JIACD
The Journal of Implant & Advanced Clinical Dentistry
Lasers for perio treatment. Which should I buy?
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Comments
The LANAP Procedure by Yukna: Very strong study
http://www.millenniumdental.com/pdf/YuknaArticle.pdf
I am thinking of buy the millennium laser after reading this study. True regeneration by a strong researcher.
Opinions?
LANAP: I use in my office....12mm to 2 mm pocket depths
The laser produces some remarkable results. I use it in my office. I convert 12MM pockets to 2mm routinely.
lasers
Dr. Yukna's study is great but only on 6 patients. I would not put my career approach to perio on that one study. The Periolase is a tool and nothing more and will not replace an understanding of Biology and proper surgical techniques.
Lasers
I believe the Periolase is excellent for removing inflammation. But in my opinion it is not a definitive procedure and cannot not change the following:
1. Biologic width invasion
2. Lack of attached gingiva
3. Irregularities on root surfaces.
4. Furcation involvement. A definitive result.
5. Definitive pocket elimination
In essence if you have a perio-rest practice in my opinion it has limited usage. ONE REQUEST MY REFERRALS HAVE OF ME IS A DEFINITIVE END RESULT and I do not believe the Periolase can accomplish that. Also to make claims that pockets depths drop from 12mm. to 2mm. should be guarded though the same can hold true with severe inflammation and 3 walled defects after scaling and curettage. I believe in the limited benefits of the Periolase but it is not a cure all for many of the periodontal concerns which I see everyday. I consider it of minimal value in a perio-rest practice.
My opinion,
Dann Melker
Dr. Melker Couldnt agree with you more
I have rarly seen a 12mm pd go to 2 unless the tooth was removed lol. I to believe the periolase has limited benefits.
Shaz
Lasers
Dr. Melker well said. I must agree. The comment of 12mm to 2mm pocket reduction with laser LANAP is "laughable" and only means that the marketing is having great effect and that some are drinking "the juice".
Dr. Melker: LANAP Where is the research
Agree with the above comments. Where is the research. 1 study isnt something to justify a 20,000 laser and obscene charges to the patient.
My Opinion
Lasers in periodontics: Sensibility on the subject?
Well, I have not posted on the journal for a while, but here I am again! ;o)
Please keep in mind that I am only addressing lasers. I provide conventional periodontal surgery and some laser assisted surgery. There are cases where each is potentially appropriate and to outright dismiss the use of a laser in periodontics might imply a lack of experience with the technology.
I recall when Stur Neyman and others first presented GTR with millipore filters and the interest that was generated at the outset, beginning with few studies and none with a high N... for example. When investigating a potential modality we must start at the beginning. However I agree that to jump in full tilt based on one small study has it's pitfalls. Ray Yukna just started at the beginning and his findings astounded him. Small N, but Ray was completely surprised. He was biased against any positive result. We are biased against new modalities also given disasters with this and that (Keyes, for example) over the years and we SHOULD be skeptical.. that is our job. But it sure changed Ray's viewpoint. Hey, I'm just sayin'.
As mentioned above, Lasers are just another instrument, and they can be very useful in a number of ways.. even in conjunction with conventional osseous surgery (tissue trimming during or post op, for example.. if you have one handy). So it must be a given that a laser is just an instrument to be used wisely, hopefully.
Danny Melker's statement above is completely appropriate. A fundamental of periodontics is to provide the appropriate treatment to the given circumstance or situation. Not one size fits all. And this is where some of the problems arise: folks grab a laser and suddenly they treat all periodontics with a one size fits all mentality... always through ignorance, right?
With a Biolase Waterlase used as a resective device a very nice long term result can be achieved. This is not the way they promote it, but having provided this and seen results out 5 years, I can say that it worked very well used that way, and the cases have been shown to be very stable and comparable to a conventionally treated case. It was used as a tool. But what about the vertical defect? Conventional treatment in concert with the above Biolase resulted in excellent results. But, again, it was just a resective device. No big magic at all. Just a tool. One can burn off tissue with a diode as well. Just a tool.
Just as there are cases that can be successfully treated with a Biolase, there are those that can be successfully treated with LANAP. The laser is only one part of that process. Three parts, really: Laser, Cleaning, Laser, and aggressive occlusal adjustment. Occlusal adjustment. I repeat because this is a very BIG part of the protocol. Does that make sense? Well, sure, especially with my background.. Penn with Mort Amsterdam, et al.
A HUGE fundamental of periodontal prosthesis is occlusion. Mort ALWAYS spoke of "lesions of trauma" when he discussed a case. Showing excellent full mouth xrays taken yearly for 50 years to see what happened to case after case after case, ad nauseam. Lesions of trauma. The first component of a perio prosth case is to eliminate subgingival calculus (flap s/rp, for example, with NO tissue removal) and then completely disclude the teeth in trauma. What happens over time is that bone mineralizes in many of these defects. Why? Because the first step in inflammation near bone is demineralization.. the tissue remaining has the potential to remineralize when the inflammation and trauma is eliminated. So, Mort's "Lesions of Trauma" (otherwise known as vertical defects on an x-ray) were minimized after cleaning and disclusion over time. If conventional osseous surgery had been provided prior to this, the remineralization potential of these lesions would have been lost in the resection.
So, aggressive occlusal adjustment and/or splinting of teeth (Yukna) has merit in eliminating or minimizing micro movement during any regeneration, the tooth being one of the walls of the wound. (And Nick S., I know there are conflicting studies on this subject.. ;0)
So the question is, what does the laser do in this? I mean, you root plane, you adjust the occlusion, so what does the laser do? That tool?
Since this has gotten so long I think I will quit for the moment. If anyone wants me to write more, say so, and if you don't, say so.. It is the end of my week and I am going to enjoy a nice glass of wine and look at my cows.
But I can take up where I left off if anyone is interested..
Michael
Periolase
As a periolase user I have read the here-to-fore comments with interest. All those who express caution or have overly negative comments have one thing in common. They do not have a periolase, they do not know the periolase protocol and they have do not therefore have firsthand knowledge of the effectiveness of the technique.
The comments regarding what a laser cannot do are mostly true. The laser is not used nor bought for what it cannot do but for what it can accomplish.
I underwent implant surgical training with Hilt Tatum Jr. He showed me ways to place implants without using a surgical handpiece. All I needed for the technique was a scalpel and bone spreaders. It worked. So from that vantage point, should I suggest that surgical units are not necessary for implant surgery?
Clinicians Report (formerly C.R.A) Founded by Gordon Christensen did a survey about three years ago of Periolase owners. One question and response caught my attention. I had previously bought a laser a decade before and it was useless. The survey question asked over one hundred users this question; "If you were to do it over again, knowing now what you do, would you buy the laser?" The response that I remember was that about 99% said that they would buy it again. That is saying something about a device that costs 70-80K.
Millennium Dental which sells the laser never claims that you will reduce a 12 mm pocket to 2 mm. They will tell you that on average, pocket depth will be cut in half or to 3 mm, whichever is greater. I have found that on average, the claim is valid and conservative and represents the results of most of my patients.
Nonetheless, every periolase user I know always has a case now and then that exceeds expectations. We do get deep "V" shaped pockets that can be very deep (9-13) mm that at times resolve to 3 mm.
I saw a patient on recall last week who came to me for dental implant therapy. Her general dentist referred her to a periodontist. The periodontist had recommended removing 12 and 13 because he thought they were hopeless and that she should replace them with implants. She also had moderate to severe perio in all other quadrants.
She had 9 mm pockets on teeth 12 and 13. From my experience, I felt I could save those teeth. I told her that for less that the placement and restoration of the two premolars, I could treat her entire mouth and most likely save those two teeth as well.
One year post-op there is obvious regeneration of bone interproximally and the pockets are 4 mm.
Yes, the laser does not meet every need. Yet, I would just as soon be an eye surgeon and shun laser technology as to be a dental practitioner and not avail myself of a periolase.
When I talk to my patients about this treatment I tell them a few things that have been universally true so far. A), You will not suffer any bone loss from this technique. B) It is vastly less painful than resective therapy. C) Everyone shows improvement. I should note in truth, I do not use it nor suggest it for smokers.
In my practice the periolase is for patients with bone loss and pockets 5 mm or great without excess mobility or if with mobility, are amenable to stabilization. Using the laser with the proper protocol gives consistent results.
I have been practicing implant dentistry since 1992. Over the years, I learned many "cutting edge" techniques that turn out to be "bleeding edge" because they do not work as well or consistent as claimed. This has not been my experience with the periolase. The company support and the results in practice exceeded my expectations. Millennium seems to under promise and over deliver.
If you really want to know if it is of value of not, instead of listening to warnings of those who are not experienced in the use of the device, I would suggest visiting with someone who has. It should be someone without financial ties to the company. Their numbers are growing greatly each year and no doubt there is someone not far from you. From my own experience laser periodontal treatment is like Cone Beam Scans for implant treatment. Currently Cone Beam is considered "great option" to help in treatment planning. Yet the day is coming when it will be the standard of care because the value is undeniable.
Best wishes
Biolase over the periolase
Randoll I couldnt agree more with your comments. Those that dont use tend to hate. I myelf use the biolase. I find it much more cost effective then the periolase and I have got similiar results from my colleague who uses the periolase.
http://www.biolase.com/
Periolase
The Periolase study at LSUSD comprised 6 patients and can be considered a proof of principle study. A better understanding of LANAP efficacy could be had with clinical studies, using a split mouth design. This type of study, sadly lacking, provides the thoroughness and intellectual rigor that our patients deserve. All I have seen thus far are case studies, most without even the rudimentary elements of first year dental school clinical examinations. For example, I've not seen pre and post treatment chartings that have landmarks to measure attachment loss or gain...no mention of CEJ's or restoration margins to measure from. It seems to me that my patients deserve to pay for treatment that has been shown to be effective through reputable research. The results of a study of 6 patients are not statistically applicable to a whole population. In our practice, we routinely employ endoscopy and microscopy and our results (case studies) are at least as impressive as the LANAP case studies I've seen, though we routinely include recession from CEJ or margins in our charting. Predictably, the argument is presented that LANAP yields cementum mediated new attachment versus the long junctional epithelium we can expect with subgingival root debridement. Firstly, the study was with only 6 patients and the slight (mm or so) of arguable new attachment cannot sensibly be extrapolated onto the general population. Secondly, the landmark Scandinavian studies which demonstrated long-term stability of periodontally compromised dentitions, and which underpin periodontal treatment, likely all healed with long junctional epithelium attachments (but which remained stable for the decades of the study). These patients underwent flap surgery which allowed for complete subgingival debridement, their occlusions were optimized and they had regular, frequent and thorough supportive periodontal treatment.
The lesson here is that a long junctional epithelium, which may form anyway despite guided tissue regeneration or LANAP (we don't know...too few subjects in the study) has not been shown to be less stable than cementum mediated new attachment. Philosophically, we'd like to achieve cementum mediated new attachment, but clinically, we know that we deal with long junctional epithelial attachments on a daily basis. To illustrate our lack of Laser Phobia, consider that we use Diode lasers a lot, including uncovering implants and contouring the peri-implant soft tissue. I have found it useful, sometimes, for treating peri-implantitis: thus far, there is no standardization for this treatment and it may help to decontaminate implant surfaces exposed with a flap . It is useful for gingival recontouring, in patients with a thin gingival phenotype. With thicker tissue, an electrosurgical tip works just fine. It is a great tool for lingual frenectomies, though I prefer a minimally invasive scalpel removal of the contents of facial frenae, with small suture closure: both done with microscope. I think that lasers are simply one of the many tools we can use to help treat periodontal disease. I know LANAP is not the "Standard of Care" as was foolishly advertised, since "Standard of Care" is an end point that is measured judicially and is independent of instruments used. I look forward to well designed double blinded split mouth design studies which measure the effectiveness of LANAP, or any other laser mediated method for treating periodontitis. Randy
Periolase: For Dr. Comeaux
I couldnt agree more with you. Very well thought out answer. The whole standard of care thing was foolish.
I have been reluctant to buy until more research comes out. I agree that well designed double blinded split mouth design studies which measure the effectiveness of LANAP, or any other laser mediated method for treating periodontitis is needed to see whether this is a viable treatment option.
Thanks for your input here and look forward to future dialique with you on these boards.
lasers
The question of being able to judge the Periolase without owning one is not as difficult as one thinks. First I have several very good friends, Periodontists mind you who own the Periolase and perform LANAP. They to the man or women state that there are significant benefits when a patient has severe perio disease with very deep pockets. So I am not disputing that type of case.
I have asked Dr. Ray Yukna to set up protocols for the use of the LANAP with no response. To me the following are limitations of LANAP
1. Can't change irregular CEJ's
2. Can't increase AG
3. Can't definitively treat furcations
4. When AAE it can't correct osseous need for removal
5. Can't remove concavities or developmental grooves
6. Can't create a parabolic architecture of bone to mimic soft tissue definitively.
7. I can definitively treat dehiscences and fenestrations- LANAP?
I could go on but the point is my referrals demand DEFINITIVE periodontal results when doing comprehensive perio-rest cases and i do not believe LANAP can be definitive with any of the above statements which is mandatory when doing comprehensive care. I would feel a lot better if there were boundaries or guidelines set for the use of the this procedure. If your practice is one of severe perio disease and limited restorative the investment in a Periolase would be great!
Junctional epithelium vs connective tissue
Randy,
Your comment below:
The lesson here is that a long junctional epithelium, which may form anyway despite guided tissue regeneration or LANAP (we don't know...too few subjects in the study) has not been shown to be less stable than cementum mediated new attachment. Philosophically, we'd like to achieve cementum mediated new attachment, but clinically, we know that we deal with long junctional epithelial attachments on a daily basis.
I am not sure I agree with this as junctional epithelium is nothing more than a glycoprotein attachment. Connective tissue attachment is in fact an attachment and I feel strongly from 35 years of doing perio-rest cases it is a far superior attachment than junctional epithelium. Clinically speaking I virtually never see recession when building a strong perio foundation with a ton of AG. Yet when I don't build such a foundation by surgical error I usually see recession. AND to me recession means bone loss.
I would go as far to say in my practice connective tissue is more important than bone as it serves as protection. I also would say there is plenty of histology to show the major difference between junctional epithelium and connective tissue.
Sorry but i really disagree with that aspect of your post. Just a clinical opinion.
Thanks,
Danny
JE vs CT
My point is that we are not sure, from a clinical standpoint, what mediates the attachment to the root: a long junctional epithelium, or a cementum mediated (connective tissue) attachment. I'm not referring to what surrounds the tooth: AG or mucosa. My preference is to have a tooth or implant surrounded by healthy AG. Hope this helps clarify. Randy
Laser discussion: LJE breaks down long term
I tend to agree with randy, I much rather a have bone, cementum, PDL and AG rather then LGE. Must studies show LGE breaks down long term. This is why I have no faith in the laser. You may convert a 12 mm pd to 2 mm, but its LGE and will break down shortly.
Oliver
Done milking the Cow?
Michael
Have you finished your wine? I would certainly like to hear the rest of your story.
Tell us
What does the laser do in this? I mean, you root plane, you adjust the occlusion, so what does the laser do? That tool?
In our patients best interest,
John
http://lasergumdentist.com/
Response to Dr. Comeaux
Randy, I think you are absolutely correct in your assessment and comments. In fact, the ADA has issued standards for assessing laser evidence in a Technical Report to the Profession that require at least 2 independent clinical trials for anything beyond a hypothesis to be stated. This, of course, is not a new standard as it applies to any kind of therapy, but the silly extrapolation of claims from the Yukna study beyond what the data actually suggest apparently triggered the clarification from the ADA that the scientific bar should not be lowered just because data is hard to get. Further, some experts consider the Yukna study to be seriously flawed, but even if it wasn't, a human histology study can comment only on mechanism of attachment, not on clinical performance in the broader population. Only clinical trials can do that.
If LANAP works, I would think that 2 well-done clinical trials are needed to give it the credibility it deserves. If it doesn't we still need clinical trials to warn us. Why don't we have any yet?? It's been over 10 years...
Personally, I use the Waterlase and get excellent results, and I don't have to worry about the risk of sloughing rather large portions of alveolar bone if you use too much energy. I've seen LANAP users present "oops" cases where this has occurred...
Just a patient
Have looked all over the web for information about the perio laster therapy performed on a molar today, glad I found you folks. From a patient's perspective, this is all very confusing and I would like to know why a procedure that isn't proven to be successful is performed on patients? And also, why will my dental insurance pay for it and your malpractice insurance cover it?
The procedure was essentially painless after adequate numbing and I have had little pain thus far (12 hours later.) The biggest concern is will the procedure I just paid for be effective or will I have revisit this problem? Apparently only one molar involved at this juncture. No evidence of periodontal disease, no bleeding gums, etc., except this one tooth. There seems to be a difference of opinion, however, between the dental assistant who cleaned my teeth and the perio as to the condition of my gums. Perio says they are fine, dentist says not, suggests deep cleanings and laser. Which only adds to my confusion.
And you may not want patient input into this discussion, it just seems we may be little more than lab rats at this juncture. Lab rats who are paying the bill, of course.
Problem with lasers is...
The problem with lasers is that some people try to sell them as a "cure all" to patients. Basically, the laser kills bacteria in the sulcus and eliminates infected epithelial tissue. With the temporarily clean sulcus environment, long junctional epithelium will form providing pocket depth reduction. Problem is, the underlying bony conditions are not addressed. If non-physiologic bony contours are present or intrabony defects, the gingival disease is going to come back.
Lasers are great in certain situations, but they aren't being used properly by many dentists. It's like what you see at the gas pump. If you add this additive to your gas for an extra buck, your engine will work like magic...problem is, if something is wrong with your engine, you still need to get it fixed.
LANAP case
Sam wrote "The comment of 12mm to 2mm pocket reduction with laser LANAP is "laughable" and only means that the marketing is having great effect and that some are drinking "the juice".
Shaz wrote "I have rarly seen a 12mm pd go to 2 unless the tooth was removed lol. I to believe the periolase has limited benefits.Shaz"
For those skeptics see this 12 to 2
https://picasaweb.google.com/103703771319230633247/LANAPBeforeAndAfter
See http://lasergumdentist.com/
Response to dndperio
NEVER has a LANAP dentist reported "sloughing". The clinical trial is under way at the U. of Maryland, U of Colorado and the U. of Louisville.
Here is another case
https://plus.google.com/u/0/photos/103703771319230633247/albums/55223674...
http://lasergumdentist.com/
libel
dndperio "I've seen LANAP users present "oops" cases where this has occurred..."
I have done over 1200 Lanap cases and am active on the Lanap periolase forum and NEVER have I seen a fellow lanaper show or have an "oops" "sloughing" case
You obviously don't know what you don't know. Find one Lanap dentist that would ever repeat such falsehoods. Not going to find one.
Here is another case
https://picasaweb.google.com/103703771319230633247/InvisalignVeneerLANAP
http://lasergumdentist.com/
LANAP case for the sceptics
Here is a LANAP Inman Aligner case.
Pre op 26 teeth have pockets = or greater than 6 mm post op only one 6 mm remains.
Nice to see your 12+mm pockets reversed to 3mm sulci.
https://picasaweb.google.com/103703771319230633247/LANAPInmanAligner#
Another one for the sceptics
Here is another case. Nice thing about being a GP I can do veneer preps the same day as surgery. http://www.youtube.com/watch?v=l3GJ46lev0k&feature=channel_video_title
Here are the photos of the case.
https://picasaweb.google.com/103703771319230633247/LumineerLANAPCase
Nice to be able to do veneers on teeth that have 8mm pockets and not have to be concerned with any recession and know that we will end up with 3mm sulci.
http://lasergumdentist.com/
Another LANAP case
Here is a case.
http://www.youtube.com/watch?v=Dd846LBK9GQ
Here are the pictures https://picasaweb.google.com/103703771319230633247/LANAPCBCase
http://lasergumdentist.com/
Another LANAP case
Here is another LANAP case
Do you like seeing bone growth on your Perio cases?
I do.
http://www.youtube.com/watch?v=wklFoBzBqus&feature=channel_video_title
See the mobility
http://www.youtube.com/watch?v=oOS54cJyyKA&feature=channel_video_title
Here is his one week interview
http://www.youtube.com/watch?v=tygWX-baWeI&src_vid=wklFoBzBqus&feature=i...
Here is the photography of the case https://picasaweb.google.com/103703771319230633247/LANAPMiniImplant
http://lasergumdentist.com/
Not all 12's go to 2 mm
Not all 12's go to 2 mm. Here is a case that required double treatment. What do you think of the bone changes?
Though as the manufacturer guarantees probing depths are cut in half. I'll take that! How about you? Are you going to wait for more research? Are you going to keep removing teeth that can now be saved?
https://picasaweb.google.com/103703771319230633247/RCTLANAPBeforeAndAfter
http://lasergumdentist.com/
Not all lasers are the same
When choosing a laser for periodontal treatment some fundamentals are important to understand. Here is an interesting video.
http://www.youtube.com/watch?v=hlRdugEwjHo