Efficacy of Photodynamic Therapy and Lasers as an Adjunct to Scaling and Root Planing in the Treatment of Aggressive Periodontitis - A Clinical and Microbiologic Short Term Study

Gingival crevicular fluid level of tumor necrosis factor-alpha as a valuable biomarker for estimation of the efficacy of adjunctive antimicrobial photodynamic therapy in stage II-IV periodontitis: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to assess the gingival crevicular fluid (GCF) level of tumor necrosis factor-alpha (TNF-alpha) as a valuable inflammatory cytokine for estimation of the efficacy of adjunctive antimicrobial photodynamic therapy (aPDT) in stage II-IV periodontitis patients.

METHODS

This review was conducted in accordance with the PRISMA statements, and registered in PROSPERO (CRD42022321211). An electronic search was conducted for articles comparing the efficacy of aPDT versus scaling and root planing (SRP) published up until June 2023. The mean GCF level of TNF-alpha and clinical attachment loss (CAL) with 95% confidence interval (CI) were pooled and compared between the groups using a random-effect model after 1-2, 4-5, 12-13, and ≥ 24 weeks. The I2 test was applied to assess the heterogeneity of the findings, and publication bias was evaluated by visual inspection of the funnel plot symmetry.

RESULTS

Analysis of 11 studies indicated a significant difference in GCF level of TNF-alpha at the 1-2, 12-13 and ≥ 24-week follow-ups in patients treated with aPDT + SRP. However, at the 4-5-week follow-up, the results were significant in favor of the control group (mean difference = -0.17, 95% CI = -1.86-152, P < 0.00001).

CONCLUSION

Despite the limitations of the included studies, aPDT can decrease the GCF level of TNF-alpha inflammatory biomarker for a longer period of time than SRP alone in grade II-IV periodontitis. However, further investigations are required to assess the efficacy of higher frequency of aPDT applications.

Effect of adjunctive photodynamic therapy on gingival crevicular fluid interleukin-1β in Stage III and IV periodontitis: A systematic review and meta-analysis

Interleukin-1β (IL-1β) is a main pro-inflammatory cytokine that is used for the assessment of treatment efficacy in periodontitis. This meta-analysis aimed to assess the effect of antimicrobial photodynamic therapy (aPDT) on Stage III-IV (severe) periodontitis-induced local IL-1β. This review study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement and registered in PROSPERO (CRD42024522546). Electronic and manual search of the literature was conducted in four databases for English articles from the first record up until June 30, 2022 comparing the effects of aPDT versus conventional scaling and root planing on IL-1β levels at different follow-up times. The mean gingival crevicular fluid level of IL-1β with 95% confidence interval (CI) was pooled using the random effect model. The I 2 statistics were applied to analyze the heterogeneity of the findings. The risk of bias (RoB) was analyzed using the revised Cochrane RoB. Analysis of 11 retrieved studies revealed that after the application of aPDT, a significant reduction in IL-1β level occurred at 1-2 (standardized mean difference [SMD]: 0.29, 95% CI: -0.57-1.15; P = 0.0002), 4-6 (SMD: 0.53; 95% CI: -0.36-1.42; P < 00001), and 12-13 (SMD: 1.04; 95% CI: -0.22-2.3; P < 0.00001) follow-up weeks. The application of aPDT can serve as an effective adjunctive therapy for the treatment of Stage III-IV periodontitis. Although the results of this meta-analysis showed that increasing the session frequency of aPDT had a higher effect size, further studies without the limitations of the existing studies are required to confirm the present results.

Clinical and microbiological efficacy of intra-pocket application of diode laser in grade C periodontitis: a randomized controlled clinical trial

BACKGROUND

Periodontitis is a microbially induced disease destroying structures anchoring teeth to jaw bones. Although metronidazole in combination with spiramycin is the effective conventional treatment of stage III grade C periodontitis, it has several systemic side effects. Laser therapy is widely used nowadays as an adjunct to scaling and root planing (SRP) to modulate inflammatory host response and eradicate microbes, due to bactericidal and detoxifying effects. Since microbiological analysis is one of the diagnostic methods identifying periodontal risk; our research aimed to investigate the efficacy of intra-pocket application of diode laser (980 nm) versus antibiotic therapy in enhancing clinical and microbiological parameters in stage III grade C periodontitis.

METHODS

A randomized controlled clinical trial was conducted on fifty patients with stage III grade C periodontitis, divided equally into two groups. We managed test group by SRP with intra-pocket application of diode laser (980 nm) and the control group by SRP with systemic antibiotic administration (spiramycin and metronidazole). Then, we measured periodontal pocket depth (PPD) and clinical attachment loss (CAL) for both groups, before treatment (baseline), four and twelve weeks after. Moreover, we collected gingival crevicular fluid from both groups at baseline, four and twelve weeks after treatment and analyzed by real-time polymerase chain reaction to detect the relative count of Aggregatibacter actinomycetemcomitans and Porhyromonas gingivalis.

RESULTS

Compared to baseline, all assessed clinical and microbiological parameters attested improvement at the end of the study period in each group individually with no significant difference between the two studied groups. Although, at twelve weeks, flare up of bacterial levels was detected with systemic antibiotic administration.

CONCLUSION

Laser therapy can be considered as an effective treatment modality in stage III grade C periodontitis, avoiding the systemic antibiotic side effects and solving the recurrence problems due to bacterial resistance by long term usage.

TRIAL REGISTRATION

NCT05222737 retrospectively on 03/02/2022, Clinicaltrial.gov.

Effects of Antimicrobial Photosensitizers of Photodynamic Therapy (PDT) to Treat Periodontitis

Antimicrobial photodynamic therapy or aPDT is an alternative therapeutic approach in which lasers and different photosensitizing agents are used to eradicate periodontopathic bacteria in periodontitis. Periodontitis is a localized infectious disease caused by periodontopathic bacteria and can destroy bones and tissues surrounding and supporting the teeth. The aPDT system has been shown by in vitro studies to have high bactericidal efficacy. It was demonstrated that aPDT has low local toxicity, can speed up dental therapy, and is cost-effective. Several photosensitizers (PSs) are available for each type of light source which did not induce any damage to the patient and are safe. In recent years, significant advances have been made in aPDT as a non-invasive treatment method, especially in treating infections and cancers. Besides, aPDT can be perfectly combined with other treatments. Hence, this survey focused on the effectiveness and mechanism of aPDT of periodontitis by using lasers and the most frequently used antimicrobial PSs such as methylene blue (MB), toluidine blue ortho (TBO), indocyanine green (ICG), malachite green (MG) (Triarylmethanes), erythrosine dyes (ERY) (Xanthenes dyes), rose bengal (RB) (Xanthenes dyes), eosin-Y (Xanthenes dyes), radachlorin group and curcumin. The aPDT with these PSs can reduce pathogenic bacterial loads in periodontitis. Therefore, it is clear that there is a bright future for using aPDT to fight microorganisms causing periodontitis.

Impact of low-level laser therapy as an adjunct to non-surgical periodontal treatment on the levels of tissue plasminogen activator and plasminogen activator inhibitor 1 in Stage 3-4, Grade C periodontitis patients: a split-mouth, randomized control study

AIM

To investigate the effects of low-level laser therapy (LLLT) as an adjunct to non-surgical periodontal treatment (NSPT) on the plasminogen-activating system.

MATERIALS AND METHODS

Stage 3-4 Grade C periodontitis and age-gender-matched healthy individuals participated in the split-mouth study (ClinicalTrials.gov identifier, NCT05233501). The study groups were Periodontitis/NSPT (Sham); Periodontitis/NSPT + LLLT (LLLT); Healthy (Control). Following NSPT, LLLT was applied on Days 0, 2 and 7. Clinical parameters were recorded at baseline and on Day 30. Gingival crevicular fluid (GCF) was collected at baseline, on days 7, 14, and 30; tissue-type plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) levels were measured with ELISA.

RESULTS

Clinical parameters, total GCF tPA (tPAt) and PAI-1 (PAI-1t) levels significantly reduced in LLLT and Sham groups (< 0.001). GCF tPAt levels in LLLT were significantly lower (< 0.05) than Sham on Day 7. GCF tPAt levels in periodontitis groups were significantly higher than the Control at baseline, on Days 7 and 14 (< 0.01). By Day 30, both groups decreased to control levels (> 0.05). GCF PAI-1t levels were significantly lower in LLLT than the Sham on day 30 (< 0.01), comparable to healthy controls (> 0.05).

CONCLUSION

Adjunctive LLLT modulates the plasminogen activating system in severe periodontitis by altering GCF tPA and PAI-1 levels.

CLINICAL RELEVANCE

LLLT as an adjunct to non-surgical periodontal treatment in patients with Stage 3-4 Grade C leads to reduced plasminogen activation.

Clinical attachment loss in the use of adjunctive antimicrobial photodynamic therapy in Stages II-IV Grade C molar-incisor periodontitis: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to assess the extent of clinical attachment loss (CAL) as a clinical parameter in the efficacy of antimicrobial photodynamic therapy (aPDT) in non-surgical management of stage II-IV grade C molar-incisor pattern Periodontitis. This review protocol was conducted in accordance with PRISMA statements and is registered in PROSPERO (CRD42022321211). An electronic and manual search was conducted for relevant articles comparing the efficacy of aPDT versus scaling and root planning (SRP) alone or with amoxicillin/metronidazole (AMX/MET) published up until December 2021. The mean clinical attachment loss (CAL), probing depth (PD) reduction, and bleeding on probing (BOP) with a 95% confidence interval (CI) were pooled and compared between the two groups with CAL < and > 7 mm using a random-effect model after 3 and 6 months. To assess the heterogeneity of the findings, the I2 test was applied and Publication bias was evaluated by visual examination of the funnel plot symmetry. Analysis of 9 studies indicated a significant difference in clinical attachment gain in patients with CAL > 7 mm between the aPDT group and the SRP alone (mean difference=0.92, 95% CI=0.01-1.84, P=0.05) and SRP + AMX/MET (mean difference=0.91, 95% CI=-0.14-1.68, P=0.02) control groups. However, this difference was not significant in patients with CAL < 7 mm. Despite the limitations of the included studies, aPDT can be suggested for the improvement of clinical parameters in grade C molar-incisor pattern Periodontitis with CAL > 7 mm. However, its application in milder cases requires further investigation.

Efficacy of Periodontal Endodontics Combined with Diode Laser (DL) Therapy on Severe Periodontitis

Background

For a long time, the impact of severe periodontitis on the pulp has been the focus of periodontal clinical research. Whether the teeth with severe periodontitis should be treated with pulp has also become the focus of clinical research.

Aims

To explore the effect of periodontal endodontic therapy combined with DL therapy on severe periodontitis.

Materials and Methods

The clinical data of 100 patients with severe periodontitis from January 2020 to July 2022 were selected and included in the retrospective study. According to the different retrieval treatment methods, they were divided into the control group and the treatment group with 50 cases in each group. The control group received periodontal endodontic treatment, and the treatment group received DL treatment on the basis of the control group. The differences in periodontal probing depth (PD), toothache degree, bleeding index (BI), inflammatory factors, plaque index (PLI), and attachment loss (AL) between the two groups were compared and analyzed.

Results

After 3 months of treatment, the bleeding index (BI), plaque index (PLI), and periodontal probing depth (PD) of the treatment group were significantly lower than those of the control group, and the difference was statistically significant (P < 0.05). The attachment loss (AL) of the group was not significantly different from that of the control group (P > 0.05). Before treatment, there was no significant difference in the levels of inflammatory factors between the two groups (P > 0.05). After 3 months of treatment, the levels of IL-6 and CRP in the treatment group were significantly lower than those in the control group, and the difference was statistically significant (P < 0.05). Before treatment, there was no significant difference in the levels of inflammatory factors between the two groups (P > 0.05). After 3 days of treatment, the VAS score of the treatment group was significantly lower than that of the control group, and the difference was statistically significant (P < 0.05).After treatment, there were no complications during follow-up in the two groups.

Conclusion

The application of DL treatment has a significant effect, which can promote the healing of periodontal tissue, reduce the depth of periodontal pockets, and reduce the degree of toothache, thereby providing a reference for clinical treatment.

Classic vs. Novel Antibacterial Approaches for Eradicating Dental Biofilm as Adjunct to Periodontal Debridement: An Evidence-Based Overview

Periodontitis is a multifactorial chronic inflammatory disease that affects tooth-supporting soft/hard tissues of the dentition. The dental plaque biofilm is considered as a primary etiological factor in susceptible patients; however, other factors contribute to progression, such as diabetes and smoking. Current management utilizes mechanical biofilm removal as the gold standard of treatment. Antibacterial agents might be indicated in certain conditions as an adjunct to this mechanical approach. However, in view of the growing concern about bacterial resistance, alternative approaches have been investigated. Currently, a range of antimicrobial agents and protocols have been used in clinical management, but these remain largely non-validated. This review aimed to evaluate the efficacy of adjunctive antibiotic use in periodontal management and to compare them to recently suggested alternatives. Evidence from in vitro, observational and clinical trial studies suggests efficacy in the use of adjunctive antimicrobials in patients with grade C periodontitis of young age or where the associated risk factors are inconsistent with the amount of bone loss present. Meanwhile, alternative approaches such as photodynamic therapy, bacteriophage therapy and probiotics showed limited supportive evidence, and more studies are warranted to validate their efficiency.

Clinical effectiveness of adjunctive diode laser on scaling and root planing in the treatment of periodontitis: is there an optimal combination of usage mode and application regimen? A systematic review and meta-analysis

This review aims to evaluate the adjunctive clinical effectiveness of diode laser (DL) to scaling and root planing (SRP) in the treatment of periodontitis, and identify the optimal combination of usage mode and application regimen of DL. Eight electronic databases were searched up to January 2021. Probing pocket depth (PPD), clinical attachment loss (CAL), bleeding on probing (BOP), plaque index (PI), and gingival index (GI) were assessed at short-term (4-6 weeks), 3-month, and 6-month follow-ups. Based on DL usage mode, studies were divided into three groups: inside, outside pocket, and combined modes. As for application regimen, studies in each group were further subdivided into single- and multiple-session subgroups. Thirty randomized controlled trials with 825 participants were included. For inside mode, single-session DL showed significant improvements for PPD (short-term, and 3-month, p < 0.05), CAL (short-term, and 3-month, p < 0.05), PI (3- and 6-month, p < 0.05), and GI (short-term, 3-month, and 6-month, p < 0.05). For outside mode, multiple-session DL showed notable improvements for most clinical outcomes (p < 0.05). The effect of combined mode was still uncertain. Adjunctive DL had additional clinical benefits in the treatment of periodontitis. One session laser treatment is suggested when DL is applied inside pocket in future clinical practice. Meanwhile, more than one session laser treatment presents better outcomes when DL is used outside pocket. PROSPERO: CRD42020156162.

Effectiveness of Antimicrobial Photodynamic Therapy in the Treatment of Periodontitis: A Systematic Review and Meta-Analysis of In Vivo Human Randomized Controlled Clinical Trials

This systematic review and meta-analysis evaluated antimicrobial photodynamic therapy (aPDT) efficacy in periodontitis. The review protocol was conducted in accordance with PRISMA statements, Cochrane Collaboration recommendations and is registered in PROSPERO (CRD 42020161516). Electronic and hand search strategies were undertaken to gather data on in vivo human RCTs followed by qualitative analysis. Differences in probing pocket depth (PPD) and clinical attachment level (CAL) were calculated with 95% confidence intervals and pooled in random effects model at three and six months. Heterogeneity was analyzed, using Q and I² tests. Publication bias was assessed by visual examination of the funnel plot symmetry. Sixty percent of 31 eligible studies showed a high risk of bias. Meta-analysis on 18 studies showed no additional benefit in split mouth studies in terms of PPD reduction (SMD 0.166; 95% CI −0.278 to 0.611; P = 0.463) and CAL gain (SMD 0.092; 95% CI −0.013 to 0.198; P = 0.088). Similar findings noted for parallel group studies; PPD reduction (SMD 0.076; 95% CI −0.420 to 0.573; P = 0.763) and CAL gain (SMD 0.056; 95% CI −0.408 to 0.552; P = 0.745). Sensitivity analysis minimized heterogeneity for both outcome variables; however, intergroup differences were not statistically significant. Future research should aim for well-designed RCTs in order to determine the effectiveness of aPDT.

[Progress on photodynamic therapy in oral diseases]

Photodynamic therapy (PDT) has developed rapidly in basic and clinical research, and its therapeutic prospects have received increasing attention. PDT has the advantages of minimally invasive, low toxicity, high selectivity, good reproducibility, protection of appearance and vital organ function, and has become a treatment. With the development of medicine, the field of application of PDT becomes more wildly, and brings a new direction for the treatment of oral diseases. This article reviews the basic principles, treatment elements and research results of PDT in the treatment of oral diseases.

Q-Switch Nd:YAG Laser-Assisted Elimination of Multi-Species Biofilm on Titanium Surfaces

(1) Background: The relatively high prevalence of peri-implantitis (PI) and the lack of a standard method for decontamination of the dental implant surface have pushed us to conduct further research in the field. Bacterial biofilms were found to play a primordial role in the etiology of PI. Therefore, the aim is to evaluate the efficacy of a laser-assisted elimination of biofilm protocol in the removal of a multi-species biofilm on titanium surfaces. (2) Methods: In total, 52 titanium discs (grade 4) were used. The study group consisted of 13 titanium disks contaminated with multi-species biofilms and subsequently irradiated with the laser (T + BF + L). The control groups consisted of the following types of titanium disks: 13 contaminated with multi-species biofilms (T + BF), 13 sterile and irradiated (T + L), 13 sterile and untreated (T). Q-Switch Nd:YAG laser Irradiation parameters were the following: energy density equal to 0.597 J/cm² per pulse, power equal to 270 milliwatt per pulse, 2.4 mm of spot diameter, and 10 Hz repetition rate for pulse duration of six nanoseconds (ns). The laser irradiation was made during 2 s of total time in non-contact and at 0.5 mm away from the titanium disc surface. After treatment, presence of biofilms on the disks was evaluated by staining with crystal violet (CV), which was measured as optical density at six hundred thirty nm, and statistical analyses were done. (3) Results: the optical density values were 0.004 ± 0.004 for the study group T + BF + L, 0.120 ± 0.039 for group T + BF, 0.006 ± 0.003 for group T + L, and 0.007 ± 0.007 for group T. For the study group, laser treatment resulted in a total elimination of the biofilm, with mean values statistically significantly lower than those of contaminated titanium surfaces and similar to those of sterile titanium surfaces. (4) Conclusions: Our irradiation protocol provided a significant elimination of the multi-species biofilm on titanium surfaces. Laser treated titanium surfaces were biofilm-free, similar to the sterile ones.

pH influences the biocompatibility of methylene blue solutions

OBJECTIVE

The aim of this study was to investigate the biocompatibility of methylene blue at different pH levels through the method of implantation in subcutaneous tissue.

MATERIALS AND METHODS

Eighty-four sterilized polyethylene tubes were allocated in the subcutaneous tissue of 28 rats, each one receiving four tubes, set into four groups: group tube (G-T)-empty tube, fibrin group (G-F)-tube filled with fibrin sponge, group methylene blue pH 7 (G-MB/pH 7)-tube filled with fibrin sponge soaked by methylene blue (100 μg/ml) at pH 7.0, and group methylene blue pH 1 (G-MB/pH 1)-tube filled with fibrin sponge and soaked by methylene blue (100 μg/ml) at pH 1.0. After 7, 15, and 30 days, seven animals from each group were euthanized, and the tubes involved by the surrounding tissue were removed and fixed with 4% buffered formaldehyde solution. The collected pieces were processed and histological sections (4 μm) were stained with hematoxylin and eosin and analyzed by light microscopy. Scores were assigned to analysis of histopathologic parameters. The results were statistically analyzed by the Kruskal-Wallis test (p ≤ 0.05).

RESULTS

At 7 and 30 days, the G-MB/pH 1 group showed no significant difference in the G-T control group, while G-MB/pH 7 had a significant increase on tissue reaction, also when compared to G-T. At 15 days, there was no statistical difference between the groups.

CONCLUSION

Within the limits of this study, it is concluded that methylene blue at pH 1.0 provides better biocompatibility than at pH 7.0.