Advanced Approaches in the Treatment of Periodontal Disease: Enhancing Dentifrices and Mouthwashes for Improved Efficacy

Periodontal disease, commonly known as gum disease, is a prevalent condition that affects millions of people worldwide [1]. It is characterized by inflammation and infection of the supporting structures around the teeth, leading to gum recession, tooth loss, and potential systemic complications [2].

The traditional approach to managing periodontal disease involves regular dental visits; deep cleanings, and the use of basic oral hygiene products such as toothpaste and mouthwash. However, with advancements in scientific research and technology, there has been a growing interest in developing more effective dentifrices and mouthwashes tailored specifically for the treatment of periodontal disease [3].

In this book, we will explore the various aspects of periodontal disease and its treatment, focusing on the advancements made in dentifrices and mouthwashes. We will explore the evolution of these products, the role of active ingredients, and the evidence-based research that supports their efficacy. Moreover, we will discuss the future directions in periodontal disease treatment, offering insights into potential breakthroughs and innovations.

In order to fully comprehend the importance of improving dentifrices and mouthwashes for periodontal disease treatment, it is crucial to have a solid understanding of the disease itself. Periodontal disease is a chronic inflammatory condition that affects the tissues surrounding the teeth, including the gums, periodontal ligament, and alveolar bone [1].

The main cause of periodontal disease is the accumulation of dental plaque, a biofilm consisting of bacteria, food debris, and other particles, on the teeth and along the gumline. If not adequately removed through regular oral hygiene practices, the plaque can harden into tartar or calculus, which further irritates the gums and leads to the progression of the disease [4].

The initial stage of periodontal disease is known as gingivitis, which is characterized by red, swollen, and bleeding gums. If left untreated, gingivitis can progress into periodontitis, a more severe form of the disease. Periodontitis involves the destruction of the underlying supporting structures, leading to gum recession, bone loss, and eventually tooth loss [5].

It is important to note that periodontal disease is not limited to its impact on oral health alone. Numerous studies have linked periodontal disease to various systemic conditions, including cardiovascular disease, diabetes, respiratory infections, and adverse pregnancy outcomes. This highlights the significance of effective periodontal disease management in promoting overall health and well-being.

Throughout history, dentifrices have played a crucial role in maintaining oral hygiene and preventing dental diseases. In the context of periodontal disease, the evolution of dentifrices has been particularly significant in improving treatment outcomes. In this chapter, we will explore the advancements made in dentifrices specifically designed for periodontal treatment [6].

Traditional Dentifrices

Traditional dentifrices, such as toothpaste, have long been the cornerstone of oral hygiene practices. These formulations typically consist of a combination of abrasive agents, detergents, humectants, flavoring agents, and fluoride. While effective in maintaining general oral health, traditional dentifrices were not specifically formulated to target the unique needs of individuals with periodontal disease [7].

Introduction of Antibacterial Agents

Recognizing the importance of combating bacterial plaque in periodontal disease, dentifrices began to incorporate antibacterial agents. One of the earliest examples was the introduction of triclosan, a broad-spectrum antibacterial agent, into toothpaste formulations. Triclosan has been shown to effectively reduce plaque accumulation and gingival inflammation, making it a valuable addition to dentifrices for periodontal treatment [8].

Anti-Inflammatory Agents

In recent years, there has been a growing understanding of the role of inflammation in periodontal disease. As a result, dentifrices have started incorporating anti-inflammatory agents to target the inflammatory response in the gums. One such agent is the inclusion of herbal extracts like aloe vera or chamomile, known for their anti-inflammatory properties. These ingredients help reduce gum inflammation and promote healing in individuals with periodontal disease [9].

Enzyme-Based Dentifrices

Enzyme-based dentifrices have gained popularity as a targeted approach to managing periodontal disease. These formulations contain enzymes, such as lysozyme or papain, that help break down the biofilm and disrupt the bacterial colonies responsible for periodontal disease. By targeting the root cause of the disease, enzyme-based dentifrices have shown promising results in improving periodontal health [10].

Nanotechnology in Dentifrices

Advancements in nanotechnology have opened up new possibilities in dentifrice development. Nanoparticles, such as silver or zinc oxide, have been incorporated into dentifrices for their antimicrobial properties. These nanoparticles can penetrate the biofilm and effectively kill the bacteria responsible for periodontal disease. Moreover, nanotechnology allows for controlled release of active ingredients, ensuring prolonged efficacy [11].

Bioactive Dentifrices

Bioactive dentifrices have emerged as a cutting-edge approach in periodontal treatment. These formulations contain ingredients that actively promote tissue regeneration and repair. For example, dentifrices may include growth factors, such as platelet-derived growth factor (PDGF), which stimulate the regeneration of periodontal tissues. Bioactive dentifrices offer a promising avenue for enhancing the healing process in individuals with periodontal disease [12, 13].

Personalized Dentifrices

With advancements in genetic testing and personalized medicine, there is a growing interest in developing dentifrices tailored to an individual’s specific needs. By analyzing an individual’s genetic profile or oral microbiome, dentifrices can be customized to target specific bacterial strains or address genetic predispositions to periodontal disease. Personalized dentifrices hold the potential to optimize treatment outcomes and improve the overall effectiveness of periodontal therapy [14].

Mouthwashes have long been used as an adjunct to oral hygiene practices, providing additional benefits in the prevention and treatment of periodontal disease. In recent years, there have been significant innovations in mouthwash formulations, specifically targeting periodontal disease management. In this chapter, we will explore the advancements made in mouthwashes and their effectiveness in improving periodontal health [15, 16].

Antibacterial Mouthwashes

One of the most notable innovations in mouthwashes for periodontal disease management is the inclusion of antibacterial agents. These mouthwashes contain active ingredients such as chlorhexidine, cetylpyridinium chloride (CPC), or essential oils like thymol or eucalyptol. These agents have potent antimicrobial properties, effectively reducing the bacterial load in the oral cavity and preventing the progression of periodontal disease [17].

Anti-inflammatory Mouthwashes

Inflammation plays a significant role in the development and progression of periodontal disease. To address this, mouthwashes have been formulated to include anti-inflammatory agents such as steroids or non-steroidal anti-inflammatory drugs (NSAIDs). These mouthwashes help reduce gingival inflammation and promote healing in individuals with periodontal disease [18, 19].

Oxygenating Mouthwashes

Oxygenating mouthwashes have gained popularity in periodontal disease management due to their ability to create an oxygen-rich environment. These mouthwashes typically contain hydrogen peroxide or stabilized chlorine dioxide, which release oxygen when in contact with oral tissues. The increased oxygen levels help eliminate anaerobic bacteria responsible for periodontal disease and promote a healthier oral environment [20].

Enzymatic Mouthwashes

Enzymatic mouthwashes have emerged as a targeted approach to managing periodontal disease. These mouthwashes contain enzymes such as lactoperoxidase or glucose oxidase, which help break down the biofilm and disrupt the bacterial colonies associated with periodontal disease. By targeting the root cause of the disease, enzymatic mouthwashes can improve periodontal health and aid in preventing disease progression [21].

Herbal Mouthwashes

Herbal mouthwashes have gained popularity due to their natural and holistic approach to periodontal disease management. These mouthwashes typically contain herbal extracts such as aloe vera, tea tree oil, or chamomile, known for their antimicrobial and anti-inflammatory properties. Herbal mouthwashes offer a gentle and soothing alternative for individuals with sensitive gums while providing effective periodontal disease management [17].

Nanotechnology in Mouthwashes

Similar to dentifrices, nanotechnology has made its way into mouthwash formulations. Nanoparticles such as silver or zinc oxide have been incorporated into mouthwashes for their antimicrobial properties. These nanoparticles can penetrate the biofilm and effectively kill bacteria associated with periodontal disease. Nanotechnology in mouthwashes allows for enhanced bacterial control and improved treatment outcomes [22, 23].

Antioxidant Mouthwashes

Periodontal disease is associated with increased oxidative stress in the oral tissues. Antioxidant mouthwashes, containing ingredients such as vitamins C and E or green tea extract, help neutralize free radicals and reduce oxidative stress. By targeting oxidative damage, these mouthwashes contribute to the overall health of periodontal tissues and aid in the management of periodontal disease [24].

Dentifrices and mouthwashes are essential tools in maintaining oral hygiene and managing periodontal diseases. The effectiveness of these oral hygiene products lies in their active ingredients, which provide specific therapeutic benefits [25]. In this chapter, we will delve into the role of active ingredients in dentifrices and mouthwashes, understanding how they contribute to the efficacy of these products.

Fluoride

Fluoride is one of the most well-known and widely used active ingredients in dentifrices and mouthwashes. Its primary role is in preventing tooth decay by strengthening tooth enamel and remineralizing early stages of dental caries. Fluoride ions replace hydroxyl ions in hydroxyapatite, forming a more resistant compound known as fluorapatite. This process makes the teeth more resistant to acid attacks from bacteria and helps prevent the formation of cavities [26].

Antibacterial Agents

Antibacterial agents play a crucial role in both dentifrices and mouthwashes, targeting the harmful bacteria responsible for oral diseases, including periodontal disease. Common antibacterial agents include chlorhexidine, triclosan, cetylpyridinium chloride (CPC), essential oils (such as thymol and eucalyptol), and hydrogen peroxide. These agents inhibit the growth and activity of bacteria, reducing the bacterial load in the oral cavity and preventing the progression of periodontal disease [27].

Anti-inflammatory Agents

Inflammatory processes are at the core of periodontal diseases, causing tissue damage and bone loss. Active ingredients with anti-inflammatory properties, such as steroids or non-steroidal anti-inflammatory drugs (NSAIDs), help control inflammation in dentifrices and mouthwashes. These agents can alleviate gingival inflammation, promote healing, and provide relief from discomfort associated with periodontal disease [28].

Enzymes

Enzymes, such as lysozyme or papain, are active ingredients found in some dentifrices and mouthwashes. These enzymes have the ability to break down the biofilm and disrupt the bacterial colonies responsible for periodontal disease. By targeting the root cause of the disease, enzyme-based products contribute to the elimination of harmful bacteria and improvement of periodontal health [29].

Herbal Extracts

Herbal extracts, including aloe vera, tea tree oil, chamomile, and green tea extract, are increasingly used in dentifrices and mouthwashes due to their natural antimicrobial and antiinflammatory properties [30]. These extracts provide a gentle and soothing effect on the oral tissues while aiding in the prevention and management of periodontal diseases. Their inclusion in oral hygiene products offers a holistic approach to oral care.

Nanoparticles

Nanotechnology has made significant advancements in the field of dentistry, including the use of nanoparticles in dentifrices and mouthwashes. Nanoparticles, such as silver or zinc oxide, exhibit antimicrobial properties that can penetrate the biofilm more effectively. These nanoparticles can disrupt the bacterial colonies associated with periodontal diseases, providing enhanced bacterial control and improving treatment outcomes [31].

Antioxidants

Oxidative stress is a contributing factor to periodontal diseases. Antioxidant active ingredients, such as vitamins C and E or green tea extract, help neutralize free radicals and reduce oxidative damage in the oral tissues. By reducing oxidative stress, these active ingredients contribute to the overall health of periodontal tissues and aid in the management of periodontal diseases [32].

In the field of oral healthcare, clinical studies and evidencebased research play a crucial role in evaluating the efficacy and safety of various treatment modalities, including those related to periodontal disease management. In this chapter, we will explore the significance of clinical studies and evidence-based research in advancing our understanding of periodontal disease and its treatment options.

Importance of Clinical Studies

Clinical studies are conducted to gather data and evaluate the effectiveness of different interventions in real-life settings. These studies involve human participants and are designed to address specific research questions or objectives. In the context of periodontal disease management, clinical studies provide valuable insights into the efficacy, safety, and long-term outcomes of various treatment approaches, such as the use of mouthwashes, dentifrices, and other adjunctive therapies [33, 34].

Randomized Controlled Trials (RCTs)

Randomized controlled trials are considered the gold standard for clinical research. In an RCT, participants are randomly assigned to different treatment groups, allowing for a comparison of outcomes between the groups. This design helps minimize bias and provides robust evidence regarding the effectiveness of a particular intervention. RCTs have been conducted to evaluate the efficacy of mouthwashes in managing periodontal disease, and their findings guide clinical practice [35, 36].

Systematic Reviews and Meta-analyses

Systematic reviews and meta-analyses are comprehensive studies that synthesize the findings of multiple individual studies. These studies meticulously analyze the available literature on a specific topic and provide a summary of the overall evidence. By pooling together data from various studies, systematic reviews and meta-analyses can offer a more comprehensive and reliable assessment of the efficacy of mouthwashes and other treatment modalities for periodontal disease management [37, 38].

Longitudinal Studies

Longitudinal studies, also known as cohort studies, follow a group of individuals over an extended period. These studies provide valuable insights into the long-term effects of interventions and the natural progression of diseases. Longitudinal studies in periodontal disease management have helped identify risk factors, evaluate the efficacy of various interventions, and assess the impact of oral hygiene practices, including the use of mouthwashes, on disease progression and recurrence [39].

Case-Control Studies

Case-control studies are retrospective studies that compare individuals with a particular condition (cases) to those without the condition (controls). These studies are valuable in exploring associations between risk factors and disease outcomes. Casecontrol studies have been conducted to assess the impact of oral hygiene practices, including the use of mouthwashes, on the development and severity of periodontal disease. Such studies provide valuable insights into the potential benefits of incorporating mouthwashes into oral hygiene routines [40].

Evidence-based Guidelines

Evidence-based guidelines are developed by expert panels or organizations to provide recommendations for clinical practice based on the best available evidence. These guidelines serve as a reference for healthcare professionals in making informed decisions about patient care. In the field of periodontal disease management, evidence-based guidelines consider the findings of clinical studies and research to provide recommendations regarding the use of mouthwashes and other adjunctive therapies [41].

Periodontal disease, a prevalent oral health condition, requires continuous advancements in treatment modalities to improve patient outcomes and enhance oral health. In this chapter, we will explore the potential future directions in periodontal disease treatment, including innovative technologies, emerging therapies, and personalized approaches [42].

Regenerative Therapies

Regenerative therapies hold great promise in the field of periodontal disease treatment. These therapies aim to stimulate the regeneration of damaged periodontal tissues, including the regeneration of lost bone and the reattachment of periodontal ligaments. Techniques such as tissue engineering, growth factors, stem cell therapy, and scaffolds are being explored to facilitate the regeneration process and restore the periodontal tissues to their optimal state [43].

Laser Therapy

Laser therapy has gained attention for its potential in treating periodontal disease. Laser technology allows for precise and minimally invasive treatment of periodontal pockets, promoting bacterial reduction, disinfection, and tissue healing. Laser therapy can target bacteria and infected tissues while preserving healthy tissues, leading to improved periodontal health and reduced posttreatment discomfort [44, 45].

Nanotechnology

Nanotechnology has the potential to revolutionize periodontal disease treatment. Nanoparticles, nanofibers, and nanoscale drug delivery systems can provide targeted and controlled delivery of therapeutic agents to periodontal tissues. This approach allows for enhanced antimicrobial activity, improved tissue regeneration, and more efficient drug delivery, thereby optimizing treatment outcomes [46].

Genetic and Precision Medicine

Advancements in genetic and precision medicine have opened up new avenues for personalized treatment approaches in periodontal disease. Understanding an individual’s genetic predisposition to periodontal disease can help tailor treatment plans and identify individuals who may benefit from specific therapies or interventions. Precision medicine approaches may include targeted antimicrobial therapy, customized oral hygiene regimens, and genetic-based risk assessments [47].

Immunomodulatory Therapies

The immune response plays a significant role in the development and progression of periodontal disease. Immunomodulatory therapies aim to modulate the immune response to restore the balance and promote healing. This approach involves the use of immunomodulatory agents, such as cytokines, antibodies, or small molecules, to regulate the immune system and reduce inflammation, thereby improving periodontal health [48].

Microbiome-based Therapies

The oral microbiome, consisting of a diverse array of microorganisms, has been implicated in the pathogenesis of periodontal disease. Microbiome-based therapies involve targeting specific microbial species or modulating the oral microbiome to promote a healthy microbial balance. This approach may include the use of probiotics, prebiotics, or targeted antimicrobial agents to restore a beneficial microbial environment and prevent disease progression [49].

Digital Dentistry

Digital dentistry, including technologies such as computeraided design and computer-aided manufacturing (CAD/CAM), 3D printing, and digital imaging, has transformed various aspects of dental care. In the realm of periodontal disease treatment, digital dentistry allows for precise diagnosis, treatment planning, and fabrication of customized surgical guides or restorations. These technologies enhance treatment accuracy, efficiency, and patient satisfaction [50].

Patient Education and Behavioral Interventions

Empowering patients with knowledge and promoting positive oral health behaviors are crucial aspects of periodontal disease management. Future directions in treatment may focus on developing innovative educational tools, mobile applications, and interactive platforms to educate and motivate patients. Additionally, behavioral interventions, such as motivational interviewing and cognitive-behavioral therapy, may be integrated into treatment plans to promote adherence to oral hygiene practices and lifestyle modifications [51].

Throughout this book, we have delved into the world of periodontal disease and its management. We have explored various aspects, from understanding the disease process to examining the role of oral hygiene practices, clinical studies, evidence-based research, and future directions in treatment.

Periodontal disease is a complex condition that affects the supporting structures of the teeth, including the gums, periodontal ligaments, and alveolar bone. It is characterized by inflammation, bacterial infection, and ultimately, the destruction of these tissues if left untreated. The consequences of untreated periodontal disease can extend beyond oral health, impacting systemic health and overall well-being.

Maintaining good oral hygiene practices, including regular brushing, flossing, and professional dental cleanings, is paramount in preventing and managing periodontal disease. However, the journey towards optimal oral health doesn’t end there. Clinical studies and evidence-based research play a crucial role in advancing our understanding of periodontal disease and its treatment options.

We have explored the significance of clinical studies, such as randomized controlled trials, systematic reviews, longitudinal studies, and case-control studies, in providing valuable insights into the efficacy, safety, and long-term outcomes of various treatment approaches. These studies have guided the development of evidence-based guidelines that serve as a reference for healthcare professionals in delivering optimal care to their patients.

Looking towards the future, we have examined potential advancements in periodontal disease treatment. From regenerative therapies and laser therapy to nanotechnology and precision medicine, these innovative approaches hold promise for enhancing treatment outcomes and revolutionizing patient care. The integration of digital dentistry, patient education, and behavioral interventions further emphasizes the importance of a multidisciplinary approach in managing periodontal disease effectively.

As we conclude our journey through the world of periodontal disease, it is important to remember that prevention is always better than cure. Maintaining good oral hygiene practices, seeking regular dental care, and being aware of the signs and symptoms of periodontal disease are essential in preserving oral health and preventing its complications.

Periodontal disease affects millions of people worldwide, and its impact on individuals and healthcare systems cannot be underestimated. By staying informed, embracing evidence-based approaches, and embracing future advancements, we can work towards a world where periodontal disease is effectively managed, and oral health is prioritized.

None.

No conflict of interest.

1. Janakiram, Chandrashekar, Bruce A Dye (2020) A public health approach for prevention of periodontal disease. Periodontol 2000 84(1): 202-214.‏
2. Nazir Muhammad (2020) Global prevalence of periodontal disease and lack of its surveillance. Scientific World Journal 2020.‏
3. Dhage, Varsha S, Pratibha Chougule (2019) Importance of oral hygiene in oro-dental diseases: A review study. International Journal of Research and Review 6(12): 69-74.‏
4. Kaskova LF (2020) Periodontal diseases in children.‏
5. Salvi Giovanni E (2023) Clinical periodontal diagnosis. Periodontol 2000.‏
6. Caffesse Raúl G, Josė J Echeverría (2019) Treatment trends in periodontics. Periodontol 2000 79(1): 7-14.‏
7. Pal Rashmi S (2020) Herbal Dentifrices: Emerging Trends and Patterns. Current Traditional Medicine 6(1): 54-64.‏
8. Breijyeh, Zeinab, Buthaina Jubeh, Rafik Karaman (2020)Resistance of gram-negative bacteria to current antibacterial agents and approaches to resolve it. Molecules 25(6): 1340.‏
9. Zappavigna Silvia (2020) Anti-inflammatory drugs as anticancer agents. Int J Mol Sci 21(7): 2605.‏
10. Chakravarthy P Kalyana, Sravan Kumar Yeturu (2020) Role of proteolytic enzymes in dental care. Natural oral care in dental therapy: 153-170.‏
11. Calisir Metin (2019) Nanotechnology in dentistry: past, present, and future. Nanomaterials for Regenerative Medicine 197-216.‏
12. Champaiboon, Chantrakorn, Napassorn Ongphichetmetha, Attawood Lertpimonchai (2023)Bioactive glass and arginine dentifrices reduce root sensitivity during daily activities following non‐surgical periodontal therapy: A randomized clinical trial. J Periodontol.‏
13. De Carvalho Leal, Isabelly, Wlhadya Kaenny De Freitas Costa, Vanara Florêncio Passos (2020) Fluoride dentifrice containing calcium silicate and sodium phosphate salts on dental erosion: in vitro study. Arch of Oral Biol 118: 104857.‏
14. Hayes, Martina, Richeal Ni Riordain, Anthony Roberts (2023) Uses of Mouthwashes in Primary Dental Care. Dental Update 50(9): 758-762.‏
15. Barzegar, Peyman Esmaeili Fard (2022) The current natural/chemical materials and innovative technologies in periodontal diseases therapy and regeneration: A narrative review. Materials Today Communications: 104099.‏
16. Scannapieco Frank A, Eva Gershovich (2020) The prevention of periodontal disease—An overview. Periodontol 2000 84(1): 9-13.‏
17. Yadav Akshay R, Shrinivas K Mohite, Chandrakant S Magdum (2020) Preparation and evaluation of antibacterial herbal mouthwash against oral pathogens. Asian Journal of Research in Pharmaceutical Science 10(3): 149-152.‏
18. Thornton Clifton P (2022) Anti-inflammatory mouthwashes for the prevention of oral mucositis in cancer therapy: an integrative review and meta-analysis. Support Care in Cancer 30(9): 7205-7218.‏
19. Pärnänen Pirjo, Pirjo Nikula Ijäs, Timo Sorsa (2019) Antimicrobial and anti-inflammatory lingonberry mouthwash—A clinical pilot study in the oral cavity. Microorganisms 7(9): 331.‏
20. Mattei Bruna Marca (2021) Mouthwash with active oxygen (blue® m) reduces postoperative inflammation and pain. Case Rep in Dent 2021: 1-6.‏
21. Vahabzadeh Zakaria (2020) Salivary enzymatic antioxidant activity and dental caries: A cross-sectional study. Dent Med Probl 57(4): 385-391.‏
22. Amissah Felix, Terrick Andey, Kristen M Ahlschwede (2021) Nanotechnology-based therapies for the prevention and treatment of Streptococcus mutans-derived dental caries. J Oral Biosci 63(4): 327-336.‏
23. Youssef Ahmed (2020) Nanotechnology in Preventive Dentistry: A Review. International Medical Journal 27(3).‏
24. Brookes Zoë, Colman McGrath, Michael McCullough (2023) Antimicrobial Mouthwashes: An Overview of Mechanisms—What Do We Still Need to Know?. Int Dent J.‏
25. Rajendiran Meenakshi (2021) Recent development of active ingredients in mouthwashes and toothpastes for periodontal diseases. Molecules 26(7): 2001.‏
26. Ten Cate JM, Marília Afonso Rabelo Buzalaf (2019) Fluoride mode of action: Once there was an observant dentist. J Dent Res 98(7): 725-730.‏
27. Theuretzbacher Ursula (2020) Critical analysis of antibacterial agents in clinical development. Nat Rev Microbiol 18(5): 286-298.‏
28. Jahnavi Kasturi (2019) Non-steroidal anti-inflammatory drugs: an overview. Journal of Drug Delivery and Therapeutics 9(1-s): 442-448.‏
29. Pawar Yuvraj V, Aaditee Gore, Megha T Salve. The review on mouth washes.‏
30. Naghsh Narges (2023) A comparative evaluation of the antimicrobial effect of chamomile, Aloe vera-green tea, and chlorhexidine mouthwashes on some oral bacterial species. Dent Res J (Isfahan) 20(1): 70.‏
31. Anselmo Aaron C, Samir Mitragotri (2019) Nanoparticles in the clinic: An update. Bioeng Transl Med 4(3): e10143.‏
32. Rowińska Ilona (2021) The influence of diet on oxidative stress and inflammation induced by bacterial biofilms in the human oral cavity. Materials 14(6): 1444.‏
33. Liss Anna (2022) Evidence-based dental hygenist practice in the non-surgical therapy of patients with periodontitis: outcomes of therapy and factors associated with the quality of care.‏
34. Di Stefano Mattia (2022) Impact of oral microbiome in periodontal health and periodontitis: a critical review on prevention and treatment. Int J Mol Sci 23(9): 5142.‏
35. Dalvi Snehal (2021) Effectiveness of antimicrobial photodynamic therapy in the treatment of periodontitis: a systematic review and meta-analysis of in vivo human randomized controlled clinical trials. Pharmaceutics 13(6): 836.‏
36. Abdelmagyd, Hossam Abdelatty Eid, Shishir Ram Shetty, Manea Musa Musleh Al-Ahmari (2019) Herbal medicine as adjunct in periodontal therapies-A review of clinical trials in past decade. J Oral Biol Craniofac Res 9(3): 212-217.‏
37. Assiri Hassan (2020) Cone beam computed tomography (CBCT) in periodontal diseases: a systematic review based on the efficacy model. BMC Oral Health 20(1): 1-15.‏
38. Natto Zuhair S, Alhassan Hameedaldain (2019) Methodological quality assessment of meta-analyses and systematic reviews of the relationship between periodontal and systemic diseases. J Evid Based Dent Pract 19(2): 131-139.‏
39. Beck JD (2019) Periodontal medicine: 100 years of progress. J Dent Res 98(10): 1053-1062.‏
40. Komlós György (2021) Periodontitis as a risk for oral cancer: a case–control study. BMC oral health 21(1): 640.‏
41. Kebschull Moritz, Iain Chapple (2020) Evidence-based, personalised and minimally invasive treatment for periodontitis patients-the new EFP S3-level clinical treatment guidelines. Br Dent J 229(7): 443-449.‏
42. Golub Lorne M, His Ming Lee (2020) Periodontal therapeutics: Current host‐modulation agents and future directions. Periodontol 2000 82(1): 186-204.‏
43. Sallum Enilson A (2019) Experimental and clinical studies on regenerative periodontal therapy. Periodontol 2000 79(1): 22-55.‏
44. Theodoro Leticia Helena (2021) LASER in periodontal treatment: is it an effective treatment or science fiction? Braz Oral Res 35.‏
45. AlAhmari Fatemah, Lujain Shaikh, Deema AlDhubaiban (2020) Photodynamic therapy in the treatment of periodontal diseases: A review. Journal of International Oral Health 12(2): 102-108.‏
46. Hassan Shaik Ali (2020) Latest advancement in periodontology.‏
47. Sima Corneliu, Thomas E Van Dyke (2020) Systems medicine and periodontal diseases. Translational Systems Medicine and Oral Disease. Academic Press 249-282.‏
48. Xu Xiao Wei (2021) Roles of immune cells and mechanisms of immune responses in periodontitis. Chin J Dent Res 24(4): 219-230.‏
49. Curtis Mike A, Patricia I Diaz, Thomas E Van Dyke (2020) The role of the microbiota in periodontal disease. Periodontol 2000 83(1): 14-25.‏
50. Lin Liwei (2019) 3D printing and digital processing techniques in dentistry: a review of literature. Advanced Engineering Materials 21(6): 1801013.‏
51. Suvan Jean E (2022) Behavioral strategies for periodontal health. Periodontol 2000 90(1): 247-261.‏