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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.
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Plasma – A Pirouette In Dentistry
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
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Plasma – A Pirouette In Dentistry
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 infra- bony 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
Vol-III, Issue - II, May-Aug 2016
Plasma – A Pirouette In Dentistry
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
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Plasma – A Pirouette In Dentistry
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
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