Laser-assisted new attachment procedure
Encyclopedia
Laser-assisted new attachment procedure (the LANAP protocol) is a surgical therapy designed for the treatment of periodontitis through regeneration
rather than resection
. This therapy and the laser
used to perform it have been in use for more than a decade. Developed and refined in Cerritos, California
, since 1991 by Dr. Robert H. Gregg II (http://abcnews.go.com/Video/playerIndex?id=4797206) and Dr. Delwin McCarthy to achieve consistently effective and predictable outcomes. The U.S. Food and Drug Administration cleared the LANAP protocol for the treatment of periodontitis, or gum disease, in 2004.
In LANAP surgery, a variable free-running pulsed neodymium
:yttrium
-aluminum-garnet
(Nd:YAG at 1064 nm wavelength) dental laser is used by a trained and certified dentist
or periodontist to treat the periodontal pocket. The laser energy selectively removes diseased or infected pocket epithelium
from the underlying connective tissue
. The necrotic
epithelium is stripped from the connective tissue at the histologic level of the rete ridges. Since the laser energy is quite selective for diseased tissue, the underlying pleuropotential connective tissue is spared, thereby permitting healing and regeneration rather than formation of a pocket seal by long junctional epithelium.
In periodontics, the LANAP protocol is a process through which cementum
-mediated periodontal ligament
new attachment to the root surface in the absence of long junctional epithelium is achieved for the treatment of moderate to severe gum disease (including gingivitis
and periodontal disease). Stimulation of existing stem cell
s permits the formation of new root surface coating (cementum) and new connective tissue (periodontal ligament) formation (collagen) on tooth roots. The procedure’s success has challenged the old paradigm of periodontal healing in the absence of guided tissue regeneration barriers (GTR) or bone grafting
materials (allografts).
Early LANAP research showed consistent mean pocket depth reduction (50%) and improved bone density
(48%) in an 8-year retrospective study of the protocol’s earliest clinical results. The Emago imaging system demonstrated that 100% of these cases showed some amount of bone density increases. The procedure has also proven effective at reducing pocket depth without gingival recession over a 6-month period.
Raymond A. Yukna (University of Colorado
, formerly Louisiana State University
) has provided histologic, statistical and radiographic evidence to demonstrate LANAP’s efficacy in pocket depth reduction via cementum-mediated new attachment. His in vivo split-mouth study comparing scaling and root planing to LANAP employed radiographic and histologic evidence derived from teeth harvested from treated patients en bloc. LANAP-treated teeth demonstrated universally cementum-mediated new attachment. Teeth treated with scaling and root planing evidenced only long junctional epithelium as the body of scientific evidence shows.
After the LANAP procedure, most patients experience new root surface coating (cementum) and new connective tissues (periodontal ligament) formation (collagen
) on tooth roots, preventing tooth loss
. Pocket depth reduction is comparable to that achieved by conventional resective osseous or pocket reduction surgery, but without the gingival recession normally associated with osseous surgery. Significant post-operative reduction in gingival indices, gingival inflammation, and bleeding on probing are also common desirable results of the LANAP protocol.
Because the LANAP protocol spares more healthy tissue than scaling and root planning or osseous surgery, patients experience minimal post-operative pain, bleeding, swelling, gum recession or root sensitivity. These results reduce the future risk of root caries
/dental decay of the tooth root. Any discomfort is easily controlled through the use of non-steroidal anti-inflammatory drug
s (over-the-counter NSAIDs) such as ibuprofen
.
With regular three-month periodontal recall and maintenance, the LANAP-provided new attachment is stable and has proven resistant to future periodontal breakdown. Patients are encouraged to improve and maintain standards of oral hygiene
to prevent further active periodontitis.
Drs. Gregg and McCarthy pioneered the use of the Nd:YAG laser to treat gum disease in the 1990s. Their success at regenerating bone growth and stimulating new attachment in their toughest patients encouraged them to perform further research and fine-tune the protocol that incorporates use of the PerioLase MPV-7 laser (Millennium Dental Technologies, Inc.)
Studies continue to uncover some startling consequences for poor gum health, which makes the creation of a palatable treatment an important tool in American health care
. Widely reported studies have linked gum disease with heart disease
and stroke
. A recent case has now linked periodontitis with a full-term baby’s death. The mother’s untreated periodontitis is thought to have introduced deadly bacteria
into her womb.
Although about 80% of Americans suffer from gum disease, about 97% of those with moderate to severe periodontitis are not being treated. Acceptance of the LANAP technique in gum disease treatment, introduces an option that more patients are willing to accept.
There are those who debate LANAP’s results. The American Academy of Periodontology
(AAP) has yet to amend its August 1999 statement questioning the procedure, when it stated, “The Academy is not aware of any randomized blinded controlled longitudinal clinical trial
s, cohort or longitudinal studies, or case-controlled studies indicating that ‘laser excisional new attachment procedure (or Laser ENAP)’ or ‘laser curettage’ offers any advantageous clinical result not achieved by traditional periodontal therapy. Moreover, published studies suggest that use of lasers for ENAP procedures and/or gingival curettage could render root surfaces and adjacent alveolar bone incompatible with normal cell attachment and healing.”
At odds with AAP’s stance are subsequent peer-reviewed articles such as Yukna’s manuscript of human histology
on 12 teeth published in the International Journal of Periodontics and Restorative Dentistry in December 2007 and the Harris article in General Dentistry in November 2004 which used a different laser. And according to the U.S. Food and Drug Administration, ENAP is not LANAP (see k030290 reference below).
Competitive procedures have been introduced to the field, but none have yet provided the science to support their results or continued use.
How the LANAP Protocol Works:
First, the patient is given local anesthetic
. Next, the patient’s pocket depths are probed down to the level of intra-osseous defects (bone sounding). The thin optic fiber is placed parallel to the root surface. The first pass with the laser, called laser troughing, is accomplished with the short duration pulse. Perio pathogens and pathologic proteins are selectively destroyed by the laser’s light energy, providing a disinfected environment that allows healing following the laser hemostasis
step.
The technique uses selective photothermolysis to remove the diseased, infected and inflamed pocket epithelium while preserving healthy connective tissue, literally separating the tissue layers at the level of the reté ridges. The practitioner is able to achieve both precise removal of deceased tissue and hemostasis by varying the laser’s energy density, pulse duration and rate of repetition. The laser assists in the destruction of perio pathogens while preserving the healthy tissue. The PerioLase MVP-7 is specifically designed to support the LANAP protocol for the treatment of moderate to severe gum disease, as well as other new treatment protocols and soft and hard tissue applications.
The tenacity of the calcified plaque and calculus adherent to the root surface is modified by the laser energy so its removal with an ultrasonic scaler is more easily accomplished.
At this point, a second pass with the laser is taken to finish debriding the pocket and achieve hemostasis with a thermal fibrin clot. Gingival tissue is compressed against the root surface as necessary to close the pocket and aid with formation and stabilization of the fibrin clot. No sutures, surgical glue or collagen plugs are needed. Mobile teeth above class II mobility are splinted. Occlusal adjustments are performed to remove interferences, minimize trauma, and provide balance to long axis forces and are considered an essential component of the LANAP protocol.
Finally, post-operative instructions specific to the LANAP protocol, diet
guidelines and oral hygiene instructions are explained and their importance is stressed, and continued periodontal maintenance is scheduled. Patients are monitored at one week, 30 days and then every 3 months for periodontal maintenance. No subsequent probing is performed for at least nine months to a year to allow sufficient healing time for the cementum-fiber PDL interface.
Regeneration
-In biology:* Regeneration , the ability to recreate lost or damaged tissues, organs and limbs* Bush regeneration, an ecological technique practiced in Australia-In music:* Regeneration , a 1977 album by Roy Orbison...
rather than resection
Resection
Resection may refer to:*Segmental resection , the partial removal of an organ or other body structure*Resection , a means of establishing a location...
. This therapy and the laser
Laser
A laser is a device that emits light through a process of optical amplification based on the stimulated emission of photons. The term "laser" originated as an acronym for Light Amplification by Stimulated Emission of Radiation...
used to perform it have been in use for more than a decade. Developed and refined in Cerritos, California
Cerritos, California
Cerritos is a city in Los Angeles County, California, United States, and is one of several cities that constitute the Gateway Cities of southeast Los Angeles County. It was incorporated on April 24, 1956...
, since 1991 by Dr. Robert H. Gregg II (http://abcnews.go.com/Video/playerIndex?id=4797206) and Dr. Delwin McCarthy to achieve consistently effective and predictable outcomes. The U.S. Food and Drug Administration cleared the LANAP protocol for the treatment of periodontitis, or gum disease, in 2004.
In LANAP surgery, a variable free-running pulsed neodymium
Neodymium
Neodymium is a chemical element with the symbol Nd and atomic number 60. It is a soft silvery metal that tarnishes in air. Neodymium was discovered in 1885 by the Austrian chemist Carl Auer von Welsbach. It is present in significant quantities in the ore minerals monazite and bastnäsite...
:yttrium
Yttrium
Yttrium is a chemical element with symbol Y and atomic number 39. It is a silvery-metallic transition metal chemically similar to the lanthanides and it has often been classified as a "rare earth element". Yttrium is almost always found combined with the lanthanides in rare earth minerals and is...
-aluminum-garnet
Garnet
The garnet group includes a group of minerals that have been used since the Bronze Age as gemstones and abrasives. The name "garnet" may come from either the Middle English word gernet meaning 'dark red', or the Latin granatus , possibly a reference to the Punica granatum , a plant with red seeds...
(Nd:YAG at 1064 nm wavelength) dental laser is used by a trained and certified dentist
Dentist
A dentist, also known as a 'dental surgeon', is a doctor that specializes in the diagnosis, prevention, and treatment of diseases and conditions of the oral cavity. The dentist's supporting team aides in providing oral health services...
or periodontist to treat the periodontal pocket. The laser energy selectively removes diseased or infected pocket epithelium
Epithelium
Epithelium is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. Epithelial tissues line the cavities and surfaces of structures throughout the body, and also form many glands. Functions of epithelial cells include secretion, selective...
from the underlying connective tissue
Connective tissue
"Connective tissue" is a fibrous tissue. It is one of the four traditional classes of tissues . Connective Tissue is found throughout the body.In fact the whole framework of the skeleton and the different specialized connective tissues from the crown of the head to the toes determine the form of...
. The necrotic
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
epithelium is stripped from the connective tissue at the histologic level of the rete ridges. Since the laser energy is quite selective for diseased tissue, the underlying pleuropotential connective tissue is spared, thereby permitting healing and regeneration rather than formation of a pocket seal by long junctional epithelium.
In periodontics, the LANAP protocol is a process through which cementum
Cementum
Cementum is a specialized calcified substance covering the root of a tooth. Cementum is excreted by cells called cementoblasts within the root of the tooth and is thickest at the root apex. These cementoblasts develop from undifferentiated mesenchymal cells in the connective tissue of the dental...
-mediated periodontal ligament
Periodontal ligament
The periodontal fiber or periodontal ligament, commonly abbreviated as the PDL, is a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which it sits...
new attachment to the root surface in the absence of long junctional epithelium is achieved for the treatment of moderate to severe gum disease (including gingivitis
Gingivitis
Gingivitis is a term used to describe non-destructive periodontal disease. The most common form of gingivitis is in response to bacterial biofilms adherent to tooth surfaces, termed plaque-induced gingivitis, and is the most common form of periodontal disease...
and periodontal disease). Stimulation of existing stem cell
Stem cell
This article is about the cell type. For the medical therapy, see Stem Cell TreatmentsStem cells are biological cells found in all multicellular organisms, that can divide and differentiate into diverse specialized cell types and can self-renew to produce more stem cells...
s permits the formation of new root surface coating (cementum) and new connective tissue (periodontal ligament) formation (collagen) on tooth roots. The procedure’s success has challenged the old paradigm of periodontal healing in the absence of guided tissue regeneration barriers (GTR) or bone grafting
Bone grafting
Bone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly....
materials (allografts).
Early LANAP research showed consistent mean pocket depth reduction (50%) and improved bone density
Bone density
Bone density is a medical term normally referring to the amount of mineral matter per square centimeter of bones. Bone density is used in clinical medicine as an indirect indicator of osteoporosis and fracture risk.This medical bone density is not the true physical "density" of the bone, which...
(48%) in an 8-year retrospective study of the protocol’s earliest clinical results. The Emago imaging system demonstrated that 100% of these cases showed some amount of bone density increases. The procedure has also proven effective at reducing pocket depth without gingival recession over a 6-month period.
Raymond A. Yukna (University of Colorado
University of Colorado at Boulder
The University of Colorado Boulder is a public research university located in Boulder, Colorado...
, formerly Louisiana State University
Louisiana State University
Louisiana State University and Agricultural and Mechanical College, most often referred to as Louisiana State University, or LSU, is a public coeducational university located in Baton Rouge, Louisiana. The University was founded in 1853 in what is now known as Pineville, Louisiana, under the name...
) has provided histologic, statistical and radiographic evidence to demonstrate LANAP’s efficacy in pocket depth reduction via cementum-mediated new attachment. His in vivo split-mouth study comparing scaling and root planing to LANAP employed radiographic and histologic evidence derived from teeth harvested from treated patients en bloc. LANAP-treated teeth demonstrated universally cementum-mediated new attachment. Teeth treated with scaling and root planing evidenced only long junctional epithelium as the body of scientific evidence shows.
After the LANAP procedure, most patients experience new root surface coating (cementum) and new connective tissues (periodontal ligament) formation (collagen
Collagen
Collagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...
) on tooth roots, preventing tooth loss
Tooth loss
Tooth loss is when one or more teeth come loose and fall out. Tooth loss is normal for deciduous teeth , when they are replaced by a person's adult teeth. Otherwise, losing teeth is undesirable and is the result of injury or disease, such as mouth trauma, tooth injury, tooth decay, and gum disease...
. Pocket depth reduction is comparable to that achieved by conventional resective osseous or pocket reduction surgery, but without the gingival recession normally associated with osseous surgery. Significant post-operative reduction in gingival indices, gingival inflammation, and bleeding on probing are also common desirable results of the LANAP protocol.
Because the LANAP protocol spares more healthy tissue than scaling and root planning or osseous surgery, patients experience minimal post-operative pain, bleeding, swelling, gum recession or root sensitivity. These results reduce the future risk of root caries
Caries
Caries is a progressive destruction of any kind of bone structure, including the skull, ribs and other bones, or the teeth. Caries can be caused by osteomyelitis, which is a microorganism disease. A disease that involves caries is mastoiditis, an inflammation of the mastoid process, in which the...
/dental decay of the tooth root. Any discomfort is easily controlled through the use of non-steroidal anti-inflammatory drug
Non-steroidal anti-inflammatory drug
Nonsteroidal anti-inflammatory drugs, usually abbreviated to NSAIDs or NAIDs, but also referred to as nonsteroidal anti-inflammatory agents/analgesics or nonsteroidal Anti-inflammatory medicines , are drugs with analgesic and antipyretic effects and which have, in higher doses, anti-inflammatory...
s (over-the-counter NSAIDs) such as ibuprofen
Ibuprofen
Ibuprofen is a nonsteroidal anti-inflammatory drug used for relief of symptoms of arthritis, fever, as an analgesic , especially where there is an inflammatory component, and dysmenorrhea....
.
With regular three-month periodontal recall and maintenance, the LANAP-provided new attachment is stable and has proven resistant to future periodontal breakdown. Patients are encouraged to improve and maintain standards of oral hygiene
Oral hygiene
Teeth cleaning is part of oral hygiene and involves the removal of dental plaque from teeth with the intention of preventing cavities , gingivitis, and periodontal disease. People routinely clean their own teeth by brushing and interdental cleaning, and dental hygienists can remove hardened...
to prevent further active periodontitis.
Drs. Gregg and McCarthy pioneered the use of the Nd:YAG laser to treat gum disease in the 1990s. Their success at regenerating bone growth and stimulating new attachment in their toughest patients encouraged them to perform further research and fine-tune the protocol that incorporates use of the PerioLase MPV-7 laser (Millennium Dental Technologies, Inc.)
Studies continue to uncover some startling consequences for poor gum health, which makes the creation of a palatable treatment an important tool in American health care
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...
. Widely reported studies have linked gum disease with heart disease
Heart disease
Heart disease, cardiac disease or cardiopathy is an umbrella term for a variety of diseases affecting the heart. , it is the leading cause of death in the United States, England, Canada and Wales, accounting for 25.4% of the total deaths in the United States.-Types:-Coronary heart disease:Coronary...
and stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
. A recent case has now linked periodontitis with a full-term baby’s death. The mother’s untreated periodontitis is thought to have introduced deadly bacteria
Bacteria
Bacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...
into her womb.
Although about 80% of Americans suffer from gum disease, about 97% of those with moderate to severe periodontitis are not being treated. Acceptance of the LANAP technique in gum disease treatment, introduces an option that more patients are willing to accept.
There are those who debate LANAP’s results. The American Academy of Periodontology
American Academy of Periodontology
The American Academy of Periodontology is the non-profit membership association for periodontists -- dental professionals specializing in the prevention, diagnosis, and treatment of diseases affecting the gums and supporting structures of the teeth and in the placement and maintenance of dental...
(AAP) has yet to amend its August 1999 statement questioning the procedure, when it stated, “The Academy is not aware of any randomized blinded controlled longitudinal clinical trial
Clinical trial
Clinical trials are a set of procedures in medical research and drug development that are conducted to allow safety and efficacy data to be collected for health interventions...
s, cohort or longitudinal studies, or case-controlled studies indicating that ‘laser excisional new attachment procedure (or Laser ENAP)’ or ‘laser curettage’ offers any advantageous clinical result not achieved by traditional periodontal therapy. Moreover, published studies suggest that use of lasers for ENAP procedures and/or gingival curettage could render root surfaces and adjacent alveolar bone incompatible with normal cell attachment and healing.”
At odds with AAP’s stance are subsequent peer-reviewed articles such as Yukna’s manuscript of human histology
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
on 12 teeth published in the International Journal of Periodontics and Restorative Dentistry in December 2007 and the Harris article in General Dentistry in November 2004 which used a different laser. And according to the U.S. Food and Drug Administration, ENAP is not LANAP (see k030290 reference below).
Competitive procedures have been introduced to the field, but none have yet provided the science to support their results or continued use.
How the LANAP Protocol Works:
First, the patient is given local anesthetic
Local anesthetic
A local anesthetic is a drug that causes reversible local anesthesia, generally for the aim of having local analgesic effect, that is, inducing absence of pain sensation, although other local senses are often affected as well...
. Next, the patient’s pocket depths are probed down to the level of intra-osseous defects (bone sounding). The thin optic fiber is placed parallel to the root surface. The first pass with the laser, called laser troughing, is accomplished with the short duration pulse. Perio pathogens and pathologic proteins are selectively destroyed by the laser’s light energy, providing a disinfected environment that allows healing following the laser hemostasis
Hemostasis
Hemostasis or haemostasis is a process which causes bleeding to stop, meaning to keep blood within a damaged blood vessel . Most of the time this includes blood changing from a liquid to a solid state. Intact blood vessels are central to moderating blood's tendency to clot...
step.
The technique uses selective photothermolysis to remove the diseased, infected and inflamed pocket epithelium while preserving healthy connective tissue, literally separating the tissue layers at the level of the reté ridges. The practitioner is able to achieve both precise removal of deceased tissue and hemostasis by varying the laser’s energy density, pulse duration and rate of repetition. The laser assists in the destruction of perio pathogens while preserving the healthy tissue. The PerioLase MVP-7 is specifically designed to support the LANAP protocol for the treatment of moderate to severe gum disease, as well as other new treatment protocols and soft and hard tissue applications.
The tenacity of the calcified plaque and calculus adherent to the root surface is modified by the laser energy so its removal with an ultrasonic scaler is more easily accomplished.
At this point, a second pass with the laser is taken to finish debriding the pocket and achieve hemostasis with a thermal fibrin clot. Gingival tissue is compressed against the root surface as necessary to close the pocket and aid with formation and stabilization of the fibrin clot. No sutures, surgical glue or collagen plugs are needed. Mobile teeth above class II mobility are splinted. Occlusal adjustments are performed to remove interferences, minimize trauma, and provide balance to long axis forces and are considered an essential component of the LANAP protocol.
Finally, post-operative instructions specific to the LANAP protocol, diet
Diet (nutrition)
In nutrition, diet is the sum of food consumed by a person or other organism. Dietary habits are the habitual decisions an individual or culture makes when choosing what foods to eat. With the word diet, it is often implied the use of specific intake of nutrition for health or weight-management...
guidelines and oral hygiene instructions are explained and their importance is stressed, and continued periodontal maintenance is scheduled. Patients are monitored at one week, 30 days and then every 3 months for periodontal maintenance. No subsequent probing is performed for at least nine months to a year to allow sufficient healing time for the cementum-fiber PDL interface.