This lecture reviews the role of laser therapy in dentistry in particular for Periodontal treatment. Dr. Smith reviews many of his own cases with the audience. Please contact Dr. Smith with questions. drsmith@cpident.com

1. Laser Assisted Periodontal Treatment:
gingivectomy to lanap
Dr. Scott K. Smith
October 30, 2013

2. 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

4. • 31% of adults surveyed by the ADA
said it was VERY important that my
dentist has a laser!

6. Excuses for not using lasers
•
Too Expensive
•
Learning Curve Too Steep
•
Safety
•
Not Better Than Traditional Treatment

7. Top Reasons dentists want
Lasers
• Frenectomy
• Gingivectomy
• Troughing
• Periodontal Disease Treatment
• Tooth Preparation
• BioStimulation – TMJ chronic pain

8. Benefits of lasers as described by
Dentists
• 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

9. History of Lasers in Dentistry

10. 1960
First Laser Developed by
Theodore Maiman
A ruby based laser

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

12. 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

13. And Now Some Physics…

14. 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

15. Einstein’s THeory
Einstein and Niels Bohr
postulate the theory of
stimulation of
electromagnetic field to
emit amplified light

16. 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.

17. Photons Emit Certain
Wavelengths

19. Herding the Photons

20. THe Medium Determines
Wavelength
• Solid State - Crystal
• Gases
• Electrical Current
Strobe Light

21. Laser Light Is:
Monochromatic Light
Collimated
Coherent
Light Amplified by Stimulated Emission of
Radiation

22. Laser Frequency

23. Continuous Wave
•
A steady beam of light with constant power

24. Pulsed Wave
http://www.youtube.com/watch?v=cZfsnA7dAHI
•
Pulsed lasers emit light in a series of pulses of duration which
increase peak power = Greater Punch can Penetrate Further

25. 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

26. Absorption of Laser Energy in
Tissue
Co2 and Erbium Lasers high
Absorption in water and
hydroxyapatite
Nd:YAG high absorption in dark

27. Absorption in Tissue

28. Tissue Penetration

30. Laser Effects on Tissue
Photothermal – absorbed by tissue and converted to heat
Photodisruptive (Acoustic) – Pulsed laser energy converted to
mechanical energy in form of shock wave
Photochemical – 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

31. Common Lasers In Dentistry
• Diode
• Nd:YAG
• Er:YAG
• CO2
– 810, 940, 980nm
– 1064nm
– 2780nm
– 10,000nm

32. WAKE UP!!!!!!

33. YOU NEED TO KNOW WHAT YOU
ARE PLAYING WITH

34. Lasers are Not Created Equal!
Laser Medium – Gas, crystal, solid state
Medium determines Wavelength (Frequency)
Wavelength Absorbed Differently by H2O and Tissue
Absorption Depth Determined by Wavelength
Pulse and Duration focus and concentrate Energy

35. Non Controversial Laser
Treatment
Frenectomy
Gingivectomy
Troughing
Uncovering implants
Cutting Teeth
Cutting Bone
Gingival Sulcus Debridement

36. 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

37. 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

39. Diode
•
940nm (810nm and 980nm also)
•
Absorbed by Water
•
Continuous wave with programmable
pulsed setting
•
Disposable fiberoptic Delivery

40. nm
nm
81
0
940
Operculecto
Operculectom my - 980
nm
y - 940 nm

50. Clean Removal around Implant

51. Sulcular troughing and
Gingivectomy

52. 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

53. 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!

54. 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!

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

57. Clinical Goals:
Decrease Bacterial Levels
Reduce Inflammation
Eliminate Infected tissue
Reduce Pocket Depths
Gain Clinical attachment

58. Consequences of Traditional
Treatment:
Recession
Sensitivity
Morbidity
Cost
Long Junctional Epithelium

59. 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

60. Regenerative Surgery

61. 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

62. Laser Assisted New Attachment
Procedure

64. Periolase MVP 7
Nd:YAG 1064Nm
Fiberoptic Delivery 200u 300u 450u size
7 Variable Pulse Settings
Absorbed by Hemoglobin and pigmented tissue

65. LANAP Protocol
Full Mouth Treatment completed in one to two visits
No need for pretreatment Scaling
Nd:YAG laser used to disinfect and de-epithelize
Ultrasonic Instrumentation of roots
Nd:YAG laser used to develop sterile clot
Occlusal management:
splinting, occlusal guards, occlusal adjustment

66. Sound
Eliminate Pocket Epithelium
Ultrasonic and Hand Scale
Coagulate
Occlusal Equilabration

67. Laser Requirements for Periodontal
Treatment
Want to Destroy Quantity and Quality of Bacteria
Want to De-Epithelialize
Want to Penetrate into cementum and gingival thickness
Want to Minimize damage to healthy tissue
Want to Stimulate Regeneration

68. 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

69. 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 Diode
Blood samples prior to and after LANAP show complete
reduction of P.gingivalis 3 days after therapy

70. BioFilm Disruption
Laser irradiated surfaces removed bacteria from biofilm and
hard surfaces
Abrupt decrease in bacterial ATP = cell mortality
Effective bacterial ablation and slower rate of recolonization

71. 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

72. 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

73. 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 proteins
Increased IL-10, IL-18

74. LANAP is Evidence Based
Only Periodontitis Protocol with Scientific Proof

75. Nd:YAG vs Diode
Won’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
tissue
Diode has Hz or Repetition rate that is unable to
generate Penetration
No Hot Tip Effect with Nd:YAG – activated tips with
Diode
Thermal Damage to Connective Tissue with Diode
Too Hot or Not Hot Enough

76. Nd:YAg vs diode

77. 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.

78. Human Histology 1999
Single Pass of Nd:YAG 4 W, 100usec, 200mj to pocket
depth of 10mm
No Damage to Connective Tissue but Pocket Epithelium
totally eliminated

79. Journal of General Dentistry –
2004, Harris, David
Laser assisted new attachment procedure in private
practice
42 patients from 200 patient records in practice
91% 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

80. Before and After 1 year

81. 14 months Post LANAP

82. 6 months Post LANAP

83. Affect it Don’t resect it

84. Histologic Evaluation of Nd:YAG
Yukna - 2007
All LANAP Specimens:
New cementum and connective tissue
Control Specimens:
No new cementum or connective tissue

85. Histologic Evaluation of Nd:YAG
Yukna - 2007
Histologic evaluation 3 months post LANAP
LANAP vs. Control of SRP alone

86. Histologic Evaluation of Nd:YAG
Yukna 2007
Mean probing depth reduction
LANAP – 4.7mm
Control – 3.7mm
Attachment Gain
LANAP – 4.2mm
Control – 2.4mm

87. Dentistry Today 2008, Long, Craig
Non Peer Reviewed
New Attachment Procedure – Case Study
Comparison of xrays and probing at one year
Results 68.9% mean probe depth reduction

88. 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% other
Re-treatment – LANAP 15% total patients

89. Research Not Yet Published
2nd LANAP Human Histology Study – Marc Nevins
12 total teeth multi and single rooted teeth
Notched at apical extent of defect
All of these Hopeless teeth (15mm, mobility, recession 50%)
– All twelve returned to clinical Radiographic and histologic
health
10 teeth new attachment to bottom of notch
6 of ten teeth had cementum mediated new attachment

91. Univ. Of Colorado
LANAP Data
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%

92. Research Current
5 multi site locations (University Settings)
Randomized, blinded, longitudinal, calibrated
4 quad design LANAP vs. SRP vs. Flap vs. Coronal
Debridement
75 Total patients – 53 done to date

94. Initial Presentation

95. First Pass

96. Second Pass

97. 4 week and 2 week

98. 4 week and 2 week

99. Advanced Periodontitis

100. Probing depths 5-10mm

101. 90% Bone loss #27

102. Laser – First Pass

103. 10mm to 3mm #27

104. Anterior bone loss
7-8mm pocketing max anterior

105. Six months later
Pocketing 3-4mm!

108. Case Presentations

124. One Year Post-Op

130. Two Year Post op

137. One year radiograph

138. Two year follow up

139. Medical Issues:
Recent Severe Stroke
Taking Coumadin

155. One Year Post Op

159. Post-Op Care - Patient
Three days of liquid diet
Soft food for one month
Two weeks Q-tip cleaning of area
Chlorhexidine on Q-tip or rinse two weeks.
Soft toothbrush for one month – then sonic brush
No flossing for two weeks
Flossing after two weeks to gum line only – one month
Maintenance visit one to two months after last session of
LANAP

160. Hygiene Post LANAP
No Probing for at least six months post LANAP
No subgingival scaling for six months post LANAP
Hand scalers and supra-coronal polish – ultrasonic on low
power just to gingival margin
Fluoride treatment OK
Low level laser treatment OK for disinfection

161. Patient Had Not been to Dentist in
20 years –
Referred to Physician – No
Systemic Problems
CT scan Obtained

169. Medical Issues:
HBP,
Imminent Hip Surgery

182. LAPip Peri-Implantitis
Same protocol but reduced power 20-30J per pass
Ultrasonics used on lower level and with special tip
Second pass done to provide fibrin clot
Results showing great promise to reduce inflammatory
effects and gain clinical attachment.

183. Six months Post Laser Tx

184. Why LANAP over Traditional Approach?
Addresses all Treatment Objectives
Better Decontamination of Pocket
BioStimulatory and Regenerative
Shorter Active Treatment 2 weeks vs. 2 years
Less Invasive and Less Morbidity than Surgery
Not Necessary to Go Off Anti-Coagulants
Better Patient Treatment Acceptance

185. Laser Assisted Hygiene Therapy
Nd:YAG, Diode, Er:YAG – All can be used
Goals: Decontaminate, De-epithelialize
Decontaminate ALL patients prior to maintenance
De-Epithelialize pockets over 5mm or bleeding
SRP with hand instruments AND ultrasonics
Irrigating via Ultrasonices with medication ?
PerioScience Anti-Inflammatory rinses
Perioscope for Better Root Debridement

186. Thank You For Your
Attention!