We were intrigued by Dr. Edward R. Kusek’s “Treating Peri-implantitis” case report in the August 2019 issue.
We respectfully acknowledge the considerable skills necessary to attempt the rather complex, multi-step surgical approach outlined by Dr. Kusek. We wonder, though, how many clinicians would be willing to undertake the technique-sensitive treatment regimen outlined by the author, given the sizable expense and time investment required to acquire the 9,300-nm CO2 and 2,780-nm erbium lasers, become trained and facile in their clinical use, purchase a platelet-rich plasma (PRP) machine and learn the technique, and become proficient in the use of bone grafts and fabrication and placement of membranes.
Given the myriad of techniques and technologies involved, the described approach may be cost prohibitive for the patient. If not done correctly, it may not be amenable to retreatment, could lead to a poor aesthetic result, or worse, fail with significant consequences for the patient and clinician.
The author enumerates a set of recommendations for treating peri-implantitis developed by a group of clinicians attending the 2017 annual meeting of the Academy of Laser Dentistry. In their zeal to develop a set of recommendations for treating peri-implantitis, they apparently chose to somehow overlook the success that can be achieved using a considerably simpler, minimally invasive, single-wavelength laser-based surgical approach that does not require the complete reflection of a full-thickness flap, application of bone substitutes and various regenerative materials, and subsequent suturing—a protocol that has been reported in the literature at least since 2013.1
This simpler approach involves the use of a multivariable pulsed Nd:YAG laser (PerioLase MVP-7, Millennium Dental Technologies) in a well-defined LAPIP peri-implantitis treatment protocol, an adaptation of the successful LANAP protocol for treating moderate-to-severe periodontal disease. This laser device was cleared by the US Food and Drug Administration (FDA) in March 2016 for periodontal regeneration—true regeneration of the attachment apparatus (new cementum, new periodontal ligament, and new alveolar bone) on a previously diseased surface, based on the results of two human histological studies.2,3
Numerous practitioners (21 clinicians in one study alone, with follow-up to 48 months post-treatment4) have published case studies of successful treatment of peri-implantitis with the LAPIP protocol.5-9
Like the LANAP protocol, the LAPIP treatment uses the body’s own healing capacity (stem cells, growth factors, and stable fibrin clot) to achieve regeneration of bone, without the use of biologics, exogenous growth factors, bone grafts, artificial membranes, scaffolding, or sutures to influence the healing pathway. The LAPIP protocol’s ability to regenerate bone, decrease inflammation, reduce bacteria,10 and restore periodontal health is based on the same biologic and photonic principles achieved with LANAP treatment.
The author of the case study states “caution is warranted with the use of Nd:YAG lasers,” but fails to note that improper use of any laser wavelength can lead to undesirable temperature increases and/or cause adverse implant surface alterations.11-14 In addition, during the LAPIP procedure, the laser fiber is not intentionally placed into contact with the implant, as the article seems to imply, but is kept parallel to the implant, to remove diseased tissue and kill bacteria within the soft tissue and bone (without removing the bone, which can happen with erbium and CO2 lasers). Moreover, the Periolase MVP-7 allows for the use of a flexible 300-µm fiber that enables treatment in areas of thin facial tissue and in sites that may be inaccessible with a thicker fiber or rigid tip.
Significantly, even though the 9,300-nm CO2 laser is prominently featured in his case report, the author cites no references for the use of this laser wavelength for treating peri-implantitis.
Like Dr. Kusek, we would like to “aid other clinicians in preventing complications associated with peri-implantitis.” At the same time, we advocate a more balanced approach that considers all the evidence and enables selection of appropriate laser wavelength(s) for adjunctive treatment of oral diseases.
References
1. Honigman AS. Laser-assisted peri-implantitis procedure: redefining the treatment of peri-implantitis. Dentaltown. 2013;14:82-86.
2. Yukna RA, Carr RL, Evans GH. Histologic evaluation of an Nd:YAG laser-assisted new attachment procedure in humans. Int J Periodontics Restorative Dent. 2007;27:577-587.
3. Nevins ML, Camelo M, Schupbach P, et al. Human clinical and histologic evaluation of laser-assisted new attachment procedure. Int J Periodontics Restorative Dent. 2012;32:497-507.
4. Nicholson D, Blodgett K, Braga C, et al. Pulsed Nd:YAG laser treatment for failing dental implants due to peri-implantitis. In: Rechmann P, Fried D, eds. Lasers in Dentistry XX. Bellingham, WA: SPIE; 2014:89290H-1–89290H-14.
5. Seamons BC. An alternative to conventional periodontal surgery. Inside Dentistry. 2015;11:66-70.
6. Suzuki JB. Salvaging implants with an Nd:YAG laser: a novel approach to a growing problem. Compend Contin Educ Dent. 2015;36:756-761.
7. Marcus EA. Laser-assisted treatment of peri-implantitis. In: Karateew ED, ed. Implant Aesthetics: Keys to Diagnosis and Treatment. Cham, Switzerland: Springer; 2017:417-426.
8. Suzuki JB, Misch CE. Periodontal and maintenance complications. In: Resnik RR, Misch CE, eds. Misch’s Avoiding Complications in Oral Implantology. St. Louis, MO: Elsevier; 2018:771-826.
9. Honigman AS, Sulewski J. Lasers in periodontal surgery. In: Nares S, ed. Advances in Periodontal Surgery: A Clinical Guide to Techniques and Interdisciplinary Approaches. Cham, Switzerland: Springer; 2019:71-83.
10. McCawley TK, McCawley MN, Rams TE. Immediate effects of laser-assisted new attachment procedure (LANAP) on human periodontitis microbiota. J Int Acad Periodontol. 2018;20:163-171.
11. Kilinc E, Rothrock J, Migliorati E, et al. Potential surface alteration effects of laser-assisted periodontal surgery on existing dental restorations. Quintessence Int. 2012;43:387-395.
12. Stübinger S, Homann F, Etter C, et al. Effect of Er:YAG, CO2 and diode laser irradiation on surface properties of zirconia endosseous dental implants. Lasers Surg Med. 2008;40:223-228.
13. Geminiani A, Caton JG, Romanos GE. Temperature change during non-contact diode laser irradiation of implant surfaces. Lasers Med Sci. 2012;27:339-342.
14. Geminiani A, Caton JG, Romanos GE. Temperature increase during CO2 and Er:YAG irradiation on implant surfaces. Implant Dent. 2011;20:379-382.
Dr. Suzuki has a presidential appointment as professor of microbiology and immunology in the School of Medicine and professor of periodontology and oral implantology in the School of Dentistry at Temple University, Philadelphia. He also serves as the chairman and program director of graduate periodontology and oral implantology at Temple University. He received his DDS from Loyola University of Chicago and PhD in microbiology from the Illinois Institute of Technology. His MBA with an emphasis on international affairs is from the Katz Graduate School of Business of the University of Pittsburgh. He is in private practice limited to hospital periodontics in Philadelphia.
Dr. Honigman was the first periodontist in Phoenix to incorporate the LANAP protocol into his practice. Currently in practice, he also lectures for the Institute for Advanced Laser Dentistry and implant companies. He holds a BSc in biochemistry, an honors degree in genetics, and a master’s degree in microbiology and immunology. He completed his doctorate of dental surgery at the University of Texas Health Science Center and his periodontics residency at UCLA.
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