Special thanksto

Dr / Ayman ShoushaHead of oral medicine departmentAlexandria dental research center

For his great efforts

Presented by:Dr / Eman Bahaa ,

Dr / Mina Saad

Few novel therapies for the treatment of oral infections have been developed over the past decade.The Current standard of care is to provide scaling and root planning, with or without antibiotics delivered either Locally or systemically. The introduction of photo disinfection for Canada and Europe in 2006 represented a Milestone in new and innovative approaches to the treatment of oral infections.

Photo disinfection is based on a well-known reaction that happens when a photo sensitizer compound is combined with a color-matched, non-thermal light source.This reaction creates a consequent reaction whereby the light-activated photo sensitizer is able to transfer energy to surrounding oxygen, creating a flux of oxygen-derived free radicals.

WHAT IS MEANT BY PHOTO DISINFECTION

These radicals, in turn, are able to physically destroy the bacterial cell membraneand, thus, the bacterial cell, significantly reducing the numbers of gram negative bacteria,Inactivating the virulence factors associated with periodontal diseases, and enhancing the healing process.

Difference between Ozone therapy & Photo-dynamic disinfection(PDT)

Photodynamicdisinfection

OzonePoint of comparison

OxidationOxidationReactionIndirect oxidationBacteria + photo-

Sensitizing solution(Methylene blue)

Oxygenfree radicalsbacterial destruction.

Direct oxidationBacteria + O3 Oxygen free radicalsbacterial destruction.

Mode of action

Diode laser

Almost no contra-

indications

1- Allergy to ozone.2- Pregnancy.3- Muscle cramps & spasms.4- Blood coagulation disorders.5- Hypoglycemia.6- Alcoholic intoxication.7- Thrombocytopenia.8- hyperthyroidism.9- Acute and chronic tendency to bleeding.10- After recent heart attack.

Contra -indications

Periowave is the newest treatment option available to help fight periodontal disease. Both fast and Painless, it is the first dental treatment to use the power of photodynamic disinfection (PDD).

What is periowave?

Its laser is different than most diode lasers used in dentistry today. Most dental lasers are meant to becutting surgical lasers which are all Class IV lasers due to their high power.

It can be used as an adjunctivetreatment to scaling and root planning (SRP) and achieves better results than SRP alone.

The Periowave laser is anon-thermal laser which does not heat tissue since its mechanism of action is by the specific wavelength of lightcausing a specific reaction process.

Classification of lasers

Class I

Low output power.-Intensity:

inherently safe , no possible eye -Eye damage:damage because of either the low output power or enclosure preventing user access to the laser beam during operation.

CD players , laser pointers. -Examples:

This classification system is only slightly altered from the original system developed in the early 1970s. It is still used by US laser product safety regulations. They are classified according to intensity to:-

mW.1up to -Intensity:The blink reflex of the human eye -Eye damage:

will prevent eye damage, unless the person deliberately stares into the beam for an extended period.

laser pointers.-Examples:

Class II

Class IIIa

mW.5 Output power does not exceed -Intensity:

dangerous in combination with -Eye damage:optical instruments.

fire arms.-Examples:

Class IIIbmW.500 –5-Intensity:

cause damage if the beam enters may-Eye damage:the eye directly and can lightly burn skin.

Class IV.mW500 more than -Intensity:

may cause severe, permanent -Eye damage:damage to eye or skin without being magnified by optics of eye.

Many industrial, scientific, military, and -Examples:medical lasers are in this category.

Periowave is used to treat:1- Gingivitis.

2- Mild , moderate and severe periodontitis.

3- Peri-implantitis.

INDICATIONS

Contra-indications1- There is a theoretical risk for patients with severe G6PD but since Periowaveis not ingested this would be extremely unlikely to cause a reaction.

Effect of systemic Methylene blue on Favism patients

Methylene blue can cause severe worsening of hemolytic anemia or methemoglobinemia in patients with G6PD deficiency (these patients do not have adequate levels of NADPH to reduce methylene blue to leukomethylene blue).

For this reason, reports have warned that methylene blue may be ineffective or dangerous if ingested in patients with G6PD deficiency.

Methylene blue should be used with caution in young patients with G6PD deficiency (due to low endogenousNADPH concentrations, which is essential to leukomethylene blue production).

A phenothiazine dye (methylene blue),pH stabilizers, taste enhancers and muco-adhesive polymers.

and The Periowave laser N.B:photosensitizing solution are carefully designed to work together, and other diode lasers or photo sensitizers will not produce the same photosensitizing effect or clinical results.

COMPOSITION OF THE PHOTOSENSITIZING SOLUTION

Mechanism

Technique

Clinical Application

action antimicrobial -A dual:Effective-1that kills harmful bacteria associated with periodontal disease, but also attacks and inactivates endotoxins responsible for tissue destruction.

intensity laser used is a -The low:Safe-2non-thermal diode laser that is safe and non-damaging to host tissues.

Advantages

There are no known :antibiotic-Non-3resistance issues with the Periowave treatment and no antibiotic side effects.

Quick and simple to :Efficient-4administer, taking no more than 60 seconds per treatment site.

The photosensitizing :Painless-5solution is applied topically and the diode laser does not produce heat resulting in virtually no discomfort for the patient.

1- The laser hazard on the eye, so both dentist and patient should wear protective glasses.

2- The photo sensitizer is a bacterial stain (dye) it can stain clothing and care should be taken to avoid getting on clothes.

3- There may be a very transient blue stain to mucosal surfaces & This resolves within a few minutes.

Precautions

1- Pocket depth(PD) reduction.

2- Clinical attachment loss (CAL) reduction.3- Decreased bleeding on probing(BOP).

4- Improvement in gingival tone and texture.

Clinical Outcome

1- The pockets are thoroughly debrided prior to photo disinfection. It does not replace scaling and root planning, so SRP should be done first.

2- Moderate to heavy bleeding must be stopped before using Periowave for a more effective result ,as significant bleeding flushes the sensitizer out of the pockets, and reduces treatment efficacy.

Instructions

3- If haemostatic agents are used, they should be gently flushed from the pocket with saline or H2O prior to application.

4- If the bleeding cannot be controlled, the patient should be brought back for Periowave treatment within 2-6 days following scaling and root planning.

5- Treat sites adjacent to the defect if possible as bacteria are at high population densities within the defect, but can migrate throughout the gingival sulcus (and hence populate other oral sites).

6- To best protect the integrity of the light-diffusing tip function, it is recommend to gently wipe the tip between treatment sites in order to maximize light transmission.

7- Continue to irrigate the pocket until a small quantity of solution can be seen flowing over the free gingival margin.

kit is PeriowaveThe small N.B:designed to treat up to four defects; the large Periowave kit is designed to treat up to ten defects8- Each treatment site must be irrigated and illuminated before the next site is treated.

9- Do not irrigate several sites at a time, as gingival crevicular fluid (GCF) flow will tend to flush the sensitizer out of the pockets before the illumination step can be carried out.

10- “Walk” the diffusing tip gently around the defect during illumination, in both apico-coronal andmesiodistal directions if possible without allowing the tip to rise above the gingival crest to allow optimal illumination of the sensitizer molecules bound to biofilm components throughout the full dimensions of the defect & this is especially important in deeper defects where SRP may have incompletely removed adherent calculus deposits.

Case studies about the effect of periowave on chronic periodontitis

Case I-Clinical examination:

1- Generalized severe bleeding

on probing.

2- Pocket depth (PD) ranges from (4-7mm).

-Treatment:

Application of SRP and Periowave.

Pretreatment 7mm pocket

Post-treatment 7mm pocket reduced to

3mm

-Clinical examination:1- The lower arch had moderate calculus formation, but few signs of clinical inflammation; probing pocket depths were generally 3-4 mm.2- The maxillary teeth exhibited severe inflammation with engorgement and bleeding.

-Treatment:Application of SRP and periowave.

Case II Gingival inflammation & tooth loss

Pre–treatment gingival inflammation

Post-treatment resolution of gingival

inflammation

-Clinical examination:1- The patient had been treated three years prior for generalized severe periodontitis &the treatment at that time consisted of SRP, home care instructions, occlusal equilibration, and osseous surgery.2- A 6 mm inflamed bleeding pocket was evident between Lower right 2&3.

-Treatment:Application of SRP and periowave.

Case III Unsuccessful prior periodontal therapy

Pre-treatment gingival

inflammation near the pocket

Post-treatment resolution of

gingival inflammation

Then, periodontal regenerative surgery was recommended for re-attachment.

Meta-analysis of three chronic periodontitistrials

with periowave photo disinfection

Ondine research laboratories,Inc,Bothell,WA,USA;

Loma Linda university,CA,USA,Shanghai second medical university,

china;Wenzhoy medical college , China

1- Studies were powered to detect statistically significant changes in PD.2- Standard inclusion / exclusion criteria included the requirement for four or more sites with pocket depth at least six mm to be present, in at least two quadrants of the mouth, with bleeding on gentle probing.3- Patients who were pregnant, or had receivedperiodontal instrumentation or antibiotics in the prior four months were excluded.

Methods

4- Patients meeting criteria were recruited in total with each receiving two sequential half-mouth SRP procedures except one group which received periowave treatment only.5- During the second visit, patients randomized to the Periowave arm received photo disinfection on all qualified pockets.6- In the re-treatment study,Periowave randomized patients received a second photo disinfection at 6 weeks.7- At the 6 and 12-week follow-ups, clinical endpoints were measured using either doublepass manual probing or electronic probing on all the three groups.

Conclusion

Pocket depth recoveries

Photo disinfection with the Periowave

system appears to significantly improve the outcome of

mechanical debridement therapy in the treatment of

chronic periodontitis.

A preliminary randomized controlled clinical study

Made by:Rafael de Oliveira , Humberto O , Schwartz-Filho ,

Arthur B.Novaes Jr and Mario Taba Jr.Department of Bucco-Maxillofacial Surgery and

Traumatology and Periodontology, School of Dentistry of Ribeirão Preto, University of São

Paulo, Ribeirão Preto, SP, Brazil.

Photodynamic therapy inthe non – surgical treatmentof aggressive periodontitis

The treatment of aggressive periodontitis has always presented a challenge for clinicians,But there are no protocols and guidelines to help in the efficient control of the disease.

-Methods:Ten patients with a clinical diagnosis of aggressive periodontitis were treated in a split – mouth design study to either photodynamic therapy(PDT) or SRP.

Clinical assessment of plaque index (PI) , gingival index (GI) , bleeding on probing (BOP),probing depth (PD) , gingival recession (GR) ,Relative clinical attachment loss (RCAL) were made at baseline and 3 months after treatment with an automated periodontal probe.

-Conclusion:1- A significant reduction of all indices was observed after 3 months of treatment in both therapies.

2- PDT and SRP showed similar clinical results in the non-surgical treatment of aggressive

periodontitis )2007 (j.periodontol

3- SRP failed to completely eradicate the main pathogens responsible for aggressive periodontitis such as Tannerella Forsthyensis and Actinobacillus actinomycetemcomitans which remained in periodontal pockets. So to prevent a return to the pretreatment level of pathogens, there is a need for a supportive photodynamic disinfection therapy to help in controlling this disease.

Further studies using larger sample sizes are Warranted to confirm

these results.

This study evaluates the effects of thePeriowave PDD system on the surface chemistry of three commonly used dental implant screws.

In addition the efficacy of the system foreradication of P.gingivalis biofilms grown on the surface of dental implant screw.

Periowave & peri-implantitis

Titanium dental implant screws from three major manufacturers designated as A, B, and C) were exposed to SRP andPeriowave treatment.

These implants were subsequently examined using Electron Spectroscopy for Surface Analysis (ESCA) and high resolution carbon scan to determine whether the treatment significantly alters the surface chemistry.

Materials & Methods

Then a homogenous biofilms ofP. gingivalis were grown anaerobically for 72 hours on dental implant screws.

Then the examined implants were placed in Periowave solution for 1 minute, followed by circumferential illumination for 1 minute using Three Periowavelaser hand pieces and light guide tips (220mW, 670nm) placed at degree angles around the implant screw.

The exposure/illumination procedure was repeated for a total of two minutes PDD treatments per implant

1- This study showed that the exposure toPeriowave did not alter the surface chemistry of three used dental implants.2- It was demonstrated that establishedbiofilms of P. gingivalis, a major pathogen associated with periodontal disease and peri-implantitis, can be effectivelyeradicated from the surface of dental implant screws using thePeriowave PDD system.

Conclusions

A study by Joseph Andary , DDSCase Report:This study was made on a 58 years – old female who is free of any systemic diseases.

Peri-implantitis in-vivo

-Clinical Findings:Generalized chronic moderate periodontitis in addition to peri-implantitis around implant #22, which had been placed approximately four years ago.On probing , deep pockets were found.e.g.: #22 implant MB = 14, 9, 7.

Additionally, there was an extensive suppuration and bleeding in the areas around the teeth and implants (Fig 1).

There was no mobility of the implant, but an extensive overhang on the prosthetic crown was notedand radiographic examinationrevealed a large degree ofangular bone loss between the implant and the central incisor (Fig 2).

-Treatment Options:The following treatment options were

-discussed with the patient::1Option

Remove the implant immediately and then follow up with one or possibly twobone grafting procedures with implantplacement in six to eight months.

:2Option Remove the implant and then place a bridge, depending on the prognosis oftooth #21.

:3Option Treat the infected area with Periowavephoto disinfection in order to eliminatethe peri-implantitis infection and then performa bone grafting procedure, therebycircumventing the need for implant removal.

The patient was very motivated to trythe third option because she wanted to try and save the implant.Treatment Plan:Three consecutive Periowaveapplications were conducted on the patient two weeks apart and successfully eliminated the infectionaround the implant.

Six weeks after the initial treatment,bone-grafting surgery was performedon the implant.

Fig 3 Fig 4

The surgical procedure involved an open flap debridement SRP and disinfection with Periowave prior to graft placement(Fig 5 & 6).

A postoperative radiographtaken (Fig7) shows the graftin place with no radiographicsigns of graft rejection.

The postoperative photographshows an excellent soft tissue response one week later (Fig 8).

Before After

Before After

Conclusion:Periowave is useful in disinfectingthe open flap surgical area prior tobone grafting, thus establishing a cleanenvironment and eliminating any bacteriathat could interfere with the healing andintegration process.

-Clinical examination:1- A complaint of gingival pain on the upper 2 centrals during eating and brushing.2- Incisional biopsies were performed, and immunofluorescence suggested oral lichen planus.

-Treatment:Application of SRP and periowave.

Effect of periowave treatmenton oral lichen planus(clinical case study)

Pre-treatment gingival

inflammation due to oral lichen

planus

Post-treatment resolution of

gingival inflammation

Further studies are recommended

to explain the effect of photo-dynamic disinfection

on oral lichen planus

References1 - UCL, Eastman Dental Institute, University College London. (periowave).2- Mechanisms and Techniques in Photodynamic Therapy XVIII. Edited by Street, Cale N.; Andersen, Roger; Loebel, Nicolas G. Proceedings of the SPIE, Volume 7164, pp. 71640R-71640R-18 (2009).3- Loebel N, Anderson R, Hammond D, Leone S, and Leone V, Ondine Biopharma Corporation. Non-Surgical Treatment of Chronic Periodontitis Using Photo activated Disinfection. International Association of Dental Research, March 2006.4- Wilson M: Bactericidal effect of laser light and its potential use in the treatment of plaque-related diseases. Int Dent J. 1994; 44(2):181-189.5- Wainright, M: Photoinactivation of viruses. Photochem Photobiol Sci. 2004;;3:406-11.6- Wilson M: Lethal photosensitization of oral bacteria and its potential application in the photodynamic therapy of oral infections. Photochem Photobiol Sci. 2004;3:412-8. 7- Komerik N, Wilson M, Poole S: The effect of photodynamic action on two virulence factors of Gram-negative bacteria. Photochem Photobiol Sci. 2000;72:5:676-680.

8 – DR JOSEPH ANDARY , DDS ,Wilson M., Lethal Photosensitization ofOral Bacteria and its Potential Application in the Photodynamic Therapy ofInfections. Photochem. Biol. Sci., 2004, 3,

Fig: 1 412-418(peri-implantitis in-vivo).9- Robert J. Scott, Lisa A. Pedigo, Nicolas G. Loebel, PhD, Cale N. Street, PhD, MBA Ondine Research Laboratories, Bothell, WA, USA (peri-implantitis in-vitro).10- Claude G. Ibbott, DMD, FRCD , Regina, Saskatchewan, Canada ( clinical case studies).11- Ondine research laboratories,Inc,Bothell,WA,USA;Loma Linda University,CA,USA,Shanghai second medical university, china;Wenzhoy medical college , China ( Meta – analysis).12- Seidler V., Linetskiy I., Hublkov H., Staňkov H.,Šmucler R., Maznek J.Charles university in Prague, First Faculty of Medicine,Department of Stomatology, Prague, Czech Republic (ozone).

11. M13ـ- LLER P., GUGGENHEIM B., SCHMIDLIN P.R.: Efficacy of gasiform ozone and photodynamic therapy on a multispecies oral biofilm in vitro. Eur. J. Oral. Sci. 115: 77–80, 2007.