Laser Periodontal Therapy: gingivectomy to LANAP

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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

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  • Thank you for coming – this is hear to stay -
  • Voice: Let’s first talk about the quality of dentistry. The exclusive 940 nm wavelength used by the Ezlase delivers better dentistry because it was developed for dental procedures. Tissue does not have to be inflamed or pink to cut well, and it provides better hemostasis than other wavelengths. And take a look at these clinical photos – the 940 nm wavelength is a much cleaner cut and does not char.
  • Jan Wixen
  • Laser Periodontal Therapy: gingivectomy to LANAP

    1. 1. Laser Assisted Periodontal Treatment: gingivectomy to lanap Dr. Scott K. Smith October 30, 2013
    2. 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
    3. 3. • 31% of adults surveyed by the ADA said it was VERY important that my dentist has a laser!
    4. 4. Excuses for not using lasers • Too Expensive • Learning Curve Too Steep • Safety • Not Better Than Traditional Treatment
    5. 5. Top Reasons dentists want Lasers • Frenectomy • Gingivectomy • Troughing • Periodontal Disease Treatment • Tooth Preparation • BioStimulation – TMJ chronic pain
    6. 6. 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
    7. 7. History of Lasers in Dentistry
    8. 8. 1960 First Laser Developed by Theodore Maiman A ruby based laser
    9. 9. So we meet again Mr. Dot. Prepare to Die!
    10. 10. 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
    11. 11. And Now Some Physics…
    12. 12. 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
    13. 13. Einstein’s THeory Einstein and Niels Bohr postulate the theory of stimulation of electromagnetic field to emit amplified light
    14. 14. 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.
    15. 15. Photons Emit Certain Wavelengths
    16. 16. Herding the Photons
    17. 17. THe Medium Determines Wavelength • Solid State - Crystal • Gases • Electrical Current Strobe Light
    18. 18. Laser Light Is: Monochromatic Light Collimated Coherent Light Amplified by Stimulated Emission of Radiation
    19. 19. Laser Frequency
    20. 20. Continuous Wave • A steady beam of light with constant power
    21. 21. 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
    22. 22. 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
    23. 23. Absorption of Laser Energy in Tissue Co2 and Erbium Lasers high Absorption in water and hydroxyapatite Nd:YAG high absorption in dark
    24. 24. Absorption in Tissue
    25. 25. Tissue Penetration
    26. 26. 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
    27. 27. Common Lasers In Dentistry • Diode • Nd:YAG • Er:YAG • CO2 – 810, 940, 980nm – 1064nm – 2780nm – 10,000nm
    28. 28. WAKE UP!!!!!!
    29. 29. YOU NEED TO KNOW WHAT YOU ARE PLAYING WITH
    30. 30. 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
    31. 31. Non Controversial Laser Treatment Frenectomy Gingivectomy Troughing Uncovering implants Cutting Teeth Cutting Bone Gingival Sulcus Debridement
    32. 32. 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
    33. 33. 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
    34. 34. Diode • 940nm (810nm and 980nm also) • Absorbed by Water • Continuous wave with programmable pulsed setting • Disposable fiberoptic Delivery
    35. 35. nm nm 81 0 940 Operculecto Operculectom my - 980 nm y - 940 nm
    36. 36. Clean Removal around Implant
    37. 37. Sulcular troughing and Gingivectomy
    38. 38. 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
    39. 39. 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!
    40. 40. 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!
    41. 41. http://www.youtube.com/watch? feature=player_embedded&v=l5rOvglzjD0
    42. 42. Clinical Goals: Decrease Bacterial Levels Reduce Inflammation Eliminate Infected tissue Reduce Pocket Depths Gain Clinical attachment
    43. 43. Consequences of Traditional Treatment: Recession Sensitivity Morbidity Cost Long Junctional Epithelium
    44. 44. 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
    45. 45. Regenerative Surgery
    46. 46. 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
    47. 47. Laser Assisted New Attachment Procedure
    48. 48. Periolase MVP 7 Nd:YAG 1064Nm Fiberoptic Delivery 200u 300u 450u size 7 Variable Pulse Settings Absorbed by Hemoglobin and pigmented tissue
    49. 49. 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
    50. 50. Sound Eliminate Pocket Epithelium Ultrasonic and Hand Scale Coagulate Occlusal Equilabration
    51. 51. 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
    52. 52. 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
    53. 53. 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
    54. 54. 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
    55. 55. 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
    56. 56. 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
    57. 57. 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
    58. 58. LANAP is Evidence Based Only Periodontitis Protocol with Scientific Proof
    59. 59. 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
    60. 60. Nd:YAg vs diode
    61. 61. 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.
    62. 62. 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
    63. 63. 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
    64. 64. Before and After 1 year
    65. 65. 14 months Post LANAP
    66. 66. 6 months Post LANAP
    67. 67. Affect it Don’t resect it
    68. 68. Histologic Evaluation of Nd:YAG Yukna - 2007 All LANAP Specimens: New cementum and connective tissue Control Specimens: No new cementum or connective tissue
    69. 69. Histologic Evaluation of Nd:YAG Yukna - 2007 Histologic evaluation 3 months post LANAP LANAP vs. Control of SRP alone
    70. 70. 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
    71. 71. 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
    72. 72. 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
    73. 73. 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
    74. 74. 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%
    75. 75. 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
    76. 76. Initial Presentation
    77. 77. First Pass
    78. 78. Second Pass
    79. 79. 4 week and 2 week
    80. 80. 4 week and 2 week
    81. 81. Advanced Periodontitis
    82. 82. Probing depths 5-10mm
    83. 83. 90% Bone loss #27
    84. 84. Laser – First Pass
    85. 85. 10mm to 3mm #27
    86. 86. Anterior bone loss 7-8mm pocketing max anterior
    87. 87. Six months later Pocketing 3-4mm!
    88. 88. Case Presentations
    89. 89. One Year Post-Op
    90. 90. Two Year Post op
    91. 91. One year radiograph
    92. 92. Two year follow up
    93. 93. Medical Issues: Recent Severe Stroke Taking Coumadin
    94. 94. One Year Post Op
    95. 95. 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
    96. 96. 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
    97. 97. Patient Had Not been to Dentist in 20 years – Referred to Physician – No Systemic Problems CT scan Obtained
    98. 98. Medical Issues: HBP, Imminent Hip Surgery
    99. 99. 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.
    100. 100. Six months Post Laser Tx
    101. 101. 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
    102. 102. 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
    103. 103. Thank You For Your Attention!

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