LIT REVIEW: Yukna's Nd:YAG LANAP Article

Let’s take a closer look at this often cited article, and see how effective the LANAP procedure really is: Yukna, Carr and Evans.  Histologic Evaluation of an Nd:YAG Laser-Assisted New Attachment Procedure in Humans.  Int J Periodontics Restorative Dent 2007 27: 576-587.

Materials and Methods

First and foremost, only 6 pairs of teeth were analyzed in this study – hardly a big sample size.

While not necessarily a major issue, it is worth noting that all experimental teeth received “occlusal adjustment and were splinted to neighboring teeth with an extracoronal bond”.  Why do I bring this up?  This is part of the LANAP protocol, but I highly doubt it is even being done in private practice.

Additionally, all teeth received an unspecified  “triple antibiotic ointment” and a “light cured dressing”.  Again, definitely not routine measures taken in private practice, and undoubtedly they play some role in the treatment outcome.  However, since all teeth received this treatment, a comparison of control vs. experiment is fair.

Discussion

Cementum mediated new attachment was evident on 4 lased teeth, but Yukna himself states that “similar periodontal healing in humans has been shown with other surgical techniques”.

How much new cementum was actually seen?  An average of 1.2mm.  Repeat, just 1.2mm.

By no means would I consider this a good result.  As Yukna clearly states in the beginning, “regeneration of the supporting tissues of the teeth is a primary goal of periodontal therapy”.  Numerous studies demonstrate superior results when regenerative materials, such as grafts, membranes, Emdogain or rhBMP are used.

How can any clinician justify lowering the bar for periodontal therapy?  How is this an advancement in patient care?

This study does clearly demonstrate “new attachment” and new cementum.  The fibrin clot in the lased pocket apparently acts as an effective barrier to epithelium advancement, thereby allowing periodontal healing to proceed favorably.  But it does not empower dentists to offer superior treatment to patients.

Closing Comments

One may ask, why not use regenerative products with a proven record, in combination with Nd:YAG therapy? Nd:YAG, being so efficient in hemorrhagic tissues, promotes a fibrin clot that prohibits the use of regenerative material simply because there is no space to place the materials.  The patient is robbed of the ability for an even better regenerative outcome.

The Case for Erbium Lasers in Periodontal Therapy

Erbium lasers (Er:YAG or YSGG) offer the same apparent periodontal benefits as the Nd:YAG: bactericidal effect and ablation of inflamed and diseased pocket epithelium.  Additionally, a space is maintained in the pocket, allowing the concomitant use of regenerative products to further enhance the healing.  De-epithelialization can then be performed with an Erbium or CO2 laser to inhibit epithelium downgrowth and prevent the formation of a long junctional epithelium.  De-epithelialization can be done at post-op visits for as long as needed to help achieve the desired results.

Doesn’t that make more sense, fellow Laser Dentists?

The Nd:YAG and LANAP seem great in mild or moderate cases, but where intrabony defects are involved or where a higher level of regenerative predictability is desired, comprehensive laser periodontal therapy with an Erbium laser is the way to go.  More Lit Reviews to follow.

Comments?  Thoughts?

3 Comments

  1. When GoreTex membranes came out in the late 80’s, we were all excited about new attachment. When the barrier was removed, the red tissue would eventually develop into a minimal amount of bone and another 1 to 2 mm of new attachment. The barrier stayed in place for 6 weeks. Now we have laser new attachment techniques that essentially create a barrier that last for about 2 weeks with Nd:Yag or erbium lasers. That 2 week time frame is adequate for new attachment in shallow and narrow intrabony defects. If the defect is narrow enough we will see some new bone develop also. Occaisionally, we will see incredible bone fill and new attachment in a few patients – but that is not the norm.
    In reality, we do not want just new attahment. We want regeration of all of the tissues that were lost. So laser new attachment in mild to moderate perio is great, but if large bony defects are present or teeth are going to be used as abutments for crown and bridge, I also augment the laser procedure with growth factors. When Schallhorn (spelling?) use graft under membranes for the first time, the perio community followed suite because we all wanted more predictable bone regeneration. We should learn from the past.

  2. Materials and Methods

    First and foremost, only 6 pairs of teeth were analyzed in this study – hardly a big sample size.

    Reply: Please cite a larger sample size in humans that recieved IRB approval in the USA. The Yukna study is the 4th largest prospective, human histology, with a control group in the perio literature….

    While not necessarily a major issue, it is worth noting that all experimental teeth received “occlusal adjustment and were splinted to neighboring teeth with an extracoronal bond”. Why do I bring this up? This is part of the LANAP protocol, but I highly doubt it is even being done in private practice.

    Reply: I cannot address your “doubt”, but clinicians that follow the LANAP protocol do exactly this, an the evidence from our doctors that return radiographs to us is that they are doing this, as I do….

    Additionally, all teeth received an unspecified “triple antibiotic ointment” and a “light cured dressing”. Again, definitely not routine measures taken in private practice, and undoubtedly they play some role in the treatment outcome. However, since all teeth received this treatment, a comparison of control vs. experiment is fair.

    Reply: Since the stable fibrin clot from the LANAP protocol seals the wound site, I do not believe this had any effect, as the results of our 1000 plus clincians (300 peridontists) indicate.

    Discussion

    Cementum mediated new attachment was evident on 4 lased teeth, but Yukna himself states that “similar periodontal healing in humans has been shown with other surgical techniques”.

    Reply: I am sitting in a lecture with Prof Yukna (2-20-2010) as I write this. He has stated that these result are “unique” in the peridontal literature, as 100% or 6 out of 6, had cementum mediated new attachment. 4 of 6 had regeneration of cementum, PDL and alveolar bone in and coronal to the experiemental reference notch placed in calculus.

    How much new cementum was actually seen? An average of 1.2mm. Repeat, just 1.2mm.
    By no means would I consider this a good result.

    Reply: Then I respectfully point you to the largest HH study on regeneration in the perio literature–the Bowers Human New Attachment Study using DFDBA. This is the justificaion study for bone grafting. The length of new cementum in the Bowers study that removed teeth en bloc at 9 months vs 3 months in the Yukna LANAP study was??? 1.2mm By no means??

    Yukna clearly states in the beginning, “regeneration of the supporting tissues of the teeth is a primary goal of periodontal therapy”. Numerous studies demonstrate superior results when regenerative materials, such as grafts, membranes, Emdogain or rhBMP are used.

    How can any clinician justify lowering the bar for periodontal therapy? How is this an advancement in patient care?

    Reply: You are not fully informed, nor have your correctly represented Prof Yukna’s considerations and conclusion regarding LANAP and all of the other materials he has researched.

    This study does clearly demonstrate “new attachment” and new cementum. The fibrin clot in the lased pocket apparently acts as an effective barrier to epithelium advancement, thereby allowing periodontal healing to proceed favorably. But it does not empower dentists to offer superior treatment to patients.

    Reply: Not true.

    Closing Comments

    One may ask, why not use regenerative products with a proven record, in combination with Nd:YAG therapy?

    Reply: Because they are foreign bodies and cause exaggerated inflammatory responses that inhibit maximum regeneration.

    Nd:YAG, being so efficient in hemorrhagic tissues, promotes a fibrin clot that prohibits the use of regenerative material simply because there is no space to place the materials.

    Reply: Not true.

    The patient is robbed of the ability for an even better regenerative outcome.

    Reply: Not true.

    The Case for Erbium Lasers in Periodontal Therapy

    Erbium lasers (Er:YAG or YSGG) offer the same apparent periodontal benefits as the Nd:YAG: bactericidal effect and ablation of inflamed and diseased pocket epithelium.

    Reply: This is not at all accurate in terms of physics and laser tissue interations. Nd:YAG is a “deep penetrating” wavelength and the erbiums are superficial absorbers. Erbium do NOT have a kill depth of perio pathogens into Socranksi’s “priviledged sites”.

    Additionally, a space is maintained in the pocket, allowing the concomitant use of regenerative products to further enhance the healing.

    Reply: There is absolutely no scientific evidence or human histological evidence to support this opinion.

    De-epithelialization can then be performed with an Erbium or CO2 laser to inhibit epithelium downgrowth and prevent the formation of a long junctional epithelium.

    Reply: This is difficult with these wavelengths. I have used them in that fashion and it is not reproducible.

    De-epithelialization can be done at post-op visits for as long as needed to help achieve the desired results.

    Reply: LANAP creates a “closed system” that eliminates the requirement to have the patient back for additional procedural irradiations.

    Doesn’t that make more sense, fellow Laser Dentists?

    Reply: Not at all……

    The Nd:YAG and LANAP seem great in mild or moderate cases, but where intrabony defects are involved or where a higher level of regenerative predictability is desired, comprehensive laser periodontal therapy with an Erbium laser is the way to go.

    Reply: I completely disagree, and I have used all wavlengths in the past 20 years ever introduced in to the dental market–and a few that never came to market.

    Comments? Thoughts?

    Reply: Thank you.

    1. Dr. Gregg,

      Thank you for your comments. Please find my responses below:

      1.

      Dr.G: Please cite a larger sample size in humans that received IRB approval in the USA. The Yukna study is the 4th largest prospective, human histology, with a control group in the perio literature….

      I don’t believe that this study’s ranking compared to others is of any real significance. 6 pairs of teeth is a small sample size, no matter how you slice and dice it. How do we know that the true results, over a large population segment, is not much better (or worse)?

      2.

      Dr. G: I am sitting in a lecture with Prof Yukna (2-20-2010) as I write this. He has stated that these result are “unique” in the periodontal literature, as 100% or 6 out of 6, had cementum mediated new attachment. 4 of 6 had regeneration of cementum, PDL and alveolar bone in and coronal to the experimental reference notch placed in calculus.

      Yes, the results are real. But the sample size is small. There are plenty of case reports in the literature that document outstanding results, but that does not mean that the results can be duplicated on a larger scale. I would have liked to see many more teeth analyzed histologically to validate the results even further. I do understand that it is a difficult task.

      Periodontists who use the Nd:YAG, that myself and my colleagues have had discussions with, cite excellent results in shallow defects (4-6mm) or deep narrow defects, but results in large defects seem better with traditional GTR.

      However, nobody can argue that the patient experience is better, and the acceptance of treatment is higher. From that standpoint, laser therapy is a win-win for everybody.

      3.

      Dr. G: Then I respectfully point you to the largest HH study on regeneration in the perio literature–the Bowers Human New Attachment Study using DFDBA. This is the justificaion study for bone grafting. The length of new cementum in the Bowers study that removed teeth en bloc at 9 months vs 3 months in the Yukna LANAP study was??? 1.2mm By no means??

      The Bowers study is 20 years old. We should not strive for 1989 clinical outcomes. The current literature is well represented with superior results using Emdogain, PDGF and other newer regenerative materials. One of the principal investigators of that study is a colleague of mine at the NYU College of Dentistry, and he does not even refer to his own research because it is outdated. If those results are acceptable to you, then by all means, go ahead and provide the treatment that works best for you.

      4.

      Dr. G: You are not fully informed, nor have your correctly represented Prof Yukna’s considerations and conclusion regarding LANAP and all of the other materials he has researched.

      I do not mean to undermine Dr. Yukna’s views and I apologize if it came across that way. I am trying to critique this article, which is the basis for LANAP, not his other research.

      5.

      Dr. S: This study does clearly demonstrate “new attachment” and new cementum. The fibrin clot in the lased pocket apparently acts as an effective barrier to epithelium advancement, thereby allowing periodontal healing to proceed favorably. But it does not empower dentists to offer superior treatment to patients.

      Dr. G Reply: Not true.

      Please explain. I stand by my view that a patient with deep periodontal defects may not be receiving the best periodontal care with LANAP alone.

      6.

      Dr. S: One may ask, why not use regenerative products with a proven record, in combination with Nd:YAG therapy?

      Dr. G Reply: Because they are foreign bodies and cause exaggerated inflammatory responses that inhibit maximum regeneration.

      I don’t even know how to respond to this statement. Please provide some evidence that Emdogain, human PDGF, collagen barriers and grafting materials cause an exaggerated response that inhibit regeneration. The entire periodontal, oral-maxillofacial, craniofacial and orthopedic community would like some clarification.

      7.

      Dr. S: Nd:YAG, being so efficient in hemorrhagic tissues, promotes a fibrin clot that prohibits the use of regenerative material simply because there is no space to place the materials.

      Dr. G Reply: Not true.

      Please provide an explanation so we can better understand why you believe this to not be true.

      8.

      Dr. G: This is not at all accurate in terms of physics and laser tissue interations. Nd:YAG is a “deep penetrating” wavelength and the erbiums are superficial absorbers. Erbium do NOT have a kill depth of perio pathogens into Socranksi’s “priviledged sites”.

      The most difficult periodontal pathogens to eradicate are those found in plaque and biofilm. Many laser wavelengths, ultrasonics, etc. disrupt the biofilm effectively. The deep laser penetration into the soft tissue should not have any impact on wound healing, as those bacteria that have begun to invade the adjacent soft tissue are easily killed by systemic antibiotics anyway, which are routinely given post-periodontal treatment as well as in the LANAP protocol.

      9.

      Dr. S: Additionally, a space is maintained in the pocket, allowing the concomitant use of regenerative products to further enhance the healing.

      Dr. G Reply: There is absolutely no scientific evidence or human histological evidence to support this opinion.

      Maybe you misunderstood me. Successful periodontal regenerative therapy depends upon the space created in the pocket from debridement of diseased tissue and removal of biofilm. The space is augmented with the regenerative material of choice, and the space is maintained with a barrier as needed. There is plenty of scientific evidence for this (just do a Google search for perio regeneration and there are countless references). Where you referring to something else?

      10.

      Dr. S: De-epithelialization can then be performed with an Erbium or CO2 laser to inhibit epithelium downgrowth and prevent the formation of a long junctional epithelium.

      Dr. G Reply: This is difficult with these wavelengths. I have used them in that fashion and it is not reproducible.

      In my experience, I haven’t noticed any problems. I do it regularly with success.

      11.

      Dr. G Reply: LANAP creates a “closed system” that eliminates the requirement to have the patient back for additional procedural irradiations.

      Re: Closed system – The idea of a using a fibrin clot for space maintenance in a periodontal defect is nothing new. The clots dissolve within 2 weeks, and a long junctional epithelium will still eventually form. In shallow or narrow defects, that 2 weeks time may be enough to allow some true regeneration, as shown in this study. The “closed system” lasts about 2 weeks.

      With the LANAP protocol, patients still have extra procedures done (occlusal equilibration, splinting of teeth, dressings). That seems like more chair time than a quick post-op de-epithelialization procedure without the need for anesthetic.

      12.

      Dr. G Reply: I completely disagree, and I have used all wavelengths in the past 20 years ever introduced in to the dental market–and a few that never came to market.

      Dr. Gregg, with you being one of the founders of Millenium, I think it would be difficult to provide a completely unbiased view, understandably so.

      Thank you again for participating, and I look forward to further discussion. Mark S.

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