R, Shashank, Kaushal S, Pahuja RK. J Periodontal Med Clin ...jpmcp.com/NEW PDF 2017/87-100.pdf · Sagar S, Uppal R, Shashank, Kaushal S, Pahuja RK.Plasma – A Pirouette in Dentistry

Sagar S, UppalR, Shashank, KaushalS, PahujaRK. Plasma – A Pirouette in Dentistry. J Periodontal Med Clin Pract 2016;03: 87-100

1 2 3 4 5Dr. Sukh Sagar , Dr. Ruchit Uppal , Dr. Shashank , Dr. Sumit Kaushal , Dr. Rasleen Kaur Pahuja

Plasma – A Pirouette In Dentistry

Review Article

Affiliation

1. Senior Lecturer, Department of Prosthodontics, National Dental College and Hospital, Gulabgarh,

DeraBassi, Punjab, India.

2. Professor, Department of Oral and Maxillofacial Surgery, BRS Dental College and Hospital, Panchkula,

Haryana, India.

3. Senior Lecturer, Department of Oral and Maxillofacial Surgery, Darshan Dental College and Hospital,

Loyara, Udaipur, Rajasthan, India.

4. Reader, Department of Periodontics, National Dental College and Hospital, Gulabgarh, DeraBassi,

Punjab, India.

5. Senior Lecturer, Department of Prosthodontics, Sri Sukhmani Dental College and Hospital, DeraBassi,

Punjab, India.

Corresponding author:

Dr. Sukh Sagar

Senior Lecturer, Department of Prosthodontics,

National Dental College and Hospital, Gulabgarh, DeraBassi, Punjab, India.

Conflict of Interest – Nil

Abstract

Matter usually includes liquids, solids, and gases.

But a fourth category of matter has been discovered

called plasma that's actually the most unusual and

the most abundant. It is a new and painless way to

prepare cavities for restoration with improved

longevity. Also, it is capable of bacterial

inactivation and non-inflammatory tissue

modification, which makes it an attractive tool for

the treatment of dental caries and for composite

restorations. This review article on plasma in

dentistry is intended to provide with a summary of

the current status of this emerging field, its scope,

and its broad interdisciplinary approach. The main

aim of this short narrative review is to 1) create

awareness about what is PRP, 2) its methods of

preparation, 3) various clinical applications and its

Vol-III, Issue - II, May-Aug 2016

87

promising results.

Introduction

Plasma is the fourth state of matter. Over 99% of 1

the visible universe is made up of plasma. It can be

defined as “Volume of autologous plasma that has 2

the platelet concentration above the baseline” , or

as “a high concentration of autologous platelets in 3, 4

a small volume of autologous plasma” . It was

identified by the British physicist Sir William 1

Crookes in 1879 . In 1927, Irving Langmuir first

described it as an ionized gas containing free

moving charge carriers (electrons and ions). The

plasma needle was tested first in 2002 by Dr. I.R.

Eva Stoffels Adamowicz at the Eindhoven 5

University of Technology. When the electrons are

stripped from atoms and molecules, they enter into

a high energetic state called plasma.Plasma is a

collection of stripped particles. When electrons

are stripped from atoms and molecules, those 1

particles change state and become plasma.

Plasmas are naturally energetic because stripping

electrons takes constant energy. If the energy

dissipates, the electrons reattach and the plasma 6

particles become a gas once again.

Platelet rich plasma

Unlike ordinary matter, plasmas can exist in a

wide range of temperatures without changing

state. Other well-known plasmas include

lightning, neon signs, and fluorescent lights.

Outside of a container, plasma resembles gas. The

particles don't have a definite shape. But unlike

gas, magnetic and electric fields can control

plasma and shape it into useful, malleable 7

structures .There are two types of plasma: thermal

and non-thermal or cold atmospheric plasma.

Thermal plasma has electrons and heavy particles

(neutral and ions) at the same temperature. Cold

Atmospheric Plasma is said to be non-thermal

because it has electron at a hotter temperature than

the heavy particles that are at room temperature.

CAP is a specific type of plasma that is less than 8

104°F at the point of application. Platelet rich

plasma is a breakthrough in stimulation and

acceleration in bone and soft tissue healing. It

represents a relatively new biotechnology that is a

part of growing interest in tissue engineering and 9

cellular therapy . It is a novel method of

concentrating platelets from autologous blood so

that high concentration of growth factors can be

delivered to the site of the defect. As the blood is

centrifuged, it is separated into three basic

components. The least dense is platelet poor

plasma. The most dense is platelet rich plasma, 10

also called as “buffy coat”. Various studies have

examined the effects of systemic hormones and

growth factors on bone and soft tissue 11-16

metabolism. In particular, growth factors

regulate cellular events in wound healing, such as

proliferation, differentiation, chemotaxis and 11,16

morphogenesis of tissues and organs.

Periodontal and oral surgical techniques may

involve use of these factors in both soft and 11,16,17

mineralized tissues. For example, local

application of growth factors is used to promote 9,12

healing, especially regeneration. Numerous

studies, including some dental research, have

shown that PDGF, TGF-b and IGF-I are found in

PRP and, because of their impact on wound

healing, the use of these factors has led to 17-26

promising results. Dental applications of CAP

include: dental caries, sterilization, elimination of

biofilms, root canal disinfection, increase in bond

strength at the dentin/composite interface and

Plasma – A Pirouette In DentistryVol-III, Issue - II, May-Aug 2016

88

bleaching. This review is an update of use of

plasma in various branches of dentistry.

Radio Frequency Plasma Jets

Atmospheric Pressure Plasma Jet, employed for

bacterial sterilization consists of two coaxial

electrodes between which a feed gas (mixtures of

helium, oxygen, and other gases) flows at a high 27rate . The outer electrode is grounded while radio

frequency power (50-100W) at 13.56 MHz is

applied to the central electrode that creates a

discharge. The reactive species produced exits the

nozzle at high velocity and arrives to the area that is 28-31 to be treated. Koinuma et al. developed the

earliest radio frequency cold plasma jet in 321992 .The cathode is a needle electrode made of

tungsten or stainless steel with a 1 mm diameter

connected to a radio frequency source (13.56

MHz). The needle electrode lies within a quartz 33, 34tube whereas the anode electrode is grounded.

In 2002, Stoffels et al. created a miniature

atmospheric plasma jet that they called plasma 35, 36needle and created a new version in 2004.

Plasma needle

Plasma Needle is handheld needle that produces

free radicals efficiently and targets the pathogenic

microbes (S.mutans, E.coli) with enhanced

fineness and precision. It also maintains the safety 36-38 and effectiveness in-vivo. The plasma needle

consists of a tungsten wire (0.3 mm diameter) with

a sharp tip at the end confined in a Perspex tube (4 36, 37, 39mm inner diameter). The Perspex tube is

filled with a mixture of helium gas and air (1%) via

the gas inlet. The gas used most frequently is

Helium due to its high thermal conductivity. The

gas is then mixed with air at the needle tip where a

micro discharge is created. Gases other than

40 Helium are also used. Its small size enables it to

be used to treat small areas where accuracy is 41, 42

required like in dentistry. It has also been used to 36

deactivate E. Coli . As the thermal conductivity of

helium is very high (144W/m/K), it is used in the

needle as the carrier agent that assists in

maintaining the temperature of the plasma to lower

levels.

Mechanism of Action

The bacterial cell membranes are made of lipid

bilayer made of unsaturated fatty acids and the

proteins. These reactive species acts on bacterial

cell membranes by cell detachment through

breaking cell adhesion molecules (like cadherin or

integrin) and finally causing programmed cell 43, 44death (apoptosis). Some methods used to

produce CAP include: Dielectric Barrier

Discharge (DBD), Atmospheric Pressure Plasma

Jet (APPJ), Plasma Needle, and Plasma Pencil. 45The plasma can remain non-thermal where the

energetic electrons can lead to reactions including

ionization of particles, production of reactive 46, 47species, and radiation.

Application of Plasma in various fields of

Dentistry�

Sterilization by eradication of bacteria

Plasma devices have shown to kill a higher

proportion of bacteria than do conventional non-

thermal methods such as UV sterilization. 48,49Unsaturated fatty acids and the proteins of

bacterial cell membrane are involved in

transportation processes. Hydroxyl radicals

generated by plasma along with other free radicals

destroy membrane lipids and thereby deactivate 32, 49, 50the bacteria.



89

Dental caries

Yang et al concluded that about 100% bacterial

elimination was achieved within 15 seconds for

Streptococcus mutans and in 5 minutes for

Lactobacillus acidophilus. Also, in comparison to

lasers, plasmas can access small irregular cavities 51

and fissure spaces. Sladek et al. studied the

interactions of the plasma with dental tissue using

a plasma needle. He concluded that plasma is an

efficient source of various radicals, does not cause

bulk destruction of the tissue. Therefore plasma

treatment is potentially a novel tissue-saving

technique, allowing irregular structures and

narrow channels within the diseased tooth to be 27,52

cleaned.

Root Canal treatment

Enterococcus faecalis is one of the main types of

bacterium causing failure of root-canal treatment.

Lu et al used plasma-jet device, which could

generate plasma inside the root canal. The plasma

could be directed manually by a user to place it into

root canal for disinfection without causing any

painful sensation. Results showed that it can

efficiently kill Enterococcus faecalis in several 53

minutes.

Intraoral disease

Oral candidiasis includes Candida-associated

denture stomatitis, angular stomatitis, median

rhomboid glossitis, and linear gingival erythema.

Koban et al., and Yamazaki et al, reported the

possibility that stomatitis caused by Candida 54,55

albicanscan be cured by plasma jets.

Plasma and Composite

The plasma generates reactive species that arrive

on the surface of the composite resulting in both

microstructural and surface chemistry

modifications that improve adhesive bonding.

Preliminary data has shown that plasma treatment

increases bonding strength at the dentin/

composite interface by roughly 60%, and thus

significantly improves composite performance, 56

durability, and longevity.

Tooth Bleaching

A non thermal, atmospheric pressure, helium

plasma jet device was developed to enhance the

tooth bleaching effect of hydrogen peroxide.

C o m b i n i n g p l a s m a a n d h y d r o g e n

peroxideimproved the bleaching efficacy

compared with using hydrogen peroxidealone.

Tooth surface proteins were noticeably removed

by plasma treatment. When a piece of tooth was

added to a solution of hydrogen peroxideas a

catalyst, production of OH after plasma treatment

was 1.9 times greater than when using hydrogen

peroxidealone. It is suggested that the

improvement in tooth bleaching induced by

plasma is due to the removal of tooth surface 57,58

proteins and to increased OH production.

Biofilms

Inflammation occurs around dental implants as

biofilms develop on tooth and oral mucosa, cause

caries, periodontal diseases, and oral mucositis.

Rupf et al demonstrated that combination

treatment with plasma and a non-abrasive

air/water spray is suitable for the elimination of

oral biofilms from microstructured titanium used 59

in dental implants. Koban et al. showed that the

treatment of dental biofilms composed of

Streptococcus mutanswith non-thermal plasma

was more efficient than the treatment with



90

60 chlorhexidinein vitro. Jiang et al in their study

used two teeth, that were placed at a distance of 5

mm from the plasma nozzle. One of them was

exposed to the helium/oxygen plasma for five

minutes, whereas the other one was exposed to the

same helium/ oxygen for five minutes, but without

plasma. They observed better results in the

reduction of the biofilms in the tooth treated with 61 plasma compared with control. Schaudinn et al.

used a plasma needle to eliminate ex vivo bio lms 62on root canals of extracted teeth.

Alveolar socket healing

PRP tends to promote tissue repair, improving the 63

quality of healing &healing time. Alissa et al,

conducted a pilot study on the effect of PRP on the

healing of the hard and soft tissues of extraction 64

sockets. Soft tissue healing was significantly

improved in patients treated with PRP compared

with patients of the control group (no treatment).

Moreover, patients untreated with PRP

experienced complications. Ogundipe in 2011

proved that when post third molar extraction was

treated with PRP they showed decrease pain and

i m p r o v e m e n t i n s w e l l i n g a n d m o u t h 65

opening. Ruktowski showed that there was a

significant increase in the radiographic density

over the baseline level after extraction if PRP was 6 6

used. However, a study conducted by

Arenazbuaet al, showed no acceleration in bone

formation at six months and no statistically

significant difference in pain, swelling, trismus and 67

infection when treated with PRP or not.

Periodontal surgery

The growth factors present in PRP are capable of

forming a fibrin clot, promoting fibroblast

proliferation and up regulating collagen synthesis

68in the extracellular matrix. The ability of these

factors to accelerate bone repair by increasing the

mitosis of osteoblasts and tissue vascularity might 69be useful in the treatment of infrabony defects.

Martinez et al, in 2009 showed that whereas it

improves gingival recession, no significant change

was seen in the clinical attachment level in 70periodontics. Moreover, Pradeepet al, who

conducted a study on the treatment of mandibular

furcation defects, have reported the lack of

complete closure of furcation defects despite a

significant improvement; this implies a limited role 71for autologous PRP as a regenerative material.

The results of the systematic review by Del Fabbro

et al, revealed that PRP may exert a positive

adjunctive effect when used in combination with

graft materials for the treatment of intrabony 72defects. However, no significant benefit of PRP

was found for the treatment of gingival recession.

Bhardwaj et al, found that the adjunct of PRP to

bone graft appeared to be beneficial in the

treatment of human periodontal intrabony 73defects.

Bone tissue and implant surgery

In the field of bone tissue surgery, a recent study by

Daif investigated the effect of autologous PRP on

bone regeneration in mandibular fractures. He

concluded that direct application of the PRP along

the f rac ture l ines may enhance bone 74

regeneration. Wojtowicz et al, compared the

effects of stimulating the osteogenesis of the

alveolar bone by transplants of autologous bone 75

marrow and PRP. It was shown that newly formed

bone increased under the influence of PRP.PRP has

also been used in sinus lift procedures, where

mixed results have come out. Esposito showed that

there was no significant improvement on using



91

PRP along with bone substitutes in sinus lifts

procedures, whereas Poeschl showed successful 76,77

results in maxillary sinus augmentation. The

preparation of PRP, as applied to an implant

surface, adheres to metal and might create a new

dynamic surface which could potentially show

biological activity. Anitua [27] in 2006 in which

osseointegration was found to be improved by

coating the implant surface.

BRONJ Surgery

BRONJ(Bisphosphonate-related osteonecrosis of

the jaw) is currently recognized as a significant

complication, which is related to the use of

bisphosphonates , a widely-used class of drugs

employed in the preventative treatment of various

pathologies leading to the alteration of bone turn-

over .BPs are capable of inhibiting osteoclast-

mediated bone resorption, also displaying anti-

angiogenetic activity. The bones of patients

treated with BPs are, therefore, poorly

vascularized and poorly supplied with the

substances necessary for wound healing. Although

some of the cases reported were asymptomatic,

most of them resulted in avascular area of necrotic

bone in the maxillofacial area, with or without 79

exposed bone.

Cosmetic surgery

There has been a recent widespread interest in use

of PRP for anti-aging and regenerative purposes. It

has been named as the vampire facial and can be

used in face lifts, Reducing fine lines and wrinkles,

Tightening and toning skin, Mild collagen and

volume loss, Dark under eye circles and acne 80

scarring. It is less invasive &less expensive than

plastic surgery, takes about 20 minutes for each

treatment, and offers improvements for up to 18

months.

Growth factors

Some have also implied that the value of PRP is

mostly related to soft tissue healing enhancement

because platelets do not contain BMP. Hence it is 2

non- osteoinductive. However, bone graft healing

and osteoconduction into bony defects and around

the numerous bone substitutes used today arise

from adult mesenchymal stem cells and their

differentiation, leading to osteoblasts, all of which

have already been proved to respond to PRP with 81

accelerated bone formation. PRP is no different in

substrate than the blood clot that forms in every

wound and therefore could not support bacterial 3

growth any more than any other blood clot. PRP

has a pH of 6.5 to 6.7 compared with a mature

blood clot of 7.0 to 7.2. PRP actually inhibits

bacterial growth. Because growth factors

stimulate cellular proliferations, there are

concerns that BMPS and PRP might stimulate

cancer. Although no growth factor can prove 4

cancer. All growth factors act on cell membrane

and not on cell nucleus & stimulate normal gene

expression.

Post and Core

Yavrich et al., studied the effects of plasma

treatment on the shear bond strength between fiber

reinforced composite posts and resin composite

for core build up and concluded that plasma

treatment appeared to increase the tensile-shear 82

bond strength between post and composite.

Safety Issues with Plasma

Plasma is a rich source of radicals and other active

species. The flame is cool to touch without any 82feeling of warmth or touch. It operates at room



92

temperature and does not cause bulk destruction of 83the tissue, being superior to lasers. When the ROS

level in body fluids becomes too high, various

types of damage occur, known under a common

name of oxidative stress. It is believed that

oxidative stress bears at least partial responsibility

for diseases like arteriosclerosis, cancer and

respi ra tory problems. Moreover, h igh

concentrations of oxygen radicals accelerate

ageing of cells and tissues. On the cellular level,

several effects leading to cell injury have been

identified: lipid peroxidation, DNA damage and 84,85 protein oxidation. On the other hand, free

radicals have various important functions in the

body. For example, macrophages generate ROS to

destroy the invading bacteria, and endothelial cells

(inner artery wall) produce nitric oxide (NO) to 85regulate the artery dilation. Plasmas are often

very complex mixtures; in fact, they owe their

specific properties to the synergy of various

components: charged particles (electrons, positive

and negative ions), metastables, revibrationally

excited molecules, active radicals and (UV) 85photons.

Merits and Demerits

Noiseless, painless cavity preparations, also, it

enables the dentist to perform procedures without 82shots and pain. Reduces or avoids the use of

routinely practiced painful and destructive 83drilling. On the other hand, the technique is highly

sensitive. It does not work well in cases where 86 amalgam restoration is present in the oral cavity.

Cost of the equipment, marketing, maintenance

and availability are also some of the issues at 87 present. Plasma needle technology has a long way

to go and shall prove its applicability in the days to 86come.

Conclusion

The natural fibrin biomaterial PRF has great

potential for surgical wound healing. The

application of PRP offers the dental patient

something that is safe from outside disease

transmission or immunogenic reactions. This PRP

can be easily done in the dental office and can be

used for various surgical procedures. CAP has a

bright future in dentistry due to its anti-microbial

properties and its cell death properties on cells.

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Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript.Source of support: NIL

Copyright © 2014 JPMCP. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



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