Question: What is the Role of Lasers in the Treatment of Periodontal Disease?
Raymond A. Yukna, DMD, MS; Francis G. Serio, DMD, MS, MBA; Peter Rubelman, DDS
Raymond A. Yukna, DMD, MS
Lasers will play an increasing role in the treatment of periodontitis and periodontal pockets in the decades to come. While a variety of laser wavelengths and types are promoted for the treatment of periodontal pockets, to date only one technology and protocol has been shown to have consistently positive clinical and histologic results. The Laser-Assisted New Attachment Procedure (LANAP™) (Millennium Dental Technologies, Inc, https://www.lanap.com) using a free-running pulsed neodymium:YAG (Nd:YAG) laser in an established, patented, single-treatment protocol has shown consistent short-term and long-term clinical results and uniformly positive histologic results in humans demonstrating cementum-mediated new connective-tissue attachment. This new minimally invasive surgical approach to periodontal pocket surgery also results in less patient morbidity (eg, decreased pain, virtually no swelling, no bleeding) than traditional periodontal surgery.
While diode-, carbon dioxide-, and erbium-based lasers are promoted for and used to some degree for the treatment of periodontal pockets, none of these wavelengths have sufficient data (and certainly no human histology) at this time to justify their claims. At best, they are an adjunct to nonsurgical periodontal therapy, with their use either as an additional step during periodontal surgery or for decreasing the microbial contents of pockets. More research and data are needed with these modalities to justify their claims and warrant their use.
The future of definitive periodontal pocket therapy will increasingly use lasers. At this time, LANAP using the PerioLase® (Millennium Dental Technologies) Nd:YAG laser is the procedure of choice and is leading the way in the exciting evolution of laser use in periodontics.
Francis G. Serio, DMD, MS, MBA
Lasers in dentistry are here to stay. The challenge has been to develop the appropriate applications for this powerful set of instruments. Lasers and minimally invasive dentistry go hand-in-hand. For example, using laser-based diagnostic devices such as DIAGNO dent® (KaVo Dental Corporation, https://www.kavo.com) for caries detection and an Er,Cr:YSGG laser (Waterlase MD®, BIOLASE Technologies, Inc, https://www.biolase.com) for tooth preparation, a clinician can chase incipient caries and minimize tooth preparation when completing a composite resin restoration. Lasers of various wavelengths also have numerous soft-tissue applications, including removal of lesions, treatment of mucosal ulcers, frenum removal, gingival recontouring, hemostasis, implant uncovering, and a host of other procedures. Advantages of laser use for these procedures include minimal bleeding; minimal suturing, fewer sutures, or no use of sutures; and improved patient comfort.
One interesting new concept is LANAP. Some promising histologic evidence regarding use of a pulsed Nd:YAG laser and patented treatment protocol has shown that new attachment, the formation of new connective tissue, and cementum is possible. New cementum and connective tissue were found only occasionally coronal to the most apical piece of calculus on the six experimental teeth, although this was a consistent finding apical to the calculus notch. This sole histologic study was published in late 2007; there are neither follow-up histologic studies by the same authors nor independent confirmation of the findings. While this is good initial proof, significantly more work is needed to explore the efficacy of this treatment in all locations, with different types of disease, predictability, and long-term success. Another interesting question: How does the wavelength of the laser light itself, not just the mechanical actions of the light, affect healing response?
As a 15-year user of clinical laser technology, I embrace the use of lasers for certain procedures and will support the claims of therapeutic success when more evidence becomes available. Until then, remember the words of Thomas Cardinal Wolsey: “Be very, very careful what you put into that head, because you will never, ever get it out.”
Peter Rubelman, DDS
It is my opinion that LANAP is a major paradigm shift that will revolutionize the treatment of periodontal disease. In the vast majority of cases, osseous surgery will be replaced by LANAP. Flap elevation to treat osseous defects will be a treatment of the past. Clinically, my results with LANAP are superior to all other methods, and this is now supported by human histologic research.
Some of the obvious advantages of LANAP include no flap elevation and therefore no incisions or sutures. As a result, the patient has much less morbidity: little, if any, discomfort, postoperative swelling, gingival recession, or root sensitivity. Immediately after surgery, the patient is able to return to daily activities. All of this results in a higher percentage of patient acceptance of treatment.
Occlusal adjustment to eliminate all interferences is an integral part of the protocol. With the proper wavelength and operating parameters, the laser fiber optic emits light energy that selectively removes the diseased epithelium. This unique specific laser energy penetrates the gingival unit, the remaining connective tissue, and the tubules in the cementum, killing most of the opportunistic periodontal pathogens, as well as neutralizing their toxins. Meticulous root preparation is followed by a second pass of the laser, with different settings, forming a fibrin clot that intimately seals the soft tissue to the tooth. This clot allows the inherent ability of the body to heal itself and, with proper lifestyle changes, maintain a state of harmony.
Less obvious advantages are that the patient does not have to discontinue anticoagulant therapy prior to surgery. Also, if necessary, the restorative dentist can place restorations prior to LANAP, unless the periodontium is of the thin, highly scalloped biotype or if the gingival tissues are very acutely inflamed, especially in the esthetic zone.
It has been my experience that LANAP reduces healing time with unrivaled results that include bone regeneration as well as a connective tissue attachment. I reiterate it is my belief that LANAP will replace flap elevation as the treatment of choice for periodontitis.
Disclosure
Dr. Yukna has received research support and honorarium from Millennium Dental Technologies and BIOLASE Technologies, Inc. He also serves as a consultant for these companies.
About the Authors
Raymond A. Yukna, DMD, MS
Dr. Yukna is a professor and director of advanced periodontal therapies at the University of Colorado School of Dental Medicine in Aurora, Colorado.
Francis G. Serio, DMD, MS, MBA
Dr. Serio is associate dean for clinical affairs and professor at East Carolina University School of Dentistry in Greenville, North Carolina.
Peter Rubelman, DDS
Dr. Rubelman is in private practice in North Miami Beach, Florida.
