Laser Assisted Periodontal Treatment:

gingivectomy to lanap

Dr. Scott K. Smith

October 30, 2013

Course Objectives

• Brief History and Science of Lasers

• Lasers and their use in Dentistry

• Lasers in the Treatment of Periodontal Disease

• LANAP and the opposing view

• What you can do with this knowledge

•31% of adults surveyed by the ADA said it was VERY important that my dentist has a laser!

Excuses for not using lasers

• Too Expensive

• Learning Curve Too Steep

• Safety

• Not Better Than Traditional Treatment

Top Reasons dentists want Lasers

•Frenectomy•Gingivectomy•Troughing•Periodontal Disease Treatment•Tooth Preparation•BioStimulation – TMJ chronic pain

•Increase patient comfort•Increase effectiveness of treatment•Improve patient acceptance of care•Increase reparative and regenerative healing of patient

•Increase types of procedures by provider•Improve office image

Benefits of lasers as described by Dentists

History of Lasers in Dentistry

First Laser Developed by Theodore Maiman

A ruby based laser

1960

So we meet again Mr. Dot. Prepare to Die!

Lasers in Dentistry

•1965 Gold used Ruby and CO2 Lasers•1970s CO2 and Nd:YAG (cw) on teeth•1980s Emphasis switched to incision of soft tissue with CO2

•1990s Introduction of Diode and Er:YAG and pulsed Nd:YAG

And Now Some Physics…

Laser Basics

• Electromagnetic Energy and the Photon and Wavelengths

• Wavelength Spectrum - Relevance to Laser Dentistry

• Pulsing Laser Energy vs. Continuous Wave Laser Energy

• Absorption of Laser Energy by Water, Hemoglobin and Pigmentation

• Effects of Laser Energy on Tissue

Einstein’s THeory

Einstein and Niels Bohr postulate the

theory of stimulation of electromagnetic

field to emit amplified light

Einstein introduces the Photon

When an electron moves from a higher energy level to a lower energy level, a photon (particle of light) is emitted. Light emitted this way (from movement of charged particles) is called radiation.

Photons Emit Certain Wavelengths

Herding the Photons

THe Medium Determines Wavelength

Strobe Light

•Solid State - Crystal•Gases•Electrical Current

Laser Light Is:

Light Amplified by Stimulated Emission of Radiation

Monochromatic Light

Collimated

Coherent

Laser Frequency

Continuous Wave

• A steady beam of light with constant power

Pulsed Wave

• Pulsed lasers emit light in a series of pulses of duration which increase peak power = Greater Punch can Penetrate Further

http://www.youtube.com/watch?v=cZfsnA7dAHI

Pulsed Vs Continuous

Continuous emission of laser energy will non-selectively ablate tissue

Pulsed Energy increases Wattage to area and reduces Duty Cycle (time laser on)

Generally Nd:YAG runs 0.2% of time. This reduces thermal effects on tissue

Varying the Pulse Duration can provide additional benefits such as ablating tissue and hemostasis

Co2 and Erbium Lasers high Absorption in water and

hydroxyapatite

Nd:YAG high absorption in dark tissue

Absorption of Laser Energy in Tissue

Absorption in Tissue

Tissue Penetration

Laser Effects on Tissue

Photothermal – absorbed by tissue and converted to heatPhotodisruptive (Acoustic) – Pulsed laser energy converted

to mechanical energy in form of shock wavePhotochemical – laser energy converted into chemical

energy.Photodynamic – Requires light absorbing chemical to

produce biochemical reactive form of oxygen – singlet oxygen

Biostimulation – LLLT absorption of photon energy directly by Mitochondria and improve healing, pain relief.

Cut tissue, ablate tissue, disinfect, coagulate, biostimulate

Common Lasers In Dentistry

•Diode – 810, 940, 980nm•Nd:YAG – 1064nm•Er:YAG – 2780nm •CO2 – 10,000nm

WAKE UP!!!!!!

YOU NEED TO KNOW WHAT YOU ARE PLAYING WITH

Lasers are Not Created Equal!

Laser Medium – Gas, crystal, solid stateMedium determines Wavelength (Frequency)Wavelength Absorbed Differently by H2O and

TissueAbsorption Depth Determined by WavelengthPulse and Duration focus and concentrate Energy

Non Controversial Laser Treatment

FrenectomyGingivectomyTroughingUncovering implantsCutting TeethCutting BoneGingival Sulcus Debridement

Er:YAG = BioLase

• 2780 Wavelength

• Absorbed by water and Hydroxyapatite

• High Surface absorption

• Excellent for hard tissue removal

• Non-Selective for Soft tissue removal

• Fiberoptic Delivery

CO2 Laser• 10,000Nm mostly continuous wave

(millisecond pulsing offered in some)

• Non contact

• Absorbed by Water and Hydroxyapatite

• Excellent for cutting soft tissue and surface ablation

• Hollow tube Delivery

Diode

• 940nm (810nm and 980nm also)

• Absorbed by Water

• Continuous wave with programmable pulsed setting

• Disposable fiberoptic Delivery

810

nm

940 nm

Operculectomy - 980 nm

Operculectomy - 940

nm

Clean Removal around Implant

Sulcular troughing and Gingivectomy

What Laser is best for Periodontal Disease?

Periodontal Disease Manifests Clinically as Red Inflamed Tissue

The Disease is initiated by Bacteria generally black pigmented anaerobes that invade tissue and cementum

Prevalence Of Periodontal Disease

•200 Million US Adults and nearly 95% have some form of Periodontal disease with 30% having Moderate to Severe Periodontitis

•Only 3% of the Moderate to Severe actually get treatment!

•When Detected and Treated Early this Disease Does not have to be as Destructive regarding, Function, Phonetics, Esthetics or Systemic Implications!

Complex Disease

•Commonly regarded as an interaction between bacteria and our body’s host Response

•Contributory Factors include – Genetic Susceptibility, Systemic Disease, Extrinsic Factors, Occlusal Forces and Local Irritants.

•Unfortunately there has been no Treatment Panacea!

http://www.youtube.com/watch?feature=player_embedded&v=l5rOvglzjD0

Clinical Goals:

Decrease Bacterial Levels

Reduce InflammationEliminate Infected tissueReduce Pocket Depths

Gain Clinical attachment

Recession SensitivityMorbidity

CostLong Junctional Epithelium

Consequences of Traditional Treatment:

Regeneration of Periodontium

•Berube – 1947 – Studied whether Regeneration was possible of alveolar bone, ligament and cementum.

•Goldman – 1949 – Intrabony Pockets and defects could be reversed via Regeneration

•Carranza – 1954 – Identified New PDL, cementum and bone – or regeneration

•Essential Elements for Regeneration: Complete Removal of Pocket Epithelium, Complete Sterility of the Pocket, Well organized Fibrin Clot

Regenerative Surgery

Disadvantages of Regenerative Surgery

• Surgical manipulation of tissue with consequences

• Increased sensitivity and risk of root decay

• Cost of Procedure

• Fear of Surgical Procedure

• Must have Patients Cleared of Any Medical Issues i.e. clotting concerns

Laser Assisted New Attachment Procedure

Periolase MVP 7

Nd:YAG 1064Nm

Fiberoptic Delivery 200u 300u 450u size

7 Variable Pulse Settings

Absorbed by Hemoglobin and pigmented tissue

LANAP Protocol

Full Mouth Treatment completed in one to two visits

No need for pretreatment ScalingNd:YAG laser used to disinfect and de-epithelizeUltrasonic Instrumentation of rootsNd:YAG laser used to develop sterile clotOcclusal management: splinting, occlusal guards, occlusal adjustment

SoundEliminate Pocket EpitheliumUltrasonic and Hand Scale

CoagulateOcclusal Equilabration

Laser Requirements for Periodontal Treatment

Want to Destroy Quantity and Quality of BacteriaWant to De-EpithelializeWant to Penetrate into cementum and gingival

thicknessWant to Minimize damage to healthy tissueWant to Stimulate Regeneration

Nd:YAG Gram Negative Effects

90% Perio Pathogens are black pigmented, gram negative, anaerobic,

Porphyromonas Gingivalis is the key Red Complex pathogen

P. gingivalis resides, replicates in Epithelial, macrophages, dentinal tubules

P. gingivalis found within Carotid Plaque

Nd:YAG Gram Negative Effects

Porphyromonas Gingivalis, Strongly correlated with Periodontitis

Ablation of Pg with Nd:YAG complete and to a depth of 2mm from surface.

Kill rate 16x greater with Nd:YAG vs DiodeBlood samples prior to and after LANAP

show complete reduction of P.gingivalis 3 days after therapy

BioFilm Disruption

Laser irradiated surfaces removed bacteria from biofilm and hard surfaces

Abrupt decrease in bacterial ATP = cell mortalityEffective bacterial ablation and slower rate of

recolonization

BioFilm Disruption

4 different substrates biofilm seen to oscillate and break off and instantly removed from substrate without effect on substrate

55% bacterial reduction from laser shockwaves alone independent of heat or wavelength

Elimination of Pocket Epithelium

Histologic study showed complete removal of diseased epithelium without damaging the underlying tissue layers with Nd:YAG.

Deeper penetration of Nd:YAG vs. Diode

Nd:YAG Host Modulation Effect

Decreased levels of pro-inflammatory proteins in tissue and GCF.

Reduced IL-1b,IL-6, TNF, MMP-8, LPS Increased levels of anti-inflammatory proteinsIncreased IL-10, IL-18

LANAP is Evidence Based

Only Periodontitis Protocol with Scientific Proof

Nd:YAG vs DiodeWon’t Achieve Same Results – Peak Power energy

over 2000 Watts with Fr Nd:YAG. Diode = 40 Watts Need high peak pulse power to achieve

penetration into tissueDiode has Hz or Repetition rate that is unable to

generate PenetrationNo Hot Tip Effect with Nd:YAG – activated tips with

DiodeThermal Damage to Connective Tissue with DiodeToo Hot or Not Hot Enough

Nd:YAg vs diode

LANAP Research - Early

10 Published Non-Peer Reviewed Articles Published between 1998-2002 75 total Patients

Radiographic Bone Gain Stable over 10 years

Probing Depth Reduction over 10 years

All Patients had positive change in probing and or radiographic sites.

Human Histology 1999Single Pass of Nd:YAG 4 W, 100usec, 200mj to

pocket depth of 10mm

No Damage to Connective Tissue but Pocket Epithelium totally eliminated

Journal of General Dentistry – 2004, Harris, David

Laser assisted new attachment procedure in private practice

42 patients from 200 patient records in practice91% of total sites reduced probing depths by

45% at 6 months.Learned from these Early Studies that the

healing time requires up to one year for Results to be seen

Before and After 1 year

14 months Post LANAP

6 months Post LANAP

Affect it Don’t resect it

Histologic Evaluation of Nd:YAG

Yukna - 2007

All LANAP Specimens:New cementum and connective tissue

Control Specimens: No new cementum or connective tissue

Histologic Evaluation of Nd:YAGYukna - 2007

Histologic evaluation 3 months post LANAP

LANAP vs. Control of SRP alone

Histologic Evaluation of Nd:YAG

Yukna 2007

Mean probing depth reductionLANAP – 4.7mmControl – 3.7mm

Attachment GainLANAP – 4.2mmControl – 2.4mm

Dentistry Today 2008, Long, Craig

Non Peer Reviewed

New Attachment Procedure – Case StudyComparison of xrays and probing at one yearResults 68.9% mean probe depth reduction

General Dentistry -2012, Tilt, Lloyd

Tooth Longevity: Measure to other Studies (laser)LANAP – Significant reduction of lost teeth in

clinical practice.LANAP – 0.4 teeth lost, other protocols average 2

teeth% Downhill patients – 5% LANAP 15-20% otherRe-treatment – LANAP 15% total patients

Research Not Yet Published2nd LANAP Human Histology Study – Marc Nevins12 total teeth multi and single rooted teethNotched at apical extent of defectAll of these Hopeless teeth (15mm, mobility,

recession 50%) – All twelve returned to clinical Radiographic and histologic health

10 teeth new attachment to bottom of notch6 of ten teeth had cementum mediated new

attachment

Univ. Of Colorado LANAP Data

One year after treatment:

PD < 3mm 52% 93%

PD 4-6mm 36% 6.6%

PD 7-9mm 8.9% 0%

PD >10mm 0.7% 0%

Research Current

5 multi site locations (University Settings)Randomized, blinded, longitudinal, calibrated4 quad design LANAP vs. SRP vs. Flap vs. Coronal

Debridement75 Total patients – 53 done to date

Initial Presentation

First Pass

Second Pass

4 week and 2 week

4 week and 2 week

Advanced Periodontitis

Probing depths 5-10mm

90% Bone loss #27

Laser – First Pass

10mm to 3mm #27

Anterior bone loss7-8mm pocketing max

anterior

Six months laterPocketing 3-4mm!

Case Presentations

One Year Post-Op

Two Year Post op

One year radiograph

Two year follow up

Medical Issues:

Recent Severe Stroke

Taking Coumadin

One Year Post Op

Post-Op Care - Patient

Three days of liquid dietSoft food for one monthTwo weeks Q-tip cleaning of area Chlorhexidine on Q-tip or rinse two weeks.Soft toothbrush for one month – then sonic brushNo flossing for two weeksFlossing after two weeks to gum line only – one

monthMaintenance visit one to two months after last

session of LANAP

Hygiene Post LANAPNo Probing for at least six months post LANAPNo subgingival scaling for six months post LANAPHand scalers and supra-coronal polish –

ultrasonic on low power just to gingival marginFluoride treatment OKLow level laser treatment OK for disinfection

Patient Had Not been to Dentist in 20 years –

Referred to Physician – No Systemic Problems

CT scan Obtained

Medical Issues:

HBP, Imminent Hip Surgery

LAPip Peri-Implantitis

Same protocol but reduced power 20-30J per passUltrasonics used on lower level and with special tipSecond pass done to provide fibrin clot

Results showing great promise to reduce inflammatory effects and gain clinical attachment.

Six months Post Laser Tx

Why LANAP over Traditional Approach?

Addresses all Treatment ObjectivesBetter Decontamination of PocketBioStimulatory and RegenerativeShorter Active Treatment 2 weeks vs. 2 yearsLess Invasive and Less Morbidity than SurgeryNot Necessary to Go Off Anti-CoagulantsBetter Patient Treatment Acceptance

Laser Assisted Hygiene Therapy

Nd:YAG, Diode, Er:YAG – All can be usedGoals: Decontaminate, De-epithelializeDecontaminate ALL patients prior to

maintenanceDe-Epithelialize pockets over 5mm or bleedingSRP with hand instruments AND ultrasonicsIrrigating via Ultrasonices with medication ?PerioScience Anti-Inflammatory rinsesPerioscope for Better Root Debridement

Thank You For Your Attention!