Non-Surgical Treatment of Periodontal Diseases: Responsibilities of the Dentist and the Patient in Periodontal Therapy

*Luis V. Maita-Véliz and Luis M. Maita-Castañeda*

## **Abstract**

Periodontal diseases, throughout history, remain among the most prevalent in humans. Despite the notable scientific advances in the knowledge of its etiology and pathophysiology, its clinical forms, diagnosis and corresponding treatment, the most transcendental stage has yet to be completed: making not only patients in particular, but the entire community aware of the need for surveillance and prevention of periodontal diseases in children, adolescents and adults. Developing a wide-ranging periodic program, with effective and sufficient procedures to anticipate the onset of periodontal diseases, would mean enormous economic savings in the public health budget of the countries. Periodontal diseases can be avoided with simple measures and procedures: correct brushing and good use of dental floss. Both practices would be enough to prevent periodontal diseases in millions of people around the planet. It is a challenge for dental professionals to achieve, through appropriate teaching techniques, that their patients learn these notions and their benefits, thus gradually turning them into essential and daily tasks. The basic objective of promotion and prevention is precisely to ensure that the information produces changes in individual oral hygiene habits.

**Keywords:** gingivitis, periodontitis, prevention, periodontal hygiene, non-surgical treatment

## **1. Introduction**

Periodontal diseases are one of the most prevalent in humans. In most countries, this index is high and has been maintained for years without major changes.

What agent or phenomenon motivates them? Basically: bacterial plaque or biofilm. Who should control that bacterial plaque? First of all, the affected person. What should you do? Exercise continuous care of your teeth.

It is worth clarifying that there are also adjuvants of a genetic or environmental nature, specific to the patient or their living conditions. These adjuvants modulate the course of periodontal diseases or infections [1, 2].

The basic periodontal therapeutic method continues to be the removal of biofilm from supragingival and/or subgingival spaces or areas, through well-known therapeutic procedures: periodontal hygiene, scaling, and root planning [3].

Non-surgical periodontal treatment is "the cornerstone of periodontal therapy or the gold standard" and is the essential procedure to combat periodontal infections [3].

Phase I is a therapy related to the cause, and therefore, the entire chronological sequence of a periodontal treatment should be initiated [4]. In many cases, only the complete fulfillment of Phase 1 is sufficient to recover periodontal health, with which it makes any other procedure in this regard dispensable.

This phase becomes a critical and fundamental part of periodontal treatment, in general. First of all, it prepares the conditions for the dentist to control the bacterial plaque or biofilm. For this, it instills and strengthens the patient the importance and the way to eliminate the biofilm. Otherwise, you will continue to lose periodontal tissues, even after surgical procedures have been carried out to heal them.

Secondly, it offers the professional the opportunity to observe and evaluate the reaction or response of the periodontal tissues to the phase, with which he can recommend reinforcements, such as careful care at home, which allows him/her to know the periodontal hygiene habits of the patient, and discuss them with him.

## **2. Bacterial plaque control**

It is essential for all types of therapy. This control must be assumed by the patient with full knowledge of what he/she must do about it and awareness of its importance [5].

Oral hygiene methods at home are fundamentally oriented toward the elimination of supragingival plaque and the maintenance of good oral health [6].

The lasting success of effective clinical treatment depends mainly on the collaboration of the patient, who is often unaware of this responsibility [7].

We must carefully and affectionately explain to the patient the nature of the biofilm and the reasons why it needs to be removed for periodontal therapy to be successful "Learning is experience, everything else is information" Einstein.

The patient must be guided in the selection of the most suitable instruments for their individual needs and instructed on the correct way to perform oral hygiene.

The time dedicated to the teaching of these actions and to the conviction of assuming the changes by the patient will depend on the individual needs of the same. It is not an easy task, the patient is not aware of the importance of having good periodontal health and updating their information on hygiene habits. In general, he/ she does not know beyond what he learned as a child [8].

Each patient deserves personalized guidance. It is essential to always schedule enough time to explain the techniques and verify the learning of it. The use of audiovisual teaching materials is also recommended to better integrate and/or clarify home oral hygiene methods. It is convenient to suggest:

*Non-Surgical Treatment of Periodontal Diseases: Responsibilities of the Dentist… DOI: http://dx.doi.org/10.5772/intechopen.107332*

If the patient wishes to use an electric toothbrush, he should be warned about the possible risk of causing non-carious cervical lesions, such as dental abrasions or cervical dentin hypersensitivity.

We must make the patient understand that his/her persevering collaboration will determine the desired result. Letting them know the etiology of the disease will facilitate the teaching of a correct periodontal hygiene technique. This means emphasizing the location or placement of the brush bristles in the gingival sulcus, as indicated by the Bass Technique.

The use of dental floss has an equal or greater role than hygiene with a brush alone. The proximal areas are crucial because periodontal disease begins precisely in these areas, because the junctional epithelium of these interproximal spaces has few layers of epithelial cells, which facilitate their conversion into vulnerable areas for the colonization of periodontal pathogens and the consequent deterioration of periodontal health; in addition, this junctional epithelium is not keratinized.

The classic study by Löe et al., in 1965, demonstrated the close relationship between the accumulation of microbial plaque and the development of gingivitis in humans. The study consisted of absolutely suppressing the means of oral hygiene in a group of volunteers. All the people in the research developed gingivitis in a range of 7–21 days. The predominant composition of the bacterial flora was gram. After 7 days of brushing again, good recovery of gingival health was achieved [10].

The careful and correct control of the supragingival biofilm modifies and affects the development and composition of the subgingival biofilm. This allows for a stable microflora and reduces stone formation [11].

Constant control of biofilm at home, added to visits to the dentist for periodontal prophylaxis and calculus removal, will reduce the amount of supragingival biofilm, decrease the total number of microorganisms sheltered in moderate periodontal pockets and furcation areas, and will finally restrict the abundance of periodontal pathogens [12, 13]. The increase in biofilm or biofilms occurs hour after hour and must be completely removed within 48 hours at most from all places with poor periodontal health to prevent inflammation [14]. The American Dental Association (ADA) recommends brushing teeth twice a day and use dental floss for interproximal cleaning once a day; in this way, we will achieve an effective removal of biofilm and prevent gingivitis [15].

A single brushing removes only part of the dental plaque. Doing it twice ensures better results. Bear in mind that periodontal disease begins and is located in the interproximal spaces, places where precisely a single brushing does not completely exclude bacterial plaque [16].

Another risk factor is that periodontal patients are easily susceptible to periodontal disease, a consequence of complex defects in the gingival architecture, caused by the same periodontal disease that afflicts them and the extensively exposed root surfaces. All this hinders correct periodontal hygiene [17].

The antibacterial agent that has shown the most effective is chlorhexidine. Various investigations have provided evidence that it almost completely inhibits the development of biofilm, calculus, and gingivitis. The most commonly used concentration is 0.12% [18]. Chlorhexidine has some reversible side effects, including slightly darkening resin restorations, tooth surfaces, and the tongue. Chlorhexidine is commonly found as a non-alcoholic preparation. In any form of presentation, it is effective for biofilm control [19].

Likewise, there are natural products that are being investigated and used as adjuvant agents in the control and treatment of periodontal disease [20, 21].

## **3. Toothbrush**

It is an implement that has two parts: a handle and a head. The head has bristles (soft or hard) whose function is to remove, through specific movements, food, and drink residues that adhere to the dental surfaces or are lodged in the adjoining interstices. Toothbrushes come with a wide variety of bristles in terms of size, design, length, hardness, and arrangement (**Figure 1**).

There is no ideal brushing technique for all patients [6].

Patients can use a brushing technique that effectively removes microbial plaque while avoiding trauma to soft tissue. It can be concluded by saying that efficiency is more important than technique [22].

The investigations, regarding the advantages of each one of the brushes, do not determine exactly if there is any superiority in cases of gingivitis or gingival bleeding. A comparative study of four different toothbrushes, in their action of removing biofilm with brushing, showed that the four chosen brushes equally removed biofilm and that a certain configuration was not more effective than another [5] (**Figures 2**–**4**).

After a systematic review of several studies on toothbrushes, it was concluded that there is no superior or better design between one or the other [24].

The effectiveness and the potential for injury offered by the different types of brushes depend to a large extent, and especially on the technique of use and manual skill.

### **Figure 1.**

*Straight-handle toothbrush with a head that houses the spaced tufts. The bristles are soft. The edge, at its end, is rounded.*

### **Figure 2.**

*Difficult access area and, therefore, difficult to clean, if a toothbrush with an excessive number of bristles is used. Adapted from MacPhee T., Cowley G [23].*

*Non-Surgical Treatment of Periodontal Diseases: Responsibilities of the Dentist… DOI: http://dx.doi.org/10.5772/intechopen.107332*

### **Figure 3.**

*Toothbrush with a sufficient number of bristles for brushing in complicated areas. Adapted from MacPhee T., Cowley G [23].*

**Figure 4.** *A plume-type brush can also be used. Adapted from MacPhee T., Cowley G [23].*

When used incorrectly, the toothbrush can cause injuries or alterations, both on the dental surface and in the gingival tissues (**Figures 5** and **6**).

The alterations, such as abrasion (non-carious cervical lesions), are related to various dental factors involved in tooth brushing: use of brushes with hard bristles,

### **Figure 5.**

*The patient has brushed to the extreme by applying excessive force. At the gingival margin of maxillary central incisors 1.1 and 2.1, erosive traumatic lesions are observed.*

### **Figure 6.**

*The patient has not brushed for several days. In both jaws, a whitish layer is noted on the marginal and attached gingiva. It is the accumulation of keratin.  The mucosal surface will not show any alteration and all features are normal.*

horizontal brushing applying excessive force, use of toothpaste with highly abrasive substances, poor dental position, and others. Any of these factors can induce the appearance of abrasive cervical lesions and gingival recessions [25].

With some frequency, traumatic injuries to soft and hard tissues are observed, due to the use of inappropriate toothbrushes with hard, uneven, or very worn bristles, and also due to inadequate or incorrect brushing techniques [26] (**Figure 7**).

Pointing out, we will say: bristles with rounded ends cause less damage to gingival tissues than flat-cut bristles with sharp ends [27, 28].

Soft-bristled toothbrushes, described by Bass more than 70 years ago, have gained wide acceptance and continue to be used by the professional dental community [29].

It is very important to consider that in order to recommend a toothbrushing technique, we must clinically assess the keratinization of the gingiva and the periodontal biotype, that is, whether it is a thick or firm biotype [30].

### **Figure 7.**

*Patient who, despite being warned of the need to change his/her brushing method, and having been given instructions for an effective brushing technique, did not cooperate in applying it.*

*Non-Surgical Treatment of Periodontal Diseases: Responsibilities of the Dentist… DOI: http://dx.doi.org/10.5772/intechopen.107332*

There are also electric brushes. They are useful in the following cases: children and adolescents, people with physical or mental disabilities, hospitalized patients including the elderly (elderly) requiring assistant careers, and, in some cases, patients with fixed orthodontia. In the case of children, it is recommended that they first learn to use a regular toothbrush, then an electric toothbrush.

The role of toothpaste is to help clean and polish the surface of the teeth, increasing the effectiveness of brushing. Toothpastes are products that contain various substances, including some abrasives. Abrasives are insoluble inorganic salts. They serve to increase the abrasive action of brushing up to 40 times more and constitute between 20% and 40% of the composition of toothpaste. Oral hygiene procedures that use abrasive toothpaste are the essential cause of hard tissue damage and it is possible that gingival lesions could also be caused by those ingredients [31].

## **4. Reasons for oral hygiene**

Several classic studies show the importance of controlling supragingival bacterial biofilm. Löe et al. unquestionably demonstrated the cause-effect relationship between the accumulation of bacterial biofilm and the appearance of gingivitis within a period of 21 days in adults [10].

Gingivitis was confirmed to be reversible during the first 7 days if the discipline of adequate brushing to remove biofilm was restored; even when, from the beginning, the supragingival plaque had been largely dominated by gram-negative microorganisms, responsible for the aforementioned gingivitis [32].

Periodontal maintenance programs, which emphasize careful toothbrushing for adequate supragingival plaque control, reduce periodontal attachment loss in adults [32].

By way of conclusion, we can affirm the following:

## **5. The dentist-educator**

Dentists must understand that they need to assume the role of educators if they want to guarantee the success of periodontal treatment. It is not easy to get any change in the lifestyle of an adult. It is not easy to convince him of the urgency of change for a healthier life [33]. Someone said: "We all want a better life but to have a better life you have to be better." And that is only achieved by learning to change.

*"Only someone who is devoted to a cause with all his might and soul can be a true teacher." – Einstein.*

There are numerous social and economic factors that are beyond the influence of the dentist, but even so, the profession has certain inalienable obligations: educate the patient about good oral hygiene habits, find ways to motivate him/her to apply the recommendations given, provide regular professional cleaning service (prophylaxis), apply fluoride to young teeth, use sealants, and, if the disease appears for collateral reasons, carry out a correct treatment that does not lead to damage or greater disease [33].

*"It is not the strongest species that survives, nor the most intelligent, but the one that best responds to change." – Charles Darwin.*

The incorporation of the philosophy of prevention into ordinary work has to do with the way of thinking and disposition of each dentist [33].

Providing a preventive service, based on the active participation of the patient, suggests that even the word "patient" in that circumstance would be inappropriate, perhaps it would be better to qualify it and see it as a "student" [33].

The values and attitudes of the dentist do not necessarily coincide with those of the patient; he/she fundamentally wants to eat comfortably and look good. Instead, the clinician wants to achieve a zero-plaque score and a balanced occlusion. These different ways of approaching the success of the treatment have to be approached little by little, by conviction, because both are essential. The dentist must grade the information and give it in simple language, adapting to the level of understanding. He must generate such stimulation that the patient puts the instructions into practice because he/she has assumed the advantages of following them, as well as the disadvantages of ignoring them. Unfortunately, many dentists do not value this teaching task enough to give it their time or do not have sufficient preparation to tackle it, and even when faced with the advice to undertake it, they are impatient or arrogant [33].

Too often, dentists find it difficult to give themselves the space to provide patients with the necessary information or, sometimes, patients do not appreciate the value of the time spent instilling this valuable information in themselves [33].

As a didactic aid, we could say that the information should be enunciated based on a direct demonstration in the patient's own mouth, even better before starting treatment. It is very useful to provide the patient with a hand mirror so that he/she can observe part of the examination, point out the bacterial plaque and the calculus, and explain the relationship of these elements with periodontal disease.

Emphasize that bacterial plaque is the main cause of the disease. The plaque is almost always imperceptible, but by applying a revealing substance it becomes visible [33]. Once this is done, the patient is given a toothbrush and asked to try to remove all the stained plaques.

As a strategy, in such an instance, the patient should not be instructed in any particular brushing technique. Let the patient realize the difficulty he/she finds in completely removing bacterial plaque. This will make you more receptive to advise and reasons. When the patient becomes aware that it is very difficult for him/her to remove all the plaque, we will teach him/her a brushing technique and how he/she can develop the necessary skill [33].

The result of the patient's motivation and prophylactic education is not seen immediately, and it requires continued support by the dental staff, organized for this purpose, and the patient's perseverance [34].

Long-term studies conducted in Sweden by Axelsson and Lindhe provide convincing evidence of the benefits of a regular professional care program [35].

## **6. Tooth brushing requirements**

1.The selected technique should clean all tooth surfaces, especially the gingival sulcus area and the interdental region.

2.Brushing should not injure hard or soft tissues.

*Non-Surgical Treatment of Periodontal Diseases: Responsibilities of the Dentist… DOI: http://dx.doi.org/10.5772/intechopen.107332*

### **Figure 8.**

*If we divide each arch into 12 areas, we will achieve an orderly brushing that covers all the teeth. Adapted from MacPhee T., Cowley G [23].*

Each patient has different characteristics and, therefore, different needs, so there is no perfect brushing for all situations, but rather a brushing adapted to the individuality of the patient [36].

## **7. Oral hygiene methods**

Several toothbrushing techniques have been proposed and recommended, including the following:

No brushing method has been shown to be superior to the rest [37].

### **7.1 Rubbing brushing method**

It is perhaps the oldest [38]. Its brushing technique is the simplest, and it places the bristles on the teeth and moves back and forth. It does not require any prior training. The method is not aimed at cleaning the gingival margin. Vigorous rubbing with a stiff bristle brush can cause trauma and gingival recession.

### **7.2 Circular brushing method**

The bristles are placed on the gums, and then, the brush is rotated over the surface of the teeth. On the upper teeth, the toothbrush is rotated downward. On the lower teeth, it goes up. The same is then done with the occlusal surfaces.

### **7.3 Charters planning method**

The brush is directed toward the crown of the tooth, at an angle of 45°, in the opposite way to the Bass Technique [39].

### **7.4 Stillman planning method**

The brush is directed at a 45° angle toward the gingiva and rotated toward the crown (twist technique) [39].

### **7.5 Bass technique**

Dr. Charles Cassidy Bass, a medical doctor and researcher, described, in 1948, a dental brushing technique aimed at removing bacterial plaque from the gingival sulcus.

The brushing bristles are arranged so that there is an angle of approximately 45° relative to the long axis of the tooth. The brushing bristles should be directed toward the gingival sulcus. The brush is pressed against the gum and activated in a small circular motion so that the bristles enter the sulcus and are drawn into the sulcus area for cleaning. This action can be painful if the gingival tissues are inflamed and tender. It has been shown that it is the most effective method to remove bacterial plaque from the gingival area of the tooth. It is the method of choice also for healthy gums. The brush should have soft, rounded, and flexible bristles [40] (**Figures 9** and **10**).

In the following clinical case, it is possible to appreciate the efficiency of the Bass technique in the solution of a gingival inflammatory process. The patient is a 22-yearold university student (health sciences) who attended our private practice due to gingival bleeding for about 6 months. He had received dental care at a university clinic for several months and had seen no recovery from his periodontal health. Periodontal examination was performed. The periodontal diagnosis was as follows: chronic gingivitis and moderate gingival enlargement in some areas. The patient was very concerned about his periodontal health. It was explained to him that the first step to recovering his health was to develop a correct periodontal brushing technique to eliminate the biofilm, which causes chronic gingivitis. We detailed the Bass technique and he was given an appropriate brush. He also received information about the use of dental floss for interproximal areas, places where the brush cannot remove the biofilm.

*Non-Surgical Treatment of Periodontal Diseases: Responsibilities of the Dentist… DOI: http://dx.doi.org/10.5772/intechopen.107332*

### **Figure 9.**

*Bass technique or sulcus brushing. The ends of the bristles are inserted into the gingival sulcus and over the marginal gingiva.*

### **Figure 10.**

*The brush of Dr. Bass, pioneer of preventive dentistry, can now be found and purchased.*

The dental assistant was in charge of biofilm control at each office visit. No other periodontal procedure such as scaling or root planning was applied. Only correct brushing was sufficient, during the period of periodontal treatment, to achieve absolute recovery of periodontal health (**Figures 1**–**20**).

### **7.6 Plate developer**

They are substances capable of staining the bacterial biofilm to make it visible so that its removal is easier. Its application should be disseminated by all dentists since it allows locating where the biofilm is located and identifying the areas of the oral cavity

### **Figure 11.**

*On the first day of the consultation, it is noted that the patient has redness of the gingival margin, of the papillae and papillary enlargement. Spontaneous gingival bleeding may be noted.*

### **Figure 12.**

*The bacterial biofilm shows greater intensity and extension in the lower teeth. Lower dental crowding contributes to bacterial buildup.*

### **Figure 13.**

*Profuse and spontaneous gingival bleeding is observed on the palatal aspect of the maxillary anterior teeth. Dental crowding of the incisors contributes to this.*

### **Figure 14.**

*After nine days of periodontal treatment with the application of the Bass technique, favorable gingival changes are manifested.*

*Non-Surgical Treatment of Periodontal Diseases: Responsibilities of the Dentist… DOI: http://dx.doi.org/10.5772/intechopen.107332*

### **Figure 15.**

*After two weeks of treatment, the recovery of the patient's periodontal health is already noticeable.*

#### **Figure 16.**

*At three weeks, the evolution of the periodontal treatment is very favorable. In the anterior and inferior regions, the periodontal tissues are completely healthy.*

#### **Figure 17.**

*After those three weeks of starting periodontal treatment, also the profuse gingival bleeding on the palatal aspects of the maxillary anterior teeth has ceased and the gingival papillae are healthier.*

### **Figure 18.**

*Two months later, periodontal treatment with the Bass technique has restored 100% periodontal health.*

### **Figure 19.**

*After one year and two months of using the Bass technique and the use of dental floss, the periodontal tissues of the palatal surfaces continue to maintain their excellent periodontal health.*

### **Figure 20.**

*In addition, after that year and two months, the periodontal tissues maintain their excellent periodontal health. If this disciplined care continues, the patient will enjoy an optimal quality of life, avoiding the appearance of periodontitis.*

*Non-Surgical Treatment of Periodontal Diseases: Responsibilities of the Dentist… DOI: http://dx.doi.org/10.5772/intechopen.107332*

that need more attention and better oral hygiene. The development of bacterial plaque or biofilm represents such an important step that it could be compared with periodontal diagnosis. Its use should be universal, even in periodontally healthy people. It is also a useful resource for choosing the most appropriate toothbrushing technique and recommending the use of dental floss. In this way, both dental caries and periodontal diseases are prevented.

Plaque or biofilm developers contain special dyes that stain biofilm red, pink, or purple. They come in pills, developer gel, developer liquid, and rinses. It is worth warning the patient that the staining will disappear with a well-executed brushing.

## **8. Dental floss**

The interdental area is where biofilm, biofilm, or plaque is usually retained and, at the same time, the area most inaccessible to tooth brushing.

The most useful element to remove biofilm is dental floss because it is more effective than others. Its handling must be careful not to injure the interproximal gingiva. There is not much difference between flossing with wax or without wax.

A threader can be a good help in cleaning up hard-to-reach posterior areas. However, dental floss is currently manufactured with a special finish that allows it to be inserted comfortably in the posterior areas (**Figure 21**).

### **8.1 Technique of use of dental floss**

1.The dental floss should be placed firmly around the knuckle of one finger of each hand. Then firmly hold a short portion between the guide fingers (**Figures 22** and **23**).

#### **Figure 21.**

*Special dental floss with the following sections and characteristics: the first section, the threader, commonly the pin; second section, "sponge thread"; third and last section, standard dental floss.*

**Figure 22.** *An effective method of holding dental floss. Adapted from Pawlak EA and Hoag P.M [41].*

### **Figure 23.**

*Flossing. The wrapping around the vestibular and palatal (lingual) faces is to eliminate the largest amount of bacterial biofilm. Adapted from Pawlak EA and Hoag P.M [41].*

## **9. Special areas for oral hygiene**

There are places or surfaces that are very difficult to clean, such as the following:

In these cases, the use of the single-plumed brush is very beneficial and favorable [42].

## **10. Other items for oral hygiene**

Longitudinal studies reveal that sites with inadequate plaque removal have deeper probing depths and attachment loss after periodontal therapy [43, 44].

Some researchers recommend that the patient be instructed in the use of gauze pads as a good alternative to remove biofilm. The use of gauze is not traumatic.

It is advisable in special cases such as the following: after periodontal surgery, implant surgery, difficulty opening the mouth, lack of manual dexterity, disabled patients or patients with mobility problems. In addition, on surfaces adjacent to edentulous areas with the presence of crowns.

The gauze is recommended when food has been eaten apart from meal times or outside the home, and also if for some other reason when the toothbrush cannot be used [42]. The use of gauze in specialized clinics is very widespread to do the cleaning of the mucous membranes of the newborn after delivery (**Figures 24** and **25**).

The buccal, palatal or lingual, and occlusal surfaces of the teeth are easy to clean with toothbrushes, but these do not reach the interdental region of the teeth efficiently [45].

Slot DE et al., after a systematic review of the efficacy of manual brushes, reached the following conclusion: at the end of a brushing exercise, and only 42% of the biofilm is removed on average [46].

Other studies indicate that even using proper technique, you can clean only 65% of the total tooth surface. Due to the limitations of brushes in penetrating proximal areas and interdental hygiene, that is, flossing gains attention as a separate title. Interdental plaque biofilm control measures should consider perfecting tooth brushing so that it is a complement to mechanical cleaning [47, 48].

### **Figure 24.**

*A female patient diagnosed with chronic periodontitis III, grade A. Tooth separation and migration of tooth 1.2 is evident.*

#### **Figure 25.**

*As an alternative, given the area, to remove the biofilm between teeth 1.2 and 1.1, the patient can use gauze.*

Since patients have different types of dentition and also different interdental spaces, it will be advisable to recommend the appropriate devices according to the individuality of the patient, and also guide him/her in considering his/her personal needs [48].

Added to this is that patients pay more attention to the anterior areas and brush the posterior teeth very superficially on their palatal and lingual surfaces.

For the maintenance of periodontal health and the prevention of dental caries, tooth brushing should be combined with interdental cleaning once every 24 hours [49, 50].

A recent study, conducted on young subjects without interdental attachment loss, found that toothbrushing, in combination with dental flossing, is capable of reducing both plaque and gingival inflammation [51].

When the interdental space is filled with the gingival papilla, especially in the case of young people, dental floss is the best option to reach this area [52].

Christo et al. designed a randomized, split-mouth clinical trial that aimed to compare the clinical efficacy of flossing and interdental brushing, along with tooth *Non-Surgical Treatment of Periodontal Diseases: Responsibilities of the Dentist… DOI: http://dx.doi.org/10.5772/intechopen.107332*

brushing. After 6 weeks, in combination with a manual toothbrush, interdental brushing was found to be more effective in removing plaque and reducing probing depth compared to flossing [53].

On the way to the definitive solution, it is an excellent support to educate patients on prevention measures, trying to be more explicit and insistent with those who do not have dental insurance. Thus, gradually, they will alleviate their periodontal diseases and achieve optimal dental health.

*"In the long history of humanity and also of the animal world, those who learned to collaborate and improvise are the ones who have prevailed." Charles Darwin [54].*

Patients may know and understand the benefits of flossing and rinsing, but only 1 in 6 make them a daily habit. These good practices are not widely executed by the general population. Among the barriers experienced by the respondents we have: fear of bleeding, gingival pain, and forgetting to floss or rinse in their daily hygiene despite knowing that these habits would improve their oral health [55].

The critical problem for clinicians is not the arrest of periodontal disease, but rather the identification of patients at high risk of experiencing the active and progressive disease. This challenge raises the issue that perhaps dentistry needs to change its approach to gum disease [56].

## **11. Conclusion**

Bacterial biofilm is the main etiological agent of periodontal diseases. Periodontal diseases can be prevented with simple procedures: good brushing technique and use of dental floss. The removal of bacterial biofilm with regular brushing is efficient, but it is not enough. The complementation with other hygiene elements (interdental brushes, dental floss, gauze, mouth rinses, interdental rubber bristles, oral irrigator, and others) achieves excellent results, as demonstrated by many research works. Dentists and auxiliary personnel must assume their roles in a leading role, and become aware of their responsibility in the prevention of periodontal diseases wherever they have to practice.

*"What would life be if we didn't have the courage to try something new?" Vincent Van Gogh.*

## **Acknowledgements**

To Professor Mag. Lily Cardich for her thorough revision of her style from the original manuscript. To Ms. Karime Z. Salas Garcia for her illustrations for the article, as well as her great responsibility. Likewise, to Ms. Nuria L. Salas Garcia for her diligent work in typing the original document.

## **Conflict of interest**

"The authors declare no conflict of interest."

*Periodontology - New Insights*

## **Author details**

Luis V. Maita-Véliz\* and Luis M. Maita-Castañeda National University of San Marcos, Lima, Peru

\*Address all correspondence to<EMAIL_ADDRESS>
© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Non-Surgical Treatment of Periodontal Diseases: Responsibilities of the Dentist… DOI: http://dx.doi.org/10.5772/intechopen.107332*

## **References**

[1] Page RC, Kornman KS. The pathogenesis of human periodontitis: An introduction. Periodontology 2000. 1997;**14**:9-11. DOI: 10.1111/j.1600-0757. 1997.tb00189.x

[2] Page RC, Offenbacher S, Schroeder HE, Seymour GJ, Kornman KS. Advances in the pathogenesis of periodontitis: Summary of developments, clinical implications and future directions. Periodontology 2000. 1997;**14**:48-216. DOI: 10.1111/ j.1600-0757.1997.tb00199.x

[3] Cobb CM. Non-surgical pocket therapy: Mechanical. Annals of Periodontology. 1996;**1**(1):90-443. DOI: 10.1902/annals.19<IP_ADDRESS>3

[4] Dentino A, Lee S, Mailhot J, et al. Principles of periodontology. Periodontology 2000. 2013;**61**(1):16-53. DOI: 10.1111/j.1600-0757.2011.00397.x

[5] Claydon N, Addy M. Comparative single-use plaque removal by toothbrushes of different designs. Journal of Clinical Periodontology. 1996; **23**(12):6-1112

[6] Egelberg J, Claffey N. Consensus report: The role of mechanical dental plaque removal in prevention and therapy of caries and periodontal diseases. In: Proceedings of the European Workshop of Mechanical Plaque Control. Chicago, Quintessence. 1998. pp. 169-172

[7] Der Weijden V, f, Slot DE. Oral hygiene in the prevention of periodontal diseases: The evidence. Periodontol. 2011;**55**:104-123

[8] Morillo M, González Y. Plan motivacional para la formación del hábito de higiene bucal en los pacientes que asisten a la clínica integral del adulto del área de odontología de la Universidad Nacional Experimental Rómulo Gallegos. Acta Odontológica Venezolana. 2018; **46**(1):56-60

[9] Roncati M. Terapia periodontal no quirúrgica. España: Editorial Quintessence S.R. Barcelona; 2016

[10] Löe H, Theilade E, Jensen SB. Experimental gingivitis in man. Journal of Periodontology. 1965;**36**:87-177

[11] Suomi JD, Green JC, Vermillion J, et al. The effect of controlled oral hygiene procedures on the progression of periodontal disease in adults: Results after two years. Journal of Periodontology. 1969;**40**(7):416-420

[12] De la Rosa M, Guerra JZ, Johnston DA, et al. Plaque growth and removal with daily toothbrushing. Journal of Periodontology. 1979;**50**(12): 661-664

[13] Hellström MK, Ramberg P, Krok L, et al. The effects of supragingival plaque control on the subgingival microflora in human periodontitis. Journal of Clinical Periodontology. 1996;**23**(10):40-934

[14] Straub AM, Salvi GE, Lang NP. Supragingival plaque formation in the human dentition. In: Lang NP, Ättstrom R, Löe H, editors. Proceedings of the European Workshop on Mechanical Plaque Control. Chicago: Quintessence; 1998

[15] Greenwell H. Committee on research, science and therapy. American academy of periodontology. position paper: Guidelines for periodontal therapy. Journal of Periodontology. 2001;**72**(11):8-1624

[16] Kinane DF. The role of interdental cleaning in effective plaque control: Need for interdental cleaning in primary and secondary prevention. In: Lang NP, Ättstrom R, Löe H, editors. Proceedings of the European Workshop on Mechanical Plaque Control. Chicago: Quintessence; 1998

[17] Teles RP, Patel M, Socransky SS, et al. Disease progression in periodontally healthy and maintenance subjects. Journal of Periodontology. 2008;**79**(5):94-784

[18] Grossman E, Reiter G, Sturzenberg OP, et al. Six-month study of the effects of a chlorhexidine mouthrinse on gingivitis in adults. Journal of Periodontal Research. 1986;**21** (Suppl):33-43

[19] Bascones A, Morante S, Mateos L, et al. Influence of additional active ingredients on the effectiveness of nonalcoholic chlorhexidine mouthwashes: A randomized controlled trial. Journal of Periodontology. 2005;**76**(9):75-1469

[20] Ramos Perfecto D, Maita VL. Tratamiento de la periodontitis en pacientes diabéticos tipo 2 mediante el uso de oleorresina de copaiba como coadyuvante. In: Centro de Producción Imprenta Editorial de la Universidad Nacional Mayor de San Marcos. 2019

[21] Ramos Perfecto D, Maita Véliz L, Maita Castañeda ML, Castro LA. Un producto natural de posible apoyo al tratamiento de la periodontitis: Revisión bibliográfica. Avances en Odontoestomatologia. 2020;**36**(3): 143-149

[22] Ciancio SG. Chemical agents: Plaque control, calculus reduction and treatment of dentinal hypersensitivity. Periodontology 2000. 1995;**8**:7-136

[23] Mac Phee T, Cowley G. Essencials of Periodontology and Periodontics. Second ed. Oxford: Blackwell Scientific Publicactions Osney Mead; 1975

[24] Drisko CL. Periodontal self-care: Evidence-based support. Periodontology 2000. 2013;**62**(1):55-243

[25] Khocht A, Simon G, Person P, et al. Gingival recession in relation to history of hard toothbrush use. Journal of Periodontology. 1993;**64**(9):5-900

[26] Agudio G, Pini Prato GP, Cortellini P. Gingival lesions due to improper methods of oral hygiene. Mondo Odontostomatologico. 1984; **26**(3):45-53

[27] Danser MM, Timmerman MF, Ijzerman Y, et al. Evaluation of the incidence of gingival abrasion as a result of toothbrushing. Journal of Clinical Periodontology. 1998;**25**(9): 6-701

[28] Silverstone LM, Featherstone MJ. A scanning electron microscope study of the end rounding of bristles in eight toothbrush types. Quintessence International. 1988;**19**(2):87-107

[29] Bass CC. The optimum characteristics of toothbrushes for personal oral hygiene. Dental Items of Interest. 1948;**70**(7):697-718

[30] West NX, Moran JM. Home-use preventive and therapentic oral products. Periodontology 2000. 2008; **48**:7-9

[31] Pattison GA. Self-inflicted gingival injuries: Literature review and case report. Journal of Periodontology. 1983; **54**(5):299-304

[32] Axelsson P, Lindhe J. Effect of controlled oral hygiene procedures on *Non-Surgical Treatment of Periodontal Diseases: Responsibilities of the Dentist… DOI: http://dx.doi.org/10.5772/intechopen.107332*

caries and periodontal disease in adults. Journal of Clinical Periodontology. 1978; **5**(2):133-151

[33] Eley BM, Soory M, MJD. Periodoncia. Sexta edición ed. España: Elsevier; 2012. pp. 152-162

[34] Sims W. Preventive dentistry for the dental practitioner. Dental Practice. 1968;**18**:309-314

[35] Axelsson P, Lindhe J. The effect of a preventive programme on dental plaque, gingivitis and caries in schoolchildren. Results after one and two years. Journal of Clinical Periodontology. 1974;**1**(2): 126-138

[36] Bascones MA. Periodoncia Clínica e Implantologia Oral. 4ta edición. 2014. Ediciones Avances Médico-Dentales, España, S.L

[37] Raposa K. Oral infections control: Toothbrushes and toothbrushing. In: Wilkins EM, editor. Clinical Practice of the Dental Hygienist. 11th ed. Philadelphia, PA: Lippincott Willians & Wilkins; 2013. pp. 389-407

[38] Perry DA, Beemsterboer PL, Essex G. Periodontología para el higienista dental. Cuarta edición. 2014 Elsevier España, S.L

[39] Müller HP. Periodontología. México: Editorial El Manual Moderno; 2006

[40] Manson JD. Manual de Periodoncia. Editorial El Manual Moderno, S.A de C.V; 1986

[41] Pawlak EA, y Hoag PM. Conceptos esenciales de periodoncia, 1ra. Editorial Mundi S.A.I.C. y F. 1978

[42] Roncati M. Terapia periodontal no quirúrgica. España: Editorial Quintessence L.L; 2016

[43] Jackson MA, Kellett M, Worthington HV, Clerehugh V. Comparison of interdental cleaning methods: A randomized controlled trial. Journal of Periodontology. 2006;**77**(8): 1421-1429

[44] Loos B, Nylund K, Claffey N, Egelberg J. Clinical effects of root debridement in molar and nonmolar teeth. A 2 year follow-up. Journal of Clinical Periodontology. 1989;**16**(8):498-504

[45] Caton JG, Blieden TM, Lowenguth RA, Frantz BJ, Wagener CJ, Doblin JM, et al. Comparison between mechanical cleaning and an antimicrobial rinse for the treatment and prevention of interdental gingivitis. Journal of Clinical Periodontology. 1993; **20**(3):172-178

[46] Solt DE, Wiggelinkhuisen L, Rosema NA, Van der Weijden GA. The efficacy of manual toothbrushes following a brushing exercise: A systematic review. International Journal of Dental Hygiene. 2012;**10**(3):187-197

[47] Lang NP, Cumming BR, Löe HA. Oral hygiene and gingival health in Danish dental students and faculty. Community Dentistry and Oral Epidemiology. 1977;**5**(5):237-242

[48] Sälzer S, Slot DE, Van der Weijden FA, Dörfer CE. Efficacy of inter-dental mechanical plaque control in managing gingivitis–A meta-review. Journal of Clinical Periodontology. 2015; **42**(Suppl 16):S92-S105

[49] Lang NP, Cumming BR, Löe H. Toothbrushing frequency as it relates to plaque development and gingival health. Journal of Periodontology. 1973;**44**(7): 396-405

[50] Axelsson P, Nyström B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. Journal of Clinical Periodontology. 2004;**31**(9): 749-757

[51] Graziani F, Palazzolo A, Gennai S, Karapetsa D, Giuca MR, Cei S, et al. Interdental plaque reduction after use of different devices in young subjects with intact papilla: A randomized clinical trial. International Journal of Dental Hygiene. 2018;**16**(3):389-396

[52] Schmage P, Platzer U, Nergiz I. Comparison between manual and mechanical methods of interproximal hygiene. Quintessence International. 1999;**30**(8):535-539

[53] Christou V, Timmerman MF, Van der Velden U, Van der Weijden FA. Comparison of different approaches of interdental oral hygiene: Interdental brushes versus dental floss. Journal of Periodontology. 1998;**69**(7):759-764

[54] Carlos Román-Mateo y Raul Delgado-Morales. Genética y evolución. Pasado y futuro de nuestros genes. El futuro de la Humanidad. National geographic. RBA Editores México. Capítulo 04. Página 113 2019

[55] Rotella K et al. Habits, practices and beliefs regarding floss and mouthrinse among habitual and non-habituals users. Journal of Dental Hygiene. 2022;**96**(3): 46-58

[56] Gellibolian R et al. Precision periodontics. Quantitave measures of disease progression. The Journal of Dryland Agriculture. 2022:**153**(9): 826-828

## **Chapter 8**


**7.1 Effect of CO2 concentration**

The concentration of CO2 is positively correlate with plant biomass. However the process is regulated by the factors like availability of water and nutrients, competition between weeds, pest and pathogens. When plant is infected with biotrophic fungi such as rust and other foliar diseases, at that time the concentration of

carbohydrates in the host tissues is increased. It is therefore can be assumed that the high concentration of carbohydrates in the host tissue promotes the development of biotrophic fungi such as rust [59]. Hence, there may be chances of increase in severity of Turcicum leaf blight, Polysora rust as well as common rust in the pockets where elevated CO2 is prevailed.

### **7.2 Effect of temperature**

Changes in temperature may favors the development of dormant pathogens, warmer mean air temperatures in India in early springs especially during winter, favors post flowering stalk rots in winter maize. However, warmer and drier summers may hinder spread of most fungal pathogens, and finally slow down or completely inhibit disease progress of foliar diseases like Turcicum leaf blight, Maydis leaf blight, banded leaf and sheath blight and downy mildews etc., resulting in the regional distribution patterns of these diseases is going to be modified and foliar diseases started to infect *rabi*/winter maize due to warming effect. Pathogens also have the capacity to adopt warmer conditions [14, 15] and temperature/humidity dependent on disease resistance of crop cultivars may be altered in the future [16, 17]. Therefore TLB prevalent cooler and temperate region, but now common in tropical in wither maize. Stalk rot diseases are anticipated to increase in hot and dry areas in summer crops as well as in winter crops of Bihar, Rajasthan, Andhra Pradesh and Karnataka due to rise in temperature in early springs at the time of flowering. Increasing trend in cultivation of *rabi*/winter maize in various states as a result host is available throughout the year round in major maize growing areas leads to multiplication of inoculum of soil borne disease which is an important factor for increasing the extent of crop losses. Therefore, the total number of diseases may not change dramatically, but there might be some changes in relocation and diversification of maize diseases in future range in India [60] also considered stalk rots of maize, particularly related to sweet corn under temperate climatic conditions. The importance of *Fusarium*/*Gibberella* stalk rots may increase in sweet corn, whereas the future importance of Pythium stalk rot might decrease.

### **7.3 Impact on ear/cob rots**

Ear rots is associated with mycotoxin contamination with negative human and animal health consequences truly an alarming issue. The potential risk may be expected to increase in a future climate change scenario. If, temperature, drought, and insect injury in subtropical and tropical regions would increase, an increase the incidence of *Aspergillus flavus* and *F. verticillioides* may occur, consequently mycotoxin contamination will increase. If hot humid weather prevailed at the time of critical silking stage of maize crop in North east, some part of Western hills with limited sunshine hours at the maturity of the maize crop are suitable condition to mycotoxin contamination. Extreme dry condition at the time of flowering is also one of the predisposing factors to AFB1 contamination. Although maize is grown mainly in wet, hot climates, it has been said to thrive in cold, hot, dry or wet conditions. Hence, in future there are more chances of mycotoxin contamination due to rise in temperature and unpredictable rainfall in Indian subcontinent.

### **8. Suggestions for new management strategies**

In present climate changing scenario, the choice of crop management practices should be based on the prevailing situation. It is therefore important that *The Impact of Climate Change on Changing Pattern of Maize Diseases in Indian Subcontinent... DOI: http://dx.doi.org/10.5772/intechopen.101053*

weather-based disease monitoring, inoculums monitoring, should be done time to time. There is an urgent need to develop maize disease forecast module.

### **8.1 Rescheduling of crop planting**

The changes in global climate changes have direct impact on temperature and rainfall pattern may result in shrinking of crop growing seasons with extreme problems of diversification and relocation of maize diseases. Therefore, the rescheduling crop planting dates as per suitability to maize crop in changing environment scenario is needed urgently. Maize disease management strategies needs to be changed in accordance with the projected changes in disease incidence and extent of crop losses in view of the changing climate.

### **8.2 Sensitization of farmers/stakeholders**

In view of the impacts of future climate change on sustainability and productivity of maize, there is an urgent need to sensitize the stakeholders, farmers/growers, extension workers, about the diversification of major diseases at zonal and regional level and management strategies to cope with the situation. Sensitization of farmers, stakeholders, industries and exporters about the importance of mycotoxin/aflatoxin and their management strategies is also needed. This can be achieved through organization of awareness campaigns, training and capacitybuilding programmes, development of learning material and support guides for different risk scenarios.

### **8.3 Breeding climate-resilient varieties**

In order to minimize the impacts of climate and other environmental changes, it will be crucial to breed new varieties for improved resistance to abiotic and biotic stresses such as resistant to cold and heat stress, as well as for drought and water log condition. Considering erratic monsoon late onset and/or shorter duration of winter, there is chance of delaying and shortening the growing seasons for certain *rabi*/cold season crops.

### **8.4 Screening of pesticides with novel mode of actions**

There is a need of screening of nano-pesticides ingredient against important maize diseases. The application of zinc oxide nano particles against disease powdery mildews has antifungal activity [61, 62]. The salicylic acid is associated with plant defense responses which enhance plant vigor and abiotic stress tolerance, independent of their insecticidal action [63–67]. This gives an insight into investigating role of insecticides in enhancing stress tolerance in plants.

### **9. Conclusion**

As the climate continues to warm in response to further greenhouse gas emissions, high temperature extremes will become hotter and cold extremes will become less cold. The amount of future global warming is closely related to cumulative CO2 emissions that weakens our ecosystems and may support pest and disease dispersal and incidence. It has impact on plant physiology and structure, as a result vulnerability of plants towards pests and diseases may increased. Degrading ecosystems and water scarcity can affect food security and livelihoods and contribute to

economic crises, forced migration and conflicts, pest and disease risks also. Indian subcontinent, being tropical area, is more challenged with impacts of impeding changes. Dealing with the climate change which is a tedious task due to its complexity, unpredictability, uncertainty and differential impacts over time period and places. However impact of climate change on crop production mediated through changes in populations of insect-pests need to be given careful attention for planning and devising adaptation and mitigation strategies for future pest management programmes. There is a need to combine both durable multiple-disease and multiple-insect resistance, using gene transfer and genome editing technology would greatly help against the pathogens and insect pests where no native resistances are available in elite breeding materials. Also steps to be taken to increase our adaptive capacity urgently so that the support to adaptation research, developing regionally differentiated contingency plans for temperature and rainfall related risks and also seasonal weather forecasts and their applications for reducing risks can be taken care. Evolvement of new land use systems, including heat and drought tolerant varieties, adapted to climatic variability and climate change. By implementing international standards for phytosanitary measures, may help countries to prevent the introduction and spread of harmful pests and to preserve biodiversity. Preserving biodiversity may helps to improve plant resilience and mitigate the impact of climate change on plant health.


**Author details**

Roua Lajnaf1,2\*, Hamadi Attia1 and Mohamed Ali Ayadi1

1 Alimentary Analysis Unit, National Engineering School of Sfax, Sfax, Tunisia

2 Montpellier University, UMR IATE, Montpellier, France

\*Address all correspondence to<EMAIL_ADDRESS><EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


**Roberto Saletti**

Prof. Roberto Saletti graduated with honors in Electronics Engineering at the University of Pisa, Italy in 1981. He was research scientist of the Italian National Research Council since 1983 to 1992. In 1987 he was visiting scientist at the Cornell University, Ithaca, New York. In 1992 he was nominated associate professor of Electronics at the Faculty of Engineering of the University of Pisa and full professor of Electronics in September 2001. Since 2016 is elected member of the Senate of the University of Pisa. His main research activities are in the fields of design and test of embedded electronic systems for data acquisition and processing and in-vehicle electrification, particularly in battery control. He is Senior Member of the IEEE and member of the Industrial Electronics Society (IES) and the IEEE Instrumentation and Measurements Society (IM). He coauthored more than 150 scientific publications in peer-reviewed international journals and conferences.


DSC Analysis

PET is a semi-crystalline polymer with a *Tg* at 80 ◦C and a *Tm* at 253 ◦C (Figure 4a); fabrics modified with PHEMA or poly(HEMA-co-PEGMA) by photochemical (UV) method and gamma irradiation showed small variations, which are highlighted in Tables 3 and 4, respectively. Pure hydrogels are amorphous polymers; the one obtained by UV treatment with 5% of PEGMA showed a *Tg* at 83 ◦C (Figure 4c), whereas the one obtained by gamma irradiation with 10% of PEGMA showed a *Tg* at 96 ◦C (Figure 5c). The modified fabrics showed different *Tg* values; in Tables 3 and 4, we can observe that the higher the PEGMA percentage, the lower the *Tg* and by UV treatment, the higher the EGDMA (crosslinker) content, the higher the *Tg* value.

**Figure 4.** Differential scanning calorimetry (DSC) curves of (**a**) PET, (**b**) UV PET95:5:0.25 96% hydrogel, and (**c**) UV PHEMA hydrogel.

**Table 3.** Results by DSC for PET fabrics modified with hydrogel, obtained by the photochemical method.

**Table 4.** Results by DSC for PET fabrics modified obtained by the direct gamma irradiation method.

**Figure 5.** DSC curves of (**a**) PET, (**b**) γ60 PET90:10:30 400% hydrogel, and (**c**) γ60 poly(HEMA-co-PEGMA) hydrogel.

On the other hand, the higher the gamma radiation dose at a given HEMA:PEGMA ratio, the higher the grafting percentage and the higher the *Tg* value; this as a result of a higher crosslinking effect. In the case of the melting temperature, it was observed that the *Tm* was maintained between 253 and 255 ◦C, which indicated that the crystalline regions were not affected by the grafting methods; therefore, the grafting was mainly performed in the amorphous regions of PET, independently of the method used.


**5.4 Myocardial bridging**

*Vascular Biology - Selection of Mechanisms and Clinical Applications*

**5.2 Anomalous coronary artery from the opposite sinus (ACAOS)**

ated with sudden death during or shortly after exercise in young persons.

these vessels with exercise and stress.

*Anomalous origin of coronary arteries to the aorta.*

two great vessels [24].

**5.3 Coronary artery fistulas**

Origin of LCA from the proximal RCA or the right aortic sinus with subsequent passage between the aorta and the right ventricular outflow tract has been associ-

The increased risk of sudden death may be due to a silt-like ostium, a bend with acute takeoff angles of the aberrant coronary arteries, or arterial compression between the pulmonary trunk and aorta when there is increased blood flow through

The RCA originated from the LCA or left aortic sinus with passage between the aorta and the right ventricular outflow tract is also associated with myocardial ischemia and sudden death [23]. In rare cases of the LCA originated from the right sinus myocardial ischemia may occur even if the LCA passes anterior to the right ventricular outflow tract or posterior to aorta, not through a tunnel between the

The revascularization approach in patients with ACAOS has been CABG surgery, although coronary stenting has been reported with acceptable medium term success.

The clinical presentation associated with coronary artery fistulas is dependent on the type of fistula, shunt volume, in situ of the shunt and presence of other cardiac

**112**

**Figure 2.**

A myocardial bridge occurs when one of the coronary arteries takes a tunneled intramuscular course under a bridge of overlying myocardium. The myocardial fibers passes over the involved segment of the LAD, and each contraction of these fibers can cause narrowing of the artery. On angiography, the bridged segment is of normal caliber during diastole and abruptly narrows with each systole.

Although bridging is not thought to have any hemodynamic significance in most cases, myocardial bridging has been associated with angina, arrhythmia, depressed left ventricular function, myocardial stunning, early death after cardiac transplantation, and sudden death [21, 26]. Intracoronary Doppler studies have shown that diastolic flow abnormalities may be present in patients with myocardial bridging. Medical treatment generally includes beta blockers, although nitrates should be avoided because they may worsen symptoms. Intracoronary stent and surgery have been attempted in selected patients, but the results have been mixed.

#### **5.5 Percutaneous coronary intervention and anomalous coronary artery**

Several problems may be encountered during the angiography and angioplasty of anomalous origin of culprit coronary artery (AOCCA), including precise diagnosis, selection of an appropriate guiding catheter, insufficient backup force, and difficulties in balloon or stent delivery. The final success of the procedure is depended from the careful assessment of the AOCCA configuration, proximal angulation, vessel course and subsequent selection of an appropriate guide catheter and guide wire.