Plasma in Periodontics: Will the Dream Come True

ISSN (Print) 2249-9725 e-ISSN 2250 - 3455 M. C. E Society's M. A. Rangoonwala College of Dental Sciences and Research Centre Pune UNIVERSAL RESEARCH Volume 5 Issue 3 September - December 2015 Also available online at www.urjd.org REVIEW ARTICLE Plasma in Periodontics: Will the Dream Come True Sapna Sharma, Rashmi Khanna, Rakesh Garg, Monika Rana Department of Periodontics, NIMS Dental College and Hospital, Jaipur, Rajasthan, India ABSTRACT Most of the people cannot even imagine that there exists a fourth state of matter other than liquids, solids, and gases known as “plasma,” which is actually the most unusual and the most abundant energy form. It exists commonly in association with galaxies, stars, and lightning and could become a new and painless way to eliminate bioilms, bacterial pathogens, plaque, and periodontal pockets. Plasmas may promise painless subgingival plaque removal and elimination of bacteria deep in the pocket without relecting the lap. The ield is immature but when developed completely will be able to be applied for many of the dental procedures for increasing the eficiency. This comprehensive review of literature is intended to provide with a summary of the current status of this emerging ield, its scope, and its use in the ield of periodontics. KEY WORDS: Non‑thermal plasma, periodontics, plasma INTRODUCTION One of the attractive features of plasma is the ability to achieve enhanced gas phase chemistry without the need for elevated gas temperatures.[1,2] This is due to the fact that plasmas possess electron energies much higher than that of the ions and the neutral species. Once the electrons are stripped from the atoms and molecules, these particles transit state and become plasma. Plasmas are very energetic as the stripping electrons utilize persistent energy. Once the energy dissipates, the electrons reattach, and the plasma particles becomes gas again. The energetic electrons enter into the collision with the background gas and cause the enhanced level of dissociation, excitation, and ionization. Because the ions and the neutrals remain comparatively cold, the plasma does not lead to any thermal damage to articles it comes in contact with. This striking property of plasma led to its use for the treatment of heat‑sensitive materials including biological matter such as cells and tissues.[3,4] HISTORY Plasma, the fourth state of matter, discovered by the British physicist Sir William Crookes in the year 1879 Access this article online Quick Response Code Website: www.urjd.org was given the name “plasma” by Irving Langmuir, an American chemist, in 1929 [Figure 1]. Plasma is a collection of stripped particles which makes up for more than 99% of the visible universe and hence is the most common form of matter. Unlike ordinary matter, plasmas can exist in a wide range of temperatures without changing state. Plasma is commonly associated with the stars and lightning while the remainder of the universe comprises of ordinary matter such as solids, liquids, and gases. Other well‑known plasmas include neon signs and fluorescent lights. The boundary between gas and plasma is often blurred. Unlike gas, magnetic, and electric fields can control plasma and shape it into useful, malleable structures.[5] Outside container plasma resembles gas as the particles do not have a definite shape. They are formed into configurations like plumes or beams. Depending on the type of the gas used and its flow rate, the plasma discharge can acquire different shapes and colors. The plasma emissions employed for dental applications resemble a narrow “glowing” blue/white mass [Figure 2]. When people hear the word “plasma,” they can only think of blood components. However, there are many other forms of plasma that have a wide range of implications. Plasmas can be either “thermal” or “non‑thermal” based on the relative temperatures of the electrons, ions, and neutrals. The electrons and the heavy particles exist in thermal equilibrium with each other in thermal plasmas. Non‑thermal plasmas/cold atmospheric Address for Correspondence: DOI: 10.4103/2249-9725.162790 Universal Research Journal of Dentistry · September-December 2015 · Vol 5 · Issue 3 Dr. Sapna Sharma, D/O, Shri Ramphal Kaushik, House Number 256, HUDA Sector 2, Rohtak ‑ 124 001, Haryana, India. E‑mail: [email protected] 145 Sharma, et al.: Plasma in periodontics Figure 2: Plasma torch Non-thermal plasma Figure 1: Four states of matter plasma/low‑temperature atmospheric pressure plasma/ non‑equilibrium plasma, on the other hand, have the ions and neutrals at a much lower temperature and electrons at relatively higher temperature. Its temperature is <40°C at the point of application.[6] Since the early 2000s, research has expanded to include work on the interaction of plasma with mammalian cells, blood coagulation, wound healing, in fighting some types of cancers by inducing apoptosis (programmed cell death), and with potential applications in dentistry by its ability to deactivate microorganisms and partly due to their easy access to narrow and confined spaces and its ability to permit surface preparation in open air at room temperature.[7] In dentistry, oral conditions could be treated and managed by numerous mechanical and chemical interventions. The procedures such as scaling and root planning, caries removal, and chemotherapeutic agent application are very common and have been used for many years and have numerous drawbacks. The emergence of the multi‑disciplinary field of plasma in dental technology has opened a new and promising approach towards dental therapeutics. This review is an update about the novel technique using plasma in the field of periodontology. 146 The electromagnetic field supplies the energy for sustaining the plasma state. Heavy ions can transfer their energies to heat their environment much faster than the highly energetic electrons. The plasma can still remain non‑thermal while the highly energetic electrons can lead to reactions such as ionization of particles, production of reactive species, and radiation.[8] These reactive oxygen and nitrogen species are the key factors for sterilization, wound healing, and tooth whitening. Out of many applications of non‑thermal plasmas in dentistry, few are biofilm elimination, treatment of peri‑implantitis, removal of dental caries, sterilization, root canal disinfection, and bleaching. In recent years, non‑thermal plasma sources have been introduced that provide the possibility to extend plasma treatment to living tissue. Various methods of non‑thermal plasma production include dielectric barrier discharge, atmospheric pressure plasma jet, plasma needle, and plasma pencil (PP). Gases that can be used to produce non‑thermal plasma are helium, argon, nitrogen, Heliox (a mix of helium and oxygen), and air. Plasmas could be produced by various means such as radio frequencies, microwave frequencies, high voltage alternating current or direct current, and many more.[7] Plasma pencil The small handheld device called the Plasma Pencil (PP) is about the size of a power toothbrush and has the capacity to kill bacteria [Figure 2]. The development of PP at the Old Dominion University is accredited to by Laroussi et al. in the late 1990s.[9‑11] It generates a non‑thermal focused plume in the form of chemically reactive, small plasma “bullets.” The PP Universal Research Journal of Dentistry · September-December 2015 · Vol 5 · Issue 3 Sharma, et al.: Plasma in periodontics plume can be directed into the microscopic crevices and around different angles, which makes this device ideal for many intra‑oral applications. Further refinement of the PP would include interchangeable tips that connect to a portable table top unit. and/or painful manner such as scaling and root planning for supra and subgingival plaque removal from the tooth. Plasma can precisely treat even difficult to reach areas (periodontal pockets), without having to open the gingival mucosa. Plasma brush A handheld plasma apparatus that can be used by dentist for multiple dental clinical applications is being developed. The apparatus applies small amounts of electricity to a nontoxic gas through a “narrow slit chamber” to generate plasma with a brush‑like shape [Figure 3]. A tiny plasma scrub brush that resembles a white‑hot flame has also been developed. However, this flame is cool to the touch. It slides over the tooth surface, killing bacteria on the dentin and enamel. Plasma in periodontics Periodontal disease is an infectious disease resulting in inflammation within the supporting tissues of the teeth, progressive attachment, and bone loss and is characterized by the pocket formation and/or recession of the gingiva. The etiology of periodontitis is multifactorial with specific bacteria residing in intraoral plaques as a necessary but not sufficient cause of the disease. Scaling and root planing, tooth brushing, fluoride uptake, antibiotics, and vaccines have been the gold standard treatment modalities for periodontal diseases, but there exist certain limitations to these procedures.[12] Heat kills bacteria, but the application of this method to living tissues is unsafe. Antibiotic resistance has been a serious issue for long‑term use of antibiotics employed for the treatment of periodontal tissues invaded by pathogens. Non‑thermal plasmas can kill bacteria efficiently in an inexpensive way; thus eliminating problems associated with the use of heat and antibiotics. Non‑thermal plasma will solve problems in dentistry, which could, so far, only be solved in a time‑consuming Action on biofilms Plaque is considered a biofilm and it is estimated that over 95% of bacteria existing in nature are in biofilms.[13] Bacterial behavior in laboratory culture differs from that in their natural ecosystems because of which systemic and locally delivered antimicrobials not always succeed, even when they were targeted at specific microorganisms.[14] It also explains the reason for mechanical plaque control and personal oral hygiene continuing to be an integral part of periodontal therapy.[15] However, since they immediately begin to reform, the search continues for ways to combat biofilms. Rupf et al. demonstrated that the combination treatment with plasma and a nonabrasive air/water spray is suitable for the elimination of oral biofilms from microstructured titanium used in dental implants.[16] Furthermore, Koban et al. showed that the treatment of dental biofilms composed of Streptococcus mutans with non‑thermal plasma was more efficient than the treatment with chlorhexidine in vitro.[17] Jiang et al. developed a plasma plume at room temperature. Two teeth were placed at a distance of 5 mm from the plasma nozzle. One of them was exposed to the helium/ oxygen plasma for 5 min, whereas the other one was exposed to the same helium/oxygen flow for 5 min, but without plasma. They observed better results in the reduction of the biofilms in the tooth treated with plasma compared with control. Nevertheless, the plasma failed to reach the lower zone of the tooth as the plasma plume did not have the optimal width and length to treat effectively the lower zone.[18] Schaudinn et al. used a plasma needle to eliminate ex vivo biofilms on root canals of extracted teeth.[19] Teeth were divided into three groups: Treatment with the plasma needle, treatment with 6% sodium hypochlorite (an antiseptic), and control. It was concluded that the plasma needle was effective at killing biofilms in extracted teeth. However, using 6% sodium hypochlorite was more efficient. Figure 3: Plasma brush Germicidal property Plasma has the ability to inactivate or kill bacteria, viruses, and fungi without adversely affecting the Universal Research Journal of Dentistry · September-December 2015 · Vol 5 · Issue 3 147 Sharma, et al.: Plasma in periodontics surrounding healthy cells. This property of plasma is due to the abundant production of reactive species in low gas temperature, which includes charged particles, radiation, and reactive oxygen species like hydrogen peroxide. As a result, bacteria have been found unable to cope with the hostile environment created by plasma, and, therefore, die very rapidly.[20‑24] The germicidal action of a plasma depends on power, type and composition of gases, flow rate, exposure time, configuration of plasma, as well as the type and concentration of the cell.[23] It is hypothesized that non‑thermal plasma exposure disturbs or destroys the bacterial cell wall and damages the DNA, thus inactivating the microorganism.[22,23,25,26] Action on Porphyromonas gingivalis Porphyromonas gingivalis is the key pathogen strongly associated with periodontal disease. Research has shown that the exposure to the plasma can inactivate P. gingivalis. Mahasneh et al. found a statistically significant difference in bacterial zones of inhibition after 5‑, 7‑, 9‑, and 11‑min intervals of non‑thermal plasma exposure compared to the unexposed bacteria (P < 0.0001), thus supporting the dose‑response germicidal characteristic of plasma.[27] Intraoral diseases A study by Koban et al. and Yamazaki et al. reported the high efficiency of non‑thermal plasmas in Candida albicans sterilization indicating that stomatitis caused by Candida albicans could be cured by plasma jets.[28,29] Disinfection of dental surfaces In a report by Rupf et al. who used atmospheric plasma jets in dental caries causing organisms, it was found that the plasma jet treatment reduced the colony forming unit by 3–4 log10 intervals on the dentin slices in comparison to the recovery rates of untreated controls. Thus, it could be concluded that non‑thermal atmospheric plasma jets could be used for the disinfection of dental surfaces.[30] Action on implant surface/surface biomodification Plasmas has the potential to alter implant surfaces by enhancing adhesion and increasing surface bonding, as well as inhibiting bacterial adhesion, and boosting the host to implant response. Plasma has the ability to increase the wettability of titanium implants as well as teeth, meaning that osteoblasts cells can spread better and thus aid in implant healing with enhanced osseointegration as well as periodontitis treatment [Figure 4].[31,32] The plasma regimes may enhance periodontal regeneration and implant success by improving cell surface interaction 148 Figure 4: Spreading of ibroblasts on implant surface and directly affecting the migration and proliferation of osteoblasts. Plasma surface engineering may provide an antibacterial coating to minimize both microbial adhesion and colonization for most of the metal and nonmetal dental materials, particularly titanium.[31,33] The only problem with these devices is device related infections, which arise when bacteria attach to and proliferate on the surface.[34] Non‑thermal plasmas also improve oral care by reducing microbial adhesion and proliferation of implants, dentures, orthodontic appliances, and mouth guards too. Wound healing As non‑thermal plasma poses no cytotoxicity, it can indeed help or accelerate the healing of wounds after periodontal therapy. By using 3‑(4,5‑dimethylthiazol‑2‑Yl)‑2,5‑diphenyltetrazolium bromide assays (measuring mitochondrial activity), Stoffels showed that the proliferation of fibroblasts does occur when exposed to low‑power density plasma.[35] Shekhter et al.,[24,36,37] claimed that fibroblast proliferation is induced by the exogenic nitric oxide (NO) generated by the plasma. NO is also known to help in the regulation of immune deficiencies, induction of phagocytosis, proliferation of keratinocytes, regulation of collagen synthesis, etc.,[24] all of these being processes that play important roles in wound healing. In addition, plasma plays a very important role in decreasing wound infection by inactivating a vast number of bacteria inhabiting the wound. Stolz et al.[38] showed that non‑thermal argon plasma treatment of chronic wounds was well‑tolerated by patients, without side effects. However, the only challenge to overcome is the uneven surfaces of the wounds, which might limit the success of the procedures. Universal Research Journal of Dentistry · September-December 2015 · Vol 5 · Issue 3 Sharma, et al.: Plasma in periodontics Blood coagulation Fridman’s group at Drexel University demonstrated that non‑thermal plasma could also quickly stop bleeding by triggering platelet activation, the formation of fibrin mesh, and platelet aggregation [Figure 5].[24,39] They also claimed that the mechanism of blood coagulation by non‑thermal plasma does not involve the release of calcium ions or induce a substantial change in the pH level of blood, factors previously thought to initiate coagulation. Instead, they proposed that non‑thermal plasma has highly selective effects on blood proteins. As evidence, they found that plasma helps the conversion of fibrinogen into fibrin without affecting albumin.[24,39] Hence, it would be very useful tool to control bleeding, which is inevitable during periodontal procedures. Advantages • It kills only the pathogens in the bacterial plaque on oral tissues without any damage to the normal tissue • Plasma is painless as it does not induce thermal damage • It may exhibit therapeutic properties that can boost wound healing and enhance tissue regeneration • According to Sladek, R.E.J et al., non‑thermal plasma is capable of bacterial decontamination and does not cause bulk destruction of the tissue.[40] Limitations As we all know that every technology has its own advantages and limitations. Non‑thermal plasma also has some limitations as this is a new technology: • Safety of the equipment has to be taken care of[41,42] • Instrument portability[43] • Cost of the equipment and its maintenance are also some of the issues at present.[5] Now‑a‑days, research on the effect of non‑thermal plasma on tumor cells is being done with some promising results, but its effect on normal cells has to be studied in depth and validation needed for its successful application.[44‑46] This is just a beginning and more research is required for this novel technology to be used in a cost‑effective, efficient, and predictable manner in clinical settings. CONCLUSION Since, oral diseases are not caused by a single pathogen; research must be conducted as to whether non‑thermal plasmas can also kill various other oral pathogens at the same time. Plasma is effective in wet and dry environments, which offers an advantage in the presence of saliva, blood, and gingival crevicular fluids. 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J Indian Acad Oral Med Radiol 2011;23:120‑3. How to cite this article: Sharma S, Khanna R, Garg R, Rana M. Plasma in Periodontics: Will the dream come true. Univ Res J Dent 2015;5:145-50. Source of Support: Nil, Conlict of Interest: None declared Universal Research Journal of Dentistry · September-December 2015 · Vol 5 · Issue 3