LANAP in the General Practice: A Case Report

I am a laser dentist beginning my eleventh year of using laser technology. Lasers have changed my everyday general dentistry operations. Lasers are my instruments of choice for caries removal, biopsies, soft-tissue cosmetics, frenectomies, lesion destruction and healing, troughing for crown and bridgework, and hemostasis for extraction, just to name some of the myriad of laser uses.

A REVIEW OF LASER ASSISTED NEW ATTACHMENT PROCEDURE
The major change to my general dental practice has been in our use of a laser to treat periodontitis. Since 1999, dentistry has had a laser technique available to treat periodontal disease in a revolutionary and minimally invasive way.¹ This FDA-cleared protocol is Laser Assisted New Attachment Procedure (LANAP) (cementum-mediated new periodontal attachment to the root surface, in the absence of long junctional epithelium).

Figure 1. LANAP Diagram: (A) Probe to measure periodontal pocket depths; (B) First pass laser exposure to remove infected tissue and decontaminate affected tissues; (C) Root preparation with ultrasonic scaler and hand instruments; (D) Second pass laser exposure ending with stable fibrin clot to seal pocket; (E) Closure of the periodontal pocket wound; (F) Occlusal adjustment of bite trauma.

LANAP results have been supported by substantial empirical and scientific evidence. The results of a peer-reviewed manuscript, published in The International Journal of Periodontics and Restorative Dentistry, demonstrate uniform histological success in the treatment of moderate to severe periodontal disease using LANAP.² New connective tissue attachment (CTA), and regeneration of root surface (cementum), was achieved in 100% of the cases studied in the human histology study using the PerioLase MVP-7 variable pulsed neodymium: yttrium-aluminum-garnet (Nd:YAG) dental laser (Millennium Dental Technologies). Raymond A. Yukna, DMD, MS, director of Advanced Periodontal Therapies, University of Colorado School of Dental Medicine, led the study that documented consistently positive responses in humans treated with LANAP.
In a split-mouth, blinded and controlled study, 12 single-rooted teeth with moderate to advanced chronic periodontitis were treated. Six teeth received treatment by LANAP, while the other 6 control teeth received scaling and root planing only. After 3 months, block section human histology demonstrated that 100% of LANAP-treated teeth showed new cementum and CTA; whereas, effectively none of the control teeth had any evidence of new attachment or regeneration. There was no evidence of any adverse changes around the LANAP specimens.
Illustrated in the diagram shown in Figure 1 (not intended to be instructional) is a depiction of the treatment sequence of LANAP.
The free running, pulsed (FRP), Nd:YAG laser uses light energy directed through a tiny glass fiber.³ It removes diseased tissue and aids in the reduction of bacteria associated with periodontal disease.⁴ When the infected area is thoroughly cleaned, the body can heal itself. Laser periodontal therapy with LANAP kills bacteria in the mouth, minimizes discomfort, eliminates bleeding, controls swelling, requires a shorter time in the chair, is less invasive, and has the perception by the patient of faster healing times than conventional scalpel surgery. No scalpels, no sutures, and no postsurgical packing materials (except for smokers) are needed with laser treatment.
Furthermore, LANAP allows the body to do more than just repair the damages resulting from periodontal disease. LANAP allows healing with regeneration of the root surface, connective tissue, and bone. Regeneration has always been the sought after goal in periodontal therapy. LANAP is now considered a legitimate treatment alternative to conventional scalpel/suture flap surgery. In fact, LANAP can be included in the standard of care.⁵

Note that a particular laser wavelength 1,064 nm (Nd:YAG) was proven effective scientifically for LANAP. Laser physics does not allow for substitution of diode, erbium, or carbon dioxide lasers in this patented laser periodontal therapy.
The laser’s use in periodontal treatment allows for end results comparable to the best traditional and conventional therapies. Successful results in dentistry are possible using different methods. Laser periodontal surgery is just one of these.
The following case demonstrates the use of LANAP in comprehensive treatment of a new patient (Figures 2 to 4).

CASE REPORT
A 71-year-old male presented with nonlocalized pain in the mandibular left quadrant. Examination showed that a severe periodontal defect existed associated with tooth No. 19. A 5 mm periodontal probe reading on the DL of tooth No. 31 was also noted. All other periodontal probings in the mouth were 4 mm and below. A restorative evaluation showed missing teeth with associated tipping, rotation, super-eruption, failing restorations, and occlusal trauma. The patient’s medical history was noncontributory. He was taking Zocor and was also on a daily aspirin regimen.

Figure 5. Periodontal Chart (1/9/00).

A full-mouth radiographic series showed bone loss, periapical pathosis associated with tooth No. 21, and evidence of periodontal disease and occlusal disharmony. Probing depths (Figure 5) were as follows:
Tooth No. 21: MB 4, B 2, DB 3, ML 4, L 2, and DL 3.
Tooth No. 19: MB 4, B 4, DB 8, ML 3, L 3, and DL 8.
Electric pulp testing showed tooth No. 21 to be nonvital, and tooth No. 19 was vital.
The treatment objectives in this case were to restore periodontal health using laser, restorative, and occlusal therapies. Treatment would consist of endodontic therapy for tooth No. 21, followed by LANAP.
Root canal therapy was successfully performed on tooth No. 21. The treatment of the abscess associated with tooth No. 21 addressed the patient’s cause of pain. The dental literature and experience has shown that successful endodontic therapy would regenerate the supporting structures on tooth No. 21. Proper root canal therapy would remove the cause of the infection, the necrotic pulpal tissues, and infected dentin. Total canal obturation, the use of antibiotics, and time would allow for resolution of the periapical pathosis. Final expected results would be resolution of the infection and new formation of CTA and bone. The same healing results are not expected with removal of the infected tissues associated with periodontal disease in the same quadrant, on the same teeth. After nonlaser surgical removal of the diseased attachment, expected favorable results would be healing through long junctional epithelium, but no true re-generation of CTA and bone.6 A closed system is needed to prevent epithelial migration into the surgical area and allow healing with the formation of new cementum, CTA, and bone. LANAP gives the body that closed system with the ability to ablate the diseased epithelial lining7 and supply the body the building blocks for healing within a stable fibrin clot, allowing for regenerative healing in the absence of long junctional epithelium.

Figure 6. Probe showing 8 mm depth during LANAP.	Figure 7. Gingival healing at 3 weeks postoperatively.

LANAP was performed following the proper protocol. Core buildups were needed on teeth Nos. 19 and 21. Occlusal adjustment was performed at each subsequent treatment and maintenance appointment (Figure 6).
At the 3-week post-LANAP examination, the occlusion was adjusted and the teeth polished. In addition, laser bacterial decontamination of tooth No. 19 was performed (Figure 7).
In following visits, the maxillary teeth were restored with a 3 unit splinted cantilever bridge Nos. 11, 12, and 13 (pontic). Teeth Nos. 19 and 21 were prepared for full coverage individual porcelain-to-gold crowns utilizing laser tissue retraction and long-term temporization. Permanent res-torations were then fabricated and cemented. The patient was placed on a rigid 3-month periodontal maintenance schedule. No subgingival scaling or probing was done at the first 2 periodontal maintenance visits. Tooth No. 15 was planned for extraction, but was never treated (Figures 8 and 9).

Follow-Up Observations

The 9-month periodontal examination showed gingival healing had occurred, pocket depths had been reduced to 3 mm and under throughout the complete mouth, except 4 to 5 mm probing with no bleeding limited to the distal of No. 19 (Figures 10 and 11).

Figure 12. Periodontal chart (10/20/03).

Long-term results were monitored in visits over the next 6 years (Figure 12). Periodontal health has been maintained. Radiographic examination shows the resolution of the periapical pathosis (tooth No. 21), and changes in bone appearance/density in the furcation area and distal aspects of tooth No. 19 (Figures 13 to 15).

CONCLUSION
The use of an FRP Nd:YAG laser and LANAP therapy demonstrated a specific protocol and set of laser operating parameters to treat chronic periodontitis. Endodontic, surgical, and restorative results show that the pathology was removed, tissue healing was accomplished, and form and function were restored to the dentition and gingival tissues. Without any further treatment, health has been shown to continue over time.

References

1. Gregg RH, McCarthy DK. Laser ENAP for periodontal ligament regeneration. Dent Today. 1998;17:86-89.
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. Myers TD. Lasers in dentistry. J Am Dent Assoc. 1991;122:46-50.
4. Harris DM. Dosimetry for laser sulcular debridement. Lasers Surg Med. 2003;33:217-218.
5. Harris DM, Gregg RH II, McCarthy DK, et al. Laser-assisted new attachment procedure in private practice. Gen Dent. 2004;52:396-403.
6. Yukna RA, Bowers GM, Lawrence JJ, et al. A clinical study of healing in humans following the excisional new attachment procedure. J Periodontol. 1976;47:696-700.
7. Whitters CJ, Macfarlane TW, MacKenzie D, et al. The bactericidal activity of pulsed Nd: YAG laser radiation in vitro. Laser Med Sci. 1994;9(4):297-303.

Dr. Cranska has a full-time family practice in Severna Park, Md. He has Advanced Proficiency Laser Certification from the Academy of Laser Dentistry, and Standard Proficiency and Training Certification from the Institute for Advanced Laser Dentistry (IALD).

Disclosure: Dr. Cranska has no financial interest in any laser company. He is compensated as a clinical consultant, lecturing and training on behalf of IALD and Millennium Dental Technologies.