in Figures 14 and 15, who was referred by his dentist. The patient experienced pain when chewing, spontaneous gingival bleeding, and bleeding while brushing. The diagnosis was moderate to advanced periodontitis in tooth 3.7. Periodontal treatment was performed with the Hirshfield file and the diamond tip.
Figure 14.
In the distal area of tooth 3.7, the periodontal probe penetrates approximately 14 mm. The gingival tissues are inflamed and bleed on probing.
Figure 15.
The radiograph of tooth 3.7 shows bone loss up to the apex in the distal root. It also reveals bone loss in the furcation.
After 5 months of treatment, the progress was excellent. There was no longer any tooth mobility or gingival bleeding. The evolution of the soft tissues can be seen in Figures 16–21.
Figure 16.
The gingival tissues have recovered and show periodontal health.
Figure 17.
The lingual side of tooth 3.7 shows periodontal health after five months of periodontal treatment.
Figure 18.
In tooth 3.7, the periodontal tissues have recovered significantly. The periodontal probe enters the probing 6 mm. This probing must be very careful so as not to alter the periodontal reattachment process.
Figure 19.
In the middle part of the buccal surface near the furcation the periodontal probe enters 3 mm.
Figure 20.
The x-ray of tooth 3.7 shows recovery of the furcation and distal root. Follow-up at 5 months. The periodontal probe enters the probing 6 mm. This probing must be performed carefully to avoid altering the periodontal reattachment process.
Figure 21.
Follow-up at 8 months. A consolidation of the bony structures including the furca area is observed.
5. Re-evaluation of periodontal therapy
The stone itself does not cause an inflammatory process in the periodontal pocket, but it does provide an ideal area for subgingival microbial colonization and the release and concentration of bacterial toxins. Most dental professionals have clinically experienced difficult removal of subgingival calculus, even when access is not restricted. The difficulties involved in definitively removing subgingival calculus through scaling and root planing are serious; therefore, dental appointments must be scheduled with enough time to scrupulously reevaluate the presence of subgingival calculus.
Periodontal maintenance appointments should include verification of the presence of exudate, bleeding on probing, tooth mobility, gingival color, and furcation involvement.
The bacterial communities installed inside the canals and lacunae of subgingival calculus are viable and are composed of various anaerobic gram-positive and gram-negative bacteria. Therefore, it is deduced that subgingival calculus can act as a reservoir for the continuous release of endotoxins and various microorganisms [33].
The incomplete removal of subgingival calculus creates a deposit of elements capable of producing reinfection of the periodontal pocket and recurrence of the process. This can be avoided with thorough periodontal treatment.
Another consideration to keep in mind is that cement is porous and allows the penetration and diffusion of biologically active substances from various sources, including saliva, GCF, and biofilm [16].
Scaling and root planing significantly reduces endotoxins but does not eliminate those already absorbed. In this regard, periodontal maintenance every 3 to 4 months is suggested to avoid retoxification of the treated root surfaces.
The complete removal of subgingival calculus is a challenge for any professional, including the most experienced ones. This is due to a series of factors, including restricted access, location and hardness of the subgingival calculus, irregular surfaces, bacterial penetration into the cement, and resorption gaps, among others [16].
Subgingival calculus may be strongly adhered to an area of hypermineralized cement, which would lead to incomplete removal of calculus deposits with a long formation time on the root surface [16].
A 30-year study of 375 rigorously controlled patients in a private dental clinic found a low incidence of dental caries and periodontal disease, with most patients experiencing no loss of periodontal adhesion [34].
6. Final considerations
An interesting investigation on the level of knowledge of dentists about non-surgical periodontal therapy yielded the following results:
General practice dentists: 50% had low knowledge, 31.5% had medium knowledge, and 18.5% had high knowledge
Dentists specialized in periodontics and implantology: 31.5 had low knowledge, 33.3% had medium knowledge, and 31.5% had high knowledge
We determined that both groups of dentists had an insufficient level of knowledge, which suggests a need to reevaluate the undergraduate curriculum in dentistry [35].
Research conducted in India examined the diagnostic knowledge, treatment strategies, and opinions of general dentists regarding periodontal treatment procedures. A questionnaire of 18 questions was administered to 100 dentists. The results showed that 64.7% of dentists responded correctly, while 85.9% believed there was a higher likelihood of recurrence in periodontal diseases and preferred extraction as a treatment option. The study concluded that dentists’ knowledge is stagnant and emphasized the need to enhance the perception of periodontal treatment among general dentists in India to elevate the professional quality of their services [36].
6.1 Pointing
Manual instrumentation has the advantage of offering greater tactile sensitivity during manual scaling and root planing procedures. Similar to a systemic disease, the chronic nature of periodontal disease requires continuous monitoring and ongoing treatment [16]. The interval for patient appointments for periodontal maintenance purposes should be a function of two aspects: the severity of the disease and the patient’s personal risk of recurrence [16]. Additionally, there are other periodontal treatment alternatives that can be used either as a standalone therapy or as an adjunct to non-surgical and surgical periodontal treatment. We discuss these alternatives in the sections that follow.
6.2 Ultrasonic root debridement
Ultrasonic root debridement is the removal of the calculus from root surfaces using high-frequency vibrations. Ultrasonic scraping devices produce vibrations ranging from 20,000 to 50,000 cycles per second. These instruments work by a combination of mechanical forces, irrigation, cavitation, and acoustic current forces. The ultrasonic technique allows the tip to remain in continuous rapid motion, thus preventing overheating of the tooth surface and directly contacting the calculus to remove it through elliptical, linear, or other movements, depending on the operator’s technical skill and experience [37].
Ultrasonic debridement is contraindicated in patients with cardiac pacemakers. The electromagnetic field generated by the turbine can interfere with the operation of some pacemakers. Since the dentist cannot determine the type of pacemaker a patient has, ultrasonic equipment should not be used on these patients to avoid complications. Similarly, dentists and dental hygienists with pacemakers should not use ultrasonic equipment [38]. Sonic reamers, which do not generate an electromagnetic field, can be used as a substitute [39].
6.3 Air polishing systems
Air polishing is a complementary tool primarily used for removing pigmentation and supragingival plaque from teeth. It employs a compressed air system attached to a mechanized turbine that sprays an abrasive suspension against tooth surfaces. The advantages of this method include fast oral cleaning, effective removal of tartar and bacterial plaque, and painless application without unpleasant sounds. This method is particularly effective for intense pigmentation, such as that found in cigarette and pipe smokers. However, attention should be paid to drawbacks like abrasion and dust dissipation.
Due to the extensive aerosol generation by this system, it is contraindicated in patients with infectious diseases, respiratory diseases, hypertension, or those on hemodialysis [40].
6.4 Laser-assisted periodontal therapy
Lasers were introduced to dentistry in the second half of the 20th century. Their clinical applications have been expanding and there are now many FDA-approved devices for a wide variety of dental treatments [37]. Each type of laser has specific characteristics and applications depending on the wavelength and its shape [41].
In periodontics, lasers are used to eliminate calculus, reduce subgingival bacterial flora, enhance root instrumentation, and perform periodontal surgery [37].
The most common lasers for soft tissue applications are Nd:YAG, diode, erbium, and carbon dioxide lasers. These are recommended for gingival scraping over the epithelial lining of the pockets [37].
Some researchers have suggested that procedures such as incision and gum recession, gingivectomy, and biopsy can be safely performed with these lasers [42, 43]. However, there is insufficient evidence to support their use for subgingival debridement or reducing subgingival microbial values. Further research is needed to determine if scaling and root planing can be enhanced by the use of lasers [37].
Lasers are considered adjuncts to periodontal therapy when the removal of soft tissues inside the periodontal pocket is needed. Experimental studies have not shown improvement in the restoration of periodontal lesions following laser application for periodontal surgery.
While effective as an adjunct, lasers are not a substitute for conventional periodontal treatment [37]. Nonetheless, lasers represent a promising technology with a growing number of applications in dentistry [37]. Future research will help define new applications in both surgical and non-surgical therapies [37].
6.5 Photodynamic therapy
Photodynamic therapy is a non-invasive procedure that reduces morbidity and increases patient comfort. It serves as a valuable complement to scaling and root planing.
Achieving optimal periodontal health may not always be possible initially due to persistent bacterial reservoirs on the root surface. These reservoirs can be influenced by factors such as lesions in the furca, concavities, periodontal anatomical variations, mechanical limitations of instruments, and even the invasion of periodontopathogens into adjacent soft tissues or intraoral niches, necessitating repeated therapy [44].
The antibacterial effect of photodynamic therapy results from damage to the cytoplasmic membrane of bacteria, leading to membrane inactivation [45], protein and ion channel destruction, removal of critical metabolic enzymes, cell agglutination, and direct inhibition of exogenous virulence factors like lipopolysaccharides, collagenase, and proteinase [44].
Photodynamic therapy is also effective against microorganisms such as fungi, viruses, and protozoa, including the herpes simplex virus [44] and periodontopathogens like
Photodynamic therapy is a good alternative to antibiotic treatments because it avoids the issue of antibiotic resistance.
6.6 Mechanical chemo debridement
Mechanical control of biofilm should be emphasized as the primary defense against periodontal disease. However, mechanical control alone is often insufficient, and thus, it is necessary to supplement with chemical agents. Using mouthwash after brushing helps control biofilm, and chlorhexidine gluconate 0.12% can reduce gingivitis and gingival bleeding. Local antimicrobials are now commonplace in non-surgical periodontal treatment.
For effective penetration into the deepest parts of periodontal pockets, antimicrobials should be administered using a syringe, soft rubber tip, or cannula.
The antimicrobial agent must meet the following requirements:
The drug must reach the focus of disease activity, i.e., the base of the bursa.
The antimicrobial should be administered in bactericidal concentration.
Drugs need to be kept in place on for a long time to take effect [47].
Single irrigation after scaling and root planing does not suffice for microbial suppression [48]. For example, chlorhexidine should remain in the periodontal pocket for several days to effectively interfere with biofilm repopulation.
7. Conclusion
Non-surgical periodontal treatment can stop the progression of initial and moderate periodontitis when performed with ethical standards and excellent professional practice.
Scaling and root planing procedures generally require more rigorous preparation and training during academic training.
All dentists must stay current with clinical and scientific knowledge of non-surgical periodontal therapy (scaling and root planing) due to the high prevalence of patients with periodontitis.
Minimally invasive non-surgical treatment is a promising solution and can complement existing treatment strategies for improved outcomes.
Thanks
We wish to thank Dr. Marco Moreno Asenjo from the Peruvian Association of Periodontology who passed away before this chapter was completed. He was an extraordinary friend and a great professional who promoted periodontics in Peru. We offer him our eternal gratitude.
We also thank Mg. Lily Cardich, who generously reviewed and corrected drafts of the chapter, and Miss Jennifer J. Peralta Burga, our assistant, for her excellent typing of the chapter including the changes that were made.
References
- 1.
Vera LV. Colegio Odontológico del Perú. Odonto antropología peruana: anomalías dentarias en cráneos de antiguos peruanos. Propaceb; 1981. Disponible en: https://books.google.com.pe/books/about/Odonto_antropolog%C3%ADa_peruana.html?id=sloeHAAACAAJ&redir_esc=y - 2.
Antúnez de Mayolo S. Enfermedad periodontal en pobladores del antiguo Perú [Trabajo de investigación]. Lima: Facultad de Odontología. UNMSM. Biblioteca Nacional del Perú; 1983. Disponible en: https://www.gob.pe/institucion/bnp/buscador?contenido=todos&institucion=bnp&sheet=1&sort_by=none&term=eNFERMEDAD%20PERIODONTAL%20EN%20POBLADORES%20DEL%20ANTIGUO%20PER%C3%9A - 3.
Samplonius A. Odontología antropológica: arte, ciencia e historia del alivio y curación de la patología dental en los Andes Centrales precolombinos. San Isidro, Lima, Perú: Edición del Autor; 2021. Disponible en: https://www.elvirrey.com/libro/odontologia-antropologica_70128672 - 4.
Caffesse RG, Mota LF, Morrison EC. The rationale for periodontal therapy. Periodontology 2000. 1995; 9 (1):7-13. DOI: 10.1111/j.1600-0757.1995.tb00051.x - 5.
Cobb CM. Clinical significance of non-surgical periodontal therapy: An evidence-based perspective of scaling and root planing. Journal of Clinical Periodontology [Internet]. 2002; 29 (Suppl 2):6-16. Disponible en:https://pubmed.ncbi.nlm.nih.gov/12010523/ [Accessed: el 26 de enero de 2024] - 6.
Maita Véliz L, Maita Castañeda LM. Tratamiento Periodontal no Quirúrgico, Enfoque Biológico. Odontología Sanmarquina [Internet]. 2014; 8 (1):51. Disponible en:https://revistasinvestigacion.unmsm.edu.pe/index.php/odont/article/view/3386 [Accessed: el 17 de enero de 2024] - 7.
Fabrizi S, Barbieri Petrelli G, Vignoletti F, Bascones-Martínez A. Tratamiento quirúrgico vs terapia periodontal básica: estudios longitudinales en periodoncia clínica. Av Periodoncia Implantol Oral [Internet]. 2007; 19 (3):161-175. Disponible en:https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1699-65852007000400005 [citado el 17 de enero de 2024] - 8.
Maita Veliz L, Maita Castañeda LM, Castañeda MM. Chapter 1, non-surgical periodontal treatment ll: Scaling and root planning. In: Advances in Biology. Volume 4. New York: Nova Science Publishers, Inc.; 2023. Disponible en: https://novapublishers.com/?s=advances+in+biology&post_type=product - 9.
Löe H, Theilade E, Jensen SB. Experimental gingivitis in man. Journal of Periodontology [Internet]. 1965; 36 (3):177-187. DOI: 10.1902/jop.1965.36.3.177 - 10.
Loesche WJ, Grossman NS. Periodontal disease as a specific, albeit chronic, infection: Diagnosis and treatment. Clinical Microbiology Reviews [Internet]. 2001; 14 (4):727-752. Disponible en:https://pubmed.ncbi.nlm.nih.gov/11585783/ [citado el 17 de enero de 2024] - 11.
Bibi T, Khurshid Z, Rehman A, Imran E, Srivastava KC, Shrivastava D. Gingival crevicular fluid (GCF): A diagnostic tool for the detection of periodontal health and diseases. Molecules [Internet]. 2021; 26 (5):1208. Disponible en:https://pubmed.ncbi.nlm.nih.gov/33668185/ [citado el 17 de enero de 2024] - 12.
Gupta S, Chhina S, Arora SA. A systematic review of biomarkers of gingival crevicular fluid: Their predictive role in diagnosis of periodontal disease status. Journal of Oral Biology and Craniofacial Research [Internet]. 2018; 8 (2):98-104. Disponible en:https://pubmed.ncbi.nlm.nih.gov/29892530/ [citado el 17 de enero de 2024] - 13.
Page RC. Peridontal disease; A new paradigm. Journal of Dental Education. 1998; 62 (10):812-821 - 14.
Eley BM, Cox SW. Advances in periodontal diagnosis. 5. Potential inflammatory and immune markers. British Dental Journal [Internet]. 1998; 184 (5):220-223. Disponible en:https://pubmed.ncbi.nlm.nih.gov/9581037/ [citado el 18 de enero de 2024] - 15.
Cobb CM. Non-surgical pocket therapy: Mechanical. Annals of Periodontology [Internet]. 1996; 1 (1):443-490. DOI: 10.1902/annals.1996.1.1.443 - 16.
Cobb CM, Sottosanti JS. A re-evaluation of scaling and root planing. Journal of Periodontology [Internet]. 2021; 92 (10):1370-1378. DOI: 10.1002/jper.20-0839 - 17.
Marsh PD. Oral ecology, and its impact on oral microbial diversity. In: Kuramitsu KK, Ellen RP, editors. Oral Bacterial Ecology: The Molecular Basis. Norfolk: Horizon Scientific Press; 2000. pp. 11-65. Disponible en: https://www.caister.com/backlist/horizonscientificpress/ora.html - 18.
Listgarten MA. The role of dental plaque in gingivitis and periodontitis. Journal of Clinical Periodontology [Internet]. 1988; 15 (8):485-487. DOI: 10.1111/j.1600-051x.1988.tb01019.x - 19.
Theilade E. The experimental gingivitis studies: The microbiological perspective. Journal of Dental Research [Internet]. 1996; 75 (7):1434-1438. DOI: 10.1177/00220345960750070201 - 20.
Dahlén G, Lindhe J, Sato K, Hanamura H, Okamoto H. The effect of supragingival plaque control on the subgingival microbiota in subjects with periodontal disease. Journal of Clinical Periodontology [Internet]. 1992; 19 (10):802-809. DOI: 10.1111/j.1600-051x.1992.tb02174.x - 21.
Hellström M-K, Ramberg P, Krok L, Lindhe J. The effect of supragingival plaque control on the subgibgival microflora in human periodontitis. Journal of Clinical Periodontology [Internet]. 1996; 23 (10):934-940. Disponible en:https://pubmed.ncbi.nlm.nih.gov/8915022/ [citado el 26 de enero de 2024] - 22.
Katsanoulas T, Reneè I, Attström R. The effect of supragingival plaque control on the composition of the subgingival flora in periodontal pockets. Journal of Clinical Periodontology [Internet]. 1992; 19 (10):760-765. DOI: 10.1111/j.1600-051x.1992.tb02167.x - 23.
Petersilka GJ, Ehmke B, Flemmig TF. Antimicrobial effects of mechanical debridement. Periodontology 2000 [Internet]. 2002; 28 (1):56-71. DOI: 10.1034/j.1600-0757.2002.280103.x - 24.
Suvan J, Leira Y, Moreno Sancho FM, Graziani F, Derks J, Tomasi C. Subgingival instrumentation for treatment of periodontitis. A systematic review. Journal of Clinical Periodontology [Internet]. 2020; 47 (S22):155-175. Disponible en:https://pubmed.ncbi.nlm.nih.gov/31889320/ [citado el 2 de febrero de 2024] - 25.
Angst PDM, Finger Stadler A, Mendez M, Oppermann RV, van der Velden U, Gomes SC. Supportive periodontal therapy in moderate-to-severe periodontitis patients: A two-year randomized clinical trial. Journal of Clinical Periodontology [Internet]. 2019; 46 (11):1083-1093. Disponible en:https://pubmed.ncbi.nlm.nih.gov/31378975/ [citado el 2 de febrero de 2024] - 26.
Maita-Véliz L, M. Maita-Castañeda L. Non-surgical treatment of periodontal diseases: Responsibilities of the dentist and the patient in periodontal therapy. En: Sridharan G, editor. Periodontology - New Insights. Londres, Inglaterra: London, UKIntechOpen; 2023. - 27.
Cugini MA, Haffajee AD, Smith C, Kent RL Jr, Socransky SS. The effect of scaling and root planing on the clinical and microbiological parameters of periodontal diseases: 12-month results. Journal of Clinical Periodontology [Internet]. 2000; 27 (1):30-36. Disponible en:https://pubmed.ncbi.nlm.nih.gov/10674959/ [citado el 2 de febrero de 2024] - 28.
van Winkelhof AJ, van der Velden U, de Graaff J. Microbial succession in recolonizing deep periodontal pockets after a single course of supra- and subgingival debridement. Journal of Clinical Periodontology [Internet]. 1988; 15 (2):116-122. DOI: 10.1111/j.1600-051x.1988.tb01004.x - 29.
Tan BTK, Mordan NJ, Embleton J, Pratten J, Galgut PN. Study of bacterial viability within human supragingival dental calculus. Journal of Clinical Periodontology [Internet]. 2004; 75 (1):23-29. Disponible en:https://pubmed.ncbi.nlm.nih.gov/15025213/ [citado el 5 de febrero de 2024] - 30.
Love RM, Jenkinson HF. Invasion of dentinal tubules by oral bacteria. Critical Reviews in Oral Biology & Medicine [Internet]. 2002; 13 (2):171-183. DOI: 10.1177/154411130201300207 - 31.
Giuliana G, Ammatuna P, Pizza G, Capone F, D’Angelo M. Occurrence of invading bacteria in radicular dentin of periodontally diseased teeth: Microbiological findings. Journal of Clinical Periodontology [Internet]. 1997; 24 (7):478-485. DOI: 10.1111/j.1600-051x.1997.tb00215.x - 32.
Adriaens PA, De Boever JA, Loesche WJ. Bacterial invasion in root cementum and radicular dentin of periodontally diseased teeth in humans: A reservoir of periodontopathic bacteria. Journal of Periodontology [Internet]. 1988; 59 (4):222-230. Disponible en:https://pubmed.ncbi.nlm.nih.gov/3164373/ [citado el 5 de febrero de 2024] - 33.
McCoy SA, Creamer HR, Kawanami M, Adams DF. The concentration of lipopolysaccharide on individual root surfaces at varying times following in vivo root planing. Journal of Periodontology [Internet]. 1987; 58 (6):393-399. Disponible en:https://pubmed.ncbi.nlm.nih.gov/3298609/ [citado el 9 de febrero de 2024] - 34.
Axelsson P, Nyström B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults: Results after 30 years of maintenance. Journal of Clinical Periodontology [Internet]. 2004; 31 (9):749-757. Disponible en:https://pubmed.ncbi.nlm.nih.gov/15312097/ [citado el 14 de febrero de 2024] - 35.
Bocanegra R. Nivel de conocimiento de los odontólogos acerca de la terapia periodontal no quirúrgica. Tesis estomatológica de especialidad Periodoncia e Implantología. Peru: Universidad Peruana Cayetano Heredia; 2019. Disponible en: https://repositorio.upch.edu.pe/bitstream/handle/20.500.12866/5952/Nivel_BocanegraArista_Rocio.pdf?sequence=1&isAllowed=y - 36.
Sathyamurthy P, Padhye A, Gupta H. Knowledge of diagnosis, treatment strategies, and opinions on periodontal treatment procedures among general dentists in an Indian urban population: A questionnaire survey. Journal of Indian Association of Public Health Dentistry [Internet]. 2018; 16 (1):62. Disponible en:https://www.jiaphd.org/temp/JIndianAssocPublicHealthDent16162-7784895_213728.pdf - 37.
Beemsterboer PL, Perry DA, Essex G. Periodontología para el higienista dental. 4ta edición ed. Barcelona, España: Elsevier Inc.; 2014. Disponible en: https://app.bibguru.com/p/b193b403-ddc3-458a-8d0a-3653003cf561 - 38.
Adams D, Fulford N, Beechy J, MacCarthy J, Stephens M. The cardiac pacemaker and ultrasonic scalers. British Dental Journal [Internet]. 1982; 152 (5):171-173. Disponible en:https://pubmed.ncbi.nlm.nih.gov/7041930/ [citado el 23 de abril de 2024] - 39.
Drisko CL, Cochran DL, Blieden T, Bouwsma OJ, Cohen RE, Damoulis P, et al. Sonic and ultrasonic scalers in periodontics*. Journal of Periodontology [Internet]. 2000; 71 (11):1792-1801. Disponible en:https://pubmed.ncbi.nlm.nih.gov/11128930/ [citado el 23 de abril de 2024] - 40.
Barnes CM. Extrinsic stain removal. In: Clinical Practice of the Dental Hygienist. 11th ed. Editorial: Wolters Kluwer Health Adis (ESP) 2013. pp. 689-708. Disponible en: https://experts.nebraska.edu/en/publications/extrinsic-stain-removal - 41.
Dederich DN, Bushick RD. Lasers in dentistry. Journal of the American Dental Association [Internet]. 2004; 135 (2):204-212. Disponible en:https://pubmed.ncbi.nlm.nih.gov/15005437/ [citado el 26 de abril de 2024] - 42.
Frentzen M, Braun A, Aniol D. Er:YAG laser scaling of diseased root surfaces. Journal of Periodontology [Internet]. 2002; 73 (5):524-530. Disponible en:https://pubmed.ncbi.nlm.nih.gov/12027255/ [citado el 26 de abril de 2024] - 43.
Schwarz F, Sculean A, Rothamel D, Schwenzer K, Georg T, Becker J. Clinical evaluation of an Er:YAG laser for nonsurgical treatment of peri-implantitis: A pilot study. Clinical Oral Implants Research [Internet]. 2005; 16 (1):44-52. Disponible en:https://pubmed.ncbi.nlm.nih.gov/15642030/ [citado el 26 de abril de 2024] - 44.
Gómez Hernández C, Domínguez Martín A, García Kass AI, García Núñez JA. Aplicación complementaria de terapia fotodinámica y de la radiación láser de Er:YAG al tratamiento no quirúrgico de la periodontitis crónica: estudio comparativo de sus efectos clínicos, antiinflamatorios y antimicrobianos. Av Odontoestomatol [Internet]. 2011; 27 (3):147-160. Disponible en:https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S0213-12852011000300005 [citado el 26 de abril de 2024] - 45.
Haas R, Dörtbudak O, Mensdorff-pouilly N, Mailath G. Elimination of bacteria on different implant surfaces through photosensitization and soft laser. An in vitro study. Clinical Oral Implants Research [Internet]. 1997; 8 (4):249-254. Disponible en:https://pubmed.ncbi.nlm.nih.gov/9586470/ [citado el 26 de abril de 2024] - 46.
de Oliveira RR, Schwartz-Filho HO, Novaes AB Jr, Taba M Jr. Antimicrobial photodynamic therapy in the non-surgical treatment of aggressive periodontitis: A preliminary randomized controlled clinical study. Journal of Periodontology [Internet]. 2007; 78 (6):965-973. Disponible en:https://pubmed.ncbi.nlm.nih.gov/17539707/ [citado el 26 de abril de 2024] - 47.
Greenstein G. Subgingival irrigation--an adjunct to periodontal therapy. Current status and future directions. Journal of Dental Hygiene [Internet]. 1990; 64 (8):389-397. Disponible en:https://pubmed.ncbi.nlm.nih.gov/2090788/ [citado el 26 de abril de 2024] - 48.
Bonito AJ, Lux L, Lohr KN. Impact of local adjuncts to scaling and root planing in periodontal disease therapy: A systematic review. Journal of Periodontology [Internet]. 2005; 76 (8):1227-1236. Disponible en:https://pubmed.ncbi.nlm.nih.gov/16101353/ [citado el 26 de abril de 2024]