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ORIGINAL ARTICLE
Year : 2015  |  Volume : 9  |  Issue : 2  |  Page : 75-79

A randomized controlled clinical trial on efficacy of photodynamic therapy as an adjunct to nonsurgical treatment of chronic periodontitis


1 Department of Periodontics, S. B. Patil Dental College and Hospital, Bidar, Karnataka, India
2 Department of Periodontics, Kamineni Institute of Dental Sciences, Nalgonda, Telangana, India

Date of Web Publication26-Nov-2015

Correspondence Address:
Suryakanth Malgikar
Department of Periodontics, S. B. Patil Dental College and Hospital, Bidar - 585 401, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-2868.170562

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  Abstract 

Background and Objectives: In recent years, there has been a growing interest in the use of dental lasers for treatment of periodontal diseases. Recent preclinical and clinical data have suggested a potential benefit of photodynamic therapy (PDT) in the treatment of periodontitis. Aim: The aim of this study was to evaluate the clinical efficacy of PDT as an adjunct to nonsurgical mechanical therapy (SRP) in the treatment of chronic periodontitis. Materials and Methods: In a single-centered randomized and controlled clinical trial, 24 patients with untreated chronic periodontitis were assigned in a split-mouth design into two treatment groups which included: Group I: SRP only (control group), Group II: SRP and PDT (1% methylene blue solution) (test group). Clinical parameters such as plaque index (PI), gingival index (GI), modified sulcular bleeding index (mSBI), probing depth (PD), and clinical attachment level (CAL) were measured at baseline, 1, 3 and 6 months after therapy. Results: Inter-group and intra-group statistical analyses were performed. The improvement in clinical parameters was significantly greater in Group II as compared to Group I. The mean PD (mm) reduction from baseline to 6 months in Group I was 2.50 ± 0.54, Group II was 2.57 ± 0.53. The mean CAL (mm) gain from baseline to 6 month in Group I was 2.63 ± 0.47, Group II was 2.55 ± 0.44. A statistically significant decrease in PI, GI, mSBI scores was seen in Group II at the end of 6 month (P < 0.001). Conclusion: The present study suggests that an additional application of single episode of PDT could be beneficial adjunct to nonsurgical treatment of chronic periodontitis in terms of clinical parameters as compared to scaling and root planing. Direct subgingival delivery of methylene blue in different concentrations should be performed to further investigate the potential antimicrobial effect of soft lasers in the human periodontal disease.

Keywords: Mechanical periodontal therapy, methylene blue, periodontal diseases/therapy, photodynamic therapy, randomized controlled trial


How to cite this article:
Malgikar S, Reddy S H, Babu P R, Sagar S V, Kumar P S, Reddy G J. A randomized controlled clinical trial on efficacy of photodynamic therapy as an adjunct to nonsurgical treatment of chronic periodontitis. J Dent Lasers 2015;9:75-9

How to cite this URL:
Malgikar S, Reddy S H, Babu P R, Sagar S V, Kumar P S, Reddy G J. A randomized controlled clinical trial on efficacy of photodynamic therapy as an adjunct to nonsurgical treatment of chronic periodontitis. J Dent Lasers [serial online] 2015 [cited 2021 Jul 23];9:75-9. Available from: https://www.jdentlasers.org/text.asp?2015/9/2/75/170562




  Introduction Top


Chronic periodontitis is an infectious inflammatory disease with continuous release of several immunoinflammatory factors that are essential for pathogen clearance, but may damage periodontal tissues.[1] Mechanical scaling and root debridement have shown to be an effective treatment approach for periodontal disease.[2] In recent years, there has been a growing interest in usage of diode lasers for periodontal treatment due to their antimicrobial and anti-inflammatory properties.[3] Photodynamic therapy (PDT) has emerged in recent years as a new noninvasive therapeutic modality for the treatment of various infections by bacteria, fungi, and viruses. This therapy can be applied topically into a periodontal pocket, hence avoiding overdoses.[4] The present study was designed for comparative evaluation of changes in clinical parameters following a single episode of PDT as an adjunct to nonsurgical mechanical therapy in the treatment of chronic periodontitis.


  Materials and Methods Top


The present double blind randomized, split-mouth controlled clinical trial was carried out at a single center, comparing the clinical effects of adjunctive use of single episode of PDT, as an adjunct to nonsurgical mechanical therapy (SRP) in the treatment of chronic periodontitis. The patients for this study were selected from outpatient's section. Ethical committee of the institution approved the study.

Twenty-four patients with untreated chronic periodontitis were enrolled in the study. Chronic periodontitis was diagnosed by macroscopic, radiography, and probing pocket depth ≥5 mm. The dentition of the patients displayed at least one site in each quadrant of the mouth having deep probing depth (PD) ≥5 mm and radiographic signs of alveolar bone loss.

Inclusion criteria

  • Age – 18–60 years
  • Periodontal pockets ≥5 mm of PD
  • Vital and asymptomatic teeth
  • Healthy systemic condition.


Exclusion criteria

  • Pregnant or lactating females
  • Use of immunosuppressive agents
  • Deleterious habits like smoking/alcohol consumption
  • Having taken systemic or local antibiotic therapy within preceding last 6 months
  • Active periodontal treatment within last 6 months.


After baseline examination, a simple randomization approach [5] using computer-generated random numbers was employed to assign patients in a split-mouth design (the sequence was concealed until interventions were assigned) to one of the following treatment modalities:

  • Group I (control group): Scaling and root planing only
  • Group II (test group): Scaling and root planing and single episode of PDT using 1% methylene blue solution as photosensitizer.


The following clinical parameters were recorded at baseline 1, 3, and 6 months which include:

  • Plaque index (PI)[6]
  • Gingival index (GI)[7]
  • Modified Sulcular Bleeding Index (mSBI)[8]
  • PDs
  • Clinical attachment level (CAL).


The probing pocket depth and CAL was measured using UNC-15 graduated periodontal probe. Measurements were done at selected sites. All measurements were performed by one experienced periodontal examiner, allowing an intra-experimental comparison of the values. Percentage agreement with another examiner within 1 mm was >96%. The reading was recorded to the nearest millimeter. 1% methylene blue was used as photosensitizer in the present study.

Periodontal and adjunctive laser treatments

Routine oral hygiene instructions were given to all patients on the first appointment and one-stage full-mouth scaling and root debridement was done employing both hand instruments (Hu-Friedy, USA) and a piezoelectric ultrasonic handpiece (EMS) under local anesthesia of 2% lidocaine with 1:80,000 adrenaline (Lignox 2% A; Indoco Remedies Ltd., L-32, Goa).

On the second appointment that is, after 24 h the test teeth in Group II underwent a single episode of PDT. The periodontal pockets were filled with 1% methylene blue solution as photosensitizer which was left for 3 min [Figure 1]. The remaining photosensitizer was activated for 30 seconds to 45 seconds per site. The remaining photosensitizer was activated for 30 seconds to 45 seconds per site. The diode laser (DenLase; China Daheng Group, Inc. Beijing, China) was operated at a peak power of 5.0 W, with a pulse length of 200 µs and pulse interval of 200 µs (average power 1.0 W), using a 400 µm fiber-optic tip and a wavelength of 980 nm [Figure 2]. The tip was initiated and introduced into the pocket with a smooth stroking action, starting coronally and working toward the bottom of the pocket. The laser device is classified as Class 4 laser system, especially designed safety glasses were provided to the patient, operator, and dental assistant for protection of the eyes from the laser beam. Oral hygiene instructions were reinforced at 1, 3, and 6 months after the treatment.
Figure 1: Placement of photosensitizer (1% methylene blue) at the test site

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Figure 2: Activation of photosensitizer (1% methylene blue) with diode laser at the test site

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Statistical analysis

The data were analyzed using the SPSS - software 19.00 program (SPSS Inc., Chicago, IL, USA). The intra group comparison of PI scores and GI scores were compared between Group I and Group II at various study intervals using Kruskal–Wallis one-way ANOVA test and intergroup comparison were done by using Mann–Whitney U-test. The intra group comparison of clinical parameters such as mSBI, PD, and CAL were compared between Group I and Group II at various study intervals using one-way ANOVA test and intergroup comparison was done by using Tukeys multiple post-hoc test. Differences were considered as statistically significant at P < 0.05*.


  Results Top


Twenty-four patients with the age group of 24–55 years (15 males and 9 females) were enrolled in the study and they were randomly distributed into split-mouth double blind according to a computer-generated random number into following Groups (Group I and Group II). All 24 patients completed the 6 months study with no patients reporting any postoperative pain, discomfort, or complications at any of the follow-up appointments. The approach of patients appeared to be positive toward laser. Mean and standard deviation age in all the groups for males was 36.73 ± 8.46 and for females was 34.33 ± 6.80.

Inter-group comparison of PI, mSBI scores showed statistically significant reduction in test group at 3 and 6 months (P < 0.05) [Table 1] and [Table 2]. Inter-group and intra-group comparison of PD in test group showed statistically significant reduction at the end of 6 months when compared to control group (P < 0.05) [Table 3]. Inter-group comparison of PI and GI showed no significant difference, but there was statistically significant reduction in mSBI scores in test group at 6 months (P < 0.05) [Table 3]. Within the limitations of this study, additional application of single episode of PDT as an adjunct to mechanical scaling and root planing is beneficial in terms of PD and bleeding scores, but there was no significant improvement in plaque and GI [Table 2] and [Table 4].
Table 1: Inter-group comparison of Group I and II with plaque index scores at different time points by Mann-Whitney U-test

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Table 2: Inter-group comparison of Group I and II with modified sulcular bleeding index scores different time points by Tukeys multiple post hoc test

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Table 3: Inter-group comparison of Group I and II with probing depth scores different time points by Tukeys multiple post hoc test

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Table 4: Inter-group comparison of Group I and II with gingival index scores at different time points by Mann-Whitney U-test

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  Discussion Top


In the initial phase of periodontal therapy, debridement of the diseased root surface is nonsurgically treated by mechanical scaling and root planing, primarily by using manual or power-driven instruments. However, complete removal of bacterial deposits and their toxins from the root surface within the periodontal pockets is not always achieved with only the use of conventional mechanical therapy.[9] Recently, PDT has been used to treat localized microbial infections because the free radicals that are formed during PDT might be toxic effect to the bacteria. Christodoulides et al.[10] reported significant decrease in percentage change of full-mouth plaque score in SRP + PDT group when compared to SRP alone, in accordance with this study for Group II. Yilmaz et al.[11] compared SRP + PDT versus SRP alone, but there were no statistically significant differences. In the present study, by inter-group comparison, the mean GI and PI difference from baseline to 6 month, there was no significance between Group I versus Group II.

By intergroup comparison, the mean mSBI difference from baseline to 6th month, there was a statistical significance between Group I versus Group II at the end of 6th month. This indicates that the adjunctive use of PDT is better than SRP alone in the reduction of mSBI scores. Lui et al.[12] reported a significant reduction in percentage of sites with bleeding on probing from 84% at baseline to 8% at 3 months (P < 0.001) as compared to SRP alone which is in accordance with our study for Group II. There was a statistical significant increase in CAL gain in Group I and Group II; however, intergroup comparison was found to be statistically insignificant [Table 5]. Even though the methodology of studies was not the same, the use of different kinds of lasers, doses, and duration preclude a comparison of these studies with our study.
Table 5: Inter-group comparison of Group I and II with clinical attachment level scores at different time points by Tukeys multiple post hoc test

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  Conclusion Top


The present study suggests that an additional application of single episode of PDT could be beneficial adjunct to nonsurgical treatment of chronic periodontitis in terms of reduction PD and mSBI scores as compared to scaling and root planing alone. Direct subgingival delivery of methylene blue in different concentrations should be performed to further investigate the potential antimicrobial effect of soft lasers in human periodontal disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Duarte PM, Bezerra JP, Miranda TS, Feres M, Chambrone L, Shaddox LM. Local levels of inflammatory mediators in uncontrolled type 2 diabetic subjects with chronic periodontitis. J Clin Periodontol 2014;41:11-8.  Back to cited text no. 1
    
2.
Brayer WK, Mellonig JT, Dunlap RM, Marinak KW, Carson RE. Scaling and root planing effectiveness: The effect of root surface access and operator experience. J Periodontol 1989;60:67-72.  Back to cited text no. 2
    
3.
Moritz A, Schoop U, Goharkhay K, Schauer P, Doertbudak O, Wernisch J, et al. Treatment of periodontal pockets with a diode laser. Lasers Surg Med 1998;22:302-11.  Back to cited text no. 3
    
4.
Jori G. Photodynamic therapy of microbial infections: State of the art and perspectives. J Environ Pathol Toxicol Oncol 2006;25:505-19.  Back to cited text no. 4
    
5.
Altman DG, Bland JM. How to randomise. BMJ 1999;319:703-4.  Back to cited text no. 5
    
6.
Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condtion. Acta Odontol Scand 1964;22:121-35.  Back to cited text no. 6
    
7.
Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.  Back to cited text no. 7
    
8.
Mombelli A, van Oosten MA, Schurch E Jr, Land NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol 1987;2:145-51.  Back to cited text no. 8
[PUBMED]    
9.
Tuner J, Hode L. Some basic laser physics. In: The Laser Therapy Handbook. Grangesberg, Sweden: Prima Books; 2007. p. 317-38.  Back to cited text no. 9
    
10.
Christodoulides N, Nikolidakis D, Chondros P, Becker J, Schwarz F, Rössler R, et al. Photodynamic therapy as an adjunct to non-surgical periodontal treatment: A randomized, controlled clinical trial. J Periodontol 2008;79:1638-44.  Back to cited text no. 10
    
11.
Yilmaz S, Kuru B, Kuru L, Noyan U, Argun D, Kadir T. Effect of gallium arsenide diode laser on human periodontal disease: A microbiological and clinical study. Lasers Surg Med 2002;30:60-6.  Back to cited text no. 11
    
12.
Lui J, Corbet EF, Jin L. Combined photodynamic and low-level laser therapies as an adjunct to nonsurgical treatment of chronic periodontitis. J Periodontal Res 2011;46:89-96.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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