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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 11  |  Issue : 1  |  Page : 24-28

Photoactivated disinfection using indocyanine green photosensitizer as an adjunct to regenerative periodontal therapy


Department of Periodontology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Hingna, Nagpur, India

Date of Web Publication23-Jun-2017

Correspondence Address:
Snehal Prabhakar Deotale
Department of Periodontology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Hingna, Nagpur - 441 110
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdl.jdl_2_17

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  Abstract 

Regenerative periodontal surgical procedures attempt to restore lost periodontal structure and functional attachment through the regeneration of cementum, periodontal ligament, and alveolar bone. Although meticulous debridement using surgical instrumentation reduces the bacterial burden, it fails to kill the periopathogens. To overcome this shortcoming, the development of alternative adjunctive or exclusive antibacterial therapeutic strategies, therefore, becomes important in the evolution of methods to control microbial growth in the oral cavity. The following case report explores the use of antimicrobial photodynamic therapy as an adjunct to regenerative periodontal therapy for the management of intrabony defects which was evaluated over a period of 6 months.

Keywords: Antimicrobial photodynamic therapy, intrabony defects, periopathogens, regenerative periodontal therapy


How to cite this article:
Deotale SP, Dubey SR, Gattani DR. Photoactivated disinfection using indocyanine green photosensitizer as an adjunct to regenerative periodontal therapy. J Dent Lasers 2017;11:24-8

How to cite this URL:
Deotale SP, Dubey SR, Gattani DR. Photoactivated disinfection using indocyanine green photosensitizer as an adjunct to regenerative periodontal therapy. J Dent Lasers [serial online] 2017 [cited 2022 Jan 22];11:24-8. Available from: https://www.jdentlasers.org/text.asp?2017/11/1/24/208945


  Introduction Top


The primary goal of periodontal therapy is to eliminate bacterial biofilm and endotoxins from root surfaces of the teeth, which is chiefly achieved by nonsurgical and/or surgical periodontal therapy. Regenerative periodontal therapy indicates that healing has occurred with restored architecture of the lost periodontium. This is obtained with surgical treatment of defects with the use of bone grafting materials, guided tissue regeneration procedures, or use of enamel matrix derivative.[1] Meticulous debridement of diseased granulation tissue and removal of calculus from the root surface lay the foundation of surgical therapy. Although the instrumentation reduces the bacterial burden, it fails to kill the periopathogens.[2] The efficacy of such treatment may be compromised by lack of routine periodontal debridement, inadequate patients' oral hygiene maintenance, and failure of patient to maintain regular periodontal recalls. This hampers disease resolution and recurrence of disease can be prophesied.

Hence, the development of alternative adjunctive or exclusive antibacterial therapeutic strategies, therefore, becomes important in the evolution of methods to control microbial growth in the oral cavity. The application of light energy, also known as phototherapy, has been used to decontaminate the pocket environment as it possesses high bactericidal properties. With regard to the sole use of ablative laser energy in bactericidal effects, phenomena such as risk of collateral damage associated with thermal rise, nontarget absorption, inadequate access, and limitations of delivery tip design have been encountered.[3] Furthermore, noteworthy improvements in clinical parameters were not acknowledged by researchers.[4],[5]

In recent years, the use of the subablative low-level laser photonic energy to initiate antimicrobial photodynamic therapy (PDT) has surfaced. Tissue irradiation is achieved through the medium of a photosensitizer dye that selectively penetrates into the deeper tissues and specifically binds to the bacterial cell wall. Upon photoexcitation after interaction with a light of a particular wavelength, there is a generation of cytotoxic singlet oxygen and reactive oxygen species which cause pronounced antimicrobial action at the treatment site. As a result of the cytotoxic nature of the singlet oxygen, it is unlikely that the microorganisms would develop resistance to it. Furthermore, host tissue damage is not encountered due to the protective presence of keratin that inhibits the cytotoxic activity, thus promoting selective bacterial killing.[2]

Indocyanine green (ICG), a photosensitizer which has been proposed for PDT recently, has an optimal peak absorption at 800–810 nm.[6],[7] At this wavelength, a tissue penetration depth of 6–6.5 mm is observed.[8] Its use in the nonsurgical management of chronic periodontitis has shown a significant reduction in the disease process along with a decline in the pathogenic microflora. Furthermore, improvements in the clinical parameters were observed.[9],[10] The implication of photoactivated disinfection in the treatment of intrabony defects after open flap debridement before guided tissue regeneration has shown optimum hard tissue regeneration.[2],[11] This case report is an attempt to add to the scientific literature on the use of ICG-mediated photoactivated disinfection.


  Case Report Top


A 33-year-old male patient was referred to the Department of Periodontology, SDKS Dental College and Hospital, Nagpur, India, for the treatment of bleeding gums and food lodgment in the lower left back region of the jaw. On clinical examination, a probing depth of 10 mm was seen on the distal surface of 36 [Figure 1]. The tooth was not mobile but showed tenderness to vertical percussion. Radiographic examination revealed severe angular bone loss around the distal root spreading periapically with 36 [Figure 2]. Endodontic treatment was opted to eliminate the periapical infection with 36. After successful completion of the endodontic therapy, there was the resolution of the periapical infection radiographically, but a persistent probing depth of 10 mm was found along the distal root of 36. Hence, reconstruction of the angular defect was indicated. Under local anesthesia, a full thickness mucoperiosteal flap was raised with respect to 36, and thorough debridement was performed [Figure 3]. A commercially available ICG photosensitizer dye (Periogreen ® Elexxion AG, Singen, Germany) was used to flush the defect [Figure 4] and [Figure 5]. Excess dye was removed using vaccum suction. A diode laser (Picasso Lite, AMD Laser ) was used at a power of 500 mW, in continuous wave, noncontact mode for a period of 30 s per site (four sites around tooth) to activate the dye [Figure 6] and [Figure 7]. The defect was restored using DFDBA bone graft followed by amnion barrier membrane placement [Figure 8] and [Figure 9]. Interrupted sutures were placed, and the site was covered with a periodontal pack. One week later, the patient was recalled for removal of the pack and sutures. Reevaluation of the patient was done at 10 days and 3 and 6 months [Figure 10],[Figure 11],[Figure 12].
Figure 1: Preoperative probing pocket depth of 10 mm

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Figure 2: Radiographic evaluation showing vertical bony defect on distal surface of 36

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Figure 3: Full thickness flap raised and debridement done with 36

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Figure 4: Contents of Periogreen® Elexxion AG, Singen, Germany

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Figure 5: Application of indocyanine green photosensitizer in defect with 36

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Figure 6: A 810 nm diode laser (Picasso Lite, AMD Laser)

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Figure 7: Exposure of defect to 810 nm diode laser

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Figure 8: Placement of demineralized freeze-dried bone allograft, bone graft in defect site

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Figure 9: Placement of amnion barrier membrane over defect site

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Figure 10: Healing at 10 days

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Figure 11: Radiographic evaluation at 3 months

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Figure 12: Radiographic evaluation at 6 months

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  Discussion Top


Several therapeutic modalities have been opted for the treatment of intrabony defects. However, optimum regeneration is hampered with the regrowth of bacterial biofilms leading to recurrence of inflammation and subsequent tissue destruction. The advent of subablative forms of laser photonic energy along with the application of a photosensitizer agent has shown to reduce the bacterial burden and alleviates clinical inflammation.

The ideal PDT photosensitizer should absorb light of wavelength that falls within the visible-red and near-infrared region of the electromagnetic spectrum (approximately 650–900 nm), known as “the therapeutic window,” where maximum penetration of light into the tissues is observed.[12] It employs nonsurgical (subablative) photonic energy values with little risk of collateral damage within confined target sites. The use of noncollimated light through a diffuser tip can overcome limited access and be further compensated by scatter through the body of the liquid sensitizer. Hence, PDT successfully overcomes the precincts of previously mentioned procedures such as thermal heat generation and resistance to systemic antibiotics.[2]In vitro studies have shown statistically significant reduction of selected bacterial species such as Staphylococcus aureus and Pseudomonas aeruginosa, Porphyromonas gingivalis, and Aggregatibacter actinomycetemcomitans, as <10% of bacteria remain viable.[6],[13] ICG-mediated PDT has shown to decrease the percentage of viable bacteria at the end of 1 week.[9]

Laser photonic energy facilitates early wound healing and favors soft and hard tissue regeneration by increasing cell function, proliferation rate of fibroblasts, collagen synthesis, and osteoblast production.[14],[15],[16] Radiographic evaluation has shown that the diode laser used in proximity to the bone does not have detrimental effects and tissue healing is uneventful postlaser use.[5] Moreover, use of low-level laser therapy as an adjunct to scaling and root planing can lead to improved radiographic bone density.[17] Thus, when used as an adjunct to regenerative therapy, PDT can help regulate the reentry of periopathogens at the surgical site and help achieve restoration of the lost tissues.


  Conclusion Top


Use of ICG photosensitizer-mediated PDT can be seen as an adjunctive therapeutic modality to the reduction of bacterial pathogens and as part of the overall treatment necessary to address causative factors and repair, remodel, or restore the tissue site as required. Primary importance must, however, be given to the role of systemic diseases and other etiological factors to decide the suitable treatment protocol. The role of patient's self-maintained plaque control cannot be overlooked as well.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
American Academy of Periodontology. Position paper on periodontal regeneration. J Periodontol 2005;76:1601-22.  Back to cited text no. 1
    
2.
Schenk G, Flemmig TF, Lob S, Ruckdeschel G, Hickel R. Lack of antimicrobial effect on periodontopathic bacteria by ultrasonic and sonic scalers in vitro. J Clin Periodontol 2000;27:116-9.  Back to cited text no. 2
    
3.
Parker S. The use of diffuse laser photonic energy and indocyanine green photosensitiser as an adjunct to periodontal therapy. Br Dent J 2013;215:167-71.  Back to cited text no. 3
    
4.
Gokhale SR, Padhye AM, Byakod G, Jain SA, Padbidri V, Shivaswamy S. A comparative evaluation of the efficacy of diode laser as an adjunct to mechanical debridement versus conventional mechanical debridement in periodontal flap surgery: A clinical and microbiological study. Photomed Laser Surg 2012;30:598-603.  Back to cited text no. 4
    
5.
Lobo TM, Pol DG. Evaluation of the use of a 940 nm diode laser as an adjunct in flap surgery for treatment of chronic periodontitis. J Indian Soc Periodontol 2015;19:43-8.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Boehm TK, Ciancio SG. Diode laser activated indocyanine green selectively kills bacteria. J Int Acad Periodontol 2011;13:58-63.  Back to cited text no. 6
    
7.
Nagahara A, Mitani A, Fukuda M, Yamamoto H, Tahara K, Morita I, et al. Antimicrobial photodynamic therapy using a diode laser with a potential new photosensitizer, indocyanine green-loaded nanospheres, may be effective for the clearance of Porphyromonas gingivalis. J Periodontal Res 2013;48:591-9.  Back to cited text no. 7
    
8.
Bashkatov AN, Genina EA, Kochubey VI, Tuchin VV. Optical properties of human skin, subcutaneous and mucous tissues in the wavelength range from 400 to 2000nm. J Phys D Appl Phys 2005;38:2543-55.  Back to cited text no. 8
    
9.
Srikanth K, Chandra RV, Reddy AA, Reddy BH, Reddy C, Naveen A. Effect of a single session of antimicrobial photodynamic therapy using indocyanine green in the treatment of chronic periodontitis: A randomized controlled pilot trial. Quintessence Int 2015;46:391-400.  Back to cited text no. 9
    
10.
Monzavi A, Chinipardaz Z, Mousavi M, Fekrazad R, Moslemi N, Azaripour A, et al. Antimicrobial photodynamic therapy using diode laser activated indocyanine green as an adjunct in the treatment of chronic periodontitis: A randomized clinical trial. Photodiagnosis Photodyn Ther 2016;14:93-7.  Back to cited text no. 10
    
11.
Parker S. Photodynamic antimicrobial chemotherapy in the general dental practice. J Laser Dent 2009;17:131-8.  Back to cited text no. 11
    
12.
Huang YY, Chen AC, Carroll JD, Hamblin MR. Biphasic dose response in low level light therapy. Dose Response 2009;7:358-83.  Back to cited text no. 12
    
13.
Topaloglu N, Gulsoy M, Yuksel S. Antimicrobial photodynamic therapy of resistant bacterial strains by indocyanine green and 809-nm diode laser. Photomed Laser Surg 2013;31:155-62.  Back to cited text no. 13
    
14.
Bednarska K, Rózga B, Kolodziejczyk K, Szosland D, Leyko W, Bryszewska M. Effect of low-power red light laser irradiation on the viability of human skin fibroblast. Radiat Environ Biophys 1998;37:215-7.  Back to cited text no. 14
    
15.
Webb C, Dyson M, Lewis WH. Stimulatory effect of 660 nm low level laser energy on hypertrophic scar-derived fibroblasts: Possible mechanisms for increase in cell counts. Lasers Surg Med 1998;22:294-301.  Back to cited text no. 15
    
16.
Stein A, Benayahu D, Maltz L, Oron U. Low-level laser irradiation promotes proliferation and differentiation of human osteoblasts in vitro. Photomed Laser Surg 2005;23:161-6.  Back to cited text no. 16
    
17.
Makhlouf M, Dahaba MM, Tunér J, Eissa SA, Harhash TA. Effect of adjunctive low level laser therapy (LLLT) on nonsurgical treatment of chronic periodontitis. Photomed Laser Surg 2012;30:160-6.  Back to cited text no. 17
    


    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]


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