review ARTICLES

THE BIOFILM: FORMATION AND REMOVAL

Doina Onisei, Dan Onisei, Ioana Feier, Darian Rusu, Stefan-Ioan Stratul

REZUMAT
Caria [i boala parodontal\ reprezint\ bolile cu cea mai mare prevalen]\ la om. Ambele sunt asociate cu bacteriile biofilmului dentar, care reprezint\ o structur\
complex\, bine organizat\. n biofilmul dentar au fost identificate peste 500 de specii bacteriene. Pentru s\n\tatea orala [i general\ a pacien]ilor, formarea acestui
biofilm trebuie impiedicat\, prin ndep\rtare meticuloas\. ndep\rtarea sau reducerea biofilmului se face prin metode mecanice, asociate uneori cu metode
chimice. n general, substan]ele chemoterapeutice singure nu penetreaz\ grosimea biofilmului, de unde rezult\ importan]a identific\rii [i ndep\rt\rii riguroase
a biofilmului.
Cuvinte cheie: biofilm, boal\ periodontal\

abstract
Dental caries and periodontal disease are among the most prevalent diseases known to man. Both are associated with the bacteria of the dental biofilm. The
dental biofilm is complex, with a well-organized structure. Up to 500 bacterial species have been identified in the dental biofilm. Studies have shown that plaque
accumulates rapidly on clinically plaque-free teeth. To maintain the oral and the systemic health, the development and maturation of dental biofilm should be
impeded and the dental biofilm needs to be regularly and meticulously removed. The removal and reduction of the biofilm can be achieved by mechanical means
or mechanical and chemical means. Current chemotherapeutics in general do not effectively penetrate thick biofilms, which underscores the importance of the
identification and rigorous mechanical removal of the dental biofilm.
Key Words: biofilm, periodontal disease

INTRODUCTION The step-by-step, gene regulated biofilm

A biofilm is a complex community of bacteria
adhering to an inert or living surface.1,2 Biofilms are
the predominant mode of bacterial growth in nature.
Many microbial species exist as sessile bacteria (attached
bacteria in the biofilms), but release into dispersion
small numbers of planctonic cells (free-floating single
cell bacteria). At the start of the biofilm formation
process, the bacteria “swim” to find an appropriate
surface to adhere to. After they attach, the bacteria
“move” on the surface to find other bacteria to form
small aggregates. Next, the bacteria produce a large
amount of matrix and the bacterial groups increase
in size and thickness until they form a mature biofilm.
After maturation, biofilms may release planctonic cells
to begin another cycle of biofilm formation.
Department of Periodontology, Faculty of Dental Medicine, Victor Babes
University of Medicine and Pharmacy, Timisoara
Correspondence to:
Prof. Doina Onisei, 9 Revolutiei Blvd., Timisoara, Tel. +40-356-425390
Email: donisei@umft.ro
Received for publication: Feb. 22, 2008. Revised: May 19, 2008.
formation process results in a bacterial community
with distinct mushroom-like structures, that consist of
a variable distribution of cells and cell aggregates, the
associated matrix, void spaces, and water channels that
allow the diffusion of nutrients and waste products.
Many bacteria are able to communicate with each
other through a process called quorum sensing gene
regulation.3 This process explains how the cells in a
biofilm are able to activate certain genes.
Understanding the biofilm is important because
the periodontal clinicians need to know the enemies
in order to defeat them. Research in biofilms may help
identify new strategies to combat bacterial infections.
Since the quorum-sensing systems (QSS) play a critical
role in the formation of biofilms, disrupting such
systems should diminish the bacterial pathogenic
ability.
Thus, a different approach is to use compounds
that interfere with the cell-to-cell communication of
the bacteria. Many superior organisms produce natural
compounds to mount a chemical warfare against
bacterial pathogens. Some of the compounds actually
work by disrupting the QSS and have the potential to
treat the bacterial infections.

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Doina Onisei et al  111

Figure 1. SEM image of the dental biofilm (courtesy of XO Care, Denmark).
Biofilm bacteria are several hundred to thousand
times more resistant to antimicrobial agents than
planctonic cells of the same species.4 This may help
explain why some chronic bacterial infections are
difficult to treat with antibiotics, even though in
vitro antimicrobial susceptibility tests predict that the
antibiotic will be effective.
While the mechanism of antimicrobial resistance
is currently unknown, a more rationale and effective
strategy of antimicrobial therapy will be identified and
the mechanism is understood.
THE STRUCTURE AND THE
BIOCHEMISTRY OF BIOFILMS
Prior to the development of dental biofilm, the
salivary (or “acquired”) pellicle forms. This occurs
through the adsorption of proteins from saliva onto
the clean tooth surface. The acquired pellicle formation
provides oral bacteria with binding sites, resulting in
bacterial adhesion - the first step in the formation of
the dental biofilm.5 Surface modifications can inhibit
the development of the acquired pellicle and of the
dental biofilm. Dental biofilms generally accumulate on
hard and soft surfaces of the oral cavity, including non-
biological surfaces such as implant surfaces, orthodontic
appliances and fillings, as well as on other bacteria.6
Bacterial adherence is essential for the formation of
dental biofilm. Following adhesion, the bacteria divide,
grow and accumulate. The bacteria contain factors
called adhesins that meet their counterparts receptors
at the site of adhesion, resulting in the adhesion of
the bacteria to the surface. Different receptors and
adhesins are present on different bacteria and surfaces,
such as fimbriae that act as receptors on subgingival
bacteria, or collagen and residues of sialic acid and
galactosyl, which display a similar function on tissue
surfaces.7
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112 TMJ 2008, Vol. 58, No. 1 - 2 
Adhesion by one species of bacteria may limit the
amount of adhesion by another species in the same
space.
For a subgingival biofilm to develop, bacteria
must be able to adhere to one or more subgingival
surfaces. This is enabled by an early inflammatory
process that creates a pseudopocket at the gingival
margin, allowing for the development of the anaerobic
species associated with the periodontal disease and the
subsequent development of true periodontal pockets,
which in turn provide extra space for the anaerobes
and an oxygen-poor environment.8,9 The presence of
subgingival calculus provides an excellent adhesion
site for bacteria and for the retention of subgingival
plaque.
Bacterial adhesion to soft tissue within the
periodontal pocket may also play a role in the deeper
invasion of periodontal tissues. Adhesion to the
basement membrane and collagen has been also
noted.
In vivo, the dental biofilm is colonized by up to 500
species. The bacteria are tightly bound to each other
and to a solid substrate, interspersed with fluid-filled
channels. The majority of these species are present
in health, and the host response and its susceptibility
determine the onset of the disease. Only 20 percent of
periodontal disease is attributed to bacterial variances,
with the host response being the key factor for most of
the forms of the infectious periodontal disease. Within
periodontal pockets, between 30 and 100 species can
be isolated from one site, and over 300 species have
been identified by cultures.
Young dental biofilm, assessed for 40 strains
of bacteria, has been found to consist mainly of
Actinomyces until between two and six hours after
the formation begins. At this point, the numbers of
Streptococci increase when compared to Actinomyces,
especially S. mitis and S. oralis.8 Periodontal pathogens
are found at extremely low levels in the up to six hours-
old biofilm. Until day three, mostly Gram-positive
Streptococci and rods are present. The next phase
maturation involves the apparition of filamentous
bacteria on the biofilm surface, which then invade the
body of the biofilm after day seven.9
CLSM (confocal laser-scanner method) combined
with fluorescence of plaque harvested from in situ
enamel blocks worn intraorally for five days has
demonstrated that bacterial vitality increases with the
depth of the biofilm and the depth of the bacteria
within. CLSM has also demonstrated voids together
with layers of live bacteria packed with nonvital
materials of bacterial origin.10

Figure 2. The formation of the dental biofilm (courtesy of XOCare, Denmark).
The composition of the biofilm depends upon its
location and its degree of maturity.
Between three and 12 weeks after supragingival
plaque starts to form, subgingival biofilm is well
differentiated with predominantly Gram-negative
anaerobic bacteria. Porphyromonas gingivalis, strongly
associated with the infectious periodontal disease,
and Treponema denticola are often found associated in
dental biofilms.11,12
The composition of subgingival plaque has
been extensively researched. Socransky and Haffajee
defined five bacterial complexes in the subgingival
plaque. In addition, specific complexes were found to
be associated with other specific complexes within the
group, demonstrating relationships between bacterial
species. While specific bacteria are known to be
pathogenic, it is also now recognized that the presence
of periodontopathogens does not predict the long-
term progress of periodontitis.13 Recent research has
identified clonal sub-groups within species of bacteria,
the relevance of which is not yet fully understood.
It has been hypothesized that the virulence within
a particular bacterial species may depend upon the
clonal subtypes present.14
The subgingival plaque is not subject to the same
hygienic/therapeutic assaults as the supragingival
plaque and is relatively protected from saliva and from
the masticatory impacts. A further factor of resistance
is the morphology of bacteria, both intraspecies
and interspecies. In vitro evaluation of the biofilm
formation with A. actinomycetemcomitans has found
that variants with a rougher morphology resulted in
more biofilm formation than in vitro, smooth variants.
It was also concluded that a rough morphology in the
biofilm in vivo may help protect bacteria from exterior
assaults.15
THE REMOVAL OF THE BIOFILM
The meticulous and regular removal of dental
biofilm is important for the oral and systemic health,
giving the strong associations between the presence
of periodontal disease and cardiovascular disease,
diabetes, respiratory diseases, disseminated infections
and other conditions.16 The meticulous removal of
biofilm is hindered by its relative lack of visibility, by
mechanical or physical difficulties, and by its chemical
resistance. The use of current antimicrobial agents
is known to be effective in the outer surface where a
thick dental biofilm is present with poor penetration
into the inner layers of the dental biofilm, which
underscores the importance of frequent and adequate
plaque removal.12
By removing the supragingival plaque in the early
phase of biofilm maturation, the microbial load can be
maintained at a relatively low level and the colonization
by anaerobic species can be contained. In the absence
of adequate oral hygiene, the subgingival plaque will
develop, at which the point elimination and the effective
control of the bacterial environment is considerably
more difficult. Daily removal of dental plaque is
essential in the prevention of oral disease as well as
in the continued rehabilitation and maintenance of
patients with preexisting periodontal disease. Reducing
the amount of biofilm and/or or selectively reducing
the number and proportion of pathogenic species will
help prevent caries and periodontal disease.17
Mechanical Removal
In developed countries, patients brush for less than
one minute on average. The education and motivation
of patients to mechanically remove as much plaque as
possible is a priority.18 The use of soft-bristled brushes,
interdental brushes, floss, toothpicks, and rubber tips
have all been recommended for the removal of plaque
from the various surfaces of the teeth during home
care.
Toothbrushes and tooth-brushing techniques
have evolved over time. Using of a soft-bristled brush
will achieve the best results for plaque removal and
will help prevent abrasion associated with the use of
hard-bristled brushes or overzealous brushing. While
a straight horizontal brushing motion may remove the
plaque, the Bass technique is well accepted as optimal.
By brushing at a 45 degree angle, the brush is more
able to reach under the gingival margin into the gingival
crevice to remove plaque in this area. Without this, the
inflammation will appear with the formation of the
pseudopocket, making it a more attractive environment
for the anaerobic colonization and for the further
formation of a true periodontal pocket. Toothbrushes
are available with ergonomically-designed handles.
Some have handle designs with thumb grips that are
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113
Doina Onisei et al 
positioned to tilt the bristles at a 45 degree angle to
the sulcus.
Electric toothbrushes are a further option. Clinical
research into the effectiveness of these toothbrushes
has produced widely varying and often contradictory
results. The selection is based upon the preference, the
ability and the willingness of patients to brush manually.
Where a dexterity problem exists, the use of an electric
toothbrush may be easier or more effective.
Interdental brushes, floss, and toothpicks are all
available as cleaning aids. Both flossing and interdental
brushing are effective with an appropriate technique.
The choice will depend upon the clinician’ and patient’s
preference, the compliance of the patient with the
method chosen, the space available, and the patient’s
dexterity.
Studies have pointed out that subgingival plaque
in deeper pockets is not responsive to home-care oral
hygiene measures alone. Professional cleaning (e.g.,
root planing and scaling, professional prophylaxis)
and home care (tooth brushing and either flossing
or an interdental brush, at a minimum) combined are
required to remove subgingival plaque. In the absence
of subgingival plaque control and therapy, supragingival
plaque control does not prevent the progression of
the periodontal disease.19
Scaling & root planing
The overall goals of periodontal treatment are
to stop the progression of the disease and to obtain
clinical attachment gains. Supra- and subgingival scaling
are the standard non-surgical treatment for periodontal
disease, and may be supplemented with systemic
or local antimicrobial therapy or other adjunctive
therapy.20,21 The objectives of scaling are to disrupt the
dental biofilm and to remove the maximum possible
amount of dental biofilm, dental calculus, periodontal
bacteria, and debris from the root surfaces and soft
tissue.22 A further objective is that the root surfaces
be biocompatible and smooth upon completion of
scaling, thereby reducing the risk of recolonization
and subgingival biofilm adhesion and retention on
biocompatible surfaces. The dental calculus provides
a distinct prominent or rough site for the adhesion of
bacteria and for biofilm retention, and also contains
endotoxins.
Supra- and subgingival scaling can be performed
with hand instruments or with power scalers. An
alternative is a procedure combining the use of both
hand instruments and power scalers. Considerations
on the choice of method include efficacy, efficiency,
safety, patient comfort, and ergonomics. The use of
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114 TMJ 2008, Vol. 58, No. 1 - 2 
hand scalers requires great care to achieve a satisfactory
result, and takes a considerable amount of time. It is
now generally held that hand scalers and ultrasonic
scalers are similar in their effectiveness in removing
subgingival biofilm.23
Hand scalers have been found to be ineffective in
removing calculus deposits in furcation areas whether
an open- or closed flap technique is used.24,25 Ultrasonic
scalers are considered superior to hand instruments for
the treatment of moderate and advanced furcations.
The precision thin tips of ultrasonic scalers are
significantly thinner than the working end of the
curettes, enabling them to enter narrow furcation
areas.26 Traditionally, scaling and root planing used a
selection of manual instruments such as curettes, chisels
and hoes. Increasingly, ultrasonic scaling becomes a
preferred choice for the initial periodontal treatment
and for the periodontal maintenance protocols as the
instruments, the comfort of the patient and of the
operator improved. Clinicians can select hand scaling,
ultrasonic scaling or a two-step protocol, whereby
ultrasonic scaling removes deposits and hand scaling
is then used for fine calculus or biofilm removal.
Ultrasonic scalers have been found to be effective in
removing also subgingival biofilm and calculus.27
The aggressive instrumentation of the root surface
was believed to be necessary to remove the embedded
endotoxins, but it is now known that endotoxins are
only loosely adsorbed on the root surface and their
removal requires only the light use of ultrasonic inserts.
Based on these considerations, a two-step protocol
involving ultrasonic scaling followed by extensive hand
scaling (rather than spot touch-ups in specific areas)
may offer little benefit.28,29
Ultrasonic Scalers
Ultrasonic scaling offers several advantages over
hand scaling. It is less fatiguing and less time consuming,
requires less force, results in less tooth substance loss,
is more effective in areas with narrow difficult root
morphology, and provides irrigation of the pocket
during instrumentation. Regarding the damage of the
root surface, Ritz et al. have found that hand scaling
with a curette resulted in a loss of 109 microns of
cementum, when compared to 12 microns of loss with
an ultrasonic scaler, after 12 working strokes.30 The
whole root surface must be instrumented with gentle
and precise overlapping strokes of the instrument.
Piezoelectric and magnetostrictive ultrasonic
scalers differ. The movement of a piezoelectric tip
results from the action of the alternative electricity on
ceramic discs, while the magnetostrictive ultrasonic
insert movement is obtained by metal stacks of
ferromagnetic material that create a magnetic field.31
Procedure and technique of the ultrasonic
removal of the dental biofilm
Piezoelectric tips move linearly, mimicking
the motion of hand scaling. Piezoelectric inserts
include beveled, bladed, slim and probe-like designs,
depending on each particular ultrasonic unit. For most
units, several inserts are used during the procedure.
The scaler inserts are mostly active on the two lateral
surfaces (for Piezon® Master - EMS; Mini Piezon®
- EMS; Symmetry IQ™ - Hu-Friedy; Varios 350 -
Brasseler; Suprasson P-Max - Satelec/Acteon). Only
these active lateral surfaces should be used against
the root surface. Positioning the inserts to the tooth
surface at a 90-degree angle would result in root surface
damages. Narrow, slim and probe-like tips offer better
adaptation to areas such as severe root curvatures and
molar furcations, and improve penetration to the base
of pockets.32
Magnetostrictive ultrasonic inserts move elliptically.
Magnetostrictive scalers (Cavitron® - Dentsply; Dual
Select™ - Dentsply) use a variety of inserts shapes
during scaling and root planing. Straight inserts are used
for gross calculus removal, and other designs such as
beavertail, chisel, probe-like, slim, furcation and curved
tips are used for specific areas. As with piezoelectric
inserts, the points of the inserts must not be directed
towards the tooth, to prevent root damage. The force
required with magnetostrictive inserts is greater than
with piezoelectric inserts. Curved universal inserts
are counter indicated in pockets of 4 mm or more, to
prevent the gouging of the root surface. Unlike most
piezoelectric units, the inserts can be used on the back,
face and lateral surfaces, enabling the clinician to select
the active surface depending on their angulations and
the area being treated. This makes the procedure less
technique-sensitive.
Figure 3. The amplitude, frequency and tip motion of powered ultrasonic
devices (courtesy of XO Care, Denmark).
Currently, only the magnetostrictive scaler XO
Odontogain® (XO Care, Denmark) has the instrument
tips equally active on all sides, rotating elliptically in
a three dimensional movement. The instrument tip
oscillates at a very high frequency (42 kHz) and it moves
with an amplitude of only 10-20 microns. Thin-profile
inserts can be used at a higher power setting, thus a
reduced risk of burnishing subgingival calculus, when
compared to the use of low power, and without risking
the insert breakage. Tips made of titanium also reduce
this risk. When used with the appropriate technique
and with appropriate inserts, the ultrasonic scaling
and root planing is highly effective.33 One of the real
advantages of ultrasonic scaling is that, unlike Gracey
curettes, slim and probe-like ultrasonic insert tips can
reach the vault of the furcations and other narrow
morphological details for thorough instrumentation.
Inserts with straight surfaces offer poorer adaptation
than rounded surfaces to a concave or convex root
surface. Lack of adaptation can be a reason for hand
scaling following ultrasonic scaling.
Figure 4. The XO Odontogain (XoCare, Denmark) ultrasonic unit.
Chemotherapeutic Reduction and Removal of
Biofilm
Chemotherapeutics can be used to reduce the
number of bacteria in the dental biofilm, to reduce the
numbers of specific pathogenic species, and to inhibit
adhesion of microbes to the tooth surface.34 Essential
oils, fluoride, chlorhexidine, povidone-iodine, zinc
citrate, and triclosan have all been used as antimicrobial
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Doina Onisei et al  115
rinses and dentifrices.
The Triclosan (the copolymer included in the
Colgate Total® toothpaste) has been shown to
significantly reduce the plaque and gingivitis and to
inhibit the progress of the periodontal disease.35
The effectiveness of chlorhexidine (CHX) is well
documented. The twice-a-day use of CHX for 21 days
in the absence of any other oral hygiene measures
has been shown to completely prevent plaque and
gingivitis from developing.36 Sekino et al. found that
twice-daily 60-second rinsing with 0.2 percent CHX
as well as gargling plus using 1 % CHX gel for tongue
brushing resulted in significant reduction of the
microbial load over a four-day period in the absence
of any mechanical oral hygiene measures. Some
microorganisms are influenced more than others, and
the presence of Actinomyces is substantially decreased
following the use of CHX.37
Promising advances are being made in the
development of antimicrobial agents, including
research into agents that alter the surface of the
tooth or the acquired pellicle, to prevent the adhesion
of bacteria and alter the formation of the biofilm.
Other areas of research include the use of bacterial
macrophages, bacterial inhibitors, vaccines, and
antimicrobial peptides.38
CONCLUSIONS
1. Periodontal disease relies upon the presence of
a mature biofilm rich in periodonto-pathogens.
2. The progression of periodontal disease is
highly variable and dependent largely upon the host
response, with bacterial variances between individuals
accounting for only 20% of cases.
3. Nonetheless, the removal of bacteria and
their byproducts is essential to prevent and stop the
periodontal disease.
4. Home care measures can be effective in removing
the supragingival biofilm when properly performed.
5. However, once a mature subgingival biofilm has
developed, or dental calculus is present, home care is
ineffective and clinical care is required.
6. In the absence of a clinical intervention, the
periodontal disease progression in individual patients
leads to attachment and bone loss.
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