When—and Why—Should LANAP vs Surgery be Considered for Advanced Periodontal Lesions?

Michael L. Colleran, DDS | Colin Richman, DDS | Paul S. Rosen, DMD, MS

Michael L. Colleran, DDS: As a practitioner of the LANAP protocol for more than 10 years, I have seen the fantastic success from this surgery in my patients. Having had patients go through conventional osseous surgery, I can say that I would never recommend anything but LANAP for infectious periodontal disease. The benefits and upsides for the patient are numerous in a side-by-side comparison. First, with LANAP there is very little pain or discomfort; only one 800-mg ibuprofen immediately after the treatment for pain takes care of the discomfort. After a 24-hour recovery, patients are ready to go back to their regular activities the next day if not sooner. In addition, if there are medical concerns, such as the patient taking blood thinners, there is no reason to stop these medications. Almost every LANAP patient has said they would go through this surgery again if needed, while having the exact opposite reaction toward conventional surgery. One patient confided in me that after conventional surgery she had constant pain for 2 months and could not eat in public for 6 months because of the discomfort.

Secondly, the results are incredible. To be able to take someone who came in with a treatment plan of complete extraction and full dentures to saving all or almost all of their teeth is life changing. Patients are so thankful that there is a chance to keep their teeth and actually have those teeth be healthy.

Finally, the scientific results keep showing the superior results achieved with LANAP. I have seen great results since my first cases of LANAP, and now the FDA has recognized from clinical studies that the LANAP surgery yields true regeneration with new attachment, new cementum, and new bone.

Colin RICHMAN, DDS: As a periodontist, I always strive to retain teeth using evidenced-based protocols, including LANAP. Exceptions might include severely broken down teeth, teeth with grade III mobility and > 75% bone loss, maxillary molars with inaccessible through-and-through furcation lesions, or if the dentition has truly failed, not failing!

Our patients are educated about LANAP versus a traditional flap surgical approach. They are then given the choice of either treatment modality. Needless to say, virtually no one has chosen traditional flap surgery as his or her first treatment option. Patients are advised that my treatment objective is the establishment of total oral and periodontal health through LANAP (a far less invasive treatment modality). On the other hand, if a tooth with an initially poor prognosis does not subsequently respond favorably to LANAP therapy (persistent BOP, residual mobility, or non-maintainable pockets), they are educated that it may subsequently need a mini-surgical intervention for conventional localized access debridement plus regenerative therapy. Alternatively, extraction and replacement might be indicated. Occasionally, a scalpel is used to reduce a thick soft-tissue tuberosity, or for functional or esthetic crown lengthening, concurrently treating the remaining teeth with LANAP.

In our office, very few teeth initially demonstrating advanced periodontitis have been extracted after LANAP treatment. I have re-entered three localized sites for flap access surgery (GTR).

Based on these observations, plus extreme patient satisfaction, the LANAP protocol will continue to be my primary and default therapeutic approach. This is predicated on well-informed patients understanding that supplemental treatment (including flap access surgery and specific tooth extractions) may be indicated in the future. From the biological perspective, LANAP facilitates the periodontium’s healing process once pathogenic etiology has been removed, together with effective home plaque control.

Paul S. Rosen, DMD, MS: When I first purchased and began using an Nd:YAG laser, I went into it with much skepticism. Yes, there have been case reports, anecdotal colleague reports, and histology attesting to its merits. However, there have been no randomized trials demonstrating its superiority. It wasn’t until I treated a case with LANAP did I begin to change my mind. A quadrant that had been scheduled for regenerative therapy responded in a manner that I’d thought not possible. An advanced angular lesion at the distal of the mandibular right second molar had what appeared to be complete osseous fill after treatment. When probing the site, the pocketing was reduced from 8 mm down to 3 mm. I have seen this occur on a number of other occasions as well. One has to bear in mind that the use of this Nd:YAG laser is part of an overall treatment algorithm that involves oral hygiene instruction, SRP, systemic antibiotics, occlusal therapy, and adherence to maintenance care. Essential always is meticulous SRP of the root. Does this always work? No, but why wouldn’t I attempt to treat an area with a less invasive approach that appears to be patient preferred? LANAP or laser-assisted therapy does not always work, but what does?

The other concern that is raised is when do I consider the treatment to have been ineffective and in need of conventional regenerative surgery? I use conventional regenerative surgery without ever first using LANAP in furcation lesions because my experiences with laser-assisted treatment for these areas has been unfavorable. On the other hand, traditional regenerative therapy for class II furcations and in some instances mandibular class IIIs has been highly successful. Furthermore, the literature on laser use for these areas has reaffirmed my desire to continue to embrace what has worked well for me in my practice. Regarding sites where the outcomes after laser-assisted therapy or LANAP remains at 5 mm or more, bleeds upon probing, fails to have any bone fill or a well-defined crestal lamina dura, they need to have surgical care. These are sites that are at risk for further breakdown due to residual disease and an inability to be maintained in health. To do anything less for your patients is to do them a disservice.

Michael L. Colleran, DDS is an Institute of Advanced Laser Dentistry instructor and has a private practice in San Luis Obispo, California.

Colin Richman, DDS has a private practice limited to periodontics in Roswell, Georgia.

Paul S. Rosen, DMD, MS is a clinical professor of periodontics at the University of Maryland Dental School in Baltimore, and has a private practice in Yardley, Pennsylvania.