PHOTODYNAMIC THERAPY

Recently a novel method of disinfection for use in both caries and endodontics has become available. The laser light is thought to be able to reach areas that are impossible with the traditional techniques. Amongst the multitude of methods to aid in eradicating microorganisms within the root canal was in the form of photo-activated disinfection. Photo-activated disinfection is defined as a method of disinfecting or sterilizing a hard tissue or soft tissue site by topically applying a photosensitizing compound to the site , and then irradiating this with laser light at a wavelength absorbed by the photosensitizing compound, so as to destroy microbes at the site (Wilson and Wilson ,1997). It is also known as photoradiation therapy, phototherapy, photochemotherapy. Among all the alternative treatments to antimicrobial agents, antimicrobial photodynamic therapy (ADPT) or photodynamic antimicrobial chemotherapy (PACT) seems to be promising one.

PHOTOSENSITIZER A photosensitizer is a chemical agent, that when activated with light at a specific wavelength reacts with the surrounding molecular oxygen to produce highly reactive singlet oxygen. Thousands of natural and synthetic photoactive compounds have photosensitizing potential. They include degradation products of chlorophyll, polyacetylenes, thiophenes, quinones (cercosporin), anthraquinones (fagopyrin, hypericin), and 9- methoxypsoralen (Ebermann et al., 1996). The majority of PDT photosensitizers possess a heterocyclic ring structure similar to that of chlorophyll or heme in hemoglobin. Upon capturing light energy by the photosensitizer, a transfer and translation of light energy into chemical reaction in the presence of molecular oxygen produces singlet oxygen (1O2) or superoxide (O2-), and induces cell damage through direct and indirect cytotoxicity. Therefore, the photosensitizer is considered to be a critical element in PDT procedures. Many photosensitizers were introduced in the 1980s and 1990s. New ones are discovered and reported regularly.

PROPERTIES OF IDEAL PHOTOSENSITIZER It should be commercially available pure chemical Low dark toxicity but strong photocytotoxicity Good selectivity towards target cells Long-wavelength absorbing Rapid removal from the body Ease of administration through various routes Absorption peaks in the low-loss transmission window of biological tissues. Optimum ratio of the fluorescence quantum yield to the interconversion quantum yield Storage and application light stability High solubility in water, injection solutions and blood substitutes It should bind with bacteria and plaque without causing any cosmetic issues, such as unwanted attaining of gingiva and other soft tissues

CLASSIFICATION OF PHOTOSENSITIZERS

1. Dyesa. Tricyclic dyes with different meso-atoms- methylene blue, toluidine blue O and acridine orange. b. Phthalocyanine- aluminium disulphonated phthalocyanine and cationic Zn (II)-phthalocyanine 2. Chlorines- chlorine e6, stannous (IV) chlorine e6, chlorine e6 -2.5 N-methyl-dglucamine(BLC1010),polysine and polyetyleneimine conjugates of chlorine e6. 3. Porphyrines- haematoporphyrin HCl,photofrin and 5aminolevulinic acid (ALA), benzoporphyrin derivative (BPD) 4. Xanthenes- erythrosine 5. Monoterpene- azulene.

LIGHT SOURCES PDT requires a source of light that activates the photosensitizer by exposure to low-power visible light at a specific wavelength. Human tissue transmits red light efficiently, and the longer activation wavelength of the photosensitizer results in deeper light penetration. Consequently, most photosensitizers are activated by red light between 630 and 700 nm, corresponding to a light penetration depth from 0.5 cm (at 630 nm) to 1.5 cm (at ~ 700 nm). (36,37) This limits the depth of necrosis and/or apoptosis and defines the therapeutic effect. In the past, photosensitizer activation was achieved via a variety of light sources, such as argon-pumped dye lasers, potassium titanyl phosphate (KTP)- or neodymium:yttrium aluminum garnet (Nd/YAG)-pumped dye lasers, and gold vapor- or copper vapor-pumped dye lasers. All these laser systems are complex and expensive. The choice of photosensitizers used in dentistry is strongly dependent on the light source used.

THREE LIGHT SYSTEMS FOR THE THERAPY: Laser sources- heliumneon lasers (633 nm), galliumaluminum arsenide diode lasers (630690, 830, or 906 nm), and argon lasers (488514 nm). The wavelengths of these sources range from visible light to the blue of argon lasers or from the red of heliumneon and galliumaluminumaresenide lasers to the infrared area of some diode lasers. High-level-energy laser irradiation is not used to activate the photoactive dye because a relatively low-level exposure produces a high bactericidal effect. Diode laser systems: They are easy to handle, portable, and cost-effective have become the preferred light source. Non-coherent light sources: Preferred for treatment of larger areas and include tungsten filament, quartz halogen, xenon arc, metal halide, and phosphor-coated sodium lamps. Non-laser light sources: include light-emitting diodes (LEDs). Recently they have also been applied in PDT. (38,39,40,41) They are small economical, light weight, and highly flexible.

PS

EXCITED STATE (SINGLET)

PS EXCITED STATE (TRIPLET)

LIGHT

TYPE I REACTION (reactive oxygen species like superoxide, hydroxyl radicals,hydrogen peroxide)

TYPE II REACTION highly reactive singlet oxygen

PS GROUND STATE BACTERIAL DEATH (SINGLET) Fig 4- Mechanism of action of PDT. Photosensitizer when irradiated with specific wavelength light undergoes transition from low energy singlet ground state to excited singlet and triplet states. It further results in the formation of reactive oxygen species and highly reactive singlet oxygen that are cytotoxic to cells.

MECHANISM OF ACTION

PDT involves three components: photosensitizer, light and oxygen. Interaction of these components results in photodynamic reaction. When a photosensitizer is irradiated with light of specific wavelength it undergoes a transition from a low-energy ground state to an excited singlet state. The wavelength of the light should be at the specific wavelength that corresponds to the absorption wavelength of the photosensitizer. The Singlet state molecule may decay back to the ground state by emitting a photon as light energy (fluorescence) or by internal conversion with energy lost as heat. Alternatively, the molecule may convert into an excited triplet state (T) molecule via intersystem crossing that involves a change in the spin of an electron. Molecules in the T state can emit light (phosphorescence) by returning to the ground state or can react further by one or both of two pathways (known as the Type I and Type II photoprocesses), both of which require oxygen. This utilization of oxygen in the production of reactive oxygen species is known as Photochemical Oxygen Consumption

THE PATHWAYSType I - The PS in its singlet or triplet state reacts with a substrate via (a) electron transfer or (b) hydrogen abstraction to yield free radicals which readily react with oxygen to form superoxide, hydroxyl radicals and hydrogen peroxide, that causes damage to biological targets (membrane, proteins, and DNA). Type II - This involves energy transfer from the photosensitizer triplet state to ground state molecular oxygen (triplet) to produce excited state singlet oxygen, which can oxidize many biological molecules , such as proteins, nucleic acids , and lipids, and leads to cytotoxicity

Nanoparticles Nanoparticles containing photosensitizers have several advantages over photosensitizing molecules not encapsulated in nanoparticles. These advantages include: (96) 1) A larger critical mass (concentrated package of photosensitizer) for the production of reactive oxygen species that destroy cells, 2) Limit the target cells ability to pump the drug molecule back out thus reducing the possibility of multiple-drug-resistance, 3) Selectivity of treatment by localized delivery agents, which can be achieved by either passive targeting or by active targeting via the charged surface of the nanoparticle, and 4) The nanoparticle matrix is non-immunogenic. Nanoparticles are ideal carriers of photosensitizer molecules for APDT. The combination of nanoparticles with photosensitizer molecules has emerged as a new interdisciplinary research field. Some nanomaterials, such as TiO2, ZnO, and fullerenes as well as their derivatives, can generate singlet oxygen. On other occasions a photosensitizer molecule is combined with nanoparticles. Figure 6 shows different strategies that have been used to combine nanoparticles with photosensitizers in order to enhance the efficacy of APDT. They are (i) photosensitizers supplemented with nanoparticles; (ii) photosensitizers encapsulated within nanoparticles; (iii) photosensitizers bound or loaded to nanoparticles; and (iv) nanoparticles themselves serving as photosensitizers.

CONCLUSION

The isolate use of PDT has been largely shown to promote adequate bacterial disinfection in infected root canals at least in vitro. The importance to test the effects of a given procedure under in vitro conditions simulating the clinical use cannot be overstated. Studies should evaluate the antibacterial effects of PDT in infected canals, by using PDT immediately after instrumentation/irrigation procedures, which is the main proposed way to apply PDT to endodontic treatment (i.e., as a supplement and not as an alternative to chemo-mechanical procedures). Instrumentation/irrigation procedures generate an environmental stress in the root canal and may disrupt biofilm structures, events that might render bacterial community members more susceptible to the antibacterial activity of PDT. Further improvements in protocols are required before PDT can be indicated for use in the clinical setting Even though the present findings cannot be directly extrapolated to the clinical situation; they showed that the PDT protocols used did not succeed in predictably eradicating or at least significantly reducing the root canal infection. Thus, when adjusting the PDT protocol for enhanced activity, one should take into account the low-oxygenated environment and the diffusibility of the photosensitizer and light to be used. It is important to reinforce the concept that the PDT protocol has yet to be refined before clinical application with predictable results can ensue. The concept of PDT is plausible and could foster new therapy concepts for endodontics. The available knowledge should enable and encourage steps forward into more clinical oriented research and development