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Disclosing solution applied to the teeth allows observation of mature bio lm for improved home hygiene measures. Professional bio lm removal can be performed with non-abrasive air polishing. In studies of PI, air-polishing with erythritol has shown superior or similar clinical outcomes to mechanical debridement with manual instruments. ese results were substantiated by the reduction in the microbial load as well as the reduction in the in ammatory cytokines 37,38 . Lasers can be a useful adjunct to root surface debridement as they allow deep and lasting decontamination of pathogens, removal of infected epithelium and inactivation of bacterial endotoxins in periodontal pockets and implant surfaces [39,40]. High powered diode lasers can be used for laser bacterial reduction (LBR), in combination with photosensitisers to release oxygen free radicals in photodynamic therapy (PDT) or in combination. Wavelengths such as Er:YAG and Nd:YAG can denature microbiota and remove diseased bio lm 41–43 . Many bacteria are resistant to conventional debridement as A.a., P. gingivalis, T. forsythia, F. nucleatum, P. intermedia and T. denticola can all internalize within epithelial cells 44,45 . Using lasers may be of bene t as a minimally invasive method of de epithelialising the deep infected pockets compared with root surface debridement alone 41–43 . e use of Er:YAG laser to create photoacoustic shockwaves for bio lm removal from the implant surface also shows merit 46–49 . Antimicrobial agents that can assist in the decontamination of the implant surface can help to maintain successful osseointegration. Ozone is a powerful oxidant that is used worldwide for water puri cation due to its antibacterial, antiviral and antifungal properties. It is a tri-oxygen molecule that can be applied in gaseous or aqueous form. Ozone has rapid acting properties to damage prokaryotic cells without antioxidant defenses. In human cells, it is also anti-in ammatory, stimulates wound healing and activates the cellular and humeral immune system 50,51 . In dentistry, we use ozonated water to manage bio lm in dental water lines,

as a pre-operative rinse and it can be used in our air polishing equipment and lasers for active disinfection during treatment 52 . It can be dispensed at various concentrations (1-4 ppm) from taps or through rechargeable portable devices for home use (Fig. 5). Patients report reduced bleeding, sensitivity and gum problems from daily use. Dramatic changes in patients’ OM have been observed in as little as two months of regular use. Mature subgingival microbiota can be observed within a week so regular and accurate disruption of the implant surface is essential to prevent peri-implant complications. Combination therapy of ozone in air polishing and laser devices shows rapid changes to bio lm and prevention of recolonisation of spirochetes. Parasites Parasites such as protozoa or helminths (worms) can be found in the oral cavity and may contribute to oral infections or diseases. e two most common oral protozoa are Entamoeba gingivalis and Trichomonas tenax . ey are considered commensal and believed to be more prevalent with poor oral hygiene and lower socioeconomic areas however that belief may be changing 53 . Several studies link the presence of amoeba with not only periodontal disease but associating it with other chronic health conditions like diabetes and hypertension 54–57 . e higher prevalence of parasites in periodontal disease may elevate its status to being more than ameremarker for the disease. Bio lms with parasites are easily distinguishable due to their movement and irregularly shaped WBCs. Clinical signs of in ammation are frequentlyalsopresentwhen theseparasites are visible. e removal of these parasites through optimal home hygiene protocols is problematic and the use of antiparasitic antibiotics such as metronidazole could improve outcomes 58,59 . Case Report 1 A 70-year old patient presented to our clinic after a recent heart attack where he had three stents placed. is was during a period when COVID-19 was considered high-risk and no hygiene procedures were being performed. His bacterial screening showed a high level of dysbiosis with clusters of spirochetes despite routine bi-daily brushing and ossing. As we were unable to perform any professional bio lm removal we advised him to use a portable ozonated water generator to ozonate water to rinse with for 60s after brushing. Within 3months, we can see that the number of spirochetes had dramatically decreased and there were minimal signs of dysbiosis (Fig. 6).

Fig. 6 Clusters of spirochetes and many background spirochetes (left), Few spirochetes (right)

Case Report 2 A 26-year old female had a bone level implant and healing abutment placed into a healed 36 position. Two months later the patient presented with implant mobility, suppuration and bleeding. Her oral bio lm showed moderately-high motility bacteria and WBCs and high numbers of spirochetes. Treatment involved Guided Bio lm erapy (GBT) and Laser Assisted Peri-Implant Treatment (LAPIT) (Fig. 7) and torquing the implant to 35Nm.

Fig. 7 Laser Assisted Peri-Implant Treatment with ozonated water

e patient maintained immaculate oral hygiene with Dr Hisham’s Vital Tooth Serum (coconut oil, xylitol, totarol oil) and 5 weeks later showed no clinical signs of in ammation, low bacterial load and low motility bacteria with minimal spirochetes. A one-month review showed no complications and the implant was successfully restored at 6 months post placement (Fig. 8). No signs of dysbiosis were present at the time of implant crown placement.

Fig. 8 Biofilm of infected implant – moderately heavy load of spirochetes and WBCs (left), Biofilm taken 5 weeks post-treatment of GBT and LAPIT (right)

Fig. 5 Ozonated water dispensers and its use in dental equipment

92 AUSTRALASIAN DENTIST