Laser tongue debridement for oral malodor-A novel approach to halitosis.

STUDY OBJECTIVE: Malodor is a multifactorial condition with oral pathology representing the main culprit and the tongue being the first to second contributor to the malodor. Bacterial load can represent a quantifiable measure regardless of the original pathology. We hypothesize that reduction in malodor can be represented by tongue changes both in appearance, bacterial and biofilm load reduction (measured by CFU and volatile gases measurement), organoleptic measurement and subjective improvement. METHODS: A randomized controlled prospective study under IRB approval. Diagnostic criteria for enrollment and follow up were organoleptic test by 2 judges, Halimeter reading, tongue colors changes HALT questionnaire and direct aerobic and anaerobic tongue cultures measured by CFU. Patients were treated with laser tongue debridement (LTD) with an Er,Cr:YSGG solid state laser has been shown to be effective in biofilm reduction. RESULTS: 54 patients recruited with 35 available for follow up. Improvement was observed on all objective and QOL subjective parameters. Treatment was tolerated well with minimal discomfort. CONCLUSIONS: The tongue is proven to be a major contributor to oral malodor and must be addressed in treatment protocol. LTD significantly reduces malodor by subjective and objective criteria. While impossible to determine whether the tongue serves as a bacterial reservoir or is the origin for oral bacteria it is clear that LTD improves oral hygiene and reduces malodor. LTD is safe and easy to perform. We encourage LTD to be a crucial part of any oral malodor treatment protocol. TRIAL REGISTRATION: clinical trials, NCT04120948. Registered 25 September 2019 - Retrospectively registered, https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S00098SX&selectaction=Edit&uid=U0000W0Y&ts=51&cx=-elnx7e.

Laser ablation of posterior nasal nerves for rhinitis.

BACKGROUND: Posterior nasal nerve (PNN) surgery, Radiofrequency (RF), and cryoablation have been described as alternative treatments for allergic and vasomotor rhinitis. We hypothesize that endoscopic (diode) laser ablation (ELA) is effective and less invasive than previously described methods. METHODS: An IRB approved prospective study was performed. Thirty-two patients with chronic rhinitis and nasal congestion resistant to medical management were recruited. Total Nasal Symptom Score (TNSS) measurements were used to assess symptom severity and treatment outcomes. ELA was performed bilaterally in the clinic with a 940 nm diode laser with CW 5 W output, under topical/local anesthesia in 21 patients, while the remaining 11 were treated under sedation in the operating room. The 400-micron uninitiated diode laser fiber tip with a malleable protective shaft was specially designed for PNN ablation. The fiber was pre-shaped according to the intranasal anatomy and endoscopically advanced toward the posterior middle meatus. Patients were followed up for the first 90 days after treatment. RESULTS: ELA was successfully completed in 97% of patients. No crusting, epistaxis, or other complications were observed. One patient could not be treated in the office due to limited endoscopic access. TNSS was reduced significantly after30 and 90 days (mean ± SD: 6.0 ± 0.7 prior to ablation, 2.3 ± 0.4 at 90 days, p < .001). Rhinitis and congestion scores decreased at 30 and 90 days after treatment compared to the baseline (p < .001). CONCLUSION: ELA of the PNN region is safe and well tolerated both in the office and ambulatory settings. Symptom scores were significantly decreased after 30 and 90 days. This new minimally invasive method appears to be a promising treatment method.

Laser tonsil cryptolysis: in-office 500 cases review.

OBJECTIVES: Tonsilloliths, proven to be tonsillar biofilms cause symptoms of halitosis, foreign body sensation and recurrent sore throats. Laser Tonsil Cryptolysis (LTC) performed in the office may represent an alternative to tonsillectomy in selected cases of persistent tonsilloliths with cryptic infections. STUDY DESIGN: A retrospective chart analysis using CPT codes. SETTING: Office and hospital. METHODS: A retrospective complications review consisting of bleeding, the need for an additional procedure, patient satisfaction and conversion rate to complete tonsillectomy was documented. RESULTS: Five hundred consecutive LTCs performed in the office under local anesthesia with a CO2 or diode laser were identified. Energy delivery was in continuous mode with power settings of 18W and 10W respectively. Bleeding occurred in 6 patients requiring unscheduled return office visit for evaluation. Eighty patients required a second procedure, comprising total of 1.16 procedures per patient. Eighteen (3.6%) patients underwent complete tonsillectomy. Patient satisfaction was high with an overall incidence of 0-2 days of work absence. Follow-up was 1-8 years. CONCLUSIONS: With a small tonsil size, controllable gag reflex and cooperative adult patient LTC allows several advantages compared to conventional tonsillectomy. Benefits of LTC include avoidance of general anesthesia and limited ablation of cryptic pockets, resulting in reduced post-operative pain, bleeding, shorter recovery time and the convenience and cost advantage of an office procedure. With 1.16 sessions required per patient, low conversion rate to standard tonsillectomy and minimal complication rate LTC can be considered an alternative option to a patient suffering from recurrent cryptic tonsillitis with or without tonsilloliths.

Laser-assisted nasal decolonization of Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus.

OBJECTIVES: Methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant S aureus (MRSA) contribute to 25% of nosocomial infections, increasing complications, health care cost, and growing antibiotic resistance. Nasal decolonization (ND) can reduce the staphylococcal infection rate. A new method of laser therapy (LT) MRSA ND was tested. STUDY DESIGN: This is a prospective, nonrandomized study. METHODS: Following institutional review board approvals, 25 patients colonized with MSSA/MRSA were allocated to 4 treatment arms; low-power, dual-wavelength 870-/930-nm laser alone (GR1); low-power, dual-wavelength laser followed by erythromycin (E-mycin) cream (GR2); low-power, dual-wavelength laser followed by peroxide irrigation (GR3); and high-power 940-nm laser alone (GR4). Quantitative cultures were obtained before and after in all arms. Laser therapy was performed via a laser fiber diffuser, delivering 200 to 600 J/cm² to each naris circumferentially. Patient's distribution was 3 in GR1, 14 in GR2, 4 in GR3, and 4 in GR4 (last 10 recruited to GR4). RESULTS: Nasal decolonization for GR1, GR2, GR3, and GR4 was 1 of 3, 13 of 14, 2 of 4, and 4 of 4, respectively. Because LT + E-mycin cleared all first 3 patients of MRSA and MSSA, all remaining patients were treated with LT + Er with over 90% of patients clearing. No adverse events or discomfort were reported. CONCLUSIONS: First human study using LT and topical E-mycin in ND is presented. Laser therapy can eradicate MRSA and potentially resensitization of bacteria to the antimicrobial effect of erythromycin. Although decolonization was maintained at 4 weeks posttreatment, further studies can determine the LT long-term effect.

Phototherapy for chronic rhinosinusitis.

OBJECTIVES: Near-infrared laser illumination (NILI), with or without photo-activated (PA) agents, has bactericidal and wound healing promoting effects. NILI may have a potential role managing chronic rhinosinusitis (CRS). METHODS: A prospective randomized study with 23 symptomatic post-surgical CRS patients with positive cultures was conducted. Two groups (GR1 and GR2) were treated with NILI. Objective nasal endoscopic scoring (NES) was elaborated. GR1 was treated with a 940 nm laser, while GR2 was treated with a topical PA agent, indocyanine-green, followed with 810 nm laser. SNOT20 scores, NES, and cultures were obtained prior to illumination. Saccharin test was performed 1 week following treatment. RESULTS: Some cultures remained positive through treatment, with Staph. aureus predominating. Both therapy arms demonstrated clinical efficacy. The SNOT20 score change was 0.9, 0.8 for GR1 and GR2, respectively (P < 0.05). Improvement (P < 0.05) was observed based on NES. No significant difference was observed between two treatment groups. All passed the saccharin test. Therapeutic effect was sustained for a minimum of 2 months. Side effects were minimal. CONCLUSIONS: NILI was objectively and subjectively beneficial in managing CRS, safe, reproducible, sustained and appeared not to interfere with ciliary motility. CRS exacerbation was avoided without using antibiotics or steroids.

Laser disruption and killing of methicillin-resistant Staphylococcus aureus biofilms.

OBJECTIVE: The aim of the study was to study the efficacy of 2 different lasers in vitro, in disrupting biofilm and killing planktonic pathogenic bacteria. MATERIALS AND METHODS: Biofilms of a stable bioluminescent of Staphylococcus aureus Xen 31 were grown in a 96-well microtiter plate for 3 days. The study included 7 arms: (a) control; (b) ciprofloxacin (3 mg/L, the established minimum inhibitory concentration [MIC]) alone; (c) shock wave (SW) laser alone; (d) near-infrared (NIR) laser alone; (e) SW laser and ciprofloxacin; (f) SW and NIR lasers; (g) SW, NIR lasers, and ciprofloxacin. The results were evaluated with an in vivo imaging system (IVIS) biophotonic system (for live bacteria) and optical density (OD) for total bacteria. RESULTS: Without antibiotics, there was a 43% reduction in OD (P < .05) caused by the combination of SW and NIR suggesting that biofilm had been disrupted. There was an 88% reduction (P < .05) in live biofilm. Ciprofloxacin alone resulted in a decrease of 28% of total live cells (biofilm remaining attached) and 58% of biofilm cells (both P > .05). Ciprofloxacin in combination with SW and SW + NIR lasers caused a decrease of more than 60% in total live biomass and more than 80% of biofilm cells, which was significantly greater than ciprofloxacin alone (P < .05). CONCLUSIONS: We have demonstrated an effective nonpharmacologic treatment method for methicillin-resistant Staphylococcus aureus (MRSA) biofilm disruption and killing using 2 different lasers. The preferred treatment sequence is a SW laser disruption of biofilm followed by NIR laser illumination. Treatment optimization of biofilm is possible with the addition of ciprofloxacin in concentrations consistent with planktonic MIC.

A new tool measuring oral malodor quality of life.

A valid measure of oral malodor (halitosis) and associated quality of life is required for the complete assessment of treatment effectiveness. The purpose of this study was to analyze the psychometric and clinimetric validity of the Halitosis Associated Life-quality Test (HALT) questionnaire, a specific 20-item quality-of-life measure for halitosis. The HALT is a de novo designed tool based on patient interviews and literature review. The University Hospital was the setting for the prospective random non-controlled study design. The comparison between the evaluator' scales on organoleptic testing and HALT scores was performed during the patient's initial visit. HALT was completed by 33 and 16 patients at the initial visit and at 3 months after treatment commencement, respectively. Two treatment arms comprising an experimental arm including Caphosol rinse for xerostomia-associated halitosis, and an established treatment arm with laser cryptolysis were compared. Cronbach's α was 0.93; coefficient alpha with deleted variables was between 0.92 and 0.94; equal length Spearman-Brown coefficient is 0.95. The Cronbach's alphas of each split questionnaire were 0.85 and 0.88, respectively, and test-retest scores were highly correlated (r = 0.85). HALT scores were significantly associated with the scales of organoleptic test (F = 118, p < 0.001; r = 0.96, p < 0.001). HALT successfully measured each treatment arm and showed improvement (p < 0.002) in both arms. Although cryptolysis was more efficacious, the encouraging results of the Caphosol arm indicate that additional investigation is warranted. HALT proved a valid outcome measure for patients with halitosis, describes its burden and is sensitive to clinical change.

Tonsillolith: not just a stone but a living biofilm.

OBJECTIVE: To study the morphology and activity of tonsilloliths, demonstrating oxygen respiration, denitrification, and acidification on exposure to sucrose. STUDY DESIGN: Tonsilloliths were extracted in atraumatic conditions during tonsillectomy from 16 adults and sent to two different laboratories for histological, bacteriological, and biofilm studies under sterile conditions. SETTING: Multicenter laboratory study. SUBJECTS AND METHODS: Multiple tonsilloliths from two patients examined by confocal microscopy and microelectrodes were used to measure aerobic/anaerobic respiration and acid production (dissolved oxygen, nitrous oxide, pH) when exposed to saliva following addition of sucrose and fluoride. RESULTS: Morphologically, tonsilloliths were similar to dental biofilms, containing corncob structures, filaments, and cocci. Microelectrodes showed that the microorganisms respired oxygen and nitrate. The oxygen concentration in the center of the tonsillolith was depleted to approximately one-tenth of that of the overlying fluid. The addition of sucrose resulted in acid production within the tonsillolith, dropping the pH from 7.3 to 5.8. The data showed stratification with oxygen respiration at the outer layer of tonsillolith, denitrification toward the middle, and acidification toward the bottom. The depletion of oxygen and acid production following addition of sucrose may allow the proliferation of anaerobic/acidophilic bacteria. Fluoride suppressed acid production in the presence of sucrose. CONCLUSIONS: Tonsilloliths exhibit biofilm structure and the formation of chemical gradients through physiological activity. Although tonsillectomy is an option for treating cryptic infections, understanding the morphology and biofilm characteristics of tonsilloliths may stimulate scientists to use limited or targeted remedies in the future.

The relationship between oral malodor and volatile sulfur compound-producing bacteria.

Halitosis can be a crippling social problem, and standard dental treatments and mouthwashes often provide only temporary relief. The mouth is home to hundreds of bacterial species that produce several fetid substances as a result of protein degradation. Volatile sulfur compound (VSC)-producing bacteria colonizing the lingual dorsum have recently been implicated in the generation of halitosis. Detection of VSCs, such as methylmercaptan and hydrogen sulfite, via organoleptic and objective methods, can aid in the identification of their source. Following comprehensive evaluation for possible causes, most halitosis in patients seen in an ENT practice can be localized to the tongue. We review methods of diagnosis and treatment of oral malodor from the overgrowth of proteolytic, anaerobic, gram-negative bacteria on the crevices of the lingual dorsum. Bacteriologic analysis of biofilm and scraped specimens obtained from the lingual dorsum and other oral sites, primarily gingival pockets and tonsillar crypts, can identify VSC-producing bacteria. Porphyromonas, Prevotella, Actinobacillus, and Fusobacterium species are the most common organisms identified. Halitosis is an oral phenomenon, with almost no cases originating distal to the tonsils. Halitosis arising from the lingual dorsum secondary to overpopulated VSC-producing bacteria can be successfully managed with a combination of mechanical cleansing using tongue brushes or scrapes and chemical solutions containing essential oils, zinc chloride, and cetylpyridinium chloride.

Laser-assisted uvulopalatoplasty revisited.

When performed correctly in a properly selected patient, LAUP provides good and lasting results in snoring improvement. A sleep study with snoring analysis helps in patient selection. Laser-assisted uvulopalatoplasty can be performed adequately in one sitting.

Transantral balloon dilation plus posterior ethmoidectomy.

OBJECTIVES/HYPOTHESIS: Transantral endoscopic balloon dilatation (TABD) was recently introduced for the management of limited mild maxillary and ethmoid disease. An expanded approach by inserting surgical tools into the antrum via a second port, directed toward the maxillary ostium, ethmoid infundibulum, and posterior ethmoids will allow for the treatment of moderate disease as well. STUDY DESIGN: Retrospective data review. METHODS: A study including all TABD procedures performed between January and December 2009 was performed. Sublabial approach with two working channels, one for the endoscope and a second port for balloon dilatation or other surgical instrumentation, was devised. Both channels were created via mini-trephine aimed toward the osteo-meatal complex (OMC) with different angulations. The same approach was used for transantral posterior ethmoidectomy (TAPE). Data collected included demographics, Sino-Nasal Outcome Test (SNOT) scores, Lund-Mackay score, and complications. RESULTS: Thirty-five patients with 64 dilated sinuses and 10 TAPE procedures were enrolled. All SNOT scores showed statistically significant improvement decreasing from 1.77 to 0.83. Complication rate was minimal. Only a small number of procedures were converted to standard endoscopic septoplasty (ESS) owing to severity of OMC disease. TAPE proved to be a minimally invasive procedure. CONCLUSIONS: Two trocars inserted through the canine fossa can achieve a successful result in moderate antral disease for TABD and allow TAPE to be performed, thus creating a bridge between mild disease and one requiring standard full ESS. The minimally invasive approach proved to be particularly useful.

Laser-generated shockwave for clearing medical device biofilms.

OBJECTIVE: This study aimed to evaluate a laser method of biofilm interruption from the surface of various common medical devices and from surgically removed sinus tissue with adherent biofilms in a timely manner. BACKGROUND: Biofilm has emerged as a new threat not amenable to most antibiotic treatments. Biofilms, as opposed to planktonic bacteria, develop an extracellular polymeric slime matrix to facilitate adherence to host tissue or a prosthetic surface and to form a protective shield. A laser-induced biofilms disruption concept was previously described. MATERIALS AND METHODS: Biofilms were grown in the laboratory on metallic and plastic medical device surfaces such as stents. Attempts to remove the biofilms with a laser were undertaken three times for each device. Q-switched Nd:YAG laser-generated shockwaves affecting Pseudomonas aeruginosa biofilms expressing yellow fluorescent protein (YFP) biofilm coating were applied with biologically safe parameters utilizing a fiber delivery system and a special probe. A confocal microscope was used to identify the biofilm structure prior to, during, and after laser application. The amount of biofilm removed from the medical devices in time was measured by quantifying green fluorescence. RESULTS: The biofilm fluctuated and eventually broke off the surface as shock waves neared the target. The time to remove 97.9 ± 0.4% (mean ± 1SD, n = 3) the biofilm from the surface of a Nitinol (NiTi) stent ranged from 4 to 10 s. The detached biofilm was observed floating in fluid media in various microscopic size particles. CONCLUSIONS: A new treatment modality using laser-generated shockwaves in the warfare against biofilms growing on surgical devices was demonstrated. Q-switched laser pulses stripped biofilm from the surface it adhered to, changing the bacteria to their planktonic form, making them amenable to conventional treatment. This therapeutic modality appears to be rapid, effective, and safe on metallic and plastic medical device surfaces.

Laser-induced microbial reduction in acute bacterial rhinosinusitis.

BACKGROUND: This study was designed to assess laser-induced manipulation on bacterial load and host in an animal model of acute bacterial rhinosinusitis (ABRS). An animal study using 12 rabbits followed an elaborated efficient in vitro model. ABRS was created by packing the nose with a sponge soaked in solution containing pathogenic microorganisms. Eight infected animals were randomly allocated to two separate groups, each being exposed to different laser therapies. Two healthy animals served as treatment controls, and one animal without ABRS and treatment was observed. METHODS: ABRS was confirmed histologically, radiologically, and bacteriologically. Two days after bacterial inoculation, packing was removed and nasal passages were treated by laser irradiation. Two laser modalities were tested. A near infrared (NIR) 940-nm diode laser with diffuser fiber tip was used in four rabbits. A photosensitizer (methylene blue 0.01 or 0.05%) and 635-nm laser combination was used in the second cohort. Nasal cultures were obtained before and after the laser treatments. Animals were killed 5-10 days after laser treatment and bacteriological/histological results were analyzed. RESULTS: An average 2 log reduction in bacterial colony counts was achieved with both laser methods compared with control. Histological studies showed tissue integrity preservation without significant damage to nasal mucosa. CONCLUSION: Significant bacterial reduction was achieved with both NIR laser and photograph activated therapies in an animal study of ABRS. This pilot study shows an innovative method of bacterial killing without host tissue damaging and may have potential future clinical application.

Laser disruption of biofilm.

OBJECTIVES/HYPOTHESIS: To demonstrate the capability of a fiber-based Q-switched Nd:YAG laser (ARCLaser, Nuremberg, Germany and Valam, Orangeburg, NY) to disrupt biofilm. STUDY DESIGN: Biofilms were grown in broth for 72 hours prior to the experiment. A clinical otorrhea isolate from Pseudomonas aeruginosa was used. Biofilms were placed in MatTek culture plates, on stainless steel screws, tympanostomy tubes, and polyethylene terephthalate (PET) sutures. METHODS: Culture plates, stainless steel screws, tympanostomy tubes, and PET sutures were used for the laser disruption of biofilm experiments. Q-switched Nd:YAG laser pulses were delivered on biofilms using shockwave probes originally designed for cataract surgery. The thin laser fiber tip was targeted against a titanium target, creating the production of plasma and resulting in a shockwave effect. RESULTS: Biofilm areas were imaged before, during, and after laser application using a confocal microscope. The biofilm was imaged growing on the glass/plastic step of the plates, in the grooves of the threads of the screws, over the tympanostomy tube, and on the PET suture. During laser treatment, a time-lapse function was used to capture the results. As a result of laser-generated shockwaves, the biofilm was initially seen to oscillate and eventually break off with individual pulses. Large and small pieces of biofilm were totally and instantly removed from the surface to which they were attached in a matter of a few seconds. CONCLUSIONS: We were able to effectively disrupt Pseudomonas aeruginosa biofilms in vitro using a miniature Q-switched Nd:YAG laser, thin fibers, and special probes that generated plasma formation and a resulting shockwave effect. This laser technology has the ability to generate a powerful stress wave sufficient to disrupt biofilm without any ill effect to the underlying host structure.