Rajiv Gandhi University of Health Sciences s46

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA ANNEXURE –II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE CANDIDATE DR. SACHIDANANDA CHUNGKHAM AND ADDRESS POST GRADUATE STUDENT (IN BLOCK LETTERS) DEPARTMENT OF PERIODONTOLOGY RAJARAJESWARI DENTAL COLLEGE AND HOSPITAL, MYSORE ROAD, BANGALORE – 560074.

2 NAME OF THE INSTITUTION RAJARAJESWARI DENTAL COLLEGE AND HOSPITAL, BANGALORE-560074.

3 COURSE OF STUDY AND MASTER OF DENTAL SURGERY SUBJECT PERIODONTOLOGY

4 DATE OF ADMISSION TO THE 29.05.13 COLLEGE

5 TITLE OF THE TOPIC: “COMPARATIVE EVALUATION OF THE EFFICACY OF PHOTODYNAMIC THERAPY (PDT) USING METHYLENE BLUE AND TOLUIDINE BLUE AS AN ADJUNCT TO SCALING AND ROOT PLANING (SRP) IN THE TREATMENT OF CHRONIC PERIODONTITIS - A CLINICAL AND MICROBIOLOGICAL STUDY.” 6 BRIEF RESUME OF THE INTENDED WORK:

6.1 NEED FOR THE STUDY :

Periodontitis is a chronic inflammatory disease involving the supporting structures of

the teeth. It is triggered by periodontopathogens, while the clinical outcome is greatly

influenced by the local host immune response.1 The main approach to treat periodontitis

involves the removal of plaque biofilm by means of mechanical debridement (i.e. non-

surgical periodontal therapy). Although, in most cases, non-surgical periodontal therapy

results in significant clinical improvements, complete removal of bacterial deposits is still

very difficult to be accomplished. In order to additionally facilitate bacterial reduction,

especially in cases that do not adequately respond to conventional mechanical treatment,

complementary methods such as systemic and local antibiotics or various laser systems have

been proposed.2

In recent years, the combination of laser light and photosensitizer known as

photodynamic therapy (PDT) has been used in periodontal therapy.3

Photodynamic therapy (PDT) can be defined as eradication of target cells by reactive

oxygen species produced by means of a photosensitizing compound and light of an

appropriate wavelength. Photodynamic action describes a process in which light, after being

absorbed by dyes, sensitizes organisms for visible light induced cell damage.4

In photodynamic therapy, the particular photosensitizers employed are phenothiazine

dyes (Toluidine blue O, Methylene blue), erythrosine, chlorine e6 and hematoporphyrin,

which have been shown to be safe when employed in the medical field. The phenothiazine

dyes (Toluidine blue O and Methylene blue) are the major photosensitizers applied clinically in the medical field.5

The photosensitizer acts as an agent of optical absorption or chromophore, which produces fluorescence after irradiation, causing cytotoxicity in the medium.6

Various in vitro studies have shown the use of a laser associated to a photosensitizer is very efficient against bacteria, yeasts, viruses and parasites.7 It has been demonstrated that photosensitizers, such as toluidine blue O and methylene blue, which undergo a pronounced cationic charge, can bind to the outer membrane of gram-negative bacteria and penetrate bacterial cells, demonstrating a high degree of selectivity for killing microorganisms compared with host mammalian cells.8 Therefore, toluidine blue O and methylene blue have been the photosensitizers of choice in the treatment of periodontitis . However, toluidine blue

O seems to exhibit a greater ability for killing gram-positive and gram-negative bacteria than methylene blue.5

According to our knowledge, there are no studies comparing the effects of photodynamic therapy using methylene blue and Toluidine blue in the treatment of chronic periodontitis. Hence the present study is aimed to assess the efficacy of photodynamic therapy (PDT) using methylene blue and Toluidine blue as an adjunct to scaling and root planing (SRP) in the treatment of periodontitis and compare the efficacy of methylene blue and Toluidine blue as photosensitizers. 6.2 REVIEW OF LITERATURE:

 A study was done to compare PDT with a diode laser and the Nd: YAG. Patients are

divided into three groups. Group I received SRP and irradiation from Nd: YAG.

Group II received SRP and irradiation from a diode laser. Group III received SRP and

PDT. Microbiological samples were examined and evaluated over a period of three

months. Significant bacterial reduction has been observed in all cases. The diode laser

with SRP presented long term positive results, while PDT showed significant bacterial

reduction during the entire observation period.3

 A study was done to evaluate the susceptibility of Candida Albicans to photodynamic

therapy using methylene blue and toluidine blue as photosensitizing dyes. This study

concluded that Candida Albicans was susceptible to PDT, using either methylene blue

or toluidine blue as photosensitizers and the number of Candida Albicans was lower

when Toluidine blue was used.6

 Another study was done to assess the effect of adjunctive antimicrobial photodynamic

therapy in chronic periodontitis. All teeth received periodontal treatment comprising

SRP.Using a split mouth design, two quadrants (test group) were additionally treated

with PDT. Bleeding on probing (BOP), relative attachment level (RAL), probing

depth (PD) were evaluated at baseline and 3 months after treatment. This study

indicates that the adjunctive use of a PDT has a positive effect on treatment outcomes.

Thus, by adding antimicrobial photodynamic treatment procedures to conventional

anti-infective approaches, it might be possible to improve non-surgical periodontal

therapy.9  A study was done to evaluate the bactericidal efficacy of Methylene Blue and

Toluidine Blue against different bacteria under light and dark conditions to determine

the most effective bactericidal dye. This study concluded that Toluidine Blue exhibits

a greater bactericidal activity than Methylene Blue against most bacteria in dark and

light conditions. Mostly, these results are consistent with their respective dye partition

coefficients.10

 Another study was done to evaluate the effects of a combination of photodynamic

therapy with low-level laser therapy as an adjunct to nonsurgical treatment

of chronic periodontitis. Patients with untreated chronic periodontitis were randomly

assigned in a split-mouth design to receive scaling and root debridement with or

without one course of adjunctive photodynamic therapy and low-level laser therapy.

This study concluded that a combined course of photodynamic therapy with low-level

laser therapy could be a beneficial adjunct to nonsurgical treatment of chronic

periodontitis on a short-term basis. Further studies are required to assess the long-term

effectiveness of the combination of photodynamic therapy with low-level laser

therapy as an adjunct in nonsurgical treatment of periodontitis.11  A study was done to compare the efficacy of photoablative and photodynamic diode

laser in adjunct to scaling and root planing (SRP) and SRP alone for the treatment of

chronic periodontitis. This study concluded that diode laser treatment (photoablation

followed by multiple photodynamic cycles) adjunctive to conventional SRP improves

healing in chronic periodontitis patients.12 6.3 AIMS AND OBJECTIVES OF THE STUDY:

1) To evaluate the efficacy of photodynamic therapy (PDT) using methylene blue and

toluidine blue as an adjunct to scaling and root planing (SRP) in the treatment of chronic

periodontitis.

2) To compare the efficacy of methylene blue and Toluidine blue as photosensitizers.

7 MATERIALS AND METHODS :

7.1 SOURCE OF DATA

Patients reporting to the Department of Periodontology, Rajarajeswari Dental College and

Hospital, Bangalore.

7.2 METHOD OF COLLECTION OF DATA :

A total of 30 patients aged between 30-50 years diagnosed as chronic generalised

periodontitis will be selected for the study, out of which 90 sites will be treated and grouped

as follows:

Group I [control group] - 30 sites will be treated with scaling and root planing.

Group II [test group] - 30 sites will be treated with scaling and root planing followed by

methylene blue mediated photodynamic therapy.

Group III [test group] - 30 sites will be treated with scaling and root planing followed by

toluidine blue mediated photodynamic therapy. INCLUSION CRITERIA :

 Systemically healthy patients.

 Patient should have more than 20 teeth remaining.

 More than 30% of sites involved.

 Presence of periodontal pocket in at least two teeth with a probing depth of >5 mm in

each quadrant.

EXCLUSION CRITERIA :

 Smokers.

 Pregnant and lactating mothers.

 Periodontal treatment within the past 6 months.

 Antibiotics or anti-inflammatory drugs taken within the preceding 6 months.

SCREENING EXAMINATION INCLUDE

 Gingival index by Loe H & Silness P, 1963.

 Plaque index by Silness P & Loe H, 1964.

 Probing Pocket Depth (PPD) to be measured using graduated Williams periodontal

probe.

 Clinical attachment level measured from CEJ to the base of the pocket.

DURATION OF THE STUDY: 18 Months PROCEDURE:

All the patients will be examined and screened for the suitability of the study and signed consent will be obtained from each patient after explaining the nature of the treatment. In each patient the sites per quadrant will be randomly allotted to the groups. Sites in group I will receive non-surgical periodontal therapy consisting of scaling and root planing. The sites in group II will receive non-surgical periodontal therapy consisting of scaling and root planing followed by methylene blue mediated photodynamic therapy. The sites in group III will receive non-surgical periodontal therapy consisting of scaling and root planing followed by toluidine blue mediated photodynamic therapy. Clinical parameters will be recorded and subgingival plaque samples from the sites will be collected at baseline (pre-treatment),

1month and 3 month interval. Subgingival plaque samples will be collected using sterilized curette and then suspended in 1ml sterile normal saline solution followed by microbiological analysis of the collected samples using Gram’s staining.

STATISTICAL ANALYSIS:

Following tests of statistics will be used in the present study:

1. ANOVA - To compare mean values between the groups.

2. Tukey Test- Pair wise comparison of the groups.

Any other statistical methods if required will be used.

7.3 Does the study require any investigations or interventions to be conducted on patients or other human or animals? If so, please describe briefly :

Yes. Patient will undergo scaling and root planing ,photodynamic therapy and

microbiological analysis pre and post treatment.

7.4 Has ethical clearance been obtained from your institution in case 7.3?

Ethical clearance letter has been attached. LIST OF REFERENCES:

8 1. Page RC, Offenbacher S, Schroeder HE, Seymour GJ, Kornman KS. Advances in the

pathogenesis of periodontitis: summary of developments, clinical implications and

future directions. Periodontol 2000. 1997;14:216–248.

2. Chondros P , Nikolidakis D, Christodoulides Nicos, Rossler Ralf, Gutknecht Norbert .

Photodynamic therapy as adjunct to non-surgical periodontal treatment in patients on

periodontal maintenance: a randomized controlled clinical trial. Lasers Med Sci

2009;24(5):681-8

3. Romano E. Photodynamic therapy in periodontal therapy: Microbiological

observations from a private practice. Gen Dent 2010;58(2):e68-73

4. Raghavendra M, Koregol A,Bhola S. Photodynamic therapy: A targeted therapy in

periodontics . Aust Dent J 2009;54(1):S102–9.

5. Takasaki AA, Aoki A,Mizutani Koji,Schwarz Frank,Sculean Anton. Application of

antimicrobial photodynamic therapy in periodontal and peri-implant diseases.

Periodontol 2000.2009; 51:109–40.

6. Pupo YM., Gomes G M. Susceptibility of candida albicans to photodynamic therapy

using methylene blue and toluidine blue as photosensitizing dyes. Acta Odontol

Latinoam 2011; 24(2):188-92. 7. Wilson M, Burns T, Pratten J, Pearson GJ. Bacteria in supragingival plaque samples

can be killed by low-power laser light in the presence of a photosensitizer. J Appl

Bacteriol 1995;78(5):569-74

8. Soukos NS, Wilson M, Burns T, Speight PM. Photodynamic effects of toluidine blue

on human oral keratinocytes and fibroblasts and Streptococcus sanguis evaluated in

vitro. Lasers Surg Med 1996; 18(3): 253–9

9. Braun A, Dehn C,Krause F,Jepsen S. Short-term clinical effects of adjunctive

antimicrobial photodynamic therapy in periodontal treatment: a randomized clinical

trial. J Clin Periodontol 2008; 35(10): 877-84.

10. Usacheva MN, Teichert MC. Comparison of the Methylene Blue and Toluidine Blue

Photobactericidal Efficacy against Gram-Positive and Gram-Negative

Microorganisms. Lasers Surg and Med 2001; 29(2):165-73.

11. Lui J, Corbet EF,Jin L. Combined photodynamic and low-level laser therapies as an

adjunct to nonsurgical treatment of chronic periodontitis. J Periodont Res

2011;46(1):89–96.

12. Giannelli M, Formigli L,Lorenzini L,Bani D. Combined photoablative and

photodynamic diode laser therapy as an adjunct to non-surgical periodontal treatment.

A randomized split-mouth clinical trial. J Clin Periodontol 2012;39: 962–970.