Antimicrobial photodynamic therapy for the treatment of peri-implantitis: A literature review

Abstract

Aim: 

The aim of this article is to describe the existing scientific literature on photodynamic therapy (PDT) effectiveness for peri-implantitis treatment.

Materials and Methods: 

A date-restricted electronic search strategy was performed in PubMed and Scopus databases. The following words were used: “peri-implant photodynamic therapy,” “photodynamic therapy in implantology,” “effectives of photodynamic therapy in peri-implantitis,” “Antimicrobial Photodynamic Therapy,” “Photodynamic Therapy for the treatment of peri-implantitis,” and “Mechanical debridement and photodynamic therapy in implantology.”

Results: 

Of the 15 articles, 13 articles were selected, of which 11 were prospective and experimental studies and 2 were longitudinal. The PDT effectiveness of peri-implantitis inflammation treatment was the most reported and investigated.

Conclusion: 

There is scientific evidence that may support the use of PDT for peri-implantitis treatments. However, even more studies would still be needed to have solid evidence.

Introduction

Dental implants are a safe treatment modality for fully and partially edentulous patients.^[1] Recently, dental implants placement has increased tremendously in the dental field. They are routinely used in dentistry with confidence. However, plaque-induced inflammation around the implant surface can cause destruction of peri-implant tissues when dental implant surfaces are colonized by pathogenic bacteria.^[2]

One of the main factors leading to implant loss is peri-implantitis and is related to certain periodontal pathogens.^[3] This infection is caused by a specific group of anaerobic bacteria implicated in the initiation of the disease.^[4] Implications of biological parts affecting osseointegrated dental implants are of great interest in contemporary dentistry.^[5]

Peri-implantitis is considered a challenge faced by most dentists in all countries. This disease should be treated by less-invasive therapies such as non-surgical therapies that include addressing all risk factors such as systemic modifiable and local contributing factors.^[6] Several conservative and surgical techniques are available for peri-implantitis treatment. Clearly, mild peri-implantitis cases can be effectively treated with conventional methods. These methods include the use of manual ablations, laser-based systems, and photodynamic therapy (PDT), which can be combined with antibiotics.^[7] Careful treatment planning for peri-implant disease is crucial for the subsequent treatment success. Local and general factors, as well as patient expectations, should be considered before proceeding, but treatment planning should also allow a degree of flexibility, appropriate for unknown parameters.^[7]

PDT was introduced in dentistry as one therapeutic facility.^[1] This therapeutic technology uses a photosensitizer and a low-level energy source to eliminate microorganism.^[3] Antimicrobial photodynamic therapy (aPDT) stimulates bacterial clearance in the implant microstructure and interproximal bone remodeling without damaging the implant surface in patients with peri-implantitis.^[8]

The aim of this literature review was to describe the aPDT effectiveness of peri-implantitis treatment.

Materials and Methods

Collection of information

The search and selection process were performed by two reviewers independently and was completed on November 26, 2021. Titles and abstracts were screened, and full texts were carefully read. After discussion among the authors, 11 prospective and experimental and 2 longitudinal studies were selected for the present literature review.

Search strategy

A date-restricted electronic search was performed in the PubMed and Scopus databases. A search was conducted to explore relevant journals websites, and the following strategy was used: (“anti infective agents”[Pharmacological Action] OR “anti infective agents”[MeSH Terms] OR (“anti infective”[All Fields] AND “agents”[All Fields]) OR “anti infective agents”[All Fields] OR “antimicrobial”[All Fields] OR “antimicrobials”[All Fields] OR “antimicrobially”[All Fields]) AND (“photochemotherapy”[MeSH Terms] OR “photochemotherapy”[All Fields] OR (“photodynamic”[All Fields] AND “therapy”[All Fields]) OR “photodynamic therapy”[All Fields]) AND (“peri implantitis”[MeSH Terms] OR “peri implantitis”[All Fields] OR (“peri”[All Fields] AND “implantitis”[All Fields]) OR “peri implantitis”[All Fields]).

Inclusion criteria

For the present review, we searched for articles that used PDT for peri-implantitis treatment including articles that showed the effectiveness of PDT, aPDT, and PDT as an adjunct to peri-implantitis mechanical debridement (MD). We also included articles from randomized controlled trials, experimental and longitudinal studies with reference to the procedures, and effectiveness of PDT when compared with other types of materials.

Exclusion criteria

Publications focussing on other applications of PDT or not related to peri-implantitis were not included in this review. Systematic review articles were also excluded.

Results

The results of the reviewed clinical studies are presented considering PDT effectiveness, aPDT, and PDT as an adjunct to peri-implantitis MD. Thirteen studies were selected, of which 11 were prospective and/or experimental studies and two had a longitudinal design. Of these articles, three discussed PDT, four discussed only aPDT, one discussed PDT, one discussed with and without adjunctive antimicrobial therapy, one reported on indocyanine green-mediated PDT, and one described the use of adjunctive antibiotic gel therapy (aAGT) and adjunctive PDT. Also, the MD with and without PDT was reported on one article. Finally, one paper reported on adjunctive photochemotherapy and local antimicrobial therapy [Table 1].

Table 1:: Summary of clinical studies

Photodynamic therapy

All studies evaluated the aPDT effectiveness in treating various oral diseases including peri-implant inflammation,^[9] periodontal disease, and oral lichen planus.^[10] In non-diabetic and diabetic smokers and non-smokers, MD with aPDT was effective on peri-implant mucositis.^[11] This technique together with various photosensitizers may lead to eliminate anaerobic bacteria around dental implants [Figure 1].^[4]

Figure 1:: Photodynamic therapy

One study showed that aPDT and antibiotic therapy evidenced equal efficacy in improving host-derived clinical immune biomarkers.^[12] Garcia de Carvalho et al.^[8] reported that aPDT improved decontamination to allow bone regeneration and decreased probing depths after a 6-month follow-up. Alqahtani et al.^[13] reported on the DM effects with adjunctive aPDT after a 6-month follow-up. Similar radiographic and clinical peri-implant outcomes were reported using aPDT after 6 and 12 months.^[14] Only one study showed microbiological cases of aPDT, with a similar effect on Treponema denticola and Tanerella forsythia.^[3]

Effectiveness of aPDT

Six studies compared the effects of aPDT after an open flap debridement (OFD). The periodontal pocket was irrigated with 0.005% Methylene blue with a needle for 10 s.^[4,14-17] Then, the dye was irradiated with a 670-nanometer laser diode at 150 mW with 0.06 mm diameter optical fiber.^[4,15,16,18] Furthermore, another study used wavelength, power, and density that were set at 660 nm, 150 mW, and 1.1 W/cm², correspondingly.^[10] Only one study used a cool red light of 630 nm applied with a FotoSan LED lamp (CMS Dental) on the tooth and implant surfaces.^[16]

The peri-implant pockets were irrigated submucosally from the bottom to the top with a photosensitizer and left in situ for 120 s. Thereafter, 3% hydrogen peroxide was applied on the peri-implant pockets according to the manufacturer’s indications.^[18] The laser was applied on implant surfaces (buccal, lingual, mesial, and distal) for 30 s on each surface using a scanning method.^[3,14]

It was concluded that no additional benefit was found on the single application of aPDT together with OFD in peri-implant parameters.^[14] In contrast, other studies found a reduction on bacterial count after peri-implantitis treatment with aPDT and OFD.^{[3,4,13,15,17]}

Open flap debridement

Three articles reported that OFD was performed by incision in the sulcus and, when necessary, with a release incision. The mucoperiosteal flaps were lifted removing the granulation tissues. Dental implants were cleaned with sterile curettes and gauze moistened in saline water.^[10,14,18] Madi and Alagl^[3] reported an animal study reflecting a mucoperiosteal flap. In one split-mouth design, aPDT was applied on one side, whereas, on the other side, a full-thickness flap was designed to perform MD with an OFD plastic curette.

Antibiotic adjunctive therapy

Only one randomized controlled clinical trial evaluated the aPDT efficacy of aAGT and aPDT on type 2 diabetes mellitus (DM2) patients. aPDT demonstrated immunological, clinical, and radiographic changes on patients with DM2.^[10]

Clinical parameters

According to Albaker et al.,^[14] peri-implant bleeding on probing (BOP) and periodontal depth (PD) parameters were reduced. There was a BOP reduction from 35.9% to 24.3% in the aPDT group (P < 0.05) and from 26.5% to 21.6% in the OFD group (P < 0.05) at 6 months. PD intragroup reduction was statistically significant in both groups between baseline and 6 months. After 12 months, no statistically significant differences were found between the groups. Statistically significant reductions on plaque scores, BOP, and PD were reported when using aPDT as an adjunct to MD at 12 weeks (P < 0.01).^[4,14,15] Experimentally induced gingivitis and peri-implant mucositis could be treated with professionally plaque removal and aPDT. The number of residual bleeding sites increased with increasing PD around either teeth or implants.^[16] Furthermore, the efficacy of MD with and without aPDT in peri-implant disease treatment in patients with prediabetes was assessed by Abduljabbar.^[17] This clinical trial in prediabetic patients reported that MD with adjunct aPDT was more effective in reducing peri-implant inflammation compared with MD alone at 3-months of follow-up. According to Zeza et al.,^[16] gingival bleeding decreased when treatment was administered around the teeth and implants. This result was statistically significant at 6-weeks of follow-up.

Microbial samples

Only one randomized controlled trial reported a reduction on Pseudomonas aeruginosa and Staphylococcus aureus levels at 12 weeks (P < 0.01) among the groups receiving aPDT with MD and systemic azithromycin with MD.^[4] According to the study by Madi and Alagl,^[3] PDT could reduce Porphyromonas gingivalis count when compared with OFD.

Discussion

The aim of applying aPDT on peri-implantitis treatment is to overcome associated difficulties. Several techniques have been introduced for peri-implantitis treatment, such as antiseptics, local and systemic antibiotics, MD with open flap surgery, and laser treatment. However, the effect of these techniques is limited, reducing bleeding and depth on probing but they do not cure this pathology. Ahmed et al.^[10] compared aPDT and aAGT and reported immunological, radiographic, and clinical improvement for peri-implantitis treatment in patients with DM2 using aPDT. Garcia de Carvalho et al.^[8] demonstrated that the use of aPDT associated with bone regeneration was effective in treating peri-implantitis.

The studies analyzed in this review used aPDT together with various types of therapy as peri-implantitis treatment. Some investigations compared PDT with other techniques, and some combined it as an adjunct to enhance its effectiveness. Most of the studies showed that PDT and aPDT were effective for the treatment of peri-implantitis. Both improved clinical and microbial parameters evaluated in smokers and DM2 patients. In addition, MD and PDT implementations have a greater effectiveness against peri-implantitis. The great majority of authors used similar techniques and in a similar proportion, which we can relate to the great effectiveness that all of them reached with the use of PDTs. However, PDT does not act alone in the procedures as there are a great variety of materials that are used to improve peri-implantitis. Among them, we can mention MD using ultrasound, scaler, or hand instruments and during the healing period irrigation with 0.12% chlorhexidine gluconate three times a week. After 8–10 days sutures were removed, and all patients received professional prophylaxis every 3 months.^[14] Also, oral hygiene recommendations and smoking remission advice were given.^[15] The evaluation time according to most of the studies was performed at 2 and 6 weeks after treatment.^[16] Under the reviewed studies, it could be assumed that due to all the recommended oral care and use of antiseptics, aPDT was effective for peri-implantitis as it could also be used mixed with MD, giving a greater result in reducing peri-implantitis. It would certainly be ideal to find further studies of aPDT in conjunction with other techniques for the improvement of peri-implantitis using in vivo studies.

Abduljabbar^[17] concluded that, in prediabetic patients, OFD with aPDT was more effective for peri-implant inflammation when compared with only MD in the short term. Similar results were found with DM2 patients using MD with aPDT on peri-implant disease treatment.^[18]

One limitation seen in the reviewed studies was the effect of small sample sizes that could influence on research outcomes and compromise the conclusions drawn from the studies. Another important factor was the inclusion of a preclinical study which could be different from the rest of human smokers and prediabetics and diabetics studies that obviously have more predisposition to this disease. In addition, the applications of the 670-nm laser diode had many variations in the studies which could have caused a different result or caused some variations. Finally, the development of new experimental substances to better control the oral microflora is recommended.^[19,20]

Conclusion

Currently, there is scientific evidence that can support the use of PDT for peri-implantitis. Also, we can highlight that aPDT with MD could be more effective on peri-implantitis treatment. However, more studies would still be needed to have solid evidence.

Acknowledgement

The authors would like to thank the Universidad Cientifica del Sur for supporting the preparation of this article.

Financial support and sponsorship

None to declare.

Conflicts of interest

None to declare.

Authors’ contributions

CJ, LL, FM-T: concept and design of study, drafting, and revision. FM-T, RM, and MEG: acquisition of data, analysis, and interpretation. CJ, LL, JO, FM-T, MEG, RM: acquisition of data, interpretation, and drafting. Finally, all authors had given approval of the version of the article to be published.

Ethical policy and institutional review board statement

Not applicable.

Patient declaration of consent

Not applicable.

Data availability statement

Within this article, the presented data set was retrieved from original articles. The data are already present in these articles.