The Effect of Antimicrobial Photodynamic Therapy on the Success of Root Canal Treatment

October 8, 2024 updated by: Saglik Bilimleri Universitesi

Evaluation of the Effectiveness of Antimicrobial Photodynamic Therapy Using Different Irrigation Activation Techniques in Teeth With Apical Periodontitis: A Randomized Controlled Clinical Trial

The decontamination of the root canal system from pathological microflora is essential for the success of endodontic treatment. Mechanical instrumentation and irrigation solutions, known as the chemomechanical process, are typically used for this purpose. However, due to the complex anatomy of teeth, residual microorganisms can remain, potentially affecting treatment success and weakening dentin walls. This has led to the development of more effective irrigation and disinfection systems.

Antimicrobial photodynamic therapy (aPDT) has emerged as a promising adjunct to traditional methods. aPDT is used to eliminate resistant microorganisms in various medical fields, including dentistry, and has been shown to effectively destroy oral bacteria in both planktonic and biofilm forms. However, aPDT is not a replacement for traditional endodontic procedures but can be used as an adjunct in root canal disinfection.

aPDT works through the presence of a photosensitizer, a radiation source with a sufficient wavelength, and oxygen, producing reactive oxygen species (ROS) that have a bactericidal effect. Methylene blue (MB) is a common photosensitizer, but it can cause tooth discoloration and is difficult to remove. Alternatives to MB are being sought.

Different activation techniques, such as passive ultrasonic irrigation (PUI) and sonic activation systems (SAS), have been developed to enhance the effectiveness of irrigation solutions. Studies have shown that PUI and SAS have similar effectiveness in traditional endodontic irrigation. Enterococcus faecalis is a particularly resistant bacterium involved in endodontic infections. While MB's effectiveness against E. faecalis is documented, there is a lack of studies comparing its effectiveness with ultrasonic and sonic systems in necrotic and periapical lesion teeth. There is also limited research on the discoloration potential and postoperative pain of MB when used with various activation systems. The study hypothesizes that there will be no significant difference in lesion healing, postoperative pain, and discoloration potential with different activation systems using aPDT.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

It is well known that the decontamination of the root canal system from pathological microflora is a prerequisite for the success of endodontic treatment. In addition to mechanical instrumentation, various irrigation solutions and intracanal medications are used to decontaminate the root canal from microorganisms. The combined use of mechanical instrumentation and irrigation solutions is referred to as the chemomechanical process. However, due to the complex anatomy of the tooth structure, such as lateral canals, isthmuses, dentinal tubules, and accessory canals, residual microorganisms may remain despite the completion of the chemomechanical process. This can negatively affect the success of the treatment. Additionally, it is noted that the dentin walls may weaken as a result of chemomechanical preparation. Therefore, researchers often emphasize the need for more effective irrigation and disinfection systems.

Recently, the application of antimicrobial photodynamic therapy (aPDT) has been shown to be a promising addition to traditional methods. Today, aPDT is used to eliminate resistant microorganisms in cancer treatment, macular degeneration, arterial plaque, arthritis treatment, and dentistry. aPDT has been reported to effectively destroy oral bacteria present in both planktonic and biofilm forms. However, researchers state that aPDT cannot replace traditional endodontic procedures but can be used as an adjunct in root canal disinfection.

The working principle of aPDT is based on the presence of a specific photosensitizer, a radiation source with a sufficient wavelength, and the presence of oxygen in the environment. As a result of the reaction caused by aPDT, reactive oxygen species (ROS) such as singlet oxygen and free radicals are produced, leading to a bactericidal effect. Thus, a wide range of microorganisms can be eliminated without encountering the resistance problem of current bacterial strains. Additionally, aPDT offers various advantages due to its repeatability, low toxicity, and minimally invasive approach.

Various photosensitizers and light sources with different wavelengths are available for use in aPDT. One of the most widely used photosensitizers in the literature is methylene blue (MB) from the phenothiazine salts group. However, it is known that MB is difficult to remove after application and can cause tooth discoloration. Therefore, alternative photosensitizers to MB are being sought. Today, the antimicrobial efficacy of MB is well recognized. Due to the low absorption exhibited by phenothiazine dyes, which are among the most commonly used photosensitizers, multiple applications are required for a high drug dose and effective treatment outcome. The effectiveness of solutions is not solely dependent on the properties of the solution but also varies with the method used. Although the traditional needle irrigation method (GII) is still in use, its effectiveness is limited. Another method, manual dynamic activation (MDA), involves creating a hydrodynamic force in the irrigation solutions by moving a gutta-percha that fits well into a shaped root canal in a corono-apical direction at the working length. This method is frequently used as it does not require additional materials.

With technological advancements, different methods have been developed to enhance the effectiveness of solutions. The passive ultrasonic irrigation (PUI) method shows effectiveness by causing acoustic streaming through the vibration it generates. The solution is activated during the application without any contact with the root canal walls. Another method, the sonic activation system (SAS), has been used in endodontics for years and has proven its effectiveness. Several SAS devices from different manufacturers have been developed. One commonly used device, Endoactivator, has a polymer tip and works through sinusoidal oscillation. Another widely used device, EDDY (VDW, Munich, Germany), oscillates at 5000-6000 Hz, causing three-dimensional movement in the root canal and triggering cavitation and acoustic streaming. Studies have shown that the effectiveness of PUI and SAS on traditional endodontic irrigation solutions is similar. Enterococcus faecalis (E. faecalis) is a gram-positive facultative bacterium. It is among the most resistant strains involved in the development of anaerobic and endodontic infections. Although detailed literature reviews have shown studies proving the effectiveness of MB on E. faecalis bacteria, there is no study comparing the effectiveness of MB solution in necrotic and periapical lesion teeth using ultrasonic and sonic systems. It has been found that there is no comprehensive study in the literature comparing the discoloration potential and postoperative pain of MB applied with various activation systems. The null hypothesis of the study is that there will be no significant difference in lesion healing, postoperative pain, and discoloration potential with different activation systems using aPDT.

Study Type

Interventional

Enrollment (Actual)

60

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Turkey
      • Ankara, Turkey
        • University of Health Sciences Gulhane

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Child
  • Adult
  • Older Adult

Accepts Healthy Volunteers

Yes

Description

Inclusion Criteria:

  • Teeth that had not undergone previous root canal treatment.
  • Teeth with a single root and a single canal.
  • Teeth with apical periodontitis.
  • Teeth with periodontal lesion size less than 5 mm.
  • Teeth without sinus tract or acute apical abscess.
  • Patients without systemic diseases.
  • Patients not pregnant.
  • Patients who volunteered to participate in the study.
  • Patients who agreed to attend follow-up sessions.

Exclusion Criteria:

  • Patients using medications such as antihypertensives or antidiabetics that could affect root canal treatment outcomes.
  • Patients using corticosteroids or antibiotics.
  • Patients with acute pain or extraoral swelling.
  • Patients with a history of sinus tract or acute apical abscess.
  • Patients with systemic diseases.
  • Patients who are pregnant.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Supportive Care
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Standard Needle Irrigation (SNI) with MB Activation
In this group, the activation of MB (Merck KgaA) was performed using a 30G NaviTip (Cermaked) with 1 activation cycle. The 30G NaviTip (Cermaked) was placed in the root canal 1 mm short of the working length and used with a 3-4 mm amplitude. The MB (Merck KgaA) solution was activated for 1 minute and renewed during the treatment
Procedure: Standard Needle Irrigation (SNI)

Standard Needle Irrigation (SNI):

Utilizes standard needle irrigation techniques for activating the antimicrobial solution within the root canal.
Experimental: Passive Ultrasonic Irrigation (PUI) with MB Activation
In this group, the activation of MB (Merck KgaA) was performed using Ultra X (Eighteeth, Changzhou, China) and a #25 ultrasonic endodontic tip (Eighteeth) at a frequency of 45 kHz. The ultrasonic endodontic tip was placed in the root canal 1 mm short of the working length and the MB (Merck KgaA) solution was activated for 1 minute. During the activation process, care was taken to ensure the ultrasonic endodontic tip moved freely within the canal, and the MB solution was renewed during the treatment.
Procedure: Passive Ultrasonic Irrigation (PUI

Passive Ultrasonic Irrigation (PUI):

Employs ultrasonic energy to enhance the activation and effectiveness of the antimicrobial solution in the root canal.
Experimental: EndoActivator(EA) with MB Activation
In this group, the activation of MB (Merck KgaA) was performed using a polymer EA tip (Dentsply, Tulsa, OK) with a 25.04 tip diameter, which was placed into the canal 2 mm short of the working length. The activation procedure was carried out for 1 minute using the EA sonic irrigation device at 10,000 cycles, and the MB (Merck KgaA) solution was renewed during the treatment.
Procedure: EndoActivator (EA)

EndoActivator (EA):

Uses a sonic activation device to facilitate the distribution and activation of the antimicrobial solution in the root canal.
Experimental: EDDY with MB Activation
In this group, the activation of MB (Merck KgaA) was performed using a polymer EDDY tip (VDW, Munich, Germany) with a 25.04 tip diameter and the Sonicmax sonic device (Maximum Dental Inc., Secaucus, NJ, USA) with one activation cycle. The EDDY (VDW) tip was placed in the canal 1 mm short of the working length and moved in a corono-apical direction at a frequency of 6 kHz and an amplitude of 5 mm for 1 minute to achieve MB activation. The MB (Merck KgaA) solution was renewed during the treatment.
Procedure: EDDY

EDDY:

Involves the use of a sonic activation device that operates at high frequency to activate the antimicrobial solution within the root canal.

These descriptions focus on the general method and purpose of each intervention without delving into the specific procedural details already covered in the arm/group descriptions.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Reduction in Bacterial Load
Time Frame: Up to 6 months
This study aims to evaluate the effectiveness of antimicrobial photodynamic therapy (aPDT) using different irrigation activation techniques in teeth with apical periodontitis. The study will be conducted as a randomized, parallel-group clinical trial with four intervention groups: Standard Needle Irrigation (SNI), Passive Ultrasonic Irrigation (PUI), EndoActivator (EA), and EDDY.
Up to 6 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Saglik Bilimleri Universitesi

Investigators

  • Study Director: Özge Hür Şahin, DDS, University of Health Sciences Gulhane
  • Study Chair: Zeliha Uğur Aydın, Assoc. Prof., University of Health Sciences Gulhane

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

June 20, 2023

Primary Completion (Actual)

March 15, 2024

Study Completion (Actual)

July 14, 2024

Study Registration Dates

First Submitted

September 27, 2024

First Submitted That Met QC Criteria

October 8, 2024

First Posted (Actual)

October 10, 2024

Study Record Updates

Last Update Posted (Actual)

October 10, 2024

Last Update Submitted That Met QC Criteria

October 8, 2024

Last Verified

May 1, 2023

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 2023/058

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

YES

IPD Plan Description

We are currently undecided about sharing individual participant data (IPD) with other researchers. A decision will be made based on further discussions within the research team, ethical considerations, and the potential value of the data for future research. We will update this section once a final decision has been reached.

IPD Sharing Time Frame

From baseline to 6 months post-treatment

IPD Sharing Access Criteria

undecided

IPD Sharing Supporting Information Type

  • STUDY_PROTOCOL
  • SAP
  • ICF
  • ANALYTIC_CODE
  • CSR

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

Clinical Trials on Antimicrobial Photodynamic Therapy

Clinical Trials on Standard Needle Irrigation (SNI)

Search Similar Trials

Sponsors and Collaborators

Medical Conditions

Drug Interventions

CROs by country

CROs in Belgium

Conditions

Rare Diseases

Drug Interventions

Dietary Supplements

Sponsor/Collaborators

Locations

Subscribe