A patient’s chief concern is to be taken seriously if we consider ourselves caring professionals.¹ Too often, we as practitioners consider diving into treatment without first addressing the reason why the patient has sought care from us in the first place.² Sometimes, this is due to treatment phasing and ensuring that treatment is completed in the proper order.³ Therefore, it is fortunate for all involved when a patient’s chief concern aligns with treatment that can be completed at his or her initial appointment. This case report demonstrates how a patient with an embarrassing condition sought help after avoiding treatment for several years and was rewarded with immediate relief.

CASE REPORT

A 32-year-old female patient presented for a comprehensive examination. Her chief concern was, “I’m embarrassed. I can’t talk very well because something is pushing under my tongue, and it’s uncomfortable.” The patient spoke with noticeable lisping. The radiographic examination, via panoramic radiograph, revealed a radiopaque mass superimposed over mandibular teeth Nos. 20 to 29. The mass measured 2 cm in height with a 6.2-cm radius (Figure 1).

Figure 1. Panoramic radiograph showing a radiopaque mass in the mandibular anterior area.

During further conversation with the patient, generalized plaque and tartar were noted on the labial surfaces of the maxillary and mandibular anterior teeth and gingiva, with pronounced calculus accumulation on the cemento-enamel junction areas of teeth Nos. 24 and 25 (Figure 2).

Figure 2. Calculus observed on the labial surfaces of the mandibular anterior teeth.

The initial clinical examination revealed an extensive red-brown mass that filled the sublingual space and extended from teeth Nos. 20 to 29 (Figure 3).

Figure 3. Extensive calculus mass in the sublingual area.

When the patient was asked about oral home care, she revealed that she hadn’t brushed her teeth or flossed “in many years.” At this time, a definitive diagnosis of sublingual calculus mass was made, and this was determined to be the cause of her speech concerns and discomfort.

Dental calculus is a mineralized mass of bacterial plaque that is most commonly seen on the surfaces of natural teeth in areas where saliva empties into the oral cavity via salivary ducts.⁴ It harbors a living, bacteria-rich biofilm, which can infect the adjacent periodontium.^5,6 Due to its proximity to sublingual salivary ducts, the most common location to find dental calculus is on the lingual surfaces of the mandibular anterior teeth.^7,8 Therefore, the mass noted on this patient wasn’t unusual due to its location but instead for its substantial size.

Treatment was performed by removing the calculus mass and debriding other supragingival calculus present. The largest section of the mass measured 3.8 × 2.0 cm (Figure 4), and other fragments were removed that adhered to the lingual and facial surfaces of teeth Nos. 20 to 29 (Figure 5).

Figure 4. Calculus mass measuring 3.8 × 2.0 cm.

Figure 5. Calculus mass and fragments.

Figure 6. Sublingual space, free of calculus mass.

Figure 7. Red and inflamed tissue following removal of calculus.

The underlying soft tissue was red and inflamed. Following the debridement, the patient reported that her tongue immediately felt freer, with increased movement (Figures 6 and 7).

The patient was able to communicate more clearly and intelligibly following treatment. She was emotional as she expressed her gratitude that she would be able to speak more confidently after years of communication deficits due to her condition.

The patient also received comprehensive oral hygiene instruction. This included an explanation of the cause of the condition the patient was experiencing,⁹ as well as modeling of proper brushing and flossing, with the patient performing what she had learned. A treatment plan was developed to address the patient’s periodontal disease by following up with full-mouth scaling and root planing, then recare.

Follow-up treatment proved to be difficult due to appointment failures. The next appointment was 5 months following the debridement. The patient reported that she was not brushing and flossing daily. The clinical evaluation revealed mandibular lingual plaque and calculus present (Figure 8), but the soft tissue had fully healed with the exception of the areas adjacent to the teeth, where calculus was present.

Figure 8. Calculus and plaque observed on the lingual surfaces of the mandibular anterior teeth.

The patient shared at this appointment that she was pleased with the results from her initial treatment, but she didn’t want to return for continued care. Although an extensive treatment plan remained, it was determined at this time that the calculus mass removal procedure successfully resolved the patient’s chief concern.

CONCLUSION

This case report briefly illustrates how an uncomplicated dental procedure can greatly impact a patient’s comfort and quality of life. It also highlights the importance of consistent home care and its role in the prevention of unwanted oral conditions. Unfortunately, patient education and treatment are restrained when patients refuse further care. As professionals, we must recognize that patients must ultimately advocate for their own health.

REFERENCES

1. Walji MF, Karimbux NY, Spielman AI. Person-centered care: opportunities and challenges for academic dental institutions and programs. J Dent Educ. 2017;81(11):1265–72. doi:10.21815/JDE.017.084 

2. Richards PS, Inglehart MR. An interdisciplinary approach to case-based teaching: does it create patient-centered and culturally sensitive providers? J Dent Educ. 2006;70(3):284–91. https://pubmed.ncbi.nlm.nih.gov/16522757/

3. Ali Z, Ashley M, West C. Factors to consider when treatment planning for patients seeking comprehensive aesthetic dental treatment. Dent Update. 2013;40(7):526–8, 531–3. doi:10.12968/denu.2013.40.7.526

4. Balaji VR, Niazi TM, Dhanasekaran M. An unusual presentation of dental calculus. J Indian Soc Periodontol. 2019;23(5):484–6. doi:10.4103/jisp.jisp_680_18 

5. White DJ. Dental calculus: recent insights into occurrence, formation, prevention, removal and oral health effects of supragingival and subgingival deposits. Eur J Oral Sci. 1997;105(5 Pt 2):508–22. doi:10.1111/j.1600-0722.1997.tb00238.x 

6. Akcalı A, Lang NP. Dental calculus: the calcified biofilm and its role in disease development. Periodontol 2000. 2018;76(1):109–15. doi:10.1111/prd.12151

7. Aghanashini S, Puvvalla B, Mundinamane DB, et al. A comprehensive review on dental calculus. J Health Sci Res. 2016;7(2):42-50.

8. Lieverse AR. Diet and the aetiology of dental calculus. Int J Osteoarchaeol. 1999;9(4): 219–32.

9. Fons-Badal C, Fons-Font A, Labaig-Rueda C, et al. Analysis of predisposing factors for rapid dental calculus formation. J Clin Med. 2020;9(3):858. doi:10.3390/jcm9030858 

ABOUT THE AUTHOR

Dr. Eaton is an assistant clinical professor at the Midwestern University College of Dental Medicine in Phoenix. He can be reached at jeaton@midwestern.edu. 

Disclosure: Dr. Eaton reports no disclosures.   

For patients who present with Stage IV advanced periodontitis, comprehensive management of their dental conditions can be challenging because the goal of therapy is not only to address their periodontal condition and help patients return to health but to also address the aesthetic and functional rehabilitation of their condition and long-term maintenance to ensure continued health. Patients with Stage IV periodontitis are at significant risk of edentulism if they are not treated or receive inadequate care. Therefore, careful planning, efficient therapy, and continued supportive care throughout and after therapy are essential to helping these patients keep their teeth. This article looks at a multi-specialty approach to the management of a patient with advanced (Stage IV) periodontitis. 

In 2017, the World Workshop on Periodontal and Peri-implant Diseases and Conditions defined periodontitis based on stage and grade. While “stage” describes the severity, complexity, extent, and distribution of disease, “grade” defines the disease’s biologic features, including the rate of progression, rate of potential poor outcome, and impact of periodontal disease treatment on the patient’s systemic health.^1,2 While “grade” involves 3 categories based on evidence of progression as slow, moderate, and rapid progression (Stage A to C) with risk factors as grade modifiers, “stage” categorizes periodontitis based on severity and complexity into Stage I to Stage IV. ¹

Stage III and Stage IV describe advanced periodontitis. Patients in both categories are categorized by interdental attachment loss of 5 mm or more, with radiographic evidence of bone loss that extends to mid-root and beyond.^1,2 Complexity for Stage III and Stage IV periodontitis patients involves more than 6 mm of probing depth, vertical bone loss of 3 mm or more, and furcation involvement that is type II or type III. For Stage III patients, it also involves tooth loss involving 4 or more teeth and a moderate ridge defect, while for Stage IV patients, it involves tooth loss involving 5 or more teeth and a severe ridge defect.^1,2 Additionally, Stage IV periodontitis patients require complex rehabilitation due to masticatory dysfunction, secondary occlusal trauma with tooth mobility of 2 or more degrees, severe ridge defect bite collapse, flaring of teeth, and less than 20 remaining teeth (<10 pairs) in both arches.^1,2   

 The need for complex rehabilitation sets Stage IV patients apart from Stage III patients, and the management of Stage IV patients is significantly more complicated. Early diagnosis is essential, and having a treatment plan that is started immediately rather than delayed is important to preventing further loss of teeth and complications with rehabilitation to restore aesthetics and function.^3,4 Stage IV periodontitis patients have a higher risk of periodontal disease-related tooth loss compared to Stage I patients in studies involving a follow-up period of 10 to 30 years (hazard ratio of 3.73), as well as a higher risk for pathologic tooth migration and other functional consequences.³

Recommendations for Management of Advanced (Stage IV) Periodontitis Patients

In 2022, the European Federation on Periodontology (EFP) developed S3-level clinical practice guidelines implementing an interdisciplinary approach to rehabilitate Stage IV periodontitis patients due to the fact that failure to treat or inadequate treatment of these patients can result in additional loss of periodontal tissue, further tooth loss, and the potential for complete edentulism.³ The goal of their guidelines is to summarize evidence-based recommendations for individual intervention involving a multi-disciplinary approach to Stage IV periodontitis.³

Based on their recommendations, assessment of Stage IV periodontitis patients comprises 5 critical dimensions³:

1. Evaluation of the amount of periodontal breakdown, patient function, and aesthetics; completing the periodontal exam, charting, and appropriate x-rays; and functional and aesthetic assessment checking for hypermobility, tooth vitality, secondary occlusal trauma, stable posterior stops, fremitus, subjective/objective assessment of chewing function, aesthetics, and phonetics.
2. Assessment of the number of teeth lost due to periodontal disease using a history of probable cause of tooth loss.
3. The prognosis of individual teeth. Establishing tooth prognosis for Stage IV periodontitis patients is important, especially when differentiating between teeth with questionable vs hopeless prognoses.
4. Restorative factors, such as the extent of edentulous spaces, distribution, and restorability of retained teeth, including the technical complexity of planned prostheses and interventions that require dental implants based on adequate ridge dimensions.
5. The prognosis of overall care, meaning the overall case prognosis has to be established using individual susceptibility of the patient via primary grade criteria, which also includes the probability of disease recurrence or progression.

In categorizing patients who have Stage IV periodontitis, 4 major phenotypes were identified:

• Case type 1. Patients with tooth hypermobility due to secondary occlusal trauma that can be corrected without tooth replacement. 
• Case type 2. Patients with pathological tooth migration characterized by tooth elongation, drifting, and flaring, which is amenable to orthodontic correction.
• Case type 3. Partially edentulous patients who can be prosthetically restored without full-arch rehabilitation.
• Case type 4. Partially edentulous patients with a dentition who need full-arch rehabilitation using either a tooth- or an implant-supported or -retained prosthesis.

For Stage IV periodontitis patients, the “no-treatment” option is highly discouraged due to the potential for complete edentulism.³ In recommending therapy for Stage IV patients, Herrera et al³ advised the use of recommendations made by the EFP for treating Stage I to III patients and added modifications for Stage IV patients. Sanz et al⁵ recommended the following steps for treating Stage I to Stage III patients:

• Step 1. Guiding behavioral change to have patients undertake successful supragingival plaque control. The goal is to build motivation and adherence, find ways to circumvent barriers, and develop skills for dental plaque removal.
• Step 2. Controlling, reducing, and eliminating bacterial biofilm and calculus involving subgingival instrumentation with or without adjunctive physical and chemical agents, local/systemic host modulation, adjunctive subgingival local delivered antimicrobial agents, or adjunctive use of systemic antimicrobials.
• Step 3. Therapy to address pockets that are more than 4 mm deep and bleeding and/or the presence of deep pockets (≥6 mm) with the goal of gaining further access for debridement, regeneration, and resection of lesions that add complexity to the management of periodontitis, such as intrabony and furcation defects. The goal is to meet the endpoints of therapy prior to starting supportive maintenance, although it might not be completely accomplished for Stage III patients.
• Step 4. Supportive therapy. The goal of therapy is aimed at maintaining periodontal stability in all treatment patients using steps 1 and 2.

In 2014, Trombelli et al⁶ looked at the impact of professional plaque removal performed during supportive therapy and found that the extent of patient adherence to professional mechanical plaque removal significantly impacted tooth mortality, with patients who attended regular maintenance visits showing tooth loss of 0.6 teeth vs 1.8 for those who did not over a 5-year period. Seirafi et al⁷ found that in private practice in Iran, bleeding on probing (BOP) was associated with increased tooth loss, and erratic-compliant patients had more BOP than regular-compliant patients. Campos et al⁸ concluded from a meta-analysis of multiple studies that there was a 26% increase in tooth loss for noncompliant patients vs patients compliant with supportive periodontal therapy. Kim et al⁹ found increased tooth loss (26% and 30%, respectively) with noncompliant and erratic-compliant patients compared to completely compliant supportive-maintenance patients (4%) in the Korean population. Hirata et al¹⁰ found that patients with prior loss of 8 or more teeth were more likely to have further tooth loss during supportive maintenance.

Based on these and other findings, the recommendation for treating Stage IV periodontitis patients is supportive therapy before, during, and after active therapy to improve oral hygiene and patient motivation.³ In addition to the recommendations for Stage I to Stage III periodontitis patients (steps 1 to 4), Herrera et al³ added these guidelines for the clinical management of Stage IV patients:

1. Temporary control of secondary occlusal trauma (extracoronal splinting, relief of fremitus by limited occlusal adjustment)
2. Orthodontic therapy (usually for flared teeth and other pathologic tooth migrations)
3. Rehabilitation of one or multiple tooth-delimited edentulous spaces
4. Rehabilitation of unilateral/bilateral posterior free edentulous sites
5. Tooth-supported, full-arch, fixed prostheses
6. Tooth-supported, full-arch, removable dental prostheses
7. Implant-supported, full-arch, fixed dental prostheses
8. Implant-supported, removable prostheses.

Recommendations for Treating Advanced (Stage IV) Periodontitis Patients 

In management of different categories of Stage IV periodontitis patients, the treatment pathways include the following³:

• Case type I. Patient with hypermobility due to secondary occlusal trauma without requiring teeth replacement. Therapy involves temporary teeth splinting or initial limited occlusal adjustment. The need for longer-term splinting occurs only after steps 1 and 2 of periodontal therapy are completed.
• Case type 2. Pathologic tooth migration causing tooth elongation, drifting, or flaring. Therapy is orthodontic therapy planned during step 2 and, in some cases, step 3. The actual orthodontic therapy is recommended to start after shallow maintainable pockets are attained and inflammation is controlled during the supportive-maintenance phase.
• Case type 3. Partially edentulous patients who can be prosthetically restored without full-arch rehabilitation. The timing of intermediate restoration is planned carefully based on the individual or the case in keeping with the patient’s wishes and aesthetic considerations. Interim restorations are usually utilized after step 2 or 3, depending on the situation. Definitive restorations or implants are usually performed during step 4 after successful completion of step 3.
• Case type 4. Partially edentulous patients who need to be restored by full-arch rehabilitation, either tooth- or implant-supported, with either fixed or removable prostheses. For these patients, the interim prosthesis occurs after the completion of step 1. Step 2 is performed with the interim prosthesis in place. Definitive restoration occurs after stage 3 with successful completion of periodontal therapy and control of periodontal inflammation.

CASE REPORT 

A healthy, 54-year-old African American female presented as a patient with Stage IV periodontitis, case type 4. The patient was very concerned about the health of her gums, aesthetics, function, and phonation with her anterior teeth (Figures 1 and 2). Following completion of steps 1 and 2, interim restorations were completed for the patient involving a temporary bridge from tooth No. 5 to 12. Following step 3, extraction of teeth Nos. 6 to 11 was performed, with implants replacing teeth Nos. 6 to 9 (4.0-mm × 12-mm BioHorizon implants) and No. 10 (a 4-mm × 10.5-mm BioHorizon implant). Figures 3 to 8 show surgical management. Figures 9 to 11 show restorative rehabilitation of her dentition. The patient was very motivated with oral hygiene and maintenance visits, and 4 years later, she presented to see us and was able to save all of her remaining teeth. 

Figures 1 and 2. Initial patient presentation.

Figures 3 to 8. Surgical pictures.

Figures 9 to 11. Four-year postoperative pictures showing restorative rehabilitation.

CONCLUSION

A high level of complexity is involved in the treatment of patients with Stage IV advanced periodontitis to ensure that they can be able to achieve periodontal health as well as be able to maintain function and aesthetics. The ability for these patients to remain motivated and compliant with their care is also essential to their being able to retain their dentition long-term. Recommendations made by Herrera et al³ include that the patients must be informed in detail about their periodontal condition, including their treatment options and risks. They also discourage early extraction of questionable teeth that might be able to respond to therapy and recommend completing steps 1 to 3 of periodontal therapy, ensuring completion of periodontal therapy prior to orthodontics, long-term tooth splinting, tooth-supported fixed and removable prostheses, and implant-supported fixed and removable prostheses.^3,5 In planning restorations for patients with Stage IV periodontitis, it is important that restorations be designed to achieve function and aesthetics using a multi-disciplinary approach. It is also essential that patients are highly motivated with their oral hygiene and supportive maintenance.

REFERENCES

1. Papapanou PN, Sanz M, Buduneli N, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S173–82. doi:10.1002/JPER.17-0721 

2. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Periodontol. 2018;89(Suppl 1):S159–72. doi:10.1002/JPER.18-0006. Erratum in: J Periodontol. 2018;89(12):1475. 

3. Herrera D, Sanz M, Kebschull M, et al; EFP Workshop Participants and Methodological Consultant. Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline. J Clin Periodontol. 2022;49(Suppl 24):4-71. doi:10.1111/jcpe.13639

4. Rasaeipour S, Siadat H, Rasouli A, et al. Implant rehabilitation in advanced generalized aggressive periodontitis: a case report and literature review. J Dent (Tehran). 2015;12(8):614–20.

5. Sanz M, Herrera D, Kebschull M, et al; EFP Workshop Participants and Methodological Consultants. Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47(Suppl 22):4-60. doi:10.1111/jcpe.13290. Erratum in: J Clin Periodontol. 2021;48(1):163.

6. Trombelli L, Franceschetti G, Farina R. Effect of professional mechanical plaque removal performed on a long-term, routine basis in the secondary prevention of periodontitis: a systematic review. J Clin Periodontol. 2015;42(Suppl 16):S221–36. doi:10.1111/jcpe.12339 

7. Seirafi AH, Ebrahimi R, Golkari A, et al. Tooth loss assessment during periodontal maintenance in erratic versus complete compliance in a periodontal private practice in Shiraz, Iran: a 10-year retrospective study. J Int Acad Periodontol. 2014;16(2):43-9. Erratum in: J Int Acad Periodontol. 2014;16(3):77.  

8. Campos ISO, de Freitas MR, Costa FO, et al. The effects of patient compliance in supportive periodontal therapy on tooth loss: A systematic review and meta-analysis. J Int Acad Periodontol. 2021;23(1):17-30. 

9. Kim SY, Lee JK, Chang BS, et al. Effect of supportive periodontal therapy on the prevention of tooth loss in Korean adults. J Periodontal Implant Sci. 2014;44(2):65-70. doi:10.5051/jpis.2014.44.2.65 

10. Hirata T, Fuchida S, Yamamoto T, et al. Predictive factors for tooth loss during supportive periodontal therapy in patients with severe periodontitis: a Japanese multicenter study. BMC Oral Health. 2019;19(1):19. doi:10.1186/s12903-019-0712-x 

ABOUT THE AUTHORS

Dr. Soolari received his DMD degree in 1990 from the University of Mississippi School of Dentistry where he received multiple awards. He received his specialty training in periodontics from Eastman Dental Center and his MS degree from the University of Rochester in New York. He has been a Diplomate of the American Academy of Periodontology since 1997. Dr. Soolari was a consultant with National Naval Medical Center Postgraduate Periodontics in Bethesda, Md, and a former clinical associate professor at the University of Maryland. He is in private practice at Soolari Dentistry in Silver Spring, Md. He can be reached at asoolari@gmail.com.

Dr. Obiechina completed her training in periodontics and implant dentistry at Columbia University in 2001. She received her DMD degree from the University of Pittsburgh in 1998. She is the recipient of the Melvin Morris Award for clinical excellence in periodontics from Columbia University as well as the Northeast Regional Board Student Award for excellence in periodontics. She has given multiple seminars for dentists on periodontics and implant dentistry and has published works, including books on dental implant therapy and periodontics for dentists as well as articles for multiple peer-reviewed journals. She remains involved in active private practice at Shady Grove Smiles in Gaithersburg, Md, in addition to being an educator. She can be reached at drobiechina@yahoo.com. 

Disclosure: The authors report no disclosures. 

The literature suggests that patients who suffer from periodontal disease will also have a higher risk of complications with their implants^4-6 and are at increased risk of peri-implant disease and eventual implant loss.⁷ Studies have shown that the implant takes on the bacteria present in the patient’s mouth; bacterial biofilm is a major concern and a risk factor for development of implant complications.⁵ If the patient has gum disease, the tissue surrounding the implant will also contain pathogens for periodontal disease.⁶ Furthermore, patients with a history of implant failure, as measured by implant removal, are 1.3 times more likely to have a second implant,8 and the greater the number of implants within one subject, the greater likelihood the subject will experience MBL greater than 3 mm.⁹

For these reasons, it is these authors’ opinion that placing implants before the periodontium is stable and healthy does patients a disservice and contributes to the failure of the implants. Moreover, achieving the proper health requires a definitive treatment modality for periodontal oral health. Probing depths must be less than 5.0 mm whenever possible and with no bleeding on probing. Patients should have excellent oral hygiene; stable occlusion; and, after implant placement, an occlusal guard. Also, patients should participate in frequent periodontal maintenance at regular 12-week intervals as management of periodontal disease is ongoing.¹⁰

Figure 1a. Preoperative radiograph, showing probing depths of 6, 6, 7 | 6, 6, 6, around site No. 8 and 6, 5, 6 | 6, 6, 6 around site No. 9.	Figure 1b. Three-year postoperative radiograph showing bone fill. Probing depths were 3 circumferentially for both Nos. 8 and 9.

After treating the oral health of the patient and placing the implant, if complications occur, both peri-implant mucositis and peri-implantitis should be identified and treated early to give the patient the best possible outcome.¹¹ Both require aggressive treatment protocols because the areas around implants experience more rapid bone loss than do teeth. Also, evidence suggests that peri-implant mucositis is reversible if caught early.^12,13

Existing literature and clinical experience point to the need for a reliable and predictable way to treat failing implants as there is no standard protocol for treating peri-implant disease.¹³ The 4 treatments for failing dental implants are mechanical debridement, pharmacological therapy, surgical procedures, and laser therapy.¹³

The following 2 mini case reports describe the successful treatment of peri-implantitis using laser-assisted regeneration (LAR) with the LAPIP protocol (Millennium Dental Technologies). In both cases, the peri-implantitis was due to periodontitis throughout much of the dentition.

Treatment Protocol
The LAPIP protocol is a multistep protocol that includes the following:

• Probing under local anesthesia to determine the full depth of bony defects
• Using a variable-pulsed 1,064-nm Nd:YAG laser (PerioLase MVP-7 Nd:YAG laser [Millennium Dental Technologies]), as the energy selectively vaporizes bacteria and endotoxins and denatures pathological proteins, ablates diseased epithelial lining and granulomatous tissue, and reduces bacteria (pocket depth, combined with tissue type, determines total energy used)
• Using an ultrasonic scaler (MiniMaster [EMS]) to remove calculus and cement, when present, from the implant surface
• Modifying bone and initiating bleeding
• Using laser energy in hemostasis mode to create a stable fibrin clot containing growth factors from the bone, acting as a natural membrane
• Approximating coronal soft tissue against the implant to achieve adhesion
• Adjusting and monitoring occlusal trauma throughout the healing process

CASE REPORTS
Case 1
A 69-year-old female presented with peri-implantitis surrounding implants placed in the No. 8 and 9 central incisors 18 months previously. In addition, she had 2 draining fistulas on the buccal of each implant, as well as circumferential bone loss around the fixtures. Probing depths around tooth No. 8 measured 6, 6, 7 from DF to MF and 6, 6, 6 from DL to ML; probing depths on tooth No. 9 measured 6, 5, 6 and 6, 6, 6. Bleeding on probing and purulence were noted. The patient had thyroid deficiency and hypercholesterolemia but no other significant medical conditions. Early periodontitis was present in the second molars on the maxilla (Figures 1 to 3).

Figure 2a. Pre-op photo.	Figure 2b. Three-month post-op view showing reduction in tissue inflammation while maintaining the gingival margin.
Figure 3a. One-week post-op view of the subepithelial connective tissue grafts (SCTGs).	Figure 3b. Six-week post-op view of the SCTGs. The SCTGs were done to increase attachment and close fistulas.
Figure 4a. Pre-op radiograph, showing probing depths of 8, 8, 8 | 8, 7, 7 around site No. 29 and over 10 circumferentially around site No. 30.	Figure 4b. One-year post-op radiograph showing bone regeneration, with probing depths of 3 circumferentially around site No. 29 and 4, 4, 5 | 4, 5, 5 around site No. 30.

Treatment Protocol and Results
LAR via the LAPIP protocol was performed using the PerioLase MVP-7 Nd:YAG laser, per the patient’s choice. Three months later, we performed subepithelial connective tissue grafts underneath the existing tissues to close the fistulas and increase the zone of keratinized tissue. After both procedures, the patient was prescribed a combination of acetaminophen and ibuprofen as an analgesic/anti-inflammatory and amoxicillin as an antibiotic. No prescription opioids were necessary. An occlusal adjustment was performed as per the protocol. Healing was uneventful; at the 6-month postoperative visit, the same laser was used again around fenestrations for disinfection. Radiographs were taken at 3 years post-LAPIP treatment. Probing depths were 3 circumferentially for both teeth Nos. 8 and 9, with no bleeding on probing or purulence.

Case 2
A 70-year-old male presented with 2 implants exhibiting signs of peri-implantitis: a compromised implant in site No. 29 and a non-integrated implant in site No. 30. His medical history included heart disease and hypertension; he was currently prescribed and taking rivaroxaban (Xarelto). He also had a history of periodontal disease in the mandible/molar with moderate-to-severe bone loss. Bleeding on probing and purulence were noted. Probing depths around implant No. 29 were 8, 8, 8 | 8, 7, 7 and implant No. 30 was over 10 circumferentially (Figure 4).

Implant No. 30 would be deemed hopeless in the eyes of most clinicians. Despite 40% bone loss on the lingual and 50% bone loss on the facial, the principles of LAR indicate that if the circumferential defect is present, there is still the potential to regenerate bone to the lid of the osseous defect. If traditional surgery and GTR were treatment planned, it would be highly difficult to predictably detoxify the implant in a hemorrhagic site.

Treatment Protocol and Results
The patient was presented with options and chose LAR via LAPIP treatment. No other regenerative materials or biologics were used during the procedure. Periodontal disease in adjacent areas was also treated with the full-mouth LANAP protocol (Millennium Dental Technologies). The patient was prescribed amoxicillin. An occlusal adjustment was performed. One-year post-op probing depths around tooth No. 29 were 3, 3, 3 | 3, 3, 3 and 4, 4, 5 | 4, 5, 5 around tooth No. 30. The patient was thrilled that the implant was re-integrated.

DISCUSSION
These 2 mini case reports demonstrate how LAR via the LAPIP protocol can resolve inflammation as well as restore some of the bone lost due to infection. These cases reflect typical results in our office, where more than 1,000 cases have been treated. Based on our experience, the LAPIP protocol is the standard of care utilized in our office for regenerative procedures around implants. As mentioned before, however, current literature does not endorse any one treatment strategy over another as the best practice for the treatment of peri-implantitis.¹³ However, it does recommend a re-examination of how much bone loss is acceptable in the long-term survival of a given implant.³

Ending bone loss is essential to the long-term survival of an implant; regeneration of lost bone is ideal. When more bony walls are available at the site, they provide more blood supply to promote bone regeneration regardless of which treatment option for a failing implant is chosen. The most predictable regeneration occurs in a circumferential defect.

Eradicating inflammation from peri-implant disease and improving soft-tissue health is the first step for preventing the loss of bone around the implant. Some research suggests that neither ultrasonic nor mechanical debridement were efficacious for reducing pocket-probing depths in patients suffering from peri-implantitis in their failing implants.¹⁴ Furthermore, while pharmacological efforts led to lower levels of bacteria in the short term, they only produced a statistically significant reduction in the proportions of bacteria present immediately after therapy.¹⁵ Let us then compare the latter 2 treatment options, guided tissue regeneration (GTR) vs LAR, using a specific treatment method, the LAPIP protocol.

In our experience, GTR is unpredictable and often results in soft- and hard-tissue loss. In the presence of a large defect, GTR surgery necessitates extensive flap reflection and removal of diseased tissue and bone. It is impossible to know if all the affected tissue has been removed, and it is very difficult to detoxify the diseased implant surface using chemical or mechanical cleaning. Additionally, GTR requires a stable blood clot to provide regeneration, relying on a membrane to exclude epithelial downgrowth and a recurrence of the pocket. Often this type of surgical approach results in soft-tissue recession or additional attachment loss, which affects patient satisfaction. Furthermore, bone regeneration around implants is often unpredictable with this method.

LAPIP treatment can eradicate infection and facilitate bone regrowth; research has indicated that all examined cases of the failing implants treated with the LAPIP protocol have reintegrated in the pocket and stabilized with bone growth of 3 to 8 threads upon radiographic examination.¹⁶ With the LAPIP protocol, the laser detoxifies the implant immediately. Then the laser biostimulation encourages the regenerative cells. The stable blood flow helps regenerate the lost bone. LAPIP also has an advantage over GTR as it does not necessitate a foreign membrane. With LAPIP, the blood clot is filled with regenerative cells and is sticky and stable, making it difficult to dislodge and creating a natural barrier. LAPIP provides biostimulation to the bone, and that biostimulation activates regenerative cells needed to regrow the hard tissue that was previously lost to infection. Also, because no reflection of a vertically oriented flap is needed, the patient retains the integrity of the structural tissue, allowing for all other future treatment options, if needed. Moreover, the LAPIP protocol maintains soft-tissue height, which sustains aesthetics and improves patient satisfaction with the outcome. The patients in our practice also report significantly less post-op discomfort with the LAPIP protocol compared to GTR, without the need for prescription opioids.

CLOSING COMMENTS
With limited success in mechanical debridement and pharmacological treatments, the 2 remaining treatments for implant failure are GTR and LAR. LAR using the LAPIP protocol and the PerioLase MVP-7 over traditional GTR can yield more predictable results with failing implants resulting from peri-implantitis; allow for definitive eradication of bacteria; maintain soft-tissue height; retain the integrity of structural tissue for any future treatment, if needed; and sustain aesthetics to improve patient satisfaction with the outcome.

References

1. Brånemark P-I, Svensson B, van Steenberghe D. Ten-year survival rates of fixed prostheses on four or six implants ad modum Brånemark in full edentulism. Clin Oral Implants Res. 1995;6:227-231.
2. Albrektsson T, Zarb G, Worthington P, et al. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants. 1986;1:11-25.
3. Schwartz-Arad D, Herzberg R, Levin L. Evaluation of long-term implant success. J Periodontol. 2005;76:1623-1628.
4. Lindhe J, Meyle J; Group D of European Workshop on Periodontology. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol. 2008;35(suppl 8):282-285.
5. Armellini D, Reynolds MA, Harro JM, et al. Biofilm formation on natural teeth and dental implants: What is the difference? In: Shirtliff M, Leid JG, eds. The Role of Biofilms in Device-Related Infections. Berlin, Germany: Springer; 2009:109-122.
6. Mombelli A. Microbiology and antimicrobial therapy of peri-implantitis. Periodontol 2000. 2002;28:177-189.
7. Valente NA, Andreana S. Peri-implant disease: what we know and what we need to know. J Periodontal Implant Sci. 2016;46:136-151.
8. Weyant RJ, Burt BA. An assessment of survival rates and within-patient clustering of failures for endosseous oral implants. J Dent Res. 1993;72:2-8.
9. Fransson C, Lekholm U, Jemt T, et al. Prevalence of subjects with progressive bone loss at implants. Clin Oral Implants Res. 2005;16:440-446.
10. Nagelberg RH. It’s all about perio maintenance. Dent Econ. 2010;100:44.
11. Levin L. Dealing with dental implant failures. J Appl Oral Sci. 2008;16:171-175.
12. Mombelli A, Lang NP. Clinical parameters for the evaluation of dental implants. Periodontol 2000. 1994;4:81-86.
13. Murray CM, Knight ET, Russell AA, et al. Peri-implant disease: current understanding and future direction. N Z Dent J. 2013;109:55-62.
14. Karring ES, Stavropoulos A, Ellegaard B, et al. Treatment of peri-implantitis by the Vector system. A pilot study. Clin Oral Implants Res. 2005;16:288-293.
15. Mombelli A, Lang NP. Antimicrobial treatment of peri-implant infections. Clin Oral Implants Res. 1992;3:162-168.
16. 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: Society of Photo-Optical Instrumentation Engineers; 2014:89290H.

Dr. Saltz attended Case Western Reserve University’s advanced 6-year dental program before attending the University of Kentucky postdoctoral program in periodontics and dental implants. He specializes in periodontics, microsurgery, laser and implant dentistry, and oral medicine, with an emphasis on comprehensive full-mouth oral rehabilitation. Dr. Saltz has lectured nationally on topics such as osseous grafts, crown lengthening and root reshaping, soft-tissue plastic surgery, aesthetic enhancement, sinus and ridge augmentation, dental implants, and CT scans and 3-D imaging. He can be reached at docjsaltz@yahoo.com.

Dr. Wilson attended Tufts University School of Dental Medicine, where she was a recipient of the US Army Health Professional’s Scholarship Program and served for 4 years in the US Army as a general dentist. Dr. Wilson attended the periodontal residency program at the University of Colorado School of Dental Medicine, where she was awarded the Robert G. Schallhorn Award for Periodontal Excellence. She can be reached at kdwilson76@gmail.com.

Disclosure: The authors report no disclosures.

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INTRODUCTION
In this article, we present a single case report involving a lower right molar that includes a clinical and serial radiographic laser-assisted regeneration (LANAP protocol) result over a 13-year time frame.

Key Points Regarding the LANAP Protocol
In the LANAP protocol, no exogenous materials, such as growth factors, bone grafting, and biologics, are used. The true periodontal regeneration achieved in the LANAP protocol is accomplished by using the patient’s own blood proteins that contain stem cells, native growth factors, and blood constituents. The blood is thermally affected in the LANAP protocol in such a manner that the regenerative factors are trapped within a red thrombus that is formed using scientifically determined algorithms of optimal laser operating parameters.

In the LANAP protocol, there is a lack of any wide surgical access outside of the bony housing, a lack of deep dissection into the vestibule or across the palate, and a lack of extensive vertical releasing incisions. The LANAP protocol uses a minimally invasive periodontal flap to enable access under the periosteum and directly to bone for an ostectomy and/or osteotomy. The soft tissues are thereby easily approximated and stabilized without the need to suture with tension to adapt the margins of the flaps together.

Background
Periodontitis is an infectious disease that progressively destroys the alveolar bone, periodontal ligament (PDL), and root cementum that attach the teeth to the bone. Destruction of this attachment apparatus results in the loss of teeth. The ultimate aim of periodontal regeneration techniques is to induce or guide healing to regenerate the morphology back to its original configuration. In order to evaluate a regeneration technique experimentally, a notch is made on the root surface at the bottom of a periodontal pocket to provide a histological landmark for the apical extent of the destruction.¹

Periodontal regeneration on a previously diseased tooth root surface is a unique, challenging, and elusive healing event to obtain in humans.^FN-1 True periodontal regeneration requires the 3 original components of the periodontal apparatus to arise anew and eventually form into new cementum, a new periodontal ligament, and new alveolar bone.^FN-2

Figure 1. The LANAP protocol: The step-by-step surgical technique is outlined here. (a) Periodontal probing indicates excessive pocket depth. (b) Laser Troughing: Free-runningFN-1 pulsed Nd:YAG laser irradiation is done at short pulse duration or longer, as warranted. Troughing provides visualization of, and access to, the root surface by removing necrotic debris, releasing tension of circumferential periodontal fibers, and controlling hemorrhages. It further defines tissue margins preceding ultrasonic and mechanical instrumentation, preserves the integrity of the mucosa, and aids maintenance of the gingival crest. This technique provides the selective removal of diseased, infected, inflamed, ulcerated pocket epithelium, preserving connective fibrous tissues and rete ridges.21,22 (c) A piezo-electric scaler with specialized tips is used to remove root surface accretions. (d) Bone modification by osteoplasty and/or ostectomy is performed, and angiogenesis is promoted. (e) A second pass with the laser at 150 to 650 µsec pulse duration finishes debriding the pocket; provides hemostasis; and creates a “soft clot,” or red thrombus, resulting in a “closed” biologic thermogenic wound (fibrin clot) from the deep bony defect to the gingival collar. (f) The tissue is adapted against the root surface to create a thin-film clot and stabilize the fibronectin. (g) Occlusal trauma is eliminated with a high-speed handpiece, and mobile teeth are splinted. (h) True periodontal regeneration occurs.

Kao et al² is the most recent in a long series of literature and systematic reviews of published methods to achieve periodontal regeneration.^3-12 Current approaches include demineralized freeze-dried bone allografts (DFDBAs), guided tissue regeneration (GTR), bone fill with enamel matrix derivatives (EMDs), recombinant human platelet-derived growth factor BB (rhPDGF-BB), and open flap debridement (OFD). Kao et al² have included a new category of regenerative approaches termed laser-assisted regeneration (LAR), which is identified specifically as the Millennium Dental Technologies LANAP protocol using the PerioLase pulsed Nd:YAG Dental Laser System.^FN-3 Based on the review of 2 peer-reviewed studies of human histology following LANAP treatment,^13,14 Kao et al² conclude, “Using the Nd:YAG laser with this [LANAP] procedure, periodontal regeneration is achievable on a previously diseased root surface.”

Data from the first human histology study post-LANAP protocol by Yukna, Carr, and Evans13 in 2007 was submitted to the FDA in 2003. Healing at 3 months clearly showed new attachment and evidence of regeneration. Subsequently, the FDA granted marketing clearance (510(k) No. K030290) on July 26, 2004, for the claim “Laser assisted new attachment procedure (cementum-mediated periodontal ligament new-attachment to the root surface in the absence of long junctional epithelium).” The second, more recent study by Nevins et al¹⁴ looked at healing 9 months following LANAP treatment. They concluded, “This report provides evidence that LANAP therapy can induce periodontal regeneration.”¹⁴ This data from the human histology study by Nevins et al¹⁴ was submitted to the FDA, which granted marketing clearance (510(k) No. K151763) on March 15, 2016, specifically for the PerioLase pulsed Nd:YAG Dental Laser System for the clinical outcome claim:

Figure 2. A patient treatment chart shows laser parameters and dosimetries.

Periodontal regeneration—true regeneration of the attachment apparatus (new cementum, new periodontal ligament, and new alveolar bone) on a previously diseased root surface when used specifically in the LANAP protocol.

In 4 previously published articles in Dentistry Today, the authors presented 10 radiographic case study examples of bone and periodontal ligament (PDL) regeneration around severely compromised, periodontally involved teeth.^15-18 It was argued by some skeptics that while those clinical examples are individually impressive, they are isolated and atypical examples of success and not likely to be repeatable. However, in a recent Dentistry Today CE article,¹⁹ we reviewed 2 human histology investigations by 2 different groups of investigators (Yukna, Carr, and Evans¹³ and Nevins et al¹⁴). This review combines the histologic findings from those investigations and offers an explanation as to why the case studies had successful outcomes. In this article, we present a single case report to add to the accumulating body of evidence that shows stability over a span of 13 years.

The LANAP protocol is a laser-based periodontal regenerative procedure invented by the lead author and developed specifically for the treatment of moderate-to-advanced periodontitis. It was patterned, conceptually, after the excisional new attachment procedure (ENAP)²⁰ to separate the epithelium from the underlying connective tissue dermis and to selectively vaporize and disrupt diseased, infected, inflamed, and necrotic tissue from the connective tissue.^21,22 Lasers are not used as replacements for the scalpel. Scalpels cannot approach the kind of differential selectivity needed to separate thin, discrete tissue types.

The LANAP protocol, which retains the original 26 sequential steps, was initially referred to as Laser-ENAP,^15,16 then laser periodontal therapy (LPT) due to FDA insistence over possible confusion with scalpel ENAP. The human histology study performed by Yukna, Evans, et al²³ in 2003 was the basis for the novel FDA 510(k) clearance for the laser-assisted new attachment procedure in 2004.

The LANAP protocol is, by definition, a one-time full-mouth treatment protocol as a complete replacement alternative to osseous resective periodontal surgery and/or scaling and root planing. The LANAP protocol is completed in a one-half mouth treatment of 2 quadrants, followed up with a second one-half mouth treatment of the other 2 quadrants after a few days, but no more than one week apart. The patient has antibiotic coverage between the separate treatment appointments. The patient can also have his or her full mouth treated (4 quadrants) in one visit. There are no subsequent treatment visits after the 4 quadrants are initially treated. Recurring periodontitis, if any, may be retreated with the full-mouth LANAP protocol years later if the disease complex returns.

Numerous other advantages of the LANAP protocol include improved patient treatment acceptance; significantly reduced patient appointments; reduced patient postoperative morbidity; tissue-height preservation; intraoperative hemostasis; and reduced post-op pain, bleeding, swelling, and infections. The procedure combines the best aspects of laser soft-tissue surgery with well-established principles of periodontal disease reversal.

Materials and Methods
A free-running (FR) pulsed Nd:YAG laser (PerioLase MVP-7 [Millennium Dental Technologies]) was used for these patients.^FN-4 This device provided an improvement over all existing FR pulsed Nd:YAG laser systems by having the availability of 7 multi-variable, operator-controlled pulse durations.^FN-5 Troughing around the tooth was typically done with a “short pulse,” having a duration of 100 to 150 µsec, although intraoperative clinical determinants allow for longer pulse durations to be used as necessary. The pulse energy was set to 160 to 200 mJ, and the repetition rate was 20 Hz, giving an average power of 3.2 to 4.0 W. Again, intraoperative clinical determinants and fiber diameters necessitate the need to adjust the average wattage up or down as necessary and as indicated. The parameters for the hemostasis, or “long pulse,” used to finish the procedure range from a duration of 150 to 650 µsec. Average powers displayed on the console are confirmed using a built-in power meter.FN-6 (Please note: Exceeding an average power of 4.0 W is not recommended for anyone except the most experienced or expertly trained laser user.^FN-7)

Another advantage of this laser system is the display of total energy delivered to the oral tissues during the procedure. This value is essential in determining the light dose (Joules per millimeter pocket depth [J/mm PD]).^FN-8 The light dose is calculated by dividing the total energy delivered by the sum of the depths of all pockets to safely dose the tissue with the appropriate range of light energy, which will safely range between 12 to 17 J/mm PD (Figure 1).

The bactericidal effects of the FR pulsed Nd:YAG laser,^24-27 plus the intraoperative use of topical antibiotics, are designed for the reduction of microbiotic pathogens (antisepsis) within the periodontal pockets and bony defects and the surrounding tissues. The red thrombus is stabilized, and occlusal trauma is eliminated to promote true periodontal regeneration. Oral hygiene is stressed, and continued periodontal maintenance is scheduled.

The desired result is to achieve true periodontal regeneration (ie, new bone, PDL, and, cementum) to the root surface, thereby decreasing pocket depth by 50% in more than 90% of patient pockets through regeneration, not amputation.

CASE REPORT
Patient: A 59-year-old male (Figures 2 to 5).
February 21, 2006: Consult.
Chief Concern: To avoid conventional surgery for the treatment of his bleeding gums.
Medical: The patient reported no health conditions or medications. He developed brain cancer in 2009 and Parkinson’s disease in 2012.
Consultation and Exam: The patient had heard of LANAP treatment from a television report. A periodontal risk assessment and prognosis form were completed with the patient. Informed consent was given after reviewing the alternatives, risks, and benefits with the patient, including no treatment. He declined alternative treatment options.

The LANAP protocol was reviewed with the patient, as well as the full-mouth treatment sequence of 2 visits, each one treating one-half of the mouth, plus a post-op assessment. The patient was informed that the LANAP protocol requires “spot grinding” of the teeth and any crowns and, separately, that laser treatment is not a “magic wand.” Laser safety was reviewed with the patient.

Patient risk assessment/patient report:

• Hygiene appointment 3 years prior
• No history of periodontal surgery
• Diagnosis of periodontal disease
• Recommendation for conventional scalpel and suture surgery
• Gingival tissues bleed “badly”

Clinical findings:

• Soft tissues were red and inflamed
• A presence of generalized calculus
• Gingival recession and mucogingival defects
• Light probing revealed generalized 6-mm-plus probe depths and bleeding on probing
• A Class IV vertically compressible mobility of tooth No. 30

Diagnosis: Generalized, severe, chronic, adult periodontitis; Case Type IV.
Prognosis: Guarded.
March 13, 2006: The right upper/lower quadrants were treated.
March 20, 2006: The left upper/lower quadrants were treated.

Bone Density
Clinical comparison of the LANAP Protocol pretreatment with post-radiographs indicates the formation of new bone. We have not completed the analysis that will indicate the frequency of this occurrence, but we can suggest that it is frequent among LANAP protocol patients. In a previous study, we presented 40 patient outcomes where sampled sites indicate that 100% of the cases demonstrated increased bone density by an average of 38%.²⁸ Crestal/horizontal height had clearly increased, but the quality and density of the bone was especially noteworthy. Also evident was new cortical crestal bone and lamina dura and a defined PDL space.

Light Dosimetry
Critical to patient safety and treatment efficacy is the ability to record and document the Joules per millimeter pocket depth (J/mm PD) of the quadrants of teeth and/or of a specific tooth. This allows the clinician to maintain the proper exposure of infrared thermal laser energy to oral tissues and eliminate adverse treatment outcomes of teeth, soft tissue, and bone.

This patient received only one full-mouth treatment of the LANAP protocol in 2006 and received no repeat treatments with the LANAP protocol.

As discussed previously in the Materials and Methods section, light dose (Joules per millimeter pocket depth) was calculated for this patient. In the 2 quadrants reported in this article, there were 6 teeth per quadrant. Their values are shown in Table 1.

CLOSING COMMENTS
The results reported here in no way suggest that other non-laser methodologies for treating periodontal bony defects (eg, guided bone regeneration) do not also lead to periodontal regeneration (eg, Straumann Emdogain).However, the LANAP protocol is a full-mouth protocol vs a site-specific regenerative treatment.

The results of real-world case results, confirmed by the research gold standard of human histology, confirm that using an FR pulsed Nd:YAG laser with optimized operating parameters, together with appropriately applied treatment algorithms, provides an additional benefit of true periodontal regeneration and reduced pocket depths over what conventional scaling and root planing, or osseous surgery alone, can achieve.FN-9 Furthermore, the LANAP protocol is another approach to minimally invasive surgical therapies, a minimally invasive surgical approach that may offer advantages in the regeneration of defects, and may be appropriate for multiple defects as a first line of management.²

Acknowledgments:
We thank John Sulewski for manuscript review, editing, and citations. We also thank Rachel Moody; Jennifer Iglesias; Veronica Santa; Vanessa Grimes; and Marika Lockhart, RDH, for radiograph and periodontal-charting graphic presentations.

Footnotes

1. “Currently, osseous grafting and guided tissue regeneration (GTR) are the 2 techniques with the most histologic documentation of periodontal regeneration. Other regenerative therapies have also provided a promising potential for significantly improving clinical parameters and demonstrating substantial “fill” of treated defects. However, only limited histologic evidence of true regeneration has been demonstrated with the majority of these therapies.”¹
2. “Regeneration refers to the reproduction or reconstitution of a lost or injured part, in contrast to repair, which describes healing of a wound by tissue that does not fully restore the architecture or the function of the original part. Periodontal regeneration is defined histologically as regeneration of the tooth’s supporting tissues, including alveolar bone, periodontal ligament, and cementum over a previously diseased root surface. New attachment is defined as the union of connective tissue or epithelium with a root surface that has been deprived of its original attachment apparatus. This new attachment may be epithelial adhesion and/or connective tissue adaptation or attachment and may include new cementum. It is to be distinguished from reattachment, which describes the reunion of epithelial and connective tissue with a root surface. Bone fill is defined as the clinical restoration of bone tissue in a treated periodontal defect. Bone fill does not address the presence or absence of histologic evidence of new connective tissue attachment or the formation of new periodontal ligament.”¹
3. “…this technique is intriguing in that it is another approach to minimally invasive surgical therapies as reviewed by Cortellini.29 A minimally invasive surgical approach may offer advantages in regeneration of defects in the aesthetic zone in which minimal soft tissue change is required. Additionally, because of the minimally invasive nature and expendable surgical materials required, this approach may be appropriate for multiple defects as a first line of management.”²
4. Free Running (FR) is the measure of the time duration of a single pulse in 10-6 seconds, or millionths of a second or microseconds (µsec). This allows for high peak powers in the order of 1,000 to 3,000 W per pulse and pulse intervals that are 500 or more times longer than the pulse “on” time.
5. Pulse Duration can be measured several ways, depending on whether the pulse is digital or analog. Digital pulse durations are qualitatively and quantitatively different from analog pulse durations. An analog pulse has a Gaussian profile (ie, a sine wave), whereas the digital pulse is square. Digital pulse durations are more accurately measured than analog ones since the shape of the area measured is a discrete area vs an alternating wave front. The convention used here is known as full width/half max. That is the pulse time (duration) in microseconds measured the full width on the x-axis (width) of an oscilloscope at one-half the maximum of the y-axis.
6. Power (Watts): The rate of doing work. It is critical to accurate communications of dosimetry that therapeutic power delivered to tissue be confirmed through measurement at the fiber tip with a calibrated power meter, as the power can vary as much as 30% or more from the power settings displayed on the console of any laser device. A power meter (PM10-19AW [Coherent, Inc]) was used in the case study presented.
7. Caution: Laser dosimetry described in this paper is not recommended unless the practitioner is well-trained and experienced. Exceeding the laser parameters or overtreating the large defects described for these cases may lead to prolonged healing, tissue and tooth loss, and other complications.
8. Light dose (Joules per millimeter pocket depth) is similar to drug dose (milligrams per kilogram of body weight) in that light dose defines the concentration of laser energy at the treatment site in a similar manner as drug dose defines the concentration of a drug in the tissues. Light dose is a very useful parameter inasmuch as certain clinical outcomes of laser surgery (eg, adverse effects) are dose-dependent.
9. Other Nd:YAG laser devices: One cannot extrapolate to other laser devices or other treatment protocols that have not defined their protocols, operating parameters, treatment algorithms, or healing events absent human histology.

References

1. Wang HL, Greenwell H, Fiorellini J, et al; Research, Science and Therapy Committee. Periodontal regeneration. J Periodontol. 2005;76:1601-1622.
2. Kao RT, Nares S, Reynolds MA. Periodontal regeneration—intrabony defects: a systematic review from the AAP Regeneration Workshop. J Periodontol. 2015;86(suppl 2):S77-S104.
3. Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL, et al. The efficacy of bone replacement grafts in the treatment of periodontal osseous defects. A systematic review. Ann Periodontol. 2003;8:227-265.
4. Murphy KG, Gunsolley JC. Guided tissue regeneration for the treatment of periodontal intrabony and furcation defects. A systematic review. Ann Periodontol. 2003;8:266-302.
5. Needleman I, Tucker R, Giedrys-Leeper E, et al. Guided tissue regeneration for periodontal intrabony defects—a Cochrane systematic review. Periodontol 2000. 2005;37:106-123.
6. Aichelmann-Reidy ME, Reynolds MA. Predictability of clinical outcomes following regenerative therapy in intrabony defects. J Periodontol. 2008;79:387-393.
7. Koop R, Merheb J, Quirynen M. Periodontal regeneration with enamel matrix derivative in reconstructive periodontal therapy: a systematic review. J Periodontol. 2012;83:707-720.
8. Esposito M, Grusovin MG, Papanikolaou N, et al. Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects. A Cochrane systematic review. Eur J Oral Implantol. 2009;2:247-266.
9. Sculean A, Nikolidakis D, Schwarz F. Regeneration of periodontal tissues: combinations of barrier membranes and grafting materials—biological foundation and preclinical evidence: a systematic review. J Clin Periodontol. 2008;35(8 suppl):106-116.
10. Esposito M, Coulthard P, Thomsen P, et al. Enamel matrix derivative for periodontal tissue regeneration in treatment of intrabony defects: a Cochrane systematic review. J Dent Educ. 2004;68:834-844.
11. Giannobile WV, Somerman MJ. Growth and amelogenin-like factors in periodontal wound healing. A systematic review. Ann Periodontol. 2003;8:193-204.
12. Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL. Regeneration of periodontal tissue: bone replacement grafts. Dent Clin North Am. 2010;54:55-71.
13. 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.
14. 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.
15. Gregg RH, McCarthy DK. Laser ENAP for periodontal bone regeneration. Dent Today. 1998;17:88-91.
16. Gregg RH, McCarthy DK. Laser ENAP for periodontal ligament regeneration. Dent Today. 1998;17:86-89.
17. Gregg RH II, McCarthy D. Laser periodontal therapy: case reports. Dent Today. 2001;20:74-81.
18. Gregg RH II, McCarthy D. Laser periodontal therapy for bone regeneration. Dent Today. 2002;21:54-59.
19. Gregg RH II, Gregg DM. Laser-assisted periodontal regeneration and human histology. Dent Today. 2019;38:70-74.
20. 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.
21. Gold SI, Vilardi MA. Pulsed laser beam effects on gingiva. J Clin Periodontol. 1994;21:391-396.
22. Ting CC, Fukuda M, Watanabe T, et al. Morphological alterations of periodontal pocket epithelium following Nd:YAG laser irradiation. Photomed Laser Surg. 2014;32:649-657.
23. Yukna RA, Evans GH, Vastardis S, et al. Laser-assisted periodontal regeneration in humans. Poster presented at: 81st General Session of the International Association for Dental Research; June 27, 2003; Goteborg, Sweden. Abstract 1735.
24. Moritz A, Schoop U, Goharkhay K, et al. The bactericidal effect of Nd:YAG, Ho:YAG, and Er:YAG laser irradiation in the root canal: an in vitro comparison. J Clin Laser Med Surg. 1999;17:161-164.
25. Whitters CJ, MacFarlane TW, MacKenzie D, et al. The bactericidal activity of pulsed Nd-YAG laser radiation in vitro. Lasers Med Sci. 1994;9:297-303.
26. Cobb CM, McCawley TK, Killoy WJ. A preliminary study on the effects of the Nd:YAG laser on root surfaces and subgingival microflora in vivo. J Periodontol. 1992;63:701-707.
27. Neill ME, Mellonig JT. Clinical efficacy of the Nd:YAG laser for combination periodontitis therapy. Pract Periodontics Aesthet Dent. 1997;9(6 suppl):1-5.
28. Gregg RH II, McCarthy DK. Eight-year retrospective review of laser periodontal therapy in private practice. Dent Today. 2003;22:74-79.
29. Cortellini P. Minimally invasive surgical techniques in periodontal regeneration. J Evid Based Dent Pract. 2012;12(3 suppl):89-100.

Dr. Robert H. Gregg II graduated from Georgetown University Dental School in 1984. He maintains a private group practice in Cerritos, Calif, that has been in the same location for 33 years. Dr. Gregg began using lasers in clinical practice in 1990 and remains at the forefront of dental laser technology, research, innovation, and clinical adoption. He invented the LANAP and LAPIP protocols while founding Millennium Dental Technologies, Inc, to provide patients with minimally invasive, regenerative treatment options and hope for hopeless teeth. He also serves as the president of the Institute for Advanced Laser Dentistry (IALD) and is an adjunct associate professor at the Rutgers School of Dental Medicine (RSDM). He can be reached via email at rgregg@lanap.com.

Disclosure: Dr. Robert Gregg II is president of Millennium Dental Technologies, Inc.

Dr. Dawn M. Gregg is a fourth-generation dentist, a Member of the Omicron Kappa Upsilon Dental Honor Society, and a graduate of the University of California, Los Angeles School of Dentistry. Dr. Gregg serves as CEO and training director for the IALD and is an adjunct associate professor at RSDM. She is responsible for ongoing initiatives with dental curricula where LANAP and LAPIP protocols are being taught, and she orchestrated a multi-center clinical study in the role of LANAP clinical study monitor. She can be reached via email at dgregg@lanap.com.

Disclosure: Dr. Dawn Gregg is vice president of operations of Millennium Dental Technologies, Inc.

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We all use a multitude of different diagnostic and restorative instruments in our daily lives as restorative dentists. Thankfully, any new instrument that promises to simultaneously save time and promote efficiency is a welcome addition to our dental armamentarium. One such instrument that has been a help in our practice will be showcased in this article.

There are several important factors that are taken into consideration when diagnosing periodontal disease. One of the most common and reliable methods in diagnosing sulcular depth is by using a periodontal probe. Although periodontal probing is mandatory for accurate diagnosis and baseline assessment, it is often met with challenges and resistance from both clinicians and patients. Because of past discomfort, patients can be both hesitant and nervous about probing and too often decline necessary periodontal probing and hygiene treatment recommendations. In turn, clinical/clinician challenges that may include time shortage, patient discomfort, and poor visibility can lead to reduced probing or no probing at all. Fortunately, one recent advancement in this area is a new probe that is more comfortable for patients and makes it much easier to visualize the actual numbers when using it.²

New Periodontal Probe Recently Introduced
The new Colorvue Goldstein Probe (Hu-Friedy), which was developed in partnership with world-renowned clinician Dr. Ronald Goldstein, differs from the typical metal probe, as it has been designed for greater accuracy for periodontal measuring and especially for use in restorative dentistry (Figure 1). This uniquely designed probe uses bright colors to differentiate measurements in 0.5-mm increments from 0.5 mm up to 3.0 mm (ie, 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0 mm) and then in 1.0-mm increments up to 13.0 mm (Figure 2). The Colorvue Goldstein Probe is not only designed to be used for a more accurate pocket depth reading (Figure 3), it is also a great diagnostic tool in instant measurement of gingival recession and assistance in margin placement (Figure 4). It can also be helpful in quick orthodontic evaluations and for instant measurement of overbites and overjets (Figure 5).

Figure 1. The bright colors of the Colorvue Goldstein Probe (Hu-Friedy) make for easier and quicker number visualization as compared to the typical metal probe. Note the gentle curve at the end and the taper that patients find more comfortable than the typical metal probe.	Figure 2. The Colorvue Goldstein Probe’s first series of measurements in 0.5-mm increments (up to 3.0 mm) are useful in the precise probing of sulcular depth for both periodontal and restorative dentistry.
Figure 3. Using bright colors clearly aids in probe-measuring a pocket depth of 3.0 mm of this central incisor.	Figure 4. Sulcular depth measurement is extremely important during margin placement.

An Essential Tool for Accurate Treatment Planning
As dental professionals, we long for predictable, ideal, and reproducible ways to achieve success in aesthetics and smile design. We often go by the Golden Proportion, which at times can be pleasing, but at other times may not be applicable to a portion of our patient population.³ In smile design and achieving the best aesthetic outcome, individual tooth size and proportion are the only certain factors.^4,5 The Colorvue Goldstein Probe can be an essential tool in your practice during diagnosis and treatment planning, in direct and indirect tooth bonding, and in indirect restoration preparation procedures.

Determining Correct Sulcular Depth
Another use of the Colorvue Goldstein Probe is to measure the sulcular depth that is essential in subgingival margin placement. Quite often (due to root sensitivity, caries, existing restoration, or aesthetics), margin placement is extended into the gingival sulcus. The common consensus among research studies, leading experts, and authors indicate that an average of 3.0 mm of biologic width is ideal.^6,7 A great rule to follow, by Grieder and Cinotti,⁸ states that the margin should be placed midway between the apical and coronal borders of the sulcus. Optimal and long-lasting post-restorative gingival health and success are highly correlated to this step-in margin placement procedure. The Colorvue Goldstein Probe’s 0.5-mm increments (up to 3.0 mm) helps clinicians arrive at a predictable subgingival margin. The bright colors of the probe make it easier to differentiate between these measurements and make the probing process much quicker and more accurate.

Figure 5a. During a first consultation appointment, an exact measurement of overjet was found to be 4.0 mm for this patient.	Figure 5b. An overbite measurement of 4.0 mm was quickly seen during orthodontic evaluation.

Figure 6. A silicone putty matrix (Sil-Tech [Ivoclar Vivadent]) made from a diagnostic wax-up was used on a preoperative study model to help measure the amount of thickness needed to build out the restorations to an ideal smile.

Measuring Optimal and Conservative Preparation Reduction
To ensure higher success with adhesive restorative procedures, we know that bond strength is much stronger with enamel than dentin; therefore, conserving as much healthy enamel tooth structure as possible should be a high-priority objective for the clinician. We often ask ourselves, “Do I have enough space required for this restoration?” The amount of tooth structure removed should be determined by the diagnostic wax-up. The information provided by the silicone putty (or vacuform matrix) made from the diagnostic wax-up can help assess the proper amount of tooth reduction needed, especially in cases where minimal reduction is needed for porcelain veneers (Figure 6). Two small holes are drilled into the labio-incisal and labio-gingival parts of each of the teeth to be prepared on the vacuform matrix (Figure 7).

Another great use of the Colorvue Goldstein Probe is during a crown preparation to predict for ideal labial, occlusal, and lingual reduction using a preformed vacuform matrix with the holes prepared (Figure 8). The Colorvue Goldstein Probe can serve as a useful tool in measuring ideal and conservative reduction during preparation of porcelain veneers.

Although the conservative nature of prepless veneers is popular and more appealing to patients, the idea of no preparation is often not practical, as some degree of preparation may be needed to achieve an optimal aesthetic outcome.

The following case (Figures 8 to 13) will demonstrate the benefits of minimal preparation using predictable measurements.

CASE REPORT
A 70-year-old patient presented with discolored teeth and a lack of lip support, desiring a fuller and brighter smile (Figure 8). A clinical examination revealed discolored and worn teeth with the presence of vertical microcracks and a loss of the interdental papillae. There was also a missing congenital lateral, creating an uneven space problem.

Porcelain veneers were recommended and explained as a potential treatment, pending analysis of the diagnostic study models and wax-up (Figure 9).

Clinical Protocol
The labial enamel was reduced to approximately 0.1 to 0.2 mm with the patient experiencing no sensitivity or discomfort (Figure 10). All areas of the teeth were prepared and measured to ensure adequate thickness of the all-ceramic veneers. The reduction of each tooth relative to the diagnostic wax-up was verified with the Colorvue Goldstein Probe through the vacuform matrix openings (Figure 11).

The silicone putty matrix (Sil-Tech [Ivoclar Vivadent]) (previously fabricated using the diagnostic wax-up) was filled with a self-curing methylacrylic provisional composite (Luxatemp Fluorescence [DMG America]) and seated over the teeth. The final provisional was polished and glazed (Figure 12), and the patient was released.

Once the final all-ceramic veneers (IPS e.max [Ivoclar Vivadent]) were received from the dental lab team, they were tried-in and approved by the patient at the delivery appointment. The restorations were adhesively bonded into place (simultaneously) using a resin cement system (Choice 2 [BISCO Dental Products]) (Figure 13).

CLOSING COMMENTS
Our patients deserve highly successful aesthetic restorative outcomes that meet their expectations. Whenever possible, this should ideally be done using a minimally invasive approach to care. Accuracy, predictability, control, comfort, safety, and visibility are all essential parts of delivering the best care possible to your patients. As described in this article, the Colorvue Goldstein Probe can play a variety of important roles (diagnostic, periodontal, and restorative) in the everyday practice.

References

1. Coachman C, Calamita M. Digital smile design: a tool for treatment planning and communication in esthetic dentistry. Quintessence Dent Technol. 2012;35:103-111.
2. White YA, Robinette CK, Bahry A. Probe selection: a hygiene team’s review of periodontal probes considers several factors. RDH. 2016;36:62-63.
3. Preston JD. The golden proportion revisited. J Esthet Dent. 1993;5:247-251.
4. Sterrett JD, Oliver T, Robinson F, et al. Width/length ratios of normal clinical crowns of the maxillary anterior dentition in man. J Clin Periodontol. 1999;26:153-157.
5. Ali Fayyad M, Jamani KD, Aqrabawi J. Geometric and mathematical proportions and their relations to maxillary anterior teeth. J Contemp Dent Pract. 2006;7:62-70.
6. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992;63:995-996.
7. Tarnow D, Stahl SS, Magner A, et al. Human gingival attachment responses to subgingival crown placement. Marginal remodeling. J Clin Periodontol. 1986;13:563-569.
8. Grieder A, Cinotti WR. Periodontal Prosthesis. St. Louis, MO: Mosby; 1968.

Dr. Esfandiari graduated from Georgia State University in 2007 and received her Doctor of Dental Medicine degree from the Dental College of Georgia in 2011, where she received the prestigious Goldstein Esthetic Award in her last year. Following graduation, she accepted a post-doctorate aesthetic Fellowship with Dr. Ronald Goldstein in Atlanta. Dr. Esfandiari worked closely with Dr. Goldstein on many large full-mouth rehab and cosmetic cases. As part of her training on the weekends, she also did research and assisted Dr. Goldstein on the 3rd edition of his book, Esthetics in Dentistry. Upon completion of her aesthetics fellowship, she was offered a full-time position as an associate dentist at Goldstein, Garber, & Salama in 2011. She can be reached via the email address at nadiadmd@yahoo.com.

Disclosure: Dr. Esfandiari reports no disclosures.

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INTRODUCTION
As a field, surgical periodontics has seen many incarnations during the decades, beginning with resections of gingiva and bone and then progressing to flap surgery, with osseous resection and recontouring, and, finally, regenerative procedures. All had the same goal in mind: pocket reduction/elimination and the restoration of periodontal health. While the first 2 left something to be desired with regard to patient comfort, all of these techniques achieved their desired outcomes with regeneration surgery being the obvious “Holy Grail.” This was due to its ability to reclaim lost periodontal structure, both bone and connective tissue. So what’s the “Holy Grail” of the “Holy Grail?” In my opinion, it is laser-assisted new attachment procedure (LANAP).
In my previous article, “Advancing the Standard of Care With the LANAP Protocol,” published in the April 2013 issue of Dentistry Today, a summary of the procedure and several cases were shown. To reiterate, LANAP (Millennium Dental Technologies) utilizes the free running pulsed Nd:YAG laser as a part of its protocol. The outright benefits of LANAP for achieving regeneration cannot be overlooked or ignored when presenting a treatment plan to a patient. LANAP is a less invasive procedure, eliminating the need for the cutting and suturing that is part of the traditional and regenerative osseous surgical procedures. It initiates and stimulates the patient’s own cellular and tissue response to restore lost bone and connective tissue attachment without the introduction of foreign substances, whether they are bone, membranes, or growth factors. This was proven histologically by Dr. Ray Yukna’s study1 that clearly demonstrated regeneration of the supporting periodontal apparatus in human specimens. In my office, we have seen undeniable clinical and radiographic proof of LANAP’s capabilities in many cases, several of which will be presented here.

CASE REPORTS
Case 1
Findings—A 57-year-old female was referred to our office by her general dentist for evaluation and treatment of the maxillary right first premolar. Clinical examination indicated pocketing of 8.0 mm along the entire palatal aspect of the tooth, extending into the mesial interproximal area. This corresponded to 5.0 mm of attachment loss. The defect could be easily seen on the radiograph (Figure 1), matching the clinical impression. The problem was further compounded by secondary trauma from occlusion in both centric relation and lateral excursions, causing a mobility of 2+.

CASE 1

Figure 1. Pre-op radiograph showing tooth No. 5. Figure 2. Six-month post-op radiograph.

Treatment and Results—A procedure was performed for the maxillary right first premolar utilizing the PerioLase MVP-7 and the LANAP protocol under local anesthetic (Mepivacaine HCl 3% without vasoconstrictor). Postoperatively, the patient was placed on Clindamycin 150 mg (No. 28, 4 times a day for one week) and chlorhexidine rinse 0.12% (Periogard [Colgate]) (30 seconds, twice a day for 2 weeks).
At the 2-week postoperative visit, the mobility of the premolar was already reduced to a +, and it was completely immobile at the 4-week postoperative visit. Clinical probing was not done until the 6-month evaluation, at which time a radiograph was also taken (Figure 2). Complete bone fill of the defect was evident, with corresponding probing depths of 2 mm at the former diseased sites equating to a clinical attachment gain of 6.0 mm.

Case 2
Findings—A 53-year-old female was referred to our office by her general dentist for treatment of generalized severe periodontitis. Of particular concern was a large intrabony defect present on the mandibular right third molar. This defect extended from the mesial aspect of the tooth to the mid-lingual aspect of the tooth (Figure 3). This tooth served as a terminal abutment for a long-span fixed bridge, so its retention was imperative.
Treatment and Results—The tooth was treated as part of the LANAP protocol for the entire dentition. The PerioLase MVP-7 was utilized with the LANAP protocol under local anesthetic (Lidocaine HCl 2% with 1:100,000 epinephrine). During the procedure, the actual condition of the molar was found to be worse than expected. Bone loss was found to be extending beyond the apex of the mesial root, and from the mesial interproximal to the midlingual aspect of the tooth. Postoperatively, the patient was placed on penicillin VK 500 mg (No. 28, 4 times a day for one week) and Periogard rinse 0.12% (30 seconds, twice a day for 2 weeks).

CASE 2

Figure 3. Pre-op radiograph showing tooth No. 32. Figure 4. Eight–month post-op radiograph.

The patient returned in 8 months for a postoperative clinical and radiographic examination of the molar. Complete bone fill of the osseous defect was seen on the radiograph (Figure 4) with corresponding pocket depths of 4.0 to 7.0 mm. This was a significant improvement over the original, nearly hopeless clinical presentation.

Case 3
Findings—A 61-year-old female was referred to our office by her general dentist for evaluation and treatment of a periodontal abscess on the maxillary left central incisor (Figures 5 and 6). Clinical examination revealed a mobility of 2 on the tooth along with pocketing of 9.0 mm along its palatal aspect, extending through the distal interproximal to the distofacial line angle. A fracture was suspected, but every effort was to be made to salvage the tooth.

Figure 5. Pre-op photo showing tooth No. 9.	Figure 6. Pre-op radiograph showing tooth No. 9.
Figure 7. During LANAP on tooth No. 9 (facial).	Figure 8. During LANAP on tooth No. 9 (lingual).
Figure 9. One-month post-op photo (facial).	Figure 10. One-month post-op photo (lingual).

Figure 11. One-month post-op radiograph.

Treatment and Results—A procedure was performed for the maxillary left central incisor utilizing the PerioLase MVP-7 and the LANAP protocol under local anesthetic (Lidocaine HCl 2% and 1:100,000 epinephrine) (Figures 7 and 8). Postoperatively, the patient was placed on penicillin VK 500 mg (No. 28, 4 times a day for one week) and Periogard rinse 0.12% (30 seconds, twice a day for 2 weeks).
The patient returned in one month for both clinical and early radiographic evaluation. The gingival condition had already resolved and returned to a state of health with mobility on the tooth reduced to + (Figures 9 and 10), and there even appeared to be some bone fill of the defect (Figure 11), although no probing could be done at this time in order not to disturb the regenerative process.

Case 4
Findings—A 62-year-old female was referred to our office by her general dentist for extraction of the mandibular right first molar and bone grafting. This was to be followed by implant placement in 6 months. Clinically, the tooth was depressible in the socket with a fistula emanating from its buccal aspect. A large area of infection and root resorption was evident in the radiograph (Figure 12). After discussion with the patient, it was decided to attempt to save the tooth using the LANAP protocol since an extraction, followed by bone grafting and implant placement, could always be done if the treatment failed.

CASE 4

Figure 12. Pre-op radiograph showing tooth No. 30. Figure 13. Five-week post-op radiograph.

Treatment and Results—A procedure was performed for the molar utilizing the PerioLase MVP-7 and the LANAP protocol under local anesthetic (Articaine HCl 4% and 1:100,000 epinephrine). Postoperatively, the patient was placed on penicillin VK 500 mg (No. 28, 4 times a day for one week) and Periogard rinse 0.12% (30 seconds, twice a day for 2 weeks).
The patient returned at 5 weeks for clinical and an early radiographic evaluation. The fistula was no longer present and the radiograph showed that some bone fill had already occurred (Figure 13); completely unexpected at such an early stage. The tooth has been retained since then.

CLOSING COMMENTS
The PerioLase MVP-7-assisted LANAP protocol is a proven and invaluable tool for the treatment of all case types of periodontitis. It is particularly effective when other treatment modalities are impractical or virtually impossible. It should be, and is in my office, considered the standard of care for the treatment of periodontal disease due to its combination of outstanding results and unparalleled patient comfort.

Reference

1. 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.

Dr. Mangot has maintained a practice limited to periodontics and implants in Clifton, NJ, for the past 23 years. He received his doctor of dental medicine in 1987 and his certificate in periodontics in 1990 from UMDNJ-New Jersey Dental School and is a Diplomate of the American Board of Periodontics. He can be reached at healthygumsnj@gmail.com.

Disclosure: Dr. Mangot reports no disclosures.

INTRODUCTION
Periodontal diseases affect a significant portion of the adult population. Periodontitis is the primary cause of tooth loss in older adults.¹ These problems also have been linked to systemic disease.^2,3 The primary extrinsic etiologic factor for these problems is associated with bacteria.4 Consequently, treatment of inflammatory periodontal diseases is focused on the effective debridement of the subgingival environment, and reducing the bacterial load with personal daily oral hygiene and professional removal of bacterial biofilm and its by-products.
Clinicians have traditionally relied on clinical observation, tactile sensation, proper instrumentation technique, and experience to noninvasively treat shallow periodontal pockets. The speciality of periodontics has conducted years of research, debate, and clinical case care to analyze the benefit and the effectiveness of nonsurgical therapy. Clinical research has provided extensive support for the use of nonsurgical therapy to treat and maintain some forms of periodontal disease.^5,6 As with any treatment modality, there are inherent limitations to effectively treat periodontitis on a predictable basis.

Limitations of Nonsurgical Therapy
Complete removal of subgingival bacterial biofilm and calculus remains a challenge.^7-12 In an effort to overcome the various limitations of nonsurgical debridement, clinicians, scientific investigators, and dental manufacturers have expended effort and resources in the search for better treatment outcomes and the technologies to facilitate these improved treatment outcomes. In 1995, the American Academy of Periodontology suggested that the evidence-based treatment approach be established as a standard of care for the delivery of periodontal treatment.¹³ Many dental practitioners would agree that this philosophy of care improves clinical outcomes because care is based on documented evidence, rather than purely on empirical experience and anecdote. There is significant evidence in the dental literature describing the limitations of nonsurgical therapy. The literature has also demonstrated the inability to tactilely evaluate root surface deposits in periodontal pockets following debridement. This limits the clinician’s ability to fully instrument root surfaces in deeper periodontal pockets.^7-9,11,14-17 Additional limitations in nonsurgical therapy include restricted access during instrumentation by various anatomic factors (eg, furcations, root grooves, concavities),^18,19 other variations (eg, cemento-enamel projections,^20,21 enamel pearls,²² the path of the cemento-enamel junction,²³ cemental tears,²⁴ and bifurcation ridges²⁵) impede access and impede the ability to fulfill the goals of nonsurgical scaling and root planing. Due to these limitations, access to the primary etiology of periodontal diseases (ie, plaque and calculus) has been limited for all periodontal therapies.²⁶

Figure 1. Tooth No. 31 had a 12.0-mm distal probing depth and a one-wall distal intraosseous defect.	Figure 2. Tooth No. 31 clinically demonstrated an 8.0-mm distal probing depth 6 months following “blind” conventional nonsurgical debridement.

Enhanced Visualization and Fiber-Optic Endoscopy
Noninvasive diagnostic imaging of tissues and body structures with the aid of magnetic resonance imaging and computed tomography is currently very common. Endoscopic and microscopic technologies have been employed in the surgical field of medicine for decades. Microsurgical techniques are not new in the field of periodontics. For years, magnification has been used to enhance visualization within the oral cavity, thereby increasing the precision of periodontal therapy. During microsurgical procedures, magnification allows the clinician to utilize smaller instruments that are less traumatic. Fiber-optic technology has also facilitated this increase in visual magnification and treatment precision. Historically, visual access to the subgingival root surface could only be attained through a periodontal flap procedure or extraction of the tooth. Now clinicians can deliver minuscule fiber-optic probes into the periodontal pocket to gain visual access.
Fiber-optic periodontal endoscopes used during instrumentation may improve scaling and root planing efficacy in deeper pockets. Advancements in fiber-optic technology, coupled with modifications of the periodontal armamentarium (eg, curets, periodontal probe, ultrasonic scaler) have led to the development of a technology that allows the clinician direct visual access of the subgingival root surface within the periodontal pocket.²⁷
Fiber-optic endoscopes contain bundles of thin glass fibers that use the principle of total internal reflection to transmit light to and from the organ being viewed and to transmit almost 100% of the light entering one end to the other. Fiber-optic endoscopes are delicate and expensive instruments. The fibers are made of a special glass, and each fiber is coated with a layer of glass with a different refractive index. Additionally, the orientation of the fibers in a bundle used for endoscopy must be “coherent” in spatial orientation for its full length.

Dental Endoscope
The Dental Endoscope, originally developed by Dentalview Incorporated and currently available from Perioscopy Incorporated, consists of a miniature fiber-optic cable that contains a 10,000-pixel scope that can magnify an image from 24x to 48x. The 0.85 mm diameter fiber-optic endoscope incorporates an integrated light source for subgingival illumination. This system incorporates the use of disposable sheaths for the fiber-optic cable and a water system to insuflate the pocket and provide lavage of the operative field. The fiber-optic image is captured through a charged coupling device camera and digital processor. The operative field is viewed on a flat panel video display.²⁸

Figure 3. Tooth No. 31 with an 8.0-mm distal probing depth (with no bleeding on probing) and one wall distal intraosseous defect. Note increased radiopacity of defect wall.	Figure 4. The periodontal endoscope.
Figure 5. Periodontal endoscope in clinical use.	Figure 6. Periodontal endoscope explorer in use on the distal of tooth No. 31.
Figure 7. Endoscopic monitor image. Subgingival bacterial biofilm and subgingival calculus present approximately 6.0 mm to 7.0 mm into the “pocket.”	Figure 8. Burnished subgingival calculus deposit.

Figure 9. Endoscopic monitor image. Clean subgingival root surface following definitive endoscopic root debridement.

Clinical Trials and Human Histology
Recent clinical trials and human histologic studies have demonstrated the effectiveness of nonsurgical debridement with the aid of the periodontal endoscope. Wilson et al,^29,30 in 2008, hypothesized that the endoscope may increase the diagnostic value of gingival redness. Gingival redness is among the cardinal signs of inflammation and a standard component of virtually all clinical indices used to assess the severity of gingival inflammation.^31-34 However, this parameter measured supragingivally does not have a high predictive value for the progression of periodontitis.³⁵ Wilson et al^29,30 examined 26 patients with moderate to severe periodontitis with the periodontal endoscope. The findings showed a statistically significant relationship between calculus covered with biofilm and inflammation, ginigival redness, in the pocket wall. More than half of the cases of the inflammation were associated with bacterial biofilm and calculus, as opposed to bacterial biofilm alone. Only subgingival calculus had a statistically significant relationship to the positive traditional gingival index. They^29,30 showed that deposits of subgingival calculus covered with biofilm were directly related to more than 60% of pocket wall inflammation as measured by increased redness of the pocket epithelium. This was in comparison to biofilm alone, which was present in more than 30% of the sites where inflammation was observed. They^29,30 concluded that calculus may be a factor in subgingival inflammation. Because it has been shown that sterilized calculus does not create inflammation,³⁶ it can be hypothesized that calculus, in some way, enhances the inflammatory effect of the biofilm observed. They²⁹ also went on to say that, “The current study found that subgingival inflammation was unrelated to any of the traditional measures of inflammation, including gingival inflammation (traditional gingival index) and the presence of bleeding on probing. However, deeper probing depths were related to subgingival inflammatory changes as viewed through the endoscope.”²⁹
In the companion study, again in humans, calculus was removed with the aid of an endoscope. This study showed no histologic signs of chronic inflammation at 6 months following a single episode of closed, subgingival scaling and root planing using the endoscope. Thus, “complete removal of subgingival deposits of bacterial biofilm and by-products, including calculus, as defined by the use of an endoscope, may be appropriate if chronic inflammation is a problem.”³⁰
In 2009, Mellonig et al³⁷ reported on a 4-subject case report using conventional blind nonsurgical debridement and the application of an enamel matrix derivative (EMD). Enamel matrix derivative is a composite of proteins that has been demonstrated histologically to work as an adjunct to periodontal regenerative surgical therapy. The purpose of this study was to evaluate the clinical and histologic effects of EMD as an adjunct to scaling and root planing. The 4 subject patients had all been diagnosed with severe chronic periodontitis and were scheduled to receive complete dentures. This study recorded probing depth and clinical attachment levels for each patient. Conventional hand and ultrasonic root surface instrumentation was completed and not limitied by time. The root was indexed for later histologic examination, and EMD was expressed into the root surface. Plaque control was accomplished for the patient every 2 weeks. Six months after treatment, probing depth and clinical attachment levels were again recorded, and the teeth were removed en bloc. The samples were then prepared and examined histologically. Probing depth reduction and clinical attachment level gains were obtained in three fourths of the specimens. Three of the 4 specimens when analyzed histologically demonstrated new cementum, bone, periodontal ligament, and connective tissue attachment coronal to the notch. In one specimen, the gingival margin had receded below the notch. The investigators³⁷ reported that, “These results were unexpected and may represent an aberration. However, the substantial reduction in deep probing depths and clinical attachment level gain in 3 of 4 specimens, in addition to the histologic findings of new cementum, new bone, a new periodontal ligament, and a new connective tissue attachment, suggest that EMD may be useful as an adjunct to scaling and root planing in single-rooted teeth.”³⁷
This case report will present the successful treatment of localized severe chronic periodontitis.

Figure 10. Emdogain (Straumann) enamel matrix derivative (EMD) placed subgingivally following smear layer removal with PrefGel (Straumann) a neutral pH buffered, water soluble ethylenediamine tetra-acetic acid.	Figure 11. Tooth No. 31 with a 3.0-mm distal probing depth at 14 months following secondary (endoscopic debridement and EMD regeneration) therapy.
Figure 12. Tooth No. 31 had a 3.0-mm distal probing depth and early radiographic defect fill. (Note: Compare to Figure 1 and Figure 3.)	Figure 13. At a 6 year follow-up, tooth No. 31 had a 3.0-mm distal probing depth and continuing radiographic defect fill. (Note: Compare to Figure 3 and Figure 12.)

Figure 14. At 8.5 year follow-up, tooth No. 31 had a 3.0 mm distal probing depth and continuing radiographic defect fill. (Note: Compare to Figures 1, 3, 12, and 13.)

CASE REPORT
Diagnosis and Treatment Planning
A 43-year-old white female was referred by her husband, a current patient. She presented with a chief complaint of, “I have a pocket behind my lower right last molar…and I don’t want surgery.” The patient’s health history was not remarkable. Her dental history and patient interview revealed an ongoing cigarette habit (one quarter pack per day for the last 23 years). Her interview also revealed a traumatic dental experience, at the age of 19 years, associated with the surgical removal of an impacted third molar. During the last 5 years, adult prophylaxis had been completed at 6-month intervals. The historical clinical records that accompanied the patient documented a 10-mm probing depth with bleeding on probing present on the distal aspect of tooth No. 31. This defect had been present for the one year period prior to the patient’s referral.
Initial examination of the patient revealed a 10-mm distobuccal and 12-mm distolingual probing depth with bleeding on probing and no recession on the distal aspect of tooth No. 31. There was also an incipient buccal furcation invasion with an accompanying 9 mm probing depth and no recession on the buccal of tooth No. 31. The tooth had no mobility (Figure 1). The guarded prognosis for tooth No. 31 and initial treatment recommendations were discussed at length with the patient.
The patient would only commit to a more frequent supportive periodontal therapy (SPT) schedule. For the first 6 months, SPT was completed on a 3-month interval. This treatment approach was followed to allay the patient’s anxiety, to build patient trust, and to provide an opportunity to help the patient improve daily oral hygiene.
After the first 6 months of patient care, initial treatment recommendations and alternatives were discussed a second time with the patient. The patient elected conventional “blind” nonsurgical debridement of tooth No. 31 under local anesthesia. At the patient’s next 3-month SPT appointment, it was determined that this treatment had resulted in a 4-mm reduction in distal probing depths and a 6-mm reduction in buccal probing depth with no bleeding on probing in either area (Figures 2 and 3). At this SPT appointment, secondary treatment recommendations and alternatives were discussed with the patient. She elected endoscopic nonsurgical debridement and Emogain (Straumann) EMD regeneration for the residual defect on the distal of tooth No. 31 (Figure 4).

Secondary Therapy
Under profound local anesthesia (1.8 mL lidocaine 2% with 1:100,000 epinephrine), the periodontal endoscope was inserted to gain visual access of the subgingival root surface (Figure 5). A manually tuned magnetostrictive ultrasonic unit was used with the periodontal endoscope (using a 2-handed technique) to debride the root surface. The root surface was instrumented (Figures 6 and 7) and visually assessed as clean with the periodontal endoscope (Figures 8 and 9). The smear layer on the root surface was removed using a 2-minute application of PrefGel (Straumann), a neutrally pH buffered, water soluble ethylenediamine tetra-acetic acid gel. The PrefGel was washed away with sterile water in a 50 cc syringe. Emdogain EMD gel was applied to the root surface (Figure 10) using the prepackaged syringe; starting at the base of the defect and expressing the EMD gel as the syringe was drawn coronally. The EMD gel was left undisturbed for 2 minutes. Postoperative instructions were reviewed with the patient. The patient was instructed to use over-the-counter ibuprofen for discomfort following the label instructions.

Follow-Up and Supportive Periodontal Therapy
No specific follow-up appointments were scheduled following endoscopic debridement, as they would be scheduled following conventional open-flap debridement. Follow-up was accomplished at the patient’s regularly scheduled SPT appointments where instrumentation was guided by periodontal examination. Six months following endoscopic secondary therapy (at the second 3-month SPT appointment), it was determined the treatment had resulted in a further 2-mm distal probing depth reduction.
SPT was continued at a 3-month interval. At the 14-month appointment, an additional 2 mm distal probing depth reduction was noted (Figures 11 and 12). The clinical parameters on tooth No. 31 were now 2 to 3 mm probing depth with no bleeding on probing and no clinical access to either furcation entrance.
The clinical status of tooth No. 31 has remained improved and stable for the last 8 years and 4 months (Figures 13 and 14) (Table).

CONCLUSION
The treatment of localized severe chronic periodontitis, as presented in this case report article, incorporated the use of the dental endoscope to facilitate subgingival visualization during nonsurgical instrumentation and a porcine derived EMD for the regeneration of the periodontal attachment apparatus. The treatment resulted in significant probing depth reduction without recession. Following successful treatment, supportive periodontal care occurred over a 9-year period, during which radiographic osseous defect improvement was documented.

References

1. Fox CH, Jette AM, McGuire SM, Feldman HA, et al. Periodontal disease among New England elders. J Periodontol. 1994;65:676-684.
2. Mattila KJ, Pussinen PJ, Paju S. Dental infections and cardiovascular diseases: a review. J Periodontol. 2005;76(suppl 11):2085-2088.
3. Taylor GW. Bidirectional interrelationships between diabetes and periodontal diseases: An epidemiologic perspective. Ann Periodontol. 2001;6:99-112.
4. Socransky SS, Haffajee AD, Cugini MA, et al. Microbial complexes in subgingival plaque. J Clin Periodontol. 1998;25:134-144.
5. Badersten A, Nilvéus R, Egelberg J. Effect of nonsurgical periodontal therapy. I. Moderately advanced periodontitis. J Clin Periodontol. 1981;8:57-72.
6. Pihlstrom BL, McHugh RB, Oliphant TH, et al. Comparison of surgical and nonsurgical treatment of periodontal disease. A review of current studies and additional results after 6 1/2 years. J Clin Periodontol. 1983;10:524-541.
7. Rabbani GM, Ash MM Jr, Caffesse RG. The effectiveness of subgingival scaling and root planing in calculus removal. J Periodontol. 1981;52:119-123.
8. Caffesse RG, Sweeney PL, Smith BA. Scaling and root planing with and without periodontal flap surgery. J Clin Periodontol. 1986;13:205-210.
9. Buchanan SA, Robertson PB. Calculus removal by scaling/root planing with and without surgical access. J Periodontol. 1987;58:159-163.
10. Fleischer HC, Mellonig JT, Brayer WK, et al. Scaling and root planing efficacy in multirooted teeth. J Periodontol. 1989;60:402-409.
11. Sherman PR, Hutchens LH Jr, Jewson LG, et al. The effectiveness of subgingival scaling and root planing. I. Clinical detection of residual calculus. J Periodontol. 1990;61:3-8.
12. Caton JG, Zander HA. The attachment between tooth and gingival tissues after periodic root planing and soft tissue curettage. J Periodontol. 1979;50:462-466.
13. McGuire MK, Newman MG. Evidenced-based periodontal treatment. I. A strategy for clinical decisions. Int J Periodontics Restorative Dent. 1995;15:70-83.
14. Waerhaug J. Healing of the dento-epithelial junction following subgingival plaque control. II: As observed on extracted teeth. J Periodontol. 1978;49:119-134.
15. Jones WA, O’Leary TJ. The effectiveness of in vivo root planing in removing bacterial endotoxin from the roots of periodontally involved teeth. J Periodontol. 1978;49:337-342.
16. Stambaugh RV, Dragoo M, Smith DM, et al. The limits of subgingival scaling. Int J Periodontics Restorative Dent. 1981;1:30-41.
17. Rateitschak-Plüss EM, Schwarz JP, Guggenheim R, et al. Non-surgical periodontal treatment: where are the limits? An SEM study. J Clin Periodontol. 1992;19:240-244.
18. Gher ME Jr, Vernino AR. Root anatomy: a local factor in inflammatory periodontal disease. Int J Periodontics Restorative Dent. 1981;1:52-63.
19. Withers JA, Brunsvold MA, Killoy WJ, et al. The relationship of palato-gingival grooves to localized periodontal disease. J Periodontol. 1981;52:41-44.
20. Masters DH, Hoskins SW. Projections of cervical enamel in molar furcations. Periodontics. 1964;35:49-53.
21. Hou GL, Tsai CC. Cervical enamel projection and intermediate bifurcational ridge correlated with molar furcation involvement. J Periodontol. 1997;68:687-693.
22. Gher ME, Vernino AR. Root morphology—clinical significance in pathogenesis and treatment of periodontal disease. J Am Dent Assoc. 1980;101:627-633.
23. Schroeder HE, Scherle WF. Cemento-enamel junction—revisited. J Periodontal Res. 1988;23:53-59.
24. Moskow BS. Calculus attachment in cemental separations. J Periodontol. 1969;40:125-130.
25. Löe H, Theilade E, Jensen SB, et al. Experimental gingivitis in man. 3. Influence of antibiotics on gingival plaque development. J Periodontal Res. 1967;2:282-289.
26. Stambaugh RV, Myers G, Ebling W, et al. Endoscopic visualization of submarginal gingival root surfaces. J Dent Res. 2000;79(Special Issue):600 (Abstract 3656).
27. Kwan JY. Enhanced periodontal debridement with the use of micro ultrasonic, periodontal endoscopy. J Calif Dent Assoc. 2005;33:241-248.
28. Stambaugh RV, Myers G, Ebling W, et al. Endoscopic visualization of the submarginal gingiva dental sulcus and tooth root surfaces. J Periodontol. 2002;73:374-382.
29. Wilson TG, Harrel SK, Nunn ME, et al. The relationship between the presence of tooth-borne subgingival deposits and inflammation found with a dental endoscope. J Periodontol. 2008;79:2029-2035.
30. Wilson TG Jr, Carnio J, Schenk R, et al. Absence of histologic signs of chronic inflammation following closed subgingival scaling and root planing using the dental endoscope: human biopsies—a pilot study. J Periodontol. 2008;79:2036-2041.
31. O’Leary T, Givson WJ, Shannon I, et al. A screening examination for detection of gingival and periodontal breakdown and local irritants. Periodontics. 1963;1:167-174.
32. Loesche WJ. Clinical and microbiological aspects of chemotherapeutic agents used according to the specific plaque hypothesis. J Dent Res. 1979;58:2404-2412.
33. Lobene RR, Weatherford T, Ross NM, et al. A modified gingival index for use in clinical trials. Clin Prev Dent. 1986;8:3-6.
34. Halazonetis TD, Haffajee AD, Socransky SS. Relationship of clinical parameters to attachment loss in subsets of subjects with destructive periodontal diseases. J Clin Periodontol. 1989;16:563-568.
35. Page RC, Beck JD. Risk assessment for periodontal diseases. Int Dent J. 1997;47:61-87.
36. Allen DL, Kerr DA. Tissue response in the guinea pig to sterile and non-sterile calculus. J Periodontol. 1965;36:121-126.
37. Mellonig JT, Valderrama P, Gregory HJ, et al. Clinical and histologic evaluation of non-surgical periodontal therapy with enamel matrix derivative: a report of four cases. J Periodontol. 2009;80:1534-1540.

Dr. Young graduated from the Indiana University School of Dentistry. After completing an Advanced Education in General Dentistry (AEGD) at the Irwin Army Hospital in Fort Riley, Kan, Dr. Young practiced general dentistry for 5 years. He completed his residency in periodontology at the University of Michigan. Dr. Young maintains a private practice limited to periodontics in Des Moines, Iowa. His practice has an emphasis in aesthetic periodontal regeneration, cosmetic periodontal reconstruction, and dental implants. He can be reached at (515) 224-1771 or at ryoungdsm@aol.com.

Disclosure: Dr. Young reports no disclosures.

INTRODUCTION
The specialty of periodontics has long relied on surgical intervention to achieve the goal of regeneration of the periodontal complex. Various surgical techniques and products have been developed throughout time to achieve this, including guided tissue regeneration/guided bone regeneration, natural and artificial bone grafting (autogenous, allografts, xenografts, hydroxyapatite, glass, etc) and growth factors (platelet-derived growth factor), among others. While these modalities have achieved their desired goals, they have relied on invasive techniques that increase postoperative morbidity and are not suitable for certain medically compromised individuals as well as the elderly.
With the advent of the Free Running Pulsed Nd:YAG PerioLase MVP-7 laser system and the FDA-cleared laser-assisted new attachment procedure (LANAP) protocol (Millennium Dental Technologies), we can not only achieve the goals of regeneration, but it can also be accomplished in a minimally invasive way. Furthermore, we can do this for a wider patient population and in a variety of cases previously thought to be untreatable, without incisions and suturing.
One mini case report will be presented, demonstrating the added benefit of the PerioLase MVP-7 in the handling of very difficult soft-tissue situations and the rapid tissue recovery that it allows.

CASE 1

Findings
A 47-year-old male was referred by his general practitoner (GP) with a chief complaint of “shifting of the lower front teeth.” Clinical findings included pocketing of 8 mm from the mesial facial line angle through the mesial lingual line angle of the mandibular right central incisor, with 5 mm of attachment loss and no recession. This was consistent with the radiographic appearance of a one-wall intrabony defect (Figure 1). Occlusal examination indicated an edge-to-edge bite, resulting in secondary occlusal trauma on the central incisor and contributing to a 2+ mobility.

CASE 1

Figure 1. Tooth No. 25 pre-op periodontal defect. Figure 2. Tooth No. 25, 3 months post-op. Figure 3. Tooth No. 25, 8 months post-op.

Treatment Protocol and Results
A procedure was performed for the central incisor utilizing the PerioLase MVP-7 and the LANAP protocol under local anesthetic using lidocaine hydrochloride (HCL) 2% (1:100,000 epinephrine). Postoperatively, the patient was placed on penicillin VK 500 mg (No. 28, four times a day for one week) and a chlorhexidine rinse 0.12% (Periogard Rinse [Colgate]) (30 seconds, 2 times a day for 2 weeks).
Evaluations were performed initially at 2 weeks (visual only), at 3 months (radiographic only), and at 8 months (radiographic and clinical probing). Initial healing was excellent at 2 weeks with no recession and the presence of a healthy pink gingival condition. The radiographic evaluation at 3 months (Figure 2), showed an approximate 75% osseous fill of the defect. The final evaluation at 8 months (Figure 3) showed complete radiographic osseous fill of the defect with probing depths reduced to 2 mm at the previous diseased sites and no gingival recession, yielding a 5 mm gain in clinical attachment. Mobility dropped from 2+ to +.

CASE 2 
Findings
A 63-year-old male was referred by his GP for removal of an existing 3-unit PFM bridge on the mandibular right. Also requested was the simultaneous extraction of the first molar, deemed by the GP as nonsalvageable due to a large endo-perio lesion stemming from failed endodontic therapy (Figure 4). The treatment was also to include concurrent bone grafting of the extraction site and the subsequent placement of 2 implants 6 months later.

CASE 2

Figure 4. Tooth No. 30 pre-op, endo-perio lesion. Figure 5. Tooth No. 30, 3 months post-op. Figure 6. Tooth No. 30, 18 months post-op.

Treatment Protocol and Results
After discussion of his options, a decision was made to attempt to save the tooth in order to avoid extensive and costly restorative treatment. This decision was made knowing and accepting that failure of the chosen procedure would necessitate implementation of the original treatment plan. This was to be done with the LANAP protocol only. No endodontic retreatment was planned.
Initial clinical probing was done to serve as a comparison with the eventual final results. The probing procedure confirmed a considerable amount of loss of bone in the jaw, well past the apices of the molar at the buccal and lingual furcations.
A procedure using the PerioLase MVP-7 and LANAP protocol was done under local anesthetic using lidocaine HCL 2% (1:100,000 epinephrine). Postoperatively, the patient was placed on penicillin VK 500 mg (No. 28, four times a day for one week) and a chlorhexidine rinse 0.12% (for 30 seconds, 2 times a day for 2 weeks).
Evaluation of the results was done at 3 months (radiographic only) (Figure 5) and 18 months (radiographic and clinical probing) (Figure 6). The radiographic evaluation at 3 months showed significant bony fill of both the apical and furcal areas of the molar. At 18 months (Figure 6), further consolidation of the apical and furcal areas was evident, with both the buccal and lingual furcation probing at just 6 mm.

CASE 3

 Findings
A 45-year-old male was referred by his GP for periodontal treatment of his remaining mandibular teeth. These included the left second premolar through the right second premolar. Pocketing around these teeth ranged from 6 to 10 mm. The deepest pockets were associated with a lateral periodontal cyst on the mesial aspect of the mandibular right canine, corresponding to a large circumferential intrabony defect (Figure 7). Three-wall intrabony defects, along with associated 7 mm pocketing, were evident radiographically on the distal aspect of the mandibular left second and, less prominently, on the first premolar (Figure 8), corresponding with 4 mm of clinical attachment loss.

CASE 3

Figure 7. Tooth No. 27 pre-op periodontal defects. Figure 8. Teeth Nos. 20 and 21, pre-op. Figure 9. Teeth Nos. 20 and 21 8 months post-op. Figure 10. Tooth No. 27, 8 months post-op.

Treatment Protocol and Results
The LANAP protocol, using the PerioLase MVP-7, was employed to treat the 8 teeth under local anesthetic, lidocaine HCL 2% (1:100,000 epinephrine). Postoperatively, the patient was placed on penicillin VK 500 mg (No. 28 four times a day for one week) and chlorhexidine rinse 0.12% (30 seconds 2 times a day for 2 weeks). An initial visual evaluation was performed at 2 weeks postoperatively; followed by radiographic evaluation with clinical probing evaluation at 9 months, during one of the patient’s recall appointments. Complete fill of the 3-wall defects on the premolars was radiographically evident (Figure 9). Pocketing had been reduced from a preoperative measurement of 7 mm to 2 mm postoperatively, with a clinical attachment gain of 5 mm. The mandibular right canine also experienced significant fill of its osseous defect; pocketing had been reduced from up to 10 mm preoperatively to 4 to 6 mm postoperatively (Figure 10).

CASE 4

Findings
A 19-year-old female presented to our office without a referral. She reported that she had experienced “bleeding from her gums” since the previous night following a dental hygiene appointment at another office. Clinical evaluation revealed torn gingiva around the mandibular anterior sextant with a liver clot present on the lingual aspect of the teeth (Figures 11 and 12). We found 3 mm of root recession on the facial aspect of the right central incisor, caused by a frenum pull. The papillae had been traumatized to the point that they were lost, leading to a compromised aesthetic situation that could not be overcome with treatment.

CASE 4

Figure 11. Pre-op facial Nos. 22 to 27. Figure 12. Pre-op lingual Nos. 22 to 27. Figure 13. Immediate post-op facial Nos. 22 to 27. Figure 14. Immediate post-op lingual Nos. 22 to 27. Figure 15. Three-week post-op lingual Nos. 22 to 27. Figure 16. Three-week post-op facial Nos. 22 to 27.

Treatment Protocol and Results
Restoration of the patient’s gingival health and soft-tissue architecture was imperative as was the need to minimize any further loss through treatment. A connective tissue graft was planned following adequate healing for root coverage on the central incisor and for the elimination of the frenum pull. The PerioLase MVP-7 was utilized in conjunction with careful scaling/root planing to restore the health and architecture of the gingiva. This was accomplished under local anesthetic with lidocaine HCL 2% (1:100,000 epinepherine). The immediate postoperative photos (Figures 13 and 14) show how the technique was able to accomplish this. At the 2-week evaluation, complete gingival health had been achieved (Figures 15 and 16). Removal of any residual calculus was easily accomplished at this point. (The patient did not return for the graft.)

CLOSING COMMENTS
The PerioLase MVP-7 system and LANAP protocol have created a paradigm shift in the way we should be viewing our cases and treating our patients. Rather than subject individuals to more invasive procedures (at times requiring the introduction of foreign substances), we can provide a much less invasive service yielding exceptional results. We can do this by utilizing the patient’s own cells to regenerate periodontal defects, thus salvaging cases that would have never before been considered as candidates for intervention. This results in negligible or no recovery time, allowing for patients to quickly return to their normal activities (work, etc). In addition, this treatment protocol also increases the likelihood of patient acceptance by eliminating the “fear factor.”
As practitioners, we can now provide an extremely valuable service for those who would otherwise not seek care and continue to languish with untreated conditions negatively impacting both their comfort and overall health.

Dr. Mangot received his doctor of dental medicine degree in 1987 and his certificate in periodontics in 1990 from the University of Medicine and Dentistry of New Jersey, New Jersey Dental School. He is a Diplomate of the American Board of Periodontology. He has maintained a private practice limited to periodontics and implants in Clifton, NJ, for the past 22 years. He was formally trained in the LANAP protocol and the PerioLase MVP-7 at the headquarters of Millennium Dental Technologies, Inc, in Cerritos, Calif, and is a contributor to their newsletter. He can be reached at healthygumsnj@gmail.com.

Disclosure: Dr. Mangot reports no disclosures.

The question, “Should I treat and preserve or should I extract and place an implant?” is best answered via evidence-based assessment and treatment planning, which begins with gauging the expectations and commitment level of your patient.

For example, if a patient comes in and says, “I want to do anything possible to save my natural teeth,” chances are you will get a high level of compliance for long-term periodontal treatment, at-home oral care, and continued periodontal maintenance.

Equally important is a patient’s willingness to undergo, and ability to afford maintenance therapy every 90 days. This is critical to achieving positive patient outcomes, because the maturation of bacterial plaque occurs within 90 days and the patient becomes disease-active again.¹

But when your patient makes statements such as “I hate going to the dentist,” or “I’ll never do that again,” it’s a definite red flag. If they say, “My insurance only pays for 2 cleanings a year,” that’s another warning sign. The bottom line is this: you can be a superstar in intricate periodontal procedures and grow bone in places where no other dentist can, but if you keep getting long-term treatment and insurance coverage objections, your success is unlikely.

Figure 1. Extraction versus conservation.3

Unfortunately, many specialists and general practice dentists alike are becoming “quick to extract.” Part of this is due to a 2-pronged campaign by the implant manufacturers. On one front, they wine and dine dentists and provide free training and continuing education credits. On the second front, they blitz the consumer media with the promise of “teeth in a day.”

The consumer marketing is prompting more and more patients to request implants rather than long-term therapy. What they don’t realize is that dental implants are not a “set it and forget it” solution; peri-implantitis has a prevalence rate ranging from 11.3% to 47.1% of implant patients.²

Figure 2a. Preoperative radiograph of tooth No. 19.	Figure 2b. A residual pocket depth of 7 mm existed on the distal of tooth No. 19.
Figure 3a. Implant tooth No. 30.	Figure 3b. Implant crown.

These are the major factors influencing clinicians and patients alike in opting for extraction and implants rather than preserving natural dentition. But even if a patient is ready, willing, and able to do whatever it takes and whatever it costs to save his or her teeth, further evidence-based analysis must be conducted to determine which course of treatment is truly best for the patient.

It takes a lot of patient education to offset the “teeth in a day” hype, and this is best achieved by forging strong relationships between general dentists and periodontists, who, in turn, need to maintain a united front in explaining treatment options to their comanaged patient in an objective manner, and work together toward the common end result of a positive patient outcome.

In my practice, I refer to the “Extraction Versus Conservation Decision Chart” developed by Avila et al3 to assess the patient’s condition and predict whether or not long-term periodontal therapy will be successful, or, in the patient’s eyes, an uncomfortable waste of time and money (Figure 1).

The decision chart contains 6 levels of detailed analysis for the following principal areas of assessment:

1. Initial assessment
2. Periodontal disease severity
3. Furcation involvement
4. Etiologic factors
5. Restorative factors
6. Other determinants.

As you can see, each of these principal areas contains several subcategories of analysis that are weighted and averaged to help the clinician determine 3 main evidence-based conclusions:

1. Long-term survival: unfavorable
2. Proceed with caution: recommended
3. Long-term maintenance: favorable.

Decision chart analysis leading to conclusion No. 1 would strongly suggest extraction. No. 2 indicates that treatment is feasible; but if it fails, extraction is advised. Conclusion No. 3, although alluding to a positive outcome, may default to No. 1 if the patient rejects the treatment plan for financial or other reasons.

This decision tree chart was used to evaluate the patient and ultimately plan and perform the following case scenario.

EVIDENCE-BASED CASE REPORT
Diagnosis and Treatment Planning
The patient, a 53-year-old white female, presented to my office requesting a comprehensive care program so that she could get re-established in a periodontal cleaning regimen. Her medical history was noncontributory. She takes no medications, some vitamins, and has no drug allergies. Her social history is negative for smoking, and she consumes 3 to 4 alcoholic beverages per week.

Her previous dental history includeed periodontal surgery in the lower quadrants, and nonsurgical therapy in the upper quadrants. Bone grafts were placed in a few areas in the lower molar areas. She has had no maintenance therapy in more than one year. Her initial periodontal exam revealed heavy subgingival calculus ,especially in the posterior areas.

Radiographs indicated that there was generalized horizontal bone loss in the maxillary arch ranging from 10% to 30%, and an isolated vertical defect on the distal of tooth No. 19. Tooth No. 19 had been grafted about 3 years prior to my examination. A residual pocket depth of 7 mm existed on the distal of No. 19 (Figures 2a and 2b).

Tooth No. 30 had been extracted almost 2 years ago, after being deemed hopeless by her previous periodontist. The patient reported that the tooth was not doing well periodontally, and her dentist thought it was also cracked, which was confirmed after extraction. The patient knew that she needed additional periodontal therapy, and also agreed to have tooth No. 30 replaced with a dental implant and PFM crown.

Treatment Protocol
Conventional periodontal osseous surgery was performed in the upper arch, scaling and root planing was administered with hand and ultrasonic instruments with the addition of local delivery antibiotics in No. 19 (Arestin) and a dental implant (Straumann Tissue Level SLActive) was placed in the position of tooth No. 30 (Figures 3a and 3b).

The patient and I discussed the importance of a 3-month maintenance interval to control her inflammatory response. Tooth No. 19 will continue in maintenance therapy that will include scaling and root planing and may require additional surgical therapy depending on whether probing depths increase, there is persistent bleeding upon probing, or radiographic evidence of decreased bone mass levels.

Closing Comments
The patient is enthusiastic about keeping her remaining teeth, even with the potential for additional surgical therapy.

This brief case report article provides an example of how treatment decisions are made in a periodontally compromised dentition. We should always refer back to the evidence in the existing literature, and perform regular thorough examination of our periodontitis patients.⁴

References

1. Cohen RE; Research, Science and Therapy Committee, American Academy of Periodontology. Position paper: periodontal maintenance. J Periodontol. 2003;74:1395-1401.
2. Koldsland OC, Scheie AA, Aass AM. Prevalence of peri-implantitis related to severity of the disease with different degrees of bone loss. J Periodontol. 2010;81:231-238.
3. Avila G, Galindo-Moreno P, Soehren S, et al. A novel decision-making process for tooth retention or extraction. J Periodontol. 2009;80:476-491.
4. American Academy of Periodontology. Comprehensive periodontal therapy: a statement by the American Academy of Periodontology. J Periodontol. 2011;82:943-949.

Dr. Masters earned her dental degree from The University of Texas Health Science Center at San Antonio (UTHSCSA) and continued her education at the dental school with a 3-year specialty program in periodontics. She is a board-certified periodontist whose expertise is in the diagnosis and treatment of all types of gum diseases and performing both aspects of surgical and nonsurgical therapy. She is certified to use several types of sedation to alleviate anxiety in patients concerned about their surgical therapy. Dr. Masters is a member of the American Academy of Periodontology, the International Congress of Oral Implantologists, the American Dental Association, Southwest Society of Periodontists, and the Texas Society of Periodontists. She is also a clinical associate professor at the UTHSCSA Dental School. She can be reached at mastersdds@mdgteam.com.

Disclosure: Dr. Masters reports no disclosures.

ORAL-BODY INFLAMMATORY CONNECTION
The connection between dental disease and cardiac disease has been recently documented. In 2005, after studying the relationship between periodontal bacteria and atherosclerosis (narrowing of the carotid arteries), Desvarieux et al² reported that periodontal disease can contribute to cardiovascular disease (CVD) and can be a major risk for death. He also showed that chronic periodontal disease may be a possible cause of CVD.
A paper published in 2010 in the British Medical Journal³ correlated tooth brushing, inflammation, and the risk of CVD from a Scottish Health Survey. Close to 12,000 participants, both men and women, with a mean age of 50 years, were studied. Oral hygiene was assessed from the self-reported frequency of tooth brushing. The reported poor oral hygiene was associated with a higher risk of low-grade inflammation and higher levels of CVD.
Because of the oral-body inflammatory connection (OBIC), clinical treatment studies have been performed to evaluate the effect that treatment of periodontal disease has on the degree of heart disease present. In April 2009, Piconi et al⁴ published a study showing that the treatment of periodontal disease reduced the narrowing of the carotid artery and resulted in an improvement in the atherosclerosis.
Slepian and Gottehrer5 in 2009 described the OBIC and discussed many of the inflammatory enzymes as being involved in patients with CVD. This has finally led to an understanding of how periodontal disease develops and progresses, leading to technology which now allows the disease to be stabilized and controlled. The following year, they authored a guide entitled Evaluation and Management of the Oral Body Inflammatory Connection Resource Guide. (This guide was published as a courtesy for all the practicing dentists in the United States by Chase Health Advance Financing Options.) It describes in detail both this critical connection and the effective, nonsurgical management of periodontal disease.
In September 2010, the US Centers for Disease Control and Prevention, Division of Oral Health completed a National Health and Nutritional Examination Survey (NHANES) published in the Journal of Dental Research,⁶ which found gum disease to be a significant health concern. NHANES has historically been the main source for determining the status of periodontal disease in the US adult population. Comprehensive periodontal exams were conducted on more than 450 adult patients over the age of 35 years. The prevalence rates were compared against previous NHANES studies, which only used a partial mouth periodontal exam. The previous studies had shown prevalence of both gingivitis and periodontitis as high as 56% in adults. The present study found that the original methodology may have understated the disease prevalence by up to 50%. These figures could easily be interpreted to represent periodontal disease as the most common disease present in the body today.

Figure 1. Stat-Ck Periodontal Risk Assessment documentation record used for periodontal risk assessment at the initial visit.

ORAL BACTERIA CAN RESULT IN BLOOD CLOTS
A recent study in 2010⁷ has discovered how bacteria in the mouth that results in tooth decay can also cause blood clots. While the study was conducted in small lab animals, it was hypothesized that poor dental hygiene conditions could lead to bleeding gums, providing the bacteria, even in gingivitis, an escape route into the blood stream. It can initiate blood clots resulting in heart disease. Streptococcus bacteria, normally present in the oral biofilm, can result in both gum disease and tooth decay. Upon entering the bloodstream through bleeding gums, they produce a protein that brings together platelets from the blood to form a clot which results in thrombosis.

THIRD PARTY VERIFICATION OF DISEASE
Considering the risk of these diseases, it is important for all patients (even those who present without active symptoms of disease) to see for themselves in the dentist’s office verification of how dental care can reduce the serious risk of disease. The simplest way to illustrate this is through third-party verification. Short duration (one to 2 minutes) in-office patient education video programs (such as CAESY [Patterson Dental]) illustrate the connections and provide verification of what the dentist/hygienist has said, confirming the need for periodontal management. Patients who have viewed these videos often comment that they wish they had been presented with this very important information earlier in life; they know that it might have prevented them from developing and suffering from their current problem.

PERIODONTAL RISK ASSESSMENT
Since less than 10% of patients who have periodontal disease are receiving treatment, a periodontal risk assessment should be performed on all new and existing patients. A common assessment now being used by many dentists is the Stat-Ck Periodontal Risk Assessment (PRA) It was developed in 2002 by Gottehrer and Shirdan.⁸ The first part of the assessment records a history of smoking, history of heart disease, medications taken, and for females, any hormonal problems.
The risk assessment is designed to provide information for both the dentist and patient concerning the present periodontal status. It is done to determine if there is active disease present by examining all the teeth circumferentially with a periodontal probing; grading each of the quadrants following the traditional test format of A to F. A is asymptomatic; B presents with bleeding; C with calculus above the gum; D with deposits below the gum; and F signifies a failing area. The categories are listed and described in the risk assessment chart, as pictured in Figure 1. The patient must participate in the screening probing by observation with a full-size patient mirror. When active disease is present, patients will see bleeding from the periodontal tissue which most likely they have not even seen when brushing. This can be the most positive confirmation of the presence of disease, affirming the need for interventional treatment.
The Stat-Ck PRA replaces the periodontal screening and recording as a screening test with actual results recorded rather than a recommendation for further evaluation. Unlike a traditional 6-point probing which must be performed once the patient begins treatment, the A to F format is more easily understood by patients, thus allowing a simple way for them to understand their current periodontal status. The patient should participate in the screening probing, observing bleeding from the periodontal pocket that occurs when the probing is done; remember that this bleeding may not have been seen with routine brushing/flossing of the same areas. This confirms for the patient that active disease is present. Once the probing is completed, it must be explained to the patient that this bleeding is not normal.
The Stat-Ck PRA explains the results of the screening, with suggestions for treatment for each category. It can include suggestions for removal of hopeless teeth and placement of crowns, or appropriate restorations to control and/or reduce risk for recurrent decay.

ROLE OF THE PERIODONTIST
A major resource impacting patient acceptance of this critical treatment is the periodontist. More periodontists are increasingly playing an active role in the management of the patient when nonsurgical care is the treatment plan. Many are even offering complimentary verifications to assist the patient in decisions with regard to treatment.
Since periodontal disease now appears to have a possible systemic impact on our patients’ health, a team approach to care involving both the periodontist and general practitioner as well as the hygienist is even more critical. Periodontists can also help to provide regenerative treatment to supplement nonsurgical care, whenever required. The whole team can provide treatment that stabilizes function and can now effectively control the active disease long-term.

Figure 2. Host response to bacterial antigens produces periodontal breakdown. (Reprinted from: Gottehrer N. Managing Risk Factors in Successful Nonsurgical Treatment of Periodontal Disease. Dent Today. 2003;22:64.)

In 1997, Kornman et al9 first summarized the various host-derived mediators present in both the gingival crevicular fluid and periodontal tissues that may contribute to periodontal tissue destruction, including cytokines that mediate inflammation, active osteoclasts that destroy bone, and matrix metalloproteinases (MMPs) which breakdown major structural tissue in the periodontal complex (Figure 2). Golub and associates,¹⁰ in 1994, developed subantimicrobial dose doxycycline (SDD) (20 mg twice per day) to treat periodontal disease by blocking these tissue-destructive enzymes.
In 2007, Caton et al¹¹ described periodontal treatment with this SDD drug to improve the efficacy of scaling/root planing in adult patients with periodontal disease. It can now be considered the standard of care for nonsurgical periodontal treatment in reducing the dental risk for cardiac disease.¹² This standard of care allows for anticipated, predictable, and successful long-term stabilization of the patient’s periodontal condition. A standard of care for the nonsurgical management of periodontal disease is required if dentists are to provide highly predictable results in periodontal management; the future of successful dental care.
This suggests that dentists should use site-specific treatment to manage periodontal disease, supported by evidence-based technology. This includes the use of toothpaste and mouthwash with power hygiene devices, including battery operated tooth brushes and electric powered water irrigators, such as the new Waterpik Water Flosser (WP-100), ultrasonic and hand instrumentation and placement of time released locally applied antimicrobial drugs below the gingival margin into periodontal pockets with 5 mm of depth or more and bleeding on probing. While use of interproximal cleaning with dental floss is still encouraged, recent evidence shows that use of a powered toothbrush appears to be as effective as manual brushing combined with interproximal cleaning.¹³ Predictable and successful long-term stabilization of the patient’s periodontal condition now relies on this specific home hygiene management program. This must be done at least twice per day to remove the offending bacteria both above and below the gingival margin.
Water irrigation (“water flossing” [Water Flosser]) should be done immediately following brushing if removal of all the offending bacteria is to be achieved. It has been shown to outperform traditional flossing with recent clinical research confirming that the Water Flosser is twice as effective as string floss in reducing gingival bleeding after 14 days of use.¹⁴ It has also been shown to significantly reduce plaque biofilm, gingivitis, and bleeding and pocket depth in periodontal patients. In addition, it has also been proven to reduce cytokines in the gingival crevicular fluid; it produced a host modulation effect by reducing interleukin (IL) 1 and Prostaglandin E2, cytokines associated with bone and attachment loss, raising IL-10, an anti-inflammatory agent. It has been proven that the addition of the Water Flosser to the patient’s armamentarium for use in carrying out daily oral hygiene inhibits the activity of periodontal disease and significantly improves periodontal health.¹⁵

IMPACT OF SYSTEMIC DRUG MANAGEMENT ON PERIODONTAL HEALTH
In March 2011, Payne et al¹⁶ completed a 2-year study using SDD to reduce systemic biomarkers including serum inflammatory MMP and high sensitivity C-reactive protein (hsCRP). There was also a statistically significant increase in high-density lipoprotein (good) cholesterol in women more than 5 years postmenopausal. Alveolar bone density loss was reduced. Clinical attachment levels were stabilized. SDD and periodontal maintenance decreases the odds of more progressive periodontitis by 19% relative to placebo.
Ridker et al¹⁷ did significant research to identify hsCRP as a systemic inflammatory biomarker, reporting it to be more predictive of cardiovascular events than elevated low-density lipoprotein cholesterol levels.

LOCAL DELIVERY OF SITE-SPECIFIC ANTIMICROBIAL DRUGS
The local delivery of antimicrobials, such as Arestin (Orapharma), offer the dentist a statistical and significant system for the treatment of periodontitis.18 The Agency for Health Care Research and Quality (the federal agency assigned to improve quality, safety, efficiency, and effectiveness of healthcare) evaluated literature on these antimicrobials in 2004.¹⁹ They concluded that scaling/root planing, when accompanied by the placement of an antimicrobial agent (Arestin) as a supplement or adjunct treatment, resulted in an improved clinical outcome in adults with chronic periodontitis. (This was compared to scaling/root planing that was done alone.) Systemic and locally placed antimicrobial drugs are therefore suggested for use when active disease is detected. They have clearly shown in the studies mentioned to be of significant help in resolving the diseased condition and restore periodontal health as quickly as possible.
Patients usually understand medical treatment with medication. It is a natural addition to periodontal treatment, following the medical model. These drugs can be used on a routine basis as a standard of care, in successfully managing periodontal disease.

ROLE OF PROBIOTICS IN MANAGING PERIODONTAL DISEASE
Periodontal disease may be impacted by the use of new probiotic products, such as GUM PerioBalance (Sunstar Americas) and Evora Plus (Oragenics). Probiotics consist of microorganisms in oral tablet/lozenge form that confer a health benefit to the patient. Current research has indicated that periodontal disease may be impacted by probiotics through the reduction of the body’s inflammatory mediators. Twetman et al²⁰, in 2009, using 2 strains of Lactobacillus reuteri, found that there was a reduction in bleeding on probing and the amount of cytokines present in the gingival crevicular fluid, a reduction in the periodontal inflammatory response. This may help to reduce oral disease. GUM Perio Balance is designed to be used once daily, immediately following flossing and brushing. The lozenge dissolves in the mouth in 10 minutes, and it is recommended that nothing be used in the mouth immediately after the use of the lozenge for 30 minutes (Figure 3).

Figure 3. Monthly oral probiotic lozenge system (GUM PerioBalance [Sunstar Americas]) for once-a-day use.	Figure 4. Gold collar (Captek crown [Precious Chemicals]) submerged in subgingival margin.

EFFECT OF NONSURGICALINSTRUMENTATION ON PERIODONTAL DISEASE
In order to obtain a predictable and stable periodontal condition, using the mechanical hygiene techniques and the SDD and the suggested site-specific antimicrobials, mechanical instrumentation with scaling and root planing is required. A 2002 literature review²¹ of mechanical instrumentation exclusively confirmed that pockets measuring 4 to 6 mm experienced a mean reduction probing depth of 1.29 mm with an additional net gain in attachment of 0.55 mm. Periodontal pockets with an initial probing depth of greater than 7 mm experienced reduction of mean probing depth of 2.16 mm and a gain in attachment of 1.19 mm.
A 6-month randomized, multicenter, placebo-controlled, examiner-masked study was undertaken by Novak et al²² in 2008. They evaluated the clinical usefulness of a combination treatment of systemically delivered SDD twice per day, plus locally delivered antimicrobial, in combination with scaling and root planing, versus scaling and root planing and placebo (control group) on clinical measures of periodontal disease. The study’s results support the use of a combination of adjunctive therapies for the nonsurgical management of chronic periodontitis. At 6 months, 3 times as many subjects in the combination group had no residual pockets less than 5 mm, compared to the placebo control group. Pocket depth reduction to less that 5 mm occurred more rapidly and more extensively with combination therapy.

PAINLESS MANAGEMENT OF DISEASE
One barrier to consumer acceptance of even conservative nonsurgical periodontal treatment is still the fear of pain. Treatment must be provided painlessly, if at all possible. In order to achieve this, analgesia must be used. It has been estimated that 15% of the US population declines dental care primarily because they fear oral injections.²³ Nitrous oxide/oxygen analgesia relaxes patients and reduces their anxiety enough to allow treatment without pain. New technology allows the use of digital flow meters, such as the Porter Instrument Conscious Sedation Flowmeter. To achieve a successful result, analgesia must be available for the patients who require it. A recent innovation (developed by the author) using topical anesthetic spray (such as Hurricane [Beutlich Pharmaceutical]) and a light-cured extended contact topical fluoride varnish (such as Vanish XT [3M ESPE]), makes it possible to perform scaling/root planing without having to use injectable local anesthetics. Previously sensitive roots, which could only be instrumented after administering local anesthetic, can now be treated after a single application of Vanish XT. After being light-cured, the fluoride varnish seals the roots with a durable layer of protection, thus relieving dentinal hypersensitivity and permitting the painless instrumentation and removal of all deposits. Being able to control root sensitivity, while improving the integrity of the root of the tooth where the toxic bacteria collects, gives the dentist/hygienist the opportunity to help control the risk of disease. Reduction of this sensitivity via an extended contact topical fluoride varnish (that can last up to 6 months) can also help to improve patient compliance for performing the required at-home daily hygiene routine; thus making it easier to control the chronic disease risks and improving the future success of dental care.

PERIO IMPLICATIONS OF RESTORATIVE MATERIALS AND MARGIN PLACEMENT
Dental crown restorations are considered a major contributing factor in the etiology of periodontal disease. Löe²⁴ in his classic 1968 paper, reviewed the reactions of the periodontal tissues to restorative procedures. His paper reviewed the reactions of the periodontal tissues and the effect of certain restorative materials on the periodontal tissues.
While optimal periodontal health is expected to the improve success of dental care, it cannot overcome the effect of a crown restoration that extends into the subgingival area and may be responsible for causing damage to the periodontal tissue. This can occur by increasing the possibility for mechanical retention of bacteria and/or by a direct irritation effect from using a restorative material that retains more dental plaque.
Amsterdam²⁵ wrote a classic treatise on periodontal prosthesis more than 30 years ago, establishing the standard of care for a crown. He described the optimal margin/finish line which should be placed in a healthy sulcus at a minimal depth, just shy of the junctional epithelium. In guidelines still followed today, he suggested that to prevent plaque buildup, it is necessary to create optimal crown contours with proper coronal form, embrasure form, and subgingival fit at the margin.
If periodontal health is to be considered the future of success for dental care, it is imperative to use restorative materials which can help maintain a healthy periodontium. Captek (Argen) provides one example of a cosmetic (crown) restorative material that is compatible with excellent periodontal health, helping to satisfy the goal of optimal tissue health. This ceramometal crown incorporates the use of a unique metal composite gold cosmetic coping. The metal can be extended to the edge, developed into a collar, or cut back from the margin for a ceramic butt margin depending on the preparation, margin placement, and/or underlying prep tooth color. When the Captek gold was in the approximation of the margin, Goodson et al²⁶ were able to document a reduction of up to 91% in the number of bacteria surrounding this tooth versus normal tooth surfaces in the same mouth. In addition, they documented 96% less bacterial adhesion compared to conventional ceramic-fused-to-noble-metal crown restorations. These crowns have been described by the author as the “periodontal crown,”²⁷ since healthy tissue can be achieved from placement of the 22K gold margin against the subgingival tissue on any periodontally-affected tooth (Figure 4).
For success to be achieved in dental care, it is essential that materials be fabricated in a manner that makes every attempt to develop periodontally healthy crowns, so as to prevent and/or reduce tissue inflammation. With the introduction of zirconia metal-free crowns, produced from pucks made from high quality zirconia powder (produced by TOSOH), the author employs a coping design modification to maximize soft-tissue health and protection against inflammation. One benefit of zirconia crowns is that they can be adapted to accommodate multiple finishlines at the margin, much like a traditional PFM. The “Periodontal Collar” for zirconia crowns was designed by the author and fabricated by Shaun Keating, owner of Keating Dental Arts Lab. (This dental laboratory was selected by Dr. Gottehrer based on its ability to reengineer new technology successfully.)
The collar is designed to allow removal of bacterial plaque on a regular basis to maintain optimal periodontal health. The subgingival collar is polished using a special material and, because of the special polishing process a very smooth surface is established.
Preliminary observations by Dr. Gottehrer and Keating Dental Arts Lab, with insertion of 50 Periodontal Collar zirconia crowns, have produced healthy gingival responses. The zirconia can be made in a CAD/CAM environment and offers benefits in the way of high hardness factors and fracture resistance. Becoming more familiar with the healthiest coping designs can create optimal periodontal health resulting in long-term success.
Restoring a tooth with compromised periodontal health with an appropriate full-crown, using modern materials that are shown to reduce the risk of additional plaque retention or a negative inflammatory response, should now be considered the treatment of choice for maintaining prolonged dental health.

DENTAL IMPLANTS: HEALTH RISKS OF MISSING TEETH
A Swedish study, completed in 2010, examined the number of teeth a patient has as a predictor of cardiac mortality.²⁸ A group of 7,674 patients were followed for 12 years. The study results showed a relationship between the number of teeth and cardiovascular disease. There was a 7-fold increased risk for mortality from cardiovascular heart disease in subjects with fewer than 10 teeth, as compared to those with more than 25 teeth.
With the knowledge that there can be a very strong connection between periodontal disease and CVD, it is very important to consider permanent replacement of teeth lost to disease. This must now be considered an important part of restoring periodontal health. It can allow the dentist to restore health to a mouth suffering from the loss of permanent teeth.
With the development of new designs in dental implants, such as seen with Hiossen, it is possible to immediately place implants at the time of extraction and often, because of design, immediately load these implants with a prefabricated abutment post and temporary crown. It is also possible, with the new modified designs such as platform loading, to prevent periodontal destruction and bone loss, which was previously observed in implants used without this design.29

CLOSING COMMENTS
The future of periodontics and the opportunity to improve success for dental care is very promising. There also appears to be a great opportunity to reduce certain medical risks with periodontal care, and for dentists to work in concert with physicians to reduce certain risks.
With periodontal risk assessments and screening exams done for patients who need treatment and/or have serious medical conditions, which may be improved, or have risk reduced with periodontal care, team management from the dentist and physician is a reality. The anticipated outcome of successful dental care may benefit everyone, the end results being a healthier population, lowered costs of medical care, and possibly a longer, more comfortable life.

References

1. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
2. Desvarieux M, Demmer RT, Rundek T, et al. Periodontal microbiota and carotid intima-media thickness: the Oral Infections and Vascular Disease Epidemiology Study (INVEST). Circulation. 2005;111:576-582.
3. de Olivera C, Watt R, Hamer M. Toothbrushing, inflammation, and risk of cardiovascular disease: results from Scottish Health Survey. British Medical Journal. 2010;340doi:10.1136/ bmj.2451.
4. Piconi S, Trabattoni D, Luraghi C, et al. Treatment of periodontal disease results in improvements in endothelial dysfunction and reduction of the carotid intima-media thickness. FASEB J. 2009;23:1196-1204.
5. Slepian M, Gottehrer NR. Oral-body inflammatory connection. Dent Today. 2009;28:140-142.
6. Eke PI, Thornton-Evans GO, Wei L, et al. Accuracy of NHANES periodontal examination protocols. J Dent Res. 2010;89:1208-1213.
7. Petersen HJ, Keane C, Jenkinson HF, et al. Human platelets recognize a novel surface protein, PadA, on Streptoccocus gordonii through a unique interaction involving fibrinogen receptor GPIIbIIIa. Infect Immun. 2010;78:413-422.
8. Gottehrer NR, Shirdan TA. A new guide to nonsurgical management of periodontal disease. Dent Today. 2002;21:54-59.
9. Kornman KS, Page RC, Tonetti MS. The host response to the microbial challenge in periodontitis: assembling the players. Periodontol 2000. 1997;14:33-53.
10. Golub LM, Wolff M, Roberts S, et al. Treating periodontal diseases by blocking tissue-destructive enzymes. J Am Dent Assoc. 1994;125:163-169.
11. Caton JG, Ciancio SG, Blieden TM, et al. Treatment with subantimicrobial dose doxycycline improves the efficacy of scaling and root planing in patients with adult periodontitis. J Periodontol. 2000;71:521-532.
12. Gottehrer NR, Martin JL. The standard of care for nonsurgical periodontal treatment for reducing the dental risk for cardiac disease. Dent Today. 2007;26:100-104.
13. Axelsson P. Mechanical plaque control by self-care. In: Axelsson P. Preventive Materials, Methods, and Programs, Volume 4. Chicago, IL: Quintessence Publishing; 2004:80-101.
14. Barnes CM, Russell CM, Reinhardt RA, et al. Comparison of irrigation to floss as an adjunct to tooth brushing: effect on bleeding, gingivitis, and supragingival plaque. J Clin Dent. 2005;16:71-77.
15. Cutler CW, Stanford TW, Abraham C, et al. Clinical benefits of oral irrigation for periodontitis are related to reduction of pro-inflammatory cytokine levels and plaque. J Clin Periodontol. 2000;27:134-143.
16. Payne JB, Golub LM, Stoner JA, et al. The effect of subantimicrobial-dose-doxycycline periodontal therapy on serum biomarkers of systemic inflammation: a randomized, double-masked, placebo-controlled clinical trial. J Am Dent Assoc. 2011;142:263-273.
17. Ridker PM, Rifai N, Rose L, et al. Comparison of C-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med. 2002;347:1557-1565.
18. Killoy WJ. The clinical significance of local chemotherapies. J Clin Periodontol. 2002;29(suppl 2):22-29.
19. Bonito AJ, Lohr KN, Lux L, et al. Effectiveness of antimicrobial adjuncts to scaling and root-planing therapy for periodontitis. Summary, Evidence Report/Technology Assessment No. 88. Rockville, MD: Agency for Healthcare Research and Quality; January 2004. ahrq.gov/ clinic/epcsums/periosum.htm. Accessed September 8, 2011.
20. Twetman S, Derawi B, Keller M, et al. Short-term effect of chewing gums containing probiotic Lactobacillus reuteri on the levels of inflammatory mediators in gingival crevicular fluid. Acta Odontol Scand. 2009;67:19-24.
21. Cobb CM. Clinical significance of non-surgical periodontal therapy: an evidence-based perspective of scaling and root planing. J Clin Periodontol. 2002;29(suppl 2):6-16.
22. Novak MJ, Dawson DR III, Magnusson I, et al. Combining host modulation and topical antimicrobial therapy in the management of moderate to severe periodontitis: a randomized multicenter trial. J Periodontol. 2008;79:33-41.
23. Capps Bowman Padgett and Associates. Dental phobia. cappsbowman.com/sep/greenville-dental-phobia.htm. Accessed September 8, 2011.
24. Löe H. Reactions of marginal periodontal tissues to restorative procedures. Int Dent J. 1968;18:759-778.
25. Amsterdam M. Periodontal prosthesis: Twenty-five years in retrospect. Alpha Omegan. 1974;67:8-52.
26. Goodson JM, Shoher I, Imber S, et al. Reduced dental plaque accumulation on composite gold alloy margins. J Periodontal Res. 2001;36:252-259.
27. Gottehrer NR. The periodontal crown: creating healthy tissue. Dent Today. 2009;28:121-123.
28. Holmlund A, Holm G, Lind L. Number of teeth as a predictor of cardiovascular mortality in a cohort of 7,674 subjects followed for 12 years. J Periodontol. 2010;81:870-876.
29. Gottehrer NR. Implant dentistry: replacement of missing teeth with predictable crestal bone levels. Compendium. 2011;32(suppl 1):12-15.

     

Additional Reading
Evaluation and Management of the Oral Body Inflammatory Connection, Resource Guide recently written by Neil R. Gottehrer, DDS, and Marvin J. Slepian, MD, has been printed for the practicing dentist as a courtesy by ChaseHealthAdvance Financing Options. It is available from ChaseHealthAdvance at no charge by calling (888) 388-7633. This resource guide explains in greater detail the process of evaluation and successful management of periodontal disease, and can make it easier for dental practices to achieve positive results with their patients.

Dr. Gottehrer has been in practice in suburban Philadelphia, Pa, for more than 30 years, focusing his practice on cosmetics, implant dentistry, and periodontics. He is a graduate of the University of Maryland Dental School, received his postgraduate periodontal training at the University of Pennsylvania, and is a board-certified periodontist. He teaches the senior elective course in periodontics at the University of Maryland Dental School. He has published and lectured internationally, and is currently the president of the Institute of Advanced Oral and Physical Health in Havertown, Pa. He is the recent recipient of the The William J. Geis Memorial Award from the American Dental Education Association Gies Foundation. He can be reached at (610) 449-9500 or at dr.neilg@verizon.net.

Disclosure: Dr. Gottehrer reports no disclosures.