Keywords
chronic periodontitis
antimicrobial photodynamic therapy
indocyanine green
photosensitizer
laser
scaling and root planing
antimicrobial photodynamic therapy
indocyanine green
photosensitizer
laser
scaling and root planing
How to Cite
SFEIR, A., & NOHRA, J. (2021). Antimicrobial photodynamic therapy using Indocyanine green for the treatment of chronic periodontitis: A randomized controlled trial. International Arab Journal of Dentistry (IAJD), 12(1), 11-24. https://doi.org/10.70174/iajd.v12i1.572
Abstract
This study evaluates the clinical effect of indocyanine green (ICG) in antimicrobial photodynamic therapy (aPDT) in a single application as an adjuvant to scaling and root planning (D/S).
15 patients, non-smokers, with chronic periodontitis, in the periodontal maintenance phase, presenting at least 2 sites in 2 different quadrants with a pocket depth ≥ 5 mm, were included in a randomized, controlled, double blind, clinical trial, split mouth design. The sites were randomized by an operator as follows: (A) D / S + sterile water + inactivated laser (control site); (B) D / S + ICG activated by a diode laser with a wavelength of 810 nm (test site). The primary parameters are: the relative clinical attachment level (RCAL) and the pocket depth (PD). The secondary parameters are: position of gingival margin (PGM), variation of recession (varREC), full mouth plaque score (FMPS), bleeding on probing (BOP) and visual analogue scale (EVA).
The assessment at baseline (T0) and the reassessment at 3 months (T1) and 6 months (T2) were performed by a second operator.
RCAL and PD were significantly decreased in both groups at T1 without significant difference between the 2 groups. They significantly decreased in the test group at T2, with no significant decrease in the control group. But the difference at T2 was significant in favor of the test group.
The aPDT using ICG, in a single application, as an adjunct to conventional treatment during the periodontal maintenance phase, shows an improvement in the clinical results in the sample studied compared with the control group, in the context of non-invasive treatments for chronic periodontitis, in non-smoking patients, in the medium term (6 months).
References
1. Consensus Report: Chronic Periodontitis. 1999 International Workshop for a Classification of Periodontal Diseases and Conditions. Ann Periodontol 1999; 4:38.
2. Panos P, Mariano S, Nurcan B. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1): S173–S182.
3. Cobb CM. Non-surgical pocket therapy: mechanical. Ann Periodontol. 1996 Nov;1(1):443-90.
4. Greenstein G. Nonsurgical periodontal therapy in 2000: a literature review. J Am Dent Assoc. 2000 Nov;131(11):1580-92.
5. Rabbani GM, Ash MM Jr, Caffesse RG. The effectiveness of subgingival scaling and root planing in calculus removal. J Periodontol. 1981 Mar;52(3):119-23.
6. Bower RC. Furcation morphology relative to periodontal treatment. Furcation root surface anatomy. J Periodontol. 1979 Jul;50(7):366-74.
7. Brayer WK, Mellonig JT, Dunlap RM, Marinak KW, Carson RE. Scaling and root planning effectiveness: the effect of root surface access and operator experience. J Periodontol. 1989 Jan;60(1):67-72.
8. Sgolastra F, Petrucci A, Gatto R, Monaco A. Effectiveness of systemic amoxicillin/ metronidazole as an adjunctive therapy to full-mouth scaling and root planning in the treatment of aggressive periodontitis: a systematic review and meta-analysis. J Periodontol. 2012 Jun ;83(6) :731-43.
9. Matesanz-Pérez P, García-Gargallo M, Figuero E, Bascones-Martínez A, Sanz M, Herrera D. A systematic review on the effects of local antimicrobials as adjuncts to subgingival debridement, compared to subgingival debridement alone, in the treatment of chronic periodontitis. J Clin Periodontol. 2013 Mar;40(3):227-41.
10. Kloostra PW, Eber RM, Wang HL, Inglehart MR. Surgical Versus Non-Surgical Periodontal Treatment: Psychosocial Factors and Treatment Outcomes. J Periodontol. 2006 Jul;77(7):1253-60.
11. Slots J, Rams TE. Antibiotics in periodontal therapy: advantages and disadvantages. J Clin Periodontol. 1990 Aug;17(7 (Pt 2)):479-93.
12. Feres M, Haffajee AD, Allard K, Som S, Goodson JM, Socransky SS. Antibiotic resistance of subgingival species during and after antibiotic therapy. J Clin Periodontol. 2002 Aug;29(8):724-35.
13. Tianhong D, Ying-Ying H, Michael R H. Photodynamic therapy for localized infections – state of the art. Photodiagnosis Photodyn Ther. 2009 Sep-Dec;6(3-4): 170–188.
14. Ando Y, Aoki A, Wantanbe H, Ishikawa I. Bactericidal effect of Erbium YAG laser on periodontopathic bacteria. Lasers Surg Med. 1996;19(2):190-200.
15. Yamaguchi H, Kobayashi K, Osada R et coll. Effects of irradiation of an erbium: YAG laser on root surfaces. J Periodontol. 1997 Dec;68(12):1151-5.
16. Schwarz F, Sculean A, Berakdar M, Georg T, Reich E, Becker J. Clinical evaluation of an Er:YAG laser combined with scaling and root planing for non-surgical periodontal treatment. A controlled, prospective clinical study. J Clin Periodontol. 2003 Jan;30(1):26-34.
17. Konopka K, Goslinski T. Photodynamic therapy in dentistry. J Dent Res. 2007 Aug;86(8):694-707.
18. Srikanth K, Chandra RV, Reddy AA, Reddy BH, Reddy C, Naveen A. Effect of a single session of antimicrobial photodynamic therapy using indocyanine green in the treatment of chronic periodontitis: a randomized controlled pilot trial. Quintessence Int. 2015 May;46(5):391-400.
19. Dougherty TJ, Gomer CJ, Henderson BW et coll. Photodynamic therapy. J Natl Cancer Inst. 1998 Jun 17;90(12):889-905.
20. Sharman WM, Allen CM, van Lier JE. Photodynamic therapeutics: basic principles and clinical applications. Drug Discov Today. 1999 Nov ;4(11) :507-517.
21. Heitz-Mayfield LJ, Lang NP. Surgical and nonsurgical periodontal therapy. Learned and unlearned concepts. Periodontol 2000. 2013 Jun;62(1):218-31.
22. Sgolastra F, Petrucci A, Severino M, Graziani F, Gatto R, Monaco A. Adjunctive photodynamic therapy to non-surgical treatment of chronic periodontitis: a systematic review and meta-analysis. J Clin Periodontol. 2013 May;40(5):514-26.
23. Azarpazhooh A, Shah PS, Tenenbaum HC, Goldberg MB. The effect of photodynamic therapy for periodontitis: a systematic review and meta-analysis. J Periodontol. 2010 Jan;81(1):4-14.
24. Haas R, Baron M, Dörtbudak O, Watzek G. Lethal photosensitization, autogenous bone, and e-PTFE membrane for the treatment of peri-implantitis: preliminary results. Int J Oral Maxillofac Implants. 2000 May-Jun;15(3):374-82.
25. Garcez AS, Ribeiro MS, Tegos GP, Núñez SC, Jorge AO, Hamblin MR. Antimicrobial photodynamic therapy combined with conventional endodontic treatment to eliminate root canal biofilm infection. Lasers Surg Med. 2007 Jan;39(1):59-66.
26. Boehm TK, Ciancio SG. Diode laser activated indocyanine green selectively kills bacteria. J Int Acad Periodontol. 2011 Jul;13(2):58-63.
27. Parker S. The use of diffuse laser photonic energy and indocyanine green photosensitizer as an adjunct to periodontal therapy. Br Dent J. 2013 Aug;215(4):167-71.
28. Benson RC, Kues HA. Fluorescence properties of indocyanine green as related to angiography. Phys Med Biol. 1978 Jan;23(1):159-63.
29. Kogure K, David NJ, Yamanouchi U, Choromokos E. Infrared absorption angiography of the fundus circulation. Arch Ophthalmol. 1970 Feb;83(2):209-14.
30. Flower RW, Hochheimer BF. A clinical technique and apparatus for simultaneous angiography of the separate retinal and choroidal circulations. Invest Ophthalmol. 1973 Apr;12(4):248-61.
31. Genina EA, Bashkatov AN, Simonenko GV, Odoevskaya OD, Tuchin VV, Altshuler GB. Low-intensity indocyanine-green laser phototherapy of acne vulgaris: pilot study. J Biomed Opt. 2004 Jul-Aug;9(4):828-34.
32. Ge L, Shu R, Li Y et coll. Adjunctive effect of photodynamic therapy to scaling and root planing in the treatment of chronic periodontitis. Photomed Laser Surg. 2011 Jan;29(1):33-7.
33. Theodoro LH, Silva SP, Pires JR et coll. Clinical and microbiological effects of photodynamic therapy associated with nonsurgical periodontal treatment. A 6- month follow-up. Lasers Med Sci. 2012 Jul;27(4):687-93.
34. Luchesi VH, Pimentel SP, Kolbe MF et coll. Photodynamic therapy in the treatment of class II furcation: a randomized controlled clinical trial. J Clin Periodontol. 2013 Aug;40(8):781-8.
35. Chondros P, Nikolidakis D, Christodoulides N, Rössler R, Gutknecht N, Sculean A. Photodynamic therapy as adjunct to non-surgical periodontal treatment in patients on periodontal maintenance: a randomized controlled clinical trial. Lasers Med Sci. 2009 Sep;24(5):681-8.
36. Campos GN, Pimentel SP, Ribeiro FV et coll. The adjunctive effect of photodynamic therapy for residual pockets in single-rooted teeth: a randomized controlled clinical trial. Lasers Med Sci. 2013 Jan;28(1):317-24.
37. Rühling A, Fanghänel J, Houshmand M et coll. Photodynamic therapy of persistent pockets in maintenance patients — a clinical study. Clin Oral Investig. 2010 Dec;14(6):637-44.
38. Cappuyns I, Cionca N, Wick P, Giannopoulou C, Mombelli A. Treatment of residual pockets with photodynamic therapy, diode laser, or deep scaling. A randomized, split-mouth controlled clinical trial. Lasers Med Sci. 2012 Sep;27(5):979-86.
39. Andersen R, Loebel N, Hammond D, Wilson M. Treatment of periodontal disease by photodisinfection compared to scaling and root planing. J Clin Dent. 2007;18(2):34-8.
40. Lulic M, Leiggener Görög I, Salvi GE, Ramseier CA, Mattheos N, Lang NP. One-year outcomes of repeated adjunctive photodynamic therapy during periodontal maintenance: a proof-of-principle randomized-controlled clinical trial. J Clin Periodontol. 2009 Aug;36(8):661-6.
41. Braun A, Dehn C, Krause F, Jepsen S. Short-term clinical effects of adjunctive antimicrobial photodynamic therapy in periodontal treatment: a randomized clinical trial. J Clin Periodontol. 2008 Oct;35(10):877-84.
42. Berakdar M, Callaway A, Eddin MF, Ross A, Willershausen B. Comparison between scaling-root-planing (SRP) and SRP/ photodynamic therapy: six-month study. Head Face Med. 2012 Apr 5; 8:12.
43. Al-Zahrani M, Austah ON. Photodynamic therapy as an adjunctive to scaling and root planing in treatment of chronic periodontitis in smokers. Saudi Med J. 2011 Nov;32(11):1183-8.
44. Kömerik N, Nakanishi H, MacRobert AJ, Henderson B, Speight P, Wilson M. In vivo killing of Porphyromonas gingivalis by Toluidine Blue-Mediated Photosensitization in an Animal Model. Antimicrob Agents Chemother. 2003 Mar; 47(3): 932–940.
45. 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. J Periodontol. 2007 Jun;78(6):965-73.
46. Van der Weijden GA, Timmerman MF. A systematic review on the clinical efficacy of subgingival debridement in the treatment of chronic periodontitis. J Clin Periodontol. 2002;29 Suppl 3:55-71.
47. Kolbe MF, Ribeiro FV, Luchesi VH, Casarin RC et coll. Photodynamic therapy during supportive periodontal care: clinical, microbiologic, immunoinflammatory, and patient-centered performance in a split-mouth randomized clinical trial. J Periodontol. 2014 Aug;85(8): e277-86.
48. Christodoulides N, Nikolidakis D, Chondros P et coll. Photodynamic therapy as an adjunct to non-surgical periodontal treatment : a randomized, controlled clinical trial. J Periodontol. 2008 Sep;79(9):1638-44.
49. Pihlstrom BL, Oliphant TH, McHugh RB. Molar and nonmolar teeth compared over 6 1/2 years following two methods of periodontal therapy. J Periodontol. 1984 Sep;55(9):499-504.
50. Del Peloso Ribeiro E, Bittencourt S, Nociti FH Jr, Sallum EA, Sallum AW, Casati MZ. Comparative study of ultrasonic instrumentation for the non-surgical treatment of interproximal and non-interproximal furcation involvements. J Periodontol. 2007 Feb;78(2):224-30.
51. Rieder C, Joss A, Lang NP. Influence of compliance and smoking habits on the outcomes of supportive periodontal therapy (SPT) in a private practice. Oral Health Prev Dent. 2004;2(2):89-94.
52. Tomasi C, Koutouzis T, Wennström JL. Locally delivered doxycycline as an adjunct to mechanical debridement at retreatment of periodontal pockets. J Periodontol. 2008 Mar;79(3):431-9.
53. Bonito AJ, Lux L, Lohr KN. Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review. J Periodontol. 2005 Aug;76(8):1227-36.
54. Paolantonio M, Dolci M, Perfetti G et coll. Effect of a subgingival chlorhexidine chip on the clinical parameters and the levels of alkaline phosphatase activity in gingival crevicular fluid during the non-surgical treatment of periodontitis. J Biol Regul Homeost Agents. 2008 Jan-Mar;22(1):63-72.
55. Lang NP, Adler R, Joss A, Nyman S. Absence of bleeding on probing. An indicator of periodontal stability. J Clin Periodontol. 1990 Nov;17(10):714-21.
56. Lang NP, Nyman S, Senn C, Joss A. Bleeding on probing as it relates to probing pressure and gingival health. J Clin Periodontol. 1991 Apr;18(4):257-61.
57. Williams JM, Murray JJ, Lund CA, Harkiss B, de Franco A. Anxiety in the child dental clinic. J Child Psychol Psychiatry. 1985 Mar;26(2):305-10.
58. Ishikawa I, Aoki A, Takasaki AA, Mizutani K, Sasaki KM, Izumi Y. Application of lasers in periodontics: True innovation or myth? Periodontol 2000. 2009; 50:90-126.
2. Panos P, Mariano S, Nurcan B. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1): S173–S182.
3. Cobb CM. Non-surgical pocket therapy: mechanical. Ann Periodontol. 1996 Nov;1(1):443-90.
4. Greenstein G. Nonsurgical periodontal therapy in 2000: a literature review. J Am Dent Assoc. 2000 Nov;131(11):1580-92.
5. Rabbani GM, Ash MM Jr, Caffesse RG. The effectiveness of subgingival scaling and root planing in calculus removal. J Periodontol. 1981 Mar;52(3):119-23.
6. Bower RC. Furcation morphology relative to periodontal treatment. Furcation root surface anatomy. J Periodontol. 1979 Jul;50(7):366-74.
7. Brayer WK, Mellonig JT, Dunlap RM, Marinak KW, Carson RE. Scaling and root planning effectiveness: the effect of root surface access and operator experience. J Periodontol. 1989 Jan;60(1):67-72.
8. Sgolastra F, Petrucci A, Gatto R, Monaco A. Effectiveness of systemic amoxicillin/ metronidazole as an adjunctive therapy to full-mouth scaling and root planning in the treatment of aggressive periodontitis: a systematic review and meta-analysis. J Periodontol. 2012 Jun ;83(6) :731-43.
9. Matesanz-Pérez P, García-Gargallo M, Figuero E, Bascones-Martínez A, Sanz M, Herrera D. A systematic review on the effects of local antimicrobials as adjuncts to subgingival debridement, compared to subgingival debridement alone, in the treatment of chronic periodontitis. J Clin Periodontol. 2013 Mar;40(3):227-41.
10. Kloostra PW, Eber RM, Wang HL, Inglehart MR. Surgical Versus Non-Surgical Periodontal Treatment: Psychosocial Factors and Treatment Outcomes. J Periodontol. 2006 Jul;77(7):1253-60.
11. Slots J, Rams TE. Antibiotics in periodontal therapy: advantages and disadvantages. J Clin Periodontol. 1990 Aug;17(7 (Pt 2)):479-93.
12. Feres M, Haffajee AD, Allard K, Som S, Goodson JM, Socransky SS. Antibiotic resistance of subgingival species during and after antibiotic therapy. J Clin Periodontol. 2002 Aug;29(8):724-35.
13. Tianhong D, Ying-Ying H, Michael R H. Photodynamic therapy for localized infections – state of the art. Photodiagnosis Photodyn Ther. 2009 Sep-Dec;6(3-4): 170–188.
14. Ando Y, Aoki A, Wantanbe H, Ishikawa I. Bactericidal effect of Erbium YAG laser on periodontopathic bacteria. Lasers Surg Med. 1996;19(2):190-200.
15. Yamaguchi H, Kobayashi K, Osada R et coll. Effects of irradiation of an erbium: YAG laser on root surfaces. J Periodontol. 1997 Dec;68(12):1151-5.
16. Schwarz F, Sculean A, Berakdar M, Georg T, Reich E, Becker J. Clinical evaluation of an Er:YAG laser combined with scaling and root planing for non-surgical periodontal treatment. A controlled, prospective clinical study. J Clin Periodontol. 2003 Jan;30(1):26-34.
17. Konopka K, Goslinski T. Photodynamic therapy in dentistry. J Dent Res. 2007 Aug;86(8):694-707.
18. Srikanth K, Chandra RV, Reddy AA, Reddy BH, Reddy C, Naveen A. Effect of a single session of antimicrobial photodynamic therapy using indocyanine green in the treatment of chronic periodontitis: a randomized controlled pilot trial. Quintessence Int. 2015 May;46(5):391-400.
19. Dougherty TJ, Gomer CJ, Henderson BW et coll. Photodynamic therapy. J Natl Cancer Inst. 1998 Jun 17;90(12):889-905.
20. Sharman WM, Allen CM, van Lier JE. Photodynamic therapeutics: basic principles and clinical applications. Drug Discov Today. 1999 Nov ;4(11) :507-517.
21. Heitz-Mayfield LJ, Lang NP. Surgical and nonsurgical periodontal therapy. Learned and unlearned concepts. Periodontol 2000. 2013 Jun;62(1):218-31.
22. Sgolastra F, Petrucci A, Severino M, Graziani F, Gatto R, Monaco A. Adjunctive photodynamic therapy to non-surgical treatment of chronic periodontitis: a systematic review and meta-analysis. J Clin Periodontol. 2013 May;40(5):514-26.
23. Azarpazhooh A, Shah PS, Tenenbaum HC, Goldberg MB. The effect of photodynamic therapy for periodontitis: a systematic review and meta-analysis. J Periodontol. 2010 Jan;81(1):4-14.
24. Haas R, Baron M, Dörtbudak O, Watzek G. Lethal photosensitization, autogenous bone, and e-PTFE membrane for the treatment of peri-implantitis: preliminary results. Int J Oral Maxillofac Implants. 2000 May-Jun;15(3):374-82.
25. Garcez AS, Ribeiro MS, Tegos GP, Núñez SC, Jorge AO, Hamblin MR. Antimicrobial photodynamic therapy combined with conventional endodontic treatment to eliminate root canal biofilm infection. Lasers Surg Med. 2007 Jan;39(1):59-66.
26. Boehm TK, Ciancio SG. Diode laser activated indocyanine green selectively kills bacteria. J Int Acad Periodontol. 2011 Jul;13(2):58-63.
27. Parker S. The use of diffuse laser photonic energy and indocyanine green photosensitizer as an adjunct to periodontal therapy. Br Dent J. 2013 Aug;215(4):167-71.
28. Benson RC, Kues HA. Fluorescence properties of indocyanine green as related to angiography. Phys Med Biol. 1978 Jan;23(1):159-63.
29. Kogure K, David NJ, Yamanouchi U, Choromokos E. Infrared absorption angiography of the fundus circulation. Arch Ophthalmol. 1970 Feb;83(2):209-14.
30. Flower RW, Hochheimer BF. A clinical technique and apparatus for simultaneous angiography of the separate retinal and choroidal circulations. Invest Ophthalmol. 1973 Apr;12(4):248-61.
31. Genina EA, Bashkatov AN, Simonenko GV, Odoevskaya OD, Tuchin VV, Altshuler GB. Low-intensity indocyanine-green laser phototherapy of acne vulgaris: pilot study. J Biomed Opt. 2004 Jul-Aug;9(4):828-34.
32. Ge L, Shu R, Li Y et coll. Adjunctive effect of photodynamic therapy to scaling and root planing in the treatment of chronic periodontitis. Photomed Laser Surg. 2011 Jan;29(1):33-7.
33. Theodoro LH, Silva SP, Pires JR et coll. Clinical and microbiological effects of photodynamic therapy associated with nonsurgical periodontal treatment. A 6- month follow-up. Lasers Med Sci. 2012 Jul;27(4):687-93.
34. Luchesi VH, Pimentel SP, Kolbe MF et coll. Photodynamic therapy in the treatment of class II furcation: a randomized controlled clinical trial. J Clin Periodontol. 2013 Aug;40(8):781-8.
35. Chondros P, Nikolidakis D, Christodoulides N, Rössler R, Gutknecht N, Sculean A. Photodynamic therapy as adjunct to non-surgical periodontal treatment in patients on periodontal maintenance: a randomized controlled clinical trial. Lasers Med Sci. 2009 Sep;24(5):681-8.
36. Campos GN, Pimentel SP, Ribeiro FV et coll. The adjunctive effect of photodynamic therapy for residual pockets in single-rooted teeth: a randomized controlled clinical trial. Lasers Med Sci. 2013 Jan;28(1):317-24.
37. Rühling A, Fanghänel J, Houshmand M et coll. Photodynamic therapy of persistent pockets in maintenance patients — a clinical study. Clin Oral Investig. 2010 Dec;14(6):637-44.
38. Cappuyns I, Cionca N, Wick P, Giannopoulou C, Mombelli A. Treatment of residual pockets with photodynamic therapy, diode laser, or deep scaling. A randomized, split-mouth controlled clinical trial. Lasers Med Sci. 2012 Sep;27(5):979-86.
39. Andersen R, Loebel N, Hammond D, Wilson M. Treatment of periodontal disease by photodisinfection compared to scaling and root planing. J Clin Dent. 2007;18(2):34-8.
40. Lulic M, Leiggener Görög I, Salvi GE, Ramseier CA, Mattheos N, Lang NP. One-year outcomes of repeated adjunctive photodynamic therapy during periodontal maintenance: a proof-of-principle randomized-controlled clinical trial. J Clin Periodontol. 2009 Aug;36(8):661-6.
41. Braun A, Dehn C, Krause F, Jepsen S. Short-term clinical effects of adjunctive antimicrobial photodynamic therapy in periodontal treatment: a randomized clinical trial. J Clin Periodontol. 2008 Oct;35(10):877-84.
42. Berakdar M, Callaway A, Eddin MF, Ross A, Willershausen B. Comparison between scaling-root-planing (SRP) and SRP/ photodynamic therapy: six-month study. Head Face Med. 2012 Apr 5; 8:12.
43. Al-Zahrani M, Austah ON. Photodynamic therapy as an adjunctive to scaling and root planing in treatment of chronic periodontitis in smokers. Saudi Med J. 2011 Nov;32(11):1183-8.
44. Kömerik N, Nakanishi H, MacRobert AJ, Henderson B, Speight P, Wilson M. In vivo killing of Porphyromonas gingivalis by Toluidine Blue-Mediated Photosensitization in an Animal Model. Antimicrob Agents Chemother. 2003 Mar; 47(3): 932–940.
45. 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. J Periodontol. 2007 Jun;78(6):965-73.
46. Van der Weijden GA, Timmerman MF. A systematic review on the clinical efficacy of subgingival debridement in the treatment of chronic periodontitis. J Clin Periodontol. 2002;29 Suppl 3:55-71.
47. Kolbe MF, Ribeiro FV, Luchesi VH, Casarin RC et coll. Photodynamic therapy during supportive periodontal care: clinical, microbiologic, immunoinflammatory, and patient-centered performance in a split-mouth randomized clinical trial. J Periodontol. 2014 Aug;85(8): e277-86.
48. Christodoulides N, Nikolidakis D, Chondros P et coll. Photodynamic therapy as an adjunct to non-surgical periodontal treatment : a randomized, controlled clinical trial. J Periodontol. 2008 Sep;79(9):1638-44.
49. Pihlstrom BL, Oliphant TH, McHugh RB. Molar and nonmolar teeth compared over 6 1/2 years following two methods of periodontal therapy. J Periodontol. 1984 Sep;55(9):499-504.
50. Del Peloso Ribeiro E, Bittencourt S, Nociti FH Jr, Sallum EA, Sallum AW, Casati MZ. Comparative study of ultrasonic instrumentation for the non-surgical treatment of interproximal and non-interproximal furcation involvements. J Periodontol. 2007 Feb;78(2):224-30.
51. Rieder C, Joss A, Lang NP. Influence of compliance and smoking habits on the outcomes of supportive periodontal therapy (SPT) in a private practice. Oral Health Prev Dent. 2004;2(2):89-94.
52. Tomasi C, Koutouzis T, Wennström JL. Locally delivered doxycycline as an adjunct to mechanical debridement at retreatment of periodontal pockets. J Periodontol. 2008 Mar;79(3):431-9.
53. Bonito AJ, Lux L, Lohr KN. Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review. J Periodontol. 2005 Aug;76(8):1227-36.
54. Paolantonio M, Dolci M, Perfetti G et coll. Effect of a subgingival chlorhexidine chip on the clinical parameters and the levels of alkaline phosphatase activity in gingival crevicular fluid during the non-surgical treatment of periodontitis. J Biol Regul Homeost Agents. 2008 Jan-Mar;22(1):63-72.
55. Lang NP, Adler R, Joss A, Nyman S. Absence of bleeding on probing. An indicator of periodontal stability. J Clin Periodontol. 1990 Nov;17(10):714-21.
56. Lang NP, Nyman S, Senn C, Joss A. Bleeding on probing as it relates to probing pressure and gingival health. J Clin Periodontol. 1991 Apr;18(4):257-61.
57. Williams JM, Murray JJ, Lund CA, Harkiss B, de Franco A. Anxiety in the child dental clinic. J Child Psychol Psychiatry. 1985 Mar;26(2):305-10.
58. Ishikawa I, Aoki A, Takasaki AA, Mizutani K, Sasaki KM, Izumi Y. Application of lasers in periodontics: True innovation or myth? Periodontol 2000. 2009; 50:90-126.