Photodynamic Therapy in Treatment of Oral Lichen Planus

Mostafa D, Tarakji BJ Clin Med Res. 2015;7(6):393-399

Lichen planus is a common

mucocutaneous disease.

first described by Wilson in 1869

Affect 0.5–1% of the world’s population.

INTRODUCTION

LichenGreek word leichen, meaning flat, and possibly

the striking clinical colour of the pimples on skin led to

the designation leichen ruber (latin; red).

Planus refers to the clinical appearance of the skin

papulae; flattened, smooth and depressed on the

summit.

INTRODUCTION

INTRODUCTION

Most common potentially malignant chronic diseases of oral mucosa

Note

A common chronic immunological

mucocutaneous disorder that varies in appearance from

keratotic to erythematous and ulcerative Wilson 1896

OLP is relatively common disorder of the stratified

squamous epithelia skully and El-kom1985

A common disorder in which auto-cytotoxic T lymphocytes trigger apoptosis of epithelial

cells leading to chronic inflammation. Crispian Scully

2007

DEFINITION

six types

reticular

papular

plaque,

atrophic,

erosive or ulcerative

and

bullousTYPES

Reticular 92

Papular 11

Bullous 1

Plaque-like 36

Atrophic 44

Erosive 9

INCIDENCE %

White reticularappearance is most common, and more than one

type of oral lesion may occur at the sametime (Andreson, 1968).

Buccal mucosa often

bilaterally

Tongue

Lip

Gingiva

Patate

Floor of mouth

Com

mon

sit

es

"5 P's“

Pruriticplanar

Purple

Polygonal

papules

Malignant potential : 0.4-6.25%.

Only lesions that have dysplasia are potentially at risk of developing into cancer. Smoking and alcohol may increase the risk of oral cancer

PDT

TREA

TMEN

T

Recent non-pharmacological treatment of OLP

• Lasers have been suggested as non-pharmacological modality to patients resistant to conventional treatment but their effectiveness is under study

• low dose 308-nm excimer laser is a palliative treatment when the mucosa lacks the overlying epithelial layer and a higher and more effective UV dose is allowed to reach the infiltrating lymphocytes

High - level laser Irradiation

low- level laser irradiation

Diode laser 980 nm was also reported as

an easy, effective, fast and safe

treatment of OLP

Photodynamic therapy

• Photoradiation therapy, • Phototherapy, • Photochemotherapy.• Photodynamic therapy (PDT) is a treatment that uses

a drug, called a photosensitizer or photosensitizing agent.

• Photosensitizers are exposed to a specific wavelength of light, photoactivation causes the formation of singlet oxygen, which produces peroxidative reactions that can cause cell damage and death.

International Journal of Laser Dentistry, January-April 2013;3(1):7-13

CLASSIFICATION 0F PHOTOSENSITIZERS

Porphyrin-based PS (e.g. photofrin, 5-aminolevulinic acid (ALA/PpIX), BPD-MA),

Chlorophyll –based PS (e.g. chlorins, purpurins, bacteriochlorins)

Dye (e.g. phtalocyanine, napthalocyanine)

International Journal of Laser Dentistry, January-April 2013;3(1):7-13

Photosensitizers

first PSs used in PDT were compounds belonging to

the group of hematoporphyrin, photofrin, and meta-tetra (hydroxyphenyl) chlorin.

After extended period of time, the PSs of choice included ALA and dyes - toluidine blue and

methylene blue.

Methyl 5-aminolevulinate (MAL) is an esterified derivative of ALA. It is lipophilic and its selectivity for specific cells is greater than that of ALA which increases its

phototoxicity effect

Types of lights source used in topical PDT

1) Lasers are considered as an ideal light source for PDT due to its coherence

and monochromaticity.

2) Lamps have been useful in PDT especially in the cure of skindiseases such as metal halogen lamp and short arc xenon lamp.

3) Lasers emitted diodes (LEDs) generate wavelength bands wider than those from lasers.

PDT essentially has two steps :• Application of photosensitizer drug.• Light activation.

2 Stage Mechanism of PDT

first stage :

• photosensitizing agent is accumulated in the target cells following topical administration. This was explained by disproportionately of high numbers of low density lipoproteins receptors of their cell membranes and abnormal microvasculature.

• microorganisms like bacteria, fungi and viruses exhibiting selective accumulation of PSs due to differences in permeability of their outer structures.

second stage

• Photosensitized cells are exposed to light source of specific wavelength that coincides with the absorption spectrum of the PS.

• measured light dose of appropriate wavelength is then used to irradiate the target tissue

• Generation of ROS

MOA :

PDT produces cytotoxic effects by three mechanisms:

Cellular

vascular

immunological responses.

Combination of these

responses depends on

the tissue oxygen

availability, the PS and

the illumination scheme

used

Aghahosseini et al in 2006

estimated that PDT is analternative method for the

treatment of OLP in 13 patientswith 26 mucosa lesions.

patients rinsed with 5% aqueous solution of dye for 5 min. After 10 min, the lesions were exposed to a low-energy

laser of 632 nm wavelength and exposure dose of 120

J/cm2

Sixteen lesions were improved and four lesions had complete

remission.

Sadaksharam et al in 2012

conducted a research on 20 patients with systemic OLP.

patients were treated by PDT using xenon arc lamp of 630 ±

5 nm wavelength and total dose of 120 J/cm2 per sitting in

four sessionsmediated by MB.

Results : a significant reduction in lesions over prolonged

period without any side effects

Sobaniec et al

clinical study of 3 patients with 48

lesions

PDT using gel containing 20%

chlorine-e-6 Photolon and 10% dimethyl sulfoxide

applied directly onto the lesion and

the surrounding healthy mucosa 1 h before exposure to

a semiconductor laser with

wavelength 660 nm.

A series of illuminations were performed using

light energy density of 90

J/cm2.

The appointments were scheduled at 2-week intervals,

but no longer than for 10 sessions.

Conclusion : useful in treatment of

OLP where the size of clinical lesions in patients decreased

significantly in 55%.

the best effects were observed on lining mucosa more than masticatory mucosa.

Sadaksharam et al, 2012, 48 Case report 20 Xenon arc lamp of 630 ± 5 nm and 120

J/cm2) Methylene blue

Kvaal et al, 2013 83 Case report 14 Diode laser (600 - 660 nm and 75 J/cm2) Methyl 5-aminolevulinate

Aghahosseini et al, 2006 82 Case report 2 Diode laser

(632 nm and 100 J/cm2) Methylene blue

Aghahosseini et al, 2006 52 Case report 13 Diode

laser (632 nm and 120 J/cm2) Methylene blue

Sobaniec et al, 2013 49 Case report 23 Diode

laser (660 nm and 90 J/cm2) Chlorine-e-6 polyvinyl

pyrrolidone (Photolon®)

2006 TO 2013

• no long term side effects when used properly.• Less invasive than surgery. • usually takes only a short time and is most often

done as an outpatient.• Can be targeted very precisely.• Unlike radiation, PDT can be repeated many times

at the same site if needed.• There’s little or no scarring after the site heals.• It often costs less than other cancer treatments.• PDT is currently used in a number of medical fields,

including oncology (cancer), dermatology (skin), and cosmetic surgery.

Advanta

ges

limitations of PDT?• The light needed to activate most

photosensitizers cannot pass through more than about one third of an inch of tissue (1 centimeter). • For this reason, PDT is usually used to treat

tumors on or just under the skin or on the lining of internal organs or cavities. • PDT is also less effective in treating other

tumors, because the light cannot pass far into these tumors.• PDT is a local treatment and generally

cannot be used to treat cancer that has spread (metastasized).

Side effects

Drugs makes the skin and eyes sensitive to

light for approximately 6

weeks after treatment

Burns , swelling, pain, and scarring in nearby healthy

tissue.

Other side effects include coughing, painful breathing,

trouble swallowing, stomach pain, or shortness of

breath; these side effects are usually

temporary.

Side effects Side effects

Future hold for PDT…

Researchers continue to study ways to improve

the effectiveness of PDT and expand it to other

cancers.

Clinical trials are under way to evaluate the use of PDT for cancers of the

head and neck, skin, prostate, cervix, and peritoneal cavity

Other research is focused on the development of

Photosensitizers that are more powerful, more

specifically target cancer cells, and are activated

by light that can penetrate tissue and treat deep or large

tumors.

Researchers are also investigating ways to

improve equipment and the delivery of the

activating light.

Future of PDT

REASON FOR CHOOSING THIS ARTICLE ??

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