TREATING ADIABETIC PATIENTWITH PERIODONTALDISEASE USING THELANAP® PROTOCOLFebruary 1, 2016

By Craig A. Long, DDS

IntroductionThis report describes the advan-tage of the LANAP protocol with the PerioLase MVP-7 digitally pulsed Nd:YAG dental laser (1) in treating diabetic patients with Type IV periodontitis.

Diabetes mellitus (DM) a�ects an estimated 29.1 million of the US population, with 8.1 million of them undiagnosed. (2) Type 1 diabetes a�ects 5%–10% of the population, and is classified by the autoimmune destruction of beta cells in the pancreas. This leads to total loss of insulin secretion, and type 1 diabetics must take insulin to remain alive. Type 2 diabetes a�ects 85%–90% of the population who become insulin-resistant without destruction of pancreatic beta cells, and patients retain some capacity for insulin production. Their hyper-glycemia can gradually increase without symptoms. (3)

Diabetes and periodontitisLong-established evidence suggests diabetes predis-poses to periodontal disease, (4) and periodontal disease adversely a�ects diabetes outcomes. (5) A study by Chapple and associates (6) found consistent evidence that severe periodontitis adversely a�ects glycemic control in diabetic patients and causes glycemia in nondiabetic patients. The study concluded that diabetes and periodontitis are complex chronic diseases with established bidirectional relationships.

Nd:YAG laser in periodontal treatmentAemaimanan et al. (7) reported a significant prevalence of red complex bacteria in subgingival biofilm of patients with poor glycemic control. These pathogens associated with periodontitis were significantly higher in DM patients compared to control groups with good glycemic control. Recent studies have shown the bactericidal e�icacy of the Nd:YAG laser. De Andrade and colleagues (8) noted the Nd:YAG laser combined with conventional treatment significantly reduced bacteria in Class II furcations. McCawley and associates (9) reported immediate suppression of bacterial pathogens following LANAP treatment.

LANAP procedureThe LANAP surgical procedure for periodontal therapy has been shown to provide new bone growth and stability in patients with Type IV chronic periodontitis, reestablish new cementum-mediated periodontal ligament attachment, and induce periodontal regeneration. (10–12)

Case studyA 62-year-old male was referred due to gingival swell-ing and bleeding. The patient reported tender gums. He indicated he was a Type 2 diabetic with glycated hemoglobin (HbA1c) levels “out of control” at 11.7% (normal is 4.5%–6.0%). He was taking medications to control cholesterol, hypertension, and diabetes.

Dental examination revealed gingival swelling and bleeding on probing. Periodontal probing showed moderate-to-deep pocket depths in all posterior teeth (figures 1–3). Generalized bone loss was observed on radiographs (figures 4–6). Tooth vitality and percussion tests were negative. Teeth 2, 3, 31, 14, and 15 had Class III mobility. The patient was diagnosed with Type IV

chronic adult periodontitis. Treatment options were discussed, and, a�er explanation, the patient agreed to the LANAP procedure.

The LANAP protocol was performed in September 2014 with use of nitrous oxide analgesia and local anesthetic. A first laser pass was performed with the fiber inserted into the pocket and moved circum-ferentially around each tooth. The fiber was angled parallel to the root surface to remove long junctional epithelium and ablate bacteria. Tooth roots were then thoroughly scaled using a piezo-electric scaler with 0.12% chlorhexidine gluconate irrigation. The fiber was used for a second laser pass to obtain a hemostatic seal. Occlusal adjustment was performed to eliminate premature contacts and balancing interferences.

The patient tolerated the procedure well, and was prescribed medications for pain control and chlor-hexidine rinses twice daily. No oral antibiotics were prescribed. At the one-week postoperative checkup, the patient reported only mild discomfort following surgery. His tissues appeared less inflamed, and gingival swelling was greatly improved. Two weeks later, the patient was continuing to heal well, his gingival swelling was decreasing, and he reported no discomfort. An occlusal guard was fabricated to help alleviate bruxing trauma.

At the three-month periodontal maintenance appointment, the patient’s gingival color was pink with no sign of inflammation (figures 7–9).

The patient also reported his HbA1c level had dropped from 11.7 to 8.2. He reported feeling better generally and more energetic. He was then rescheduled for regular periodontal maintenance at three-month intervals.

At nine months, the patient’s tissues appeared pink with no inflammation. Radiographs revealed new bone growth, especially around teeth Nos. 3, 15, and 31 (figures 10–12). The patient reported his HbA1c level stable at 8.2.

Reprint with the permission of Dentistry IQ.

CASE STUDY

IntroductionThis report describes the advan-tage of the LANAP protocol with the PerioLase MVP-7 digitally pulsed Nd:YAG dental laser (1) in treating diabetic patients with Type IV periodontitis.

Diabetes mellitus (DM) a�ects an estimated 29.1 million of the US population, with 8.1 million of them undiagnosed. (2) Type 1 diabetes a�ects 5%–10% of the population, and is classified by the autoimmune destruction of beta cells in the pancreas. This leads to total loss of insulin secretion, and type 1 diabetics must take insulin to remain alive. Type 2 diabetes a�ects 85%–90% of the population who become insulin-resistant without destruction of pancreatic beta cells, and patients retain some capacity for insulin production. Their hyper-glycemia can gradually increase without symptoms. (3)

Diabetes and periodontitisLong-established evidence suggests diabetes predis-poses to periodontal disease, (4) and periodontal disease adversely a�ects diabetes outcomes. (5) A study by Chapple and associates (6) found consistent evidence that severe periodontitis adversely a�ects glycemic control in diabetic patients and causes glycemia in nondiabetic patients. The study concluded that diabetes and periodontitis are complex chronic diseases with established bidirectional relationships.

Nd:YAG laser in periodontal treatmentAemaimanan et al. (7) reported a significant prevalence of red complex bacteria in subgingival biofilm of patients with poor glycemic control. These pathogens associated with periodontitis were significantly higher in DM patients compared to control groups with good glycemic control. Recent studies have shown the bactericidal e�icacy of the Nd:YAG laser. De Andrade and colleagues (8) noted the Nd:YAG laser combined with conventional treatment significantly reduced bacteria in Class II furcations. McCawley and associates (9) reported immediate suppression of bacterial pathogens following LANAP treatment.

LANAP procedureThe LANAP surgical procedure for periodontal therapy has been shown to provide new bone growth and stability in patients with Type IV chronic periodontitis, reestablish new cementum-mediated periodontal ligament attachment, and induce periodontal regeneration. (10–12)

Case studyA 62-year-old male was referred due to gingival swell-ing and bleeding. The patient reported tender gums. He indicated he was a Type 2 diabetic with glycated hemoglobin (HbA1c) levels “out of control” at 11.7% (normal is 4.5%–6.0%). He was taking medications to control cholesterol, hypertension, and diabetes.

Dental examination revealed gingival swelling and bleeding on probing. Periodontal probing showed moderate-to-deep pocket depths in all posterior teeth (figures 1–3). Generalized bone loss was observed on radiographs (figures 4–6). Tooth vitality and percussion tests were negative. Teeth 2, 3, 31, 14, and 15 had Class III mobility. The patient was diagnosed with Type IV

chronic adult periodontitis. Treatment options were discussed, and, a�er explanation, the patient agreed to the LANAP procedure.

The LANAP protocol was performed in September 2014 with use of nitrous oxide analgesia and local anesthetic. A first laser pass was performed with the fiber inserted into the pocket and moved circum-ferentially around each tooth. The fiber was angled parallel to the root surface to remove long junctional epithelium and ablate bacteria. Tooth roots were then thoroughly scaled using a piezo-electric scaler with 0.12% chlorhexidine gluconate irrigation. The fiber was used for a second laser pass to obtain a hemostatic seal. Occlusal adjustment was performed to eliminate premature contacts and balancing interferences.

The patient tolerated the procedure well, and was prescribed medications for pain control and chlor-hexidine rinses twice daily. No oral antibiotics were prescribed. At the one-week postoperative checkup, the patient reported only mild discomfort following surgery. His tissues appeared less inflamed, and gingival swelling was greatly improved. Two weeks later, the patient was continuing to heal well, his gingival swelling was decreasing, and he reported no discomfort. An occlusal guard was fabricated to help alleviate bruxing trauma.

At the three-month periodontal maintenance appointment, the patient’s gingival color was pink with no sign of inflammation (figures 7–9).

The patient also reported his HbA1c level had dropped from 11.7 to 8.2. He reported feeling better generally and more energetic. He was then rescheduled for regular periodontal maintenance at three-month intervals.

At nine months, the patient’s tissues appeared pink with no inflammation. Radiographs revealed new bone growth, especially around teeth Nos. 3, 15, and 31 (figures 10–12). The patient reported his HbA1c level stable at 8.2.

IntroductionThis report describes the advan-tage of the LANAP protocol with the PerioLase MVP-7 digitally pulsed Nd:YAG dental laser (1) in treating diabetic patients with Type IV periodontitis.

Diabetes mellitus (DM) a�ects an estimated 29.1 million of the US population, with 8.1 million of them undiagnosed. (2) Type 1 diabetes a�ects 5%–10% of the population, and is classified by the autoimmune destruction of beta cells in the pancreas. This leads to total loss of insulin secretion, and type 1 diabetics must take insulin to remain alive. Type 2 diabetes a�ects 85%–90% of the population who become insulin-resistant without destruction of pancreatic beta cells, and patients retain some capacity for insulin production. Their hyper-glycemia can gradually increase without symptoms. (3)

Diabetes and periodontitisLong-established evidence suggests diabetes predis-poses to periodontal disease, (4) and periodontal disease adversely a�ects diabetes outcomes. (5) A study by Chapple and associates (6) found consistent evidence that severe periodontitis adversely a�ects glycemic control in diabetic patients and causes glycemia in nondiabetic patients. The study concluded that diabetes and periodontitis are complex chronic diseases with established bidirectional relationships.

Nd:YAG laser in periodontal treatmentAemaimanan et al. (7) reported a significant prevalence of red complex bacteria in subgingival biofilm of patients with poor glycemic control. These pathogens associated with periodontitis were significantly higher in DM patients compared to control groups with good glycemic control. Recent studies have shown the bactericidal e�icacy of the Nd:YAG laser. De Andrade and colleagues (8) noted the Nd:YAG laser combined with conventional treatment significantly reduced bacteria in Class II furcations. McCawley and associates (9) reported immediate suppression of bacterial pathogens following LANAP treatment.

LANAP procedureThe LANAP surgical procedure for periodontal therapy has been shown to provide new bone growth and stability in patients with Type IV chronic periodontitis, reestablish new cementum-mediated periodontal ligament attachment, and induce periodontal regeneration. (10–12)

Case studyA 62-year-old male was referred due to gingival swell-ing and bleeding. The patient reported tender gums. He indicated he was a Type 2 diabetic with glycated hemoglobin (HbA1c) levels “out of control” at 11.7% (normal is 4.5%–6.0%). He was taking medications to control cholesterol, hypertension, and diabetes.

Dental examination revealed gingival swelling and bleeding on probing. Periodontal probing showed moderate-to-deep pocket depths in all posterior teeth (figures 1–3). Generalized bone loss was observed on radiographs (figures 4–6). Tooth vitality and percussion tests were negative. Teeth 2, 3, 31, 14, and 15 had Class III mobility. The patient was diagnosed with Type IV

chronic adult periodontitis. Treatment options were discussed, and, a�er explanation, the patient agreed to the LANAP procedure.

The LANAP protocol was performed in September 2014 with use of nitrous oxide analgesia and local anesthetic. A first laser pass was performed with the fiber inserted into the pocket and moved circum-ferentially around each tooth. The fiber was angled parallel to the root surface to remove long junctional epithelium and ablate bacteria. Tooth roots were then thoroughly scaled using a piezo-electric scaler with 0.12% chlorhexidine gluconate irrigation. The fiber was used for a second laser pass to obtain a hemostatic seal. Occlusal adjustment was performed to eliminate premature contacts and balancing interferences.

The patient tolerated the procedure well, and was prescribed medications for pain control and chlor-hexidine rinses twice daily. No oral antibiotics were prescribed. At the one-week postoperative checkup, the patient reported only mild discomfort following surgery. His tissues appeared less inflamed, and gingival swelling was greatly improved. Two weeks later, the patient was continuing to heal well, his gingival swelling was decreasing, and he reported no discomfort. An occlusal guard was fabricated to help alleviate bruxing trauma.

At the three-month periodontal maintenance appointment, the patient’s gingival color was pink with no sign of inflammation (figures 7–9).

The patient also reported his HbA1c level had dropped from 11.7 to 8.2. He reported feeling better generally and more energetic. He was then rescheduled for regular periodontal maintenance at three-month intervals.

At nine months, the patient’s tissues appeared pink with no inflammation. Radiographs revealed new bone growth, especially around teeth Nos. 3, 15, and 31 (figures 10–12). The patient reported his HbA1c level stable at 8.2.

Patient presentation before LANAP treatment (figures 1–6)

Clinical presentation three months a�er LANAP treatment (figures 7–9)

Figure 1: Gingival bleeding and swelling at teeth Nos. 28–30.

Figure 2: Exudate, bleeding, and swelling at teeth Nos. 2–4.

Figure 3: Gingival bleeding and swelling at teeth Nos. 12 and 13.

Figure 7: No inflammation or bleeding was present at teeth Nos. 29–31.

Figure 8: Swelling and inflammation were absent at teeth Nos. 2 and 3, and mobility had improved from Class III to Class I.

Figure 9: No inflammation was present at teeth Nos. 12–14.

Figure 10: Bone regeneration apparent on distal aspect of tooth No. 3. Mobility had improved from Class III to Class I.

Figure 11: Teeth Nos. 29–31 with new bone growth visible on tooth No. 31. Mobility of tooth No. 31 had improved from Class III to Class I.

Figure 12: Teeth Nos. 12–14 with slight bone growth visible. Mobility on tooth No. 14 had improved from Class III to Class I. Tooth No. 15 had been extracted, as planned.

Figure 4: Generalized bone loss on teeth Nos. 2, 3, 4, 30, and 31.

Figure 5: Generalized bone loss on teeth Nos. 12 and 13.

Figure 6: Generalized bone loss at teeth Nos. 14, 15, and 19. As part of the treatment plan, tooth No. 15 was to be extracted due to lack of opposing occlusion and poor prognosis.

IntroductionThis report describes the advan-tage of the LANAP protocol with the PerioLase MVP-7 digitally pulsed Nd:YAG dental laser (1) in treating diabetic patients with Type IV periodontitis.

Diabetes mellitus (DM) a�ects an estimated 29.1 million of the US population, with 8.1 million of them undiagnosed. (2) Type 1 diabetes a�ects 5%–10% of the population, and is classified by the autoimmune destruction of beta cells in the pancreas. This leads to total loss of insulin secretion, and type 1 diabetics must take insulin to remain alive. Type 2 diabetes a�ects 85%–90% of the population who become insulin-resistant without destruction of pancreatic beta cells, and patients retain some capacity for insulin production. Their hyper-glycemia can gradually increase without symptoms. (3)

Diabetes and periodontitisLong-established evidence suggests diabetes predis-poses to periodontal disease, (4) and periodontal disease adversely a�ects diabetes outcomes. (5) A study by Chapple and associates (6) found consistent evidence that severe periodontitis adversely a�ects glycemic control in diabetic patients and causes glycemia in nondiabetic patients. The study concluded that diabetes and periodontitis are complex chronic diseases with established bidirectional relationships.

Nd:YAG laser in periodontal treatmentAemaimanan et al. (7) reported a significant prevalence of red complex bacteria in subgingival biofilm of patients with poor glycemic control. These pathogens associated with periodontitis were significantly higher in DM patients compared to control groups with good glycemic control. Recent studies have shown the bactericidal e�icacy of the Nd:YAG laser. De Andrade and colleagues (8) noted the Nd:YAG laser combined with conventional treatment significantly reduced bacteria in Class II furcations. McCawley and associates (9) reported immediate suppression of bacterial pathogens following LANAP treatment.

LANAP procedureThe LANAP surgical procedure for periodontal therapy has been shown to provide new bone growth and stability in patients with Type IV chronic periodontitis, reestablish new cementum-mediated periodontal ligament attachment, and induce periodontal regeneration. (10–12)

Case studyA 62-year-old male was referred due to gingival swell-ing and bleeding. The patient reported tender gums. He indicated he was a Type 2 diabetic with glycated hemoglobin (HbA1c) levels “out of control” at 11.7% (normal is 4.5%–6.0%). He was taking medications to control cholesterol, hypertension, and diabetes.

Dental examination revealed gingival swelling and bleeding on probing. Periodontal probing showed moderate-to-deep pocket depths in all posterior teeth (figures 1–3). Generalized bone loss was observed on radiographs (figures 4–6). Tooth vitality and percussion tests were negative. Teeth 2, 3, 31, 14, and 15 had Class III mobility. The patient was diagnosed with Type IV

chronic adult periodontitis. Treatment options were discussed, and, a�er explanation, the patient agreed to the LANAP procedure.

The LANAP protocol was performed in September 2014 with use of nitrous oxide analgesia and local anesthetic. A first laser pass was performed with the fiber inserted into the pocket and moved circum-ferentially around each tooth. The fiber was angled parallel to the root surface to remove long junctional epithelium and ablate bacteria. Tooth roots were then thoroughly scaled using a piezo-electric scaler with 0.12% chlorhexidine gluconate irrigation. The fiber was used for a second laser pass to obtain a hemostatic seal. Occlusal adjustment was performed to eliminate premature contacts and balancing interferences.

The patient tolerated the procedure well, and was prescribed medications for pain control and chlor-hexidine rinses twice daily. No oral antibiotics were prescribed. At the one-week postoperative checkup, the patient reported only mild discomfort following surgery. His tissues appeared less inflamed, and gingival swelling was greatly improved. Two weeks later, the patient was continuing to heal well, his gingival swelling was decreasing, and he reported no discomfort. An occlusal guard was fabricated to help alleviate bruxing trauma.

At the three-month periodontal maintenance appointment, the patient’s gingival color was pink with no sign of inflammation (figures 7–9).

The patient also reported his HbA1c level had dropped from 11.7 to 8.2. He reported feeling better generally and more energetic. He was then rescheduled for regular periodontal maintenance at three-month intervals.

At nine months, the patient’s tissues appeared pink with no inflammation. Radiographs revealed new bone growth, especially around teeth Nos. 3, 15, and 31 (figures 10–12). The patient reported his HbA1c level stable at 8.2.

About the AuthorCraig A. Long, DDS, received his degree in zoology and biochemistry from

the University of Missouri in 1975 and graduated from the University of

Missouri Kansas City School of Dentistry in 1979. He has been in private

general practice for more than 30 years and now practices in San Antonio,

Texas. Dr. Long is a certified instructor for the Institute of Advanced Laser

Dentistry, teaching the minimally invasive LANAP procedure since 2003.

He has lectured and taught laser dentistry in the United States and

abroad. He can be reached at txlaserdr@gmail.com.

ConclusionThis clinical case demonstrates the e�icacy of the LANAP protocol in treating adult periodontitis in a patient with diabetes mellitus. It also demonstrates the correlation of uncontrolled DM and its e�ect on chronic adult periodontitis. The patient’s HbA1c levels and periodontal health exhibited marked improvement a�er LANAP treatment.

References1. Millennium Dental Technologies, www.lanap.com, (888) 638-5262.2. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Division of Diabetes Translation. National Diabetes Statistics Report, 2014. http://ww-w.cdc.gov/diabetes/data/statistics/2014Statistics-Report.html. Accessed September 14, 2015.3. Mealey BL. Periodontal disease and diabetes. A two-way street. J Am Dent Assoc. 2006;137 Suppl:26S–31S.4. Kıran M, Arpak N, Ünsal E, Erdoğan MF. The e�ect of improved periodontal health on metabolic control in type 2 diabetes mellitus. J Clin Periodon-tol. 2005;32(3):266–272.5. Borgnakke WS, Ylöstalo PV, Taylor GW, Genco RJ. E�ect of periodontal disease on diabetes: Systemic review of epidemiologic observational evidence. J Periodontol. 2013;84(4 Suppl):S135–S152.6. Chapple ILC, Genco R. Working group 2 of the joint EFP/AAP workshop. Diabetes and periodontal diseases: Consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol. 2013;84(4 Suppl):S106–S112.

7. Aemaimanan P, Amimanan P, Taweechaisupapong S. Quantification of key periodontal pathogens in insulin-dependent type 2 diabetic and nondiabetic patients with generalized chronic periodontitis. Anaerobe. 2013;22:64–68.8. de Andrade AKP, Feist IS, Pannuti CM, Cai S, Zezell DM, De Micheli G. Nd:YAG laser clinical assisted in Class II furcation treatment. Lasers Med Sci. 2008;23(4):341–347.9. McCawley TK, McCawley MN, Rams TE. LANAP immediate e�ects in vivo on human chronic periodontitis microbiota. J Dent Res. 2014;93(Spec. Issue A):Abstract 428.10. Long CA. New attachment procedure: Using the pulsed Nd:YAG laser. Dent Today. 2008;27(2):166–171.11. Yukna RA, Carr RL, Evans GH. Histologic evaluation of an Nd:YAG laser-assisted new attachment proce-dure in humans. Int J Periodontics Restorative Dent. 2007;27(6):577–587.12. Nevins ML, Camelo M, Schupbach P, Kim S-W, Nevins M. Human clinical and histologic evidence of laser-assisted new attachment procedure. Int J Periodontics Restorative Dent. 2012;32(5):497–507.

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