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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 16  |  Issue : 1  |  Page : 84-90

Role of Photo Dynamic Therapy as an adjunct in periodontal therapy


1 Department of Periodontology, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Oral and Maxillofacial Surgery, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission14-Nov-2021
Date of Acceptance14-Jan-2022
Date of Web Publication05-Apr-2022

Correspondence Address:
T Prasanth
Department of Periodontology, Armed Forces Medical College, Wanowrie, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodd.jodd_44_21

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  Abstract 


Antimicrobial photodynamic therapy (aPDT) is an emerging treatment modality in the field of Dentistry aimed at reducing the microbial load and accelerating the healing process, thereby widening its application base in the field of periodontics, oral surgery, endodontics, pedodontics, etc. The process involves the blending of a nontoxic photosensitizer dye with a suitable wavelength of a visible low-level laser, this combination helps in the formation of the reactive oxygen species, which causes lethal and irreversible damage to the bacterial cell. Various dyes and light sources of different wavelengths are used in several permutation and combination to achieve the desired results. In periodontology, aPDT has been used as an adjunct in the treatment of chronic periodontitis, peri-implantitis, red and white lesions etc. The aim of this case report was to highlight the uses of aPDT in such cases.

Keywords: Antimicrobial photodynamic therapy, photodynamic therapy, photosensitive dye


How to cite this article:
Prasanth T, Roy I D, Nanavati G, Satisha T S. Role of Photo Dynamic Therapy as an adjunct in periodontal therapy. J Dent Def Sect. 2022;16:84-90

How to cite this URL:
Prasanth T, Roy I D, Nanavati G, Satisha T S. Role of Photo Dynamic Therapy as an adjunct in periodontal therapy. J Dent Def Sect. [serial online] 2022 [cited 2022 Aug 16];16:84-90. Available from: http://www.journaldds.org/text.asp?2022/16/1/84/342646




  Introduction Top


A bacterial plaque has been implicated as the most important etiological factor in the diseases of oral cavity, and over the period, efficacy of various treatment modalities has been assessed to reduce this microbial load. Mechanical and chemical methods have been employed for the treatment of several periodontal diseases with varying degree of success.[1] In recent times, antimicrobial photodynamic therapy (aPDT) has emerged as an alternative adjunct treatment modality to lessen this bacterial burden.[2]

Initially, photodynamic theory was developed as a complementary approach for the treatment of malignancies. Later, aPDT gained popularity in the treatment of other bacterial, viral and fungal infections as well. This mainly is attributed to the absence of any side effects of the said treatment modality. The process consists of the use of a unique wavelength of red/infrared light within a range of 600–900 nm, capable of activating the “photosensitizer.” In low-level laser therapy, diode lasers are used with a dose less than 500 mW. Photosensitizer is an external dye applied during PDT is absorbed by the microbes and when activated the specific wavelength of laser releases free radicles of oxygen, thereby locally destroying the microorganism and reduce microbial load. The most used photosensitizers are methylene blue, phenothiazine chloride, toluidine blue, and indocyanine green.[3]

The main objective of photodynamic therapy (PDT) is to eliminate the bacterial load along with accelerate the healing process. The use of contemporary PDT was first reported by Danish physician, Niels Finsen in 1901, and is based on the principle of combining two nontoxic elements, i.e., the photosensitizer dye and the light (low-level laser), in an oxygenated environment leading to a phototoxic effect [Figure 1].[4] The light source causes the activation of the dye, transmitting the momentum to the surrounding oxygen molecules increasing the production of reactive oxygen species (ROS) such as singlet oxygen, hydroxyl ions [Figure 1]. These ROS led to oxidation of cellular content thereby having a lethal effect on the microorganisms. Other deleterious actions include alteration of the DNA and the plasma membrane, lipid peroxidation, and protein agglutination. The efficiency is limited only to the cells with adequate adsorption of the dye. Due to its selective localized action, aPDT can be repeated multiple times with no collateral damage. These procedures can easily be applied to patients with systemic complications.[3]
Figure 1: Mechanics of aPDT

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aPDT has a broader spectrum of therapeutic applications; from eliminating disease-causing organisms to increase the healing potential of the tissue. This procedure is used to manage peri-implantitis, sterilization of periodontal pockets, treatment of furcation defects, management of red/white lesion, etc., In addition, it has also been observed that aPDT implicitly affects Gm + ve organisms as compared to Gm-ve, due to structural differences of the cell membrane. Furthermore, the presence of plaque or biofilm decreases the potency of the same due to limited penetration of the dye. The procedure exhibits a detrimental effect on various periodontal pathogens such as Porphyromonas gingivalis, AA comitans, Capnocytophaga gingivalis, Fusobacterium nucleatum, Prevotella intermedia etc.[5]

The aim of the present case series is to showcase the role of aPDT as an adjunct in scaling and root planing (SRP) and treatment of peri-implantitis.


  Case Report Top


Case 1: Antimicrobial photodynamic therapy as an adjunct to scaling and root planing

A 48-year-old female patient reported with a complaint of generalized mobility in her teeth which had deteriorated substantially over a period of 1 year. The patient had dull, gnawing type of pain which aggravated while chewing food and relieved on its own. On examination, the gingiva was reddish-pink in color, soft and edematous which bleed easily on probing [Figure 2]. Generalized grade I mobility was evident. A UNC-15 probe was used to determine clinical attachment level (CAL), observed to be up to 5 mm generalized [Figure 3].
Figure 2: Periodontitis Stage III Grade B

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Figure 3: Generalised probing depth of 5 mm

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Based on the clinical and radiological evaluation diagnosis of Periodontitis Stage III Grade B (AAP 2017 classification of periodontal disease) was arrived on.[6]

The patient did not present with any systemic illness or condition. Hematological investigations were within normal limits. The treatment plan was formulated and was well explained to the patient and a written consent was taken. SRP was performed followed by the application of aPDT using phenothiazine chloride dye and 660 nm low-level diode laser [Figure 4] and [Figure 5].[7] After 10 min of NSPT, photosensitizer dye was directly applied to the pocket region with the help of a disposable needle tip and washed with 0.9N saline postsoaking period of 4 min [Figure 6] and [Figure 7]. Successively, 800 μ of diode laser tip was introduced in the pocket. Each tooth was divided into a sextant and each sextant was irradiated for 10 s [Figure 8], adding up to 1 min of exposure per tooth. The diode laser was used with 100 mW energy output in continuous wave mode delivering 6 J energy per tooth.
Figure 4: PDT kit

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Figure 5: Scaling & Root planing

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Figure 6: Application of photosensitizer dye

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Figure 7: Washing off dye

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Figure 8: Activation of dye with Laser

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The patient was apprised with oral hygiene instructions and recalled after 07 days and aPDT was repeated. The patient was placed under maintenance therapy and was recalled after 6 months to assess the pocket depth and CAL. There was a considerable reduction in the gingival inflammation, bleeding on probing, and probing depth [Figure 9].
Figure 9: Six months post-op probing 3 mm

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Case 2: Antimicrobial photodynamic therapy in management of peri-implantitis

In the 2nd case, a 24-year-old female patient was concerned with bleeding from the gums near the dental implant in lower right region since 2 months. She complains of food accumulation and bleeding from gums in the same region. The patient had undergone implant placement along with cement-retained ceramic restoration dating back to 2 years. On examination, it was observed that the gingiva in the 45i region was reddish-pink, edematous with bleeding on exploration. Generalized probing in the region was more than 6 mm (Colorvue probe, Hu-Friedy®) [Figure 10] and [Figure 11].
Figure 10: Peri-implantitis w.r.t 45i region

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Figure 11: Probing > 6 MM

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The periapical radiograph showed significant crestal bone loss at the implant site, consistent with the probing depth [Figure 12]. Based on the clinical and radiological findings, a diagnosis of “Moderate Peri-implantitis w. r. t 45i region” was given (Forem SJ classification of peri-implantitis 2012).[8] Based on AKUT protocol (Lang 2004) a regenerative therapy was planned to inhibit further bone loss and to reinstate a maintainable peri-implant region.[9] This included mechanical debridement with aPDT as an adjunct to reduce microbial load, followed by filling the defect with a bone graft. The procedure was explained to the patient and an informed consent was obtained. All the patient's investigations were satisfactory.
Figure 12: Pre-op IOPA

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Prior to the procedure, the crown and the abutment were removed and replaced with a healing screw, and the area was anesthetized (2% Lidocaine with 1:80000 epinephrine). Full thickness flap was raised [Figure 13] and the probing depth was reconfirmed [Figure 14]. The debris and the granulation tissue attached to the exposed implant threads were removed using a plastic implant curette (Implacare® II, Hu-Friedy). Photosensitizer dye (phenothiazine chloride) was applied in the region for 2 min and excess dye was washed off using normal saline. Six hundred and sixty nm diode laser at 100 mW and 6J (Helbo®) was applied in continuous contact mode around the implant in all the sextants [Figure 15]. Postlaser irradiation, a xenograft (Bio-Oss®) and resorbable collagen membrane were placed and secured with the sutures [Figure 16]. Healing was uneventful and for the next 6 months, the patient was placed under maintenance phase. Upon follow-up, the area appeared healthy with decrease in the signs of inflammation along with reduced probing depth (<3 mm). Radiological bone fill was confirmed, and a screw-retained ceramic crown was placed in 45i region [Figure 17] and [Figure 18].
Figure 13: Incision and flap elevation

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Figure 14: Probing > 6 MM

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Figure 15: Activation of dye

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Figure 16: Placement of particulate xenograft

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Figure 17: Six months post op

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Figure 18: Screw retained prosthesis

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  Discussion Top


aPDT has a wider application base in dental procedures. The main aim of the procedure is a reduction in the microbial load thereby decreasing the cause for the inflammation and accelerating the healing process. The process consists of a combination of the photosensitizer dye and a light source of appropriate wavelength, which are not harmful individually, but when combined help release the ROS (singlet oxygen and hydroxyl ion) causing a localized antimicrobial action. The method has been compared with the use of oral/systemic antibiotics, where aPDT has better patient compliance due to nil side effects and increased frequency of application. Furthermore, reduction in pain postapplication of aPDT, further increases its acceptability.[3]

In first case, the use of aPDT as an adjunct post SRP showed a significant reduction not only in the inflammatory component but also in the generalized probing depth. This is in agreement with the systematic review and meta-analysis by Saini et al., where they compared the outcome of supportive periodontal therapy with aPDT in cases of chronic periodontitis. It was seen that not only was there decrease in the clinical parameters (postpartum depression, attachment loss, and bleeding on probing), but also noticeable progress in biochemical parameters such as interleukin-1 β, Tumor necrosis factor-α, and RANKL/OPG.[10]

In the second case, aPDT was used to disinfect the peri-implant area as an adjunct to mechanical debridement during regenerative procedure. There was increase in the bone fill and reduction in the inflammatory component when observed after 6 months. This is in accordance with a study by Almohareb et al., where it was observed that there was decrease in the symptoms of peri-implantitis when aPDT used as an adjunct to mechanical debridement as compared to use of systemic antimicrobials.[11]

Although the use of PDT has a rich history in the field of medicine, there is a lacuna of the long-term studies in the treatment of periodontal diseases. Although no harmful side effects are documented, many studies are inconclusive due to the unavailability of the long-duration studies. The major drawback of the procedure is that it can be used as an adjunct and not as a primary therapy. Furthermore, the therapy is limited to the region accessible to the laser light further restricting its application. Based on the present literature, the PDT does help reduce the microbial load without increasing the bacterial resistance, thereby not limiting the frequency of application. Also increases the patient compliance due to ease of application, reduced postoperative pain, and assisting the host mechanism toward healing.[3]


  Conclusion Top


aPDT has a wide area of application in the field of dentistry. It helps diminish the viability of microbial cells and microbial biofilms, thereby reducing the microbial load. It acts as a valuable adjunct to the conventional therapy. The major advantage being the absence of side effects which enables multiple application possible. The procedure can be safely used in immunologically compromised patients as well as geriatric patients with minimum risks. Although it cannot replace the primary therapeutic procedure is definitely an important adjunct. Furthermore, long-term data, well-designed, large-scale clinical trials with microbiological parameters, and long follow-up periods are essential to assess the efficacy of aPDT as an adjunct therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pfitzner A, Sigusch BW, Albrecht V, Glockmann E. Killing of periodontopathogenic bacteria by photodynamic therapy. J Periodontol 2004;75:1343-9.  Back to cited text no. 1
    
2.
Hamblin MR, Hasan T. Photodynamic therapy: A new antimicrobial approach to infectious disease? Photochem Photobiol Sci 2004;3:436-50.  Back to cited text no. 2
    
3.
Stájer A, Kajári S, Gajdács M, Musah-Eroje A, Baráth Z. Utility of photodynamic therapy in dentistry: Current concepts. Dent J 2020;8:43.  Back to cited text no. 3
    
4.
Grzybowski A, Pietrzak K. From patient to discoverer – Niels Ryberg Finsen (1860-1904) – The founder of phototherapy in dermatology. Clin Dermatol 2012;30:451-5.  Back to cited text no. 4
    
5.
Carrera ET, Dias HB, Corbi SC, Marcantonio RA, Bernardi AC, Bagnato VS, et al. The application of Antimicrobial Photodynamic Therapy (aPDT) in dentistry: A critical review. Laser Phys 2016;26:123001.  Back to cited text no. 5
    
6.
Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH. Periodontitis: Consensus report of workgroup 2 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions. J Periodontol 2018;89:S173-82.  Back to cited text no. 6
    
7.
Xue D, Tang L, Bai Y, Ding Q, Wang P, Zhao Y. Clinical efficacy of photodynamic therapy adjunctive to scaling and root planing in the treatment of chronic periodontitis: A systematic review and meta-analysis. Photodiagnosis Photodyn Ther 2017;18:119-27.  Back to cited text no. 7
    
8.
Froum SJ, Rosen PS. A proposed classification for peri-implantitis. Int J Periodon Restor Dent 2012;32:533-40.  Back to cited text no. 8
    
9.
Lang N. Consensus statements and recommend clinical procedures regarding implants survival and complications. Int Oral Maxillofac Implants 2004;19:150-4.  Back to cited text no. 9
    
10.
Saini A, Arora SA, Mathur RK, Saurav K, Choudhary SB. Effect of photodynamic therapy in the management of periodontal disease – A systematic review. National Journal of Integrated Research in Medicine 2021;12:72-8.  Back to cited text no. 10
    
11.
Almohareb T, Alhamoudi N, Al Deeb M, Bin-Shuwaish MS, Mokeem SA, Saad Shafqat S, et al. Clinical efficacy of photodynamic therapy as an adjunct to mechanical debridement in the treatment of per-implantitis with abscess. Photodiagnosis Photodyn Ther 2020;30:101750.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18]



 

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