It is exciting times for our office and for the treatment of gum disease. According to the World Health Organization over 85% of the adult population have some form of periodontal disease (gum disease). To simplify, periodontal disease is caused by bacteria living around the necks of the teeth which pour out their waste products into the gums making them sick. When the tissues of the body get sick they swell and blood flow increases to help fight against infection. Between the teeth there is not very much room for the blood vessels to move in to, so as a consequence the underlying supporting bone dissolves away to make room. When this happens, you have periodontal disease.
In the past, dentistry has treated periodontal disease with cleanings, scaling/root planing, medications and surgery. Recently, dentists have looked for advanced technologies to help treat periodontal disease and one such treatment that has shown excellent results is the Er:YAG/Nd:YAG laser. We are proud to be able to provide our patients with a new periodontal treatment called Wavelength-optimized Periodontal Therapy (WPT invented by Dr. Robert Barr). Sometimes this procedure is confused with another dissimilar, less evolved procedure called Laser-Assisted New Attachment Procedure (LANAP), but whatever you call it, it works!
Laser perio surgery is different from regular surgery in that instead of a sharp knife to peel the gums off of the bone (or teeth) to treat the infected gums (or teeth), a thin laser quartz, glass, or saphire fiber is inserted between the tooth and gum-line to remove the diseased gum tissue, remove the tartar (calculus/plaque), decontaminate the root surfaces, and sterilize the pockets. In addition to performing the surgery, the laser causes minimal swelling and the added affect of “Nd:YAG Biostimulation” to help assist in the healing and calming of the treated area.
I’ve written a pretty neat CareStream/Kodak PracticeWorks note for the WPT procedure that is segmented into Early WPT, Moderate WPT, and Advanced WPT. I’ll show you the advanced note first because the others are just dumbed down versions of the first.
This is the code for Advanced WPT:
<HlthHx> <Consent> The patient has <WPTadv> <Quadrant1> <WPTadv> <Quadrant1> <WPTadv> <Quadrant1> <WPTadv> <Quadrant1> and we will used advanced Wavelength-optimized Periodontal Therapy to treat the patient’s periodontal disease.First Pass: Disease epithelial tissue removed with the Nd:YAG laser (100us pulse, 20Hz, 2.0W) through the sulcuses. Starting at the top of the sulcus with a sweeping motion the diseased epithelium was removed to within 1mm of the bottom of the sulcus.Second Pass: Calculus removal with the Er:YAG laser (50us pulse, 40Hz, 20 mJ) with the 600u flat quartz tip. With light up and down forces the laser tip was used like an explorer to first detect and then remove the calculus off of the surface of the roots. This was done paying particular attention to leave the cementum layer intact for future reattachment of bone. Supplemented where necessary with hand scalers.Third Pass: Dentin/cementum surface modification/detoxification with the Er:YAG laser (50us pulse, 40Hz, 20 mJ) with the 600u radial WPT/PIPS quartz tip. Starting at the top of the sulcus with sweeping motions to the bottom of the pocket dissecting the fibrous attachment to the bone of the 6+mm pockets.Decortication of the 6+mm pockets with an endo explorer 5 to 10 times depending on the size of the pocket to release the osteoblastic stem cells into the clot.Fourth Pass: Clot formation in all pockets >5mm with the Nd:YAG laser (650us pulse, 20Hz, 4.0W). Starting at the bottom of each pocket, activating the laser and drawing it out taking 1-2 seconds, repeating 3-5 time until the blood clot just begins to turn darker.Placed pieces of <membrane> into all the decorticated sites to create a 3 dimensional clot to stabilize, protect the clot from bacterial invasion, and to create a matrix for bone regeneration.Post-op defocused biostimulation with Nd:YAG (650us pulse, 20Hz, 4.0W) X 20-30 seconds per site. <Tolerated> <OHI> Topical anesthetic <Topical> with <AnesNumMg> of <Anesthetic> <AnesthFil> <AnesthBlock> <AnesthMental> <AnesthPulp> <AnesthLig> <AnesthAkin> local anesthetic<CompuDent> <addAnesth> <AnesNumMg> <Anesthetic> <AnesthFil> <AnesthBlock> <AnesthMental> <AnesthPulp> <AnesthLig> <AnesthAkin><CompuDent> Pt informed not to eat food, bite or chew on lips or tongue while anesthetic is still working. <OraVerse> <Next Visit><secNV><secNV><secNV>
Post-op instructions: Peridex mouth rinse b.i.d. after the second day x 2 weeks. The patient was told that this will stain their teeth and that it is easily removed with a post-op prophy. Soft diet X 1 week. No smoking for 6 weeks post-op.Post-op 2-3 minute biostimulation is included with this procedure and is to be done on days 1, 2, 4, 7, and 14.This is considered critical to the overall success of the WPT.
This is the noted filled out as it appears in the patient chart:
Post-op instructions: Peridex mouth rinse b.i.d. after the second day x 2 weeks. The patient was told that this will stain their teeth and that it is easily removed with a post-op prophy. Soft diet X 1 week. No smoking for 6 weeks post-op.Post-op 2-3 minute biostimulation is included with this procedure and is to be done on days 1, 2, 4, 7, and 14. The patient was informed that this is considered critical to the overall success of the WPT.
See “How to Write Carestream/Kodak PracticeWorks Dental Notes: Local Anesthetics” for more information on the anesthesia portion of this note.
This is the code for the Moderate WPT note:
<HlthHx> <Consent> The patient has <WPTmod> <Quadrant1> <WPTmod> <Quadrant1> <WPTmod> <Quadrant1> <WPTmod> <Quadrant1> and we will used moderate Wavelength-optimized Periodontal Therapy to treat the patient’s periodontal disease.
First Pass: Disease epithelial tissue removed with the Nd:YAG laser (100us pulse, 20Hz, 2.0W) through the sulcuses. Starting at the top of the sulcus with a sweeping motion the diseased epithelium was removed to within 1mm of the bottom of the sulcus.
Second Pass: Calculus removal with the Er:YAG laser (50us pulse, 40Hz, 20 mJ) with the 600u flat quartz tip. With light up and down forces the laser tip was used like an explorer to first detect and then remove the calculus off of the surface of the roots. This was done paying particular attention to leave the cementum layer intact for future reattachment of bone. Supplemented where necessary with hand scalers.
Third Pass: Dentin/cementum surface modification/detoxification with the Er:YAG laser (50us pulse, 40Hz, 20 mJ) with the 600u radial WPT/PIPS quartz tip. Starting at the top of the sulcus with sweeping motions to the bottom of the pocket.
Fourth Pass: Clot formation in all pockets >5mm with the Nd:YAG laser (650us pulse, 20Hz, 4.0W). Starting at the bottom of each pocket, activating the laser and drawing it out taking 1-2 seconds, repeating 3-5 time until the blood clot just begins to turn darker.
Post-op defocused biostimulation with Nd:YAG (same settings) X 20-30 seconds per site. <Tolerated> <OHI> Topical anesthetic <Topical> with <AnesNumMg> of <Anesthetic> <AnesthFil> <AnesthBlock> <AnesthMental> <AnesthPulp> <AnesthLig> <AnesthAkin> local anesthetic<CompuDent> <addAnesth> <AnesNumMg> <Anesthetic> <AnesthFil> <AnesthBlock> <AnesthMental> <AnesthPulp> <AnesthLig> <AnesthAkin><CompuDent> Pt informed not to eat food, bite or chew on lips or tongue while anesthetic is still working. <OraVerse> <Next Visit><secNV><secNV><secNV>
This is the code for Early WPT note:
<HlthHx> <Consent> The patient has generalized soft tissue inflammation in the <Quadrant1> <Quadrant1> <Quadrant1> <Quadrant1> and we will used early Wavelength-optimized Periodontal Therapy to treat the patient’s periodontal disease. Disease epithelial tissue removed with the Nd:YAG laser (100us pulse, 20Hz, 2.0W) through the sulcuses. Post-op defocused biostimulation with Nd:YAG (same settings) X 20-30 seconds per site. <Tolerated> <OHI> Topical anesthetic <Topical> with <AnesNumMg> of <Anesthetic> <AnesthFil> <AnesthBlock> <AnesthMental> <AnesthPulp> <AnesthLig> <AnesthAkin> local anesthetic<CompuDent> <addAnesth> <AnesNumMg> <Anesthetic> <AnesthFil> <AnesthBlock> <AnesthMental> <AnesthPulp> <AnesthLig> <AnesthAkin><CompuDent> Pt informed not to eat food, bite or chew on lips or tongue while anesthetic is still working. <OraVerse> <Next Visit><secNV><secNV><secNV>
27 comments
Allen Honigman DDS, MS says:
Dec 14, 2010
“We are proud to be able to provide our patients laser periodontal treatment called Wavelength-optimized Periodontal Therapy (WPT invented by Dr. Robert Barr). Sometimes this procedure is confused with another dissimilar less envolved procedure called Laser-assisted New Attachment Procedure “(LANAP)”, but whatever you call it, it works!”
Actually Dr. Kraver, LANAP was patented first, WPT is the copy cat and a poor one at that. LANAP is less involved and less harmful than WPT, and has ACTUAL HISTOLOGY and peer reviewed publications to back up its claims..while WPT has nothing but poor understanding of laser physics and no actual research. If you truly understood laser physics, you would understand why the WPT procedure and laser settings might actually be more harmful to the periodontium than beneficial.
Of course, my guess is, you will delete this from your blog..I mean why would you want the truth to be known.
Mark Kraver DDS says:
Dec 15, 2010
Delete this! Are you kidding me? This exchange of ideas is exactly what blogs like this one are all about. Give me more information on LANAP to support why you think it isn’t a lesser procedure than WPT, and why you think WPT is more harmful. Why do we have to patent procedures in dentistry in the first place? You don’t pay a royalty to someone to use it, do you? What kind of laser do you have, and how long have you been using it? What kind of results have you been getting? Have you seen any cases that were done with WPT? I’ve got an open mind, do you?
John McAllister DDS Inc says:
Dec 15, 2010
I’ll show you mine if you show me yours?
Here is the Human Histological paper published in the prestigious IJPRD.
http://www.lanap.com//pdf/YuknaArticle.pdf
What has been published on WPT?
Nothing? Wow!
Mark Kraver DDS says:
Dec 16, 2010
John, why don’t you show us your cases so we can get a good idea what you can do with LANAP.
John McAllister DDS Inc says:
Dec 17, 2010
I have published in a peer reviewed journal; have you or any WPT ever?
http://www.compendiumlive.com/article.php?id=2791
Mark Kraver DDS says:
Dec 17, 2010
Great article! Good work. I can see what you are talking about. How do you remove the calculus on the root surfaces? So basically WPT is an extension of LANAP? Is the use of an Er:YAG in conjunction with the Nd:YAG, is what bothers you? If it is, then don’t be afraid of using an Er:YAG PIPS at such low settings, in competent hands, it’s not going to hurt anything, it will only help.
Allen Honigman DDS. MS says:
Dec 15, 2010
Well I have been doing LANAP since 2006, but it has been around for over a decade. WPT has been out for less than 1 year, so how many cases or followup can you have all together? Can those who “invented” WPT show any histological, controlled published studies demonstrating what you are peddling to the public? That would be a big NO!!!! I have cases showing bone regeneration going back at least 4 years. How about yourself or WPT for that matter.
LANAP uses the Periolase MVP-7: a free running digitally pulsed Nd-YAG laser, that is used in a very specific, patented procedure that actually works to allow for regeneration of the periodontium.
Why Patented? To protect the patient from things like your posting of the settings and how to do it, so that inexperienced doctors who probably have a minimal understanding at best of laser physices, cannot hurt the patient.
Since we know from laser physics, that the erbium is highly absorbed in water and hydroxyapatite, how do you remove the calculus without removing cementum? Can you actually see the the your are not removing the cementum?Those must be some pretty powerful loops then.
We also know from lasers physics that at 2W, there is no tissue removal, so you are not removing the inner lining of the pocket, and if you are, you are using a heck of alot energy to get any tissue interaction….not a good thing.
I do not pay any royalties, but I was extremely well trained (3 initial days) PRIOR to getting the laser, so that I and my patients would be safe.
WPT and LANAP are not equal…one has studies and research behind it and the other does not (and I think we know which one that is)
However, maybe you should go to LANAP.com and read and learn and watch the webinars.
[WATCH]: Laser Dentistry LANAP/ Charles Wright DMD/ Waccamaw Dental Care | dentalcare says:
Dec 15, 2010
[...] Wavelength-Optimized Periodontal Therapy – WPT | Cape Dental Care Official Blog [...]
Mark Kraver DDS says:
Dec 15, 2010
Thanks for your quick reply. I was hoping that doctors that posted comments would not fall into petty pissing matches.
“The LANAP protocol is a laser-based and patient-preferred method of treating mild to severe cases of gum disease without the use of scalpels or sutures. The LANAP protocol was developed by Robert H. Gregg, DDS and Delwin K. McCarthy, DDS in 1991, patented in 1994 and FDA cleared in 2004. The LANAP protocol is supported by the 4th largest human histology with a control group – the gold standard of research – in the published, prestigious, peer-reviewed periodontal literature and was the basis for the FDA’s decision to clear “laser assisted new attachment procedure.” See: http://www.accessdata.fda.gov/cdrh_docs/pdf3/K030290.pdf”
So your process took over 10 years to get FDA approval. This new WPT process then doesn’t have to re-invent the wheel, and can build upon the histology already presented by years of good research.
Is the Periolase MVP-7 a Er:YAG laser, too? The Lares PowerLaser AT is a digital Nd:YAG and a digital Er:YAG laser, but I’m not trying to say one laser is better than another. I’m sure you get good results with your machine, and technique. I’m just wondering why you are so hostile to something new, and possibly improved. This reminds me of the Endo wars in the 1990′s between lateral condensation vs vertical; Zoom vs Sapphire whitening; ClinPro vs MI paste. I would suggest you do your thing with LANAP, and keep an eye out for what’s on the horizon.
Charles Payet, DDS says:
Dec 16, 2010
Mark, I think it’s great that you are open to keeping these comments on your blog – definitely a good sign of intellectual honesty, so I respect that.
I am also a Periolase owner for about 16 months now, and I’ve been floored by the results, even in the most severe cases. All I know about erbiums is what I’ve learned in Boot Camp in my LANAP training with the IALD, so I’m no expert. Given the number of doctors who are now using the PowerLase for WPT, I am going to guess that they are seeing pretty good clinical results, or we surely would have heard many nightmare stories. I am very curious to learn more, and I am considering the new Er:YAG only Lightwalker for late next year, but there are certain absolutes in physics that can’t be ignored, and the absorption of the Er:YAG in water and hydroxyapatite is the biggie. Obviously, I’m sure you can’t reveal how the PowerLase removes the calculus so selectively, but I”m curious nonetheless.
One real inaccuracy in the video, which would be good to correct, has to do with the collagen plug, as the video states,
Mark Kraver DDS says:
Dec 16, 2010
Charles, thanks for adding your comments to my blog. As you read in the main portion of this blog, I have just started to do these cases, and so far they are healing well. Very little post-op sensitivity. Good patient acceptance. During my WPT training course, I did see numerous cases that had spectacular results, and really inspired me to help my patient’s with this technology.
The Lightwalker is a sweet looking machine that not only has the Er:YAG, but 2 Nd:YAG’s with two different diameter fibers. They are now around $29,990 and at that price it is a good buy (and more people will purchase them which will interpret into more chances for research). You can definitely do LANAP with this machine. Not only that, but PIPS Endo, too! http://www.capedental.com/blog/2010/09/30/new-service-to-our-patients-laser-root-canals/. Speaking of PIPS, I believe that this is the effect Er:YAG is having inside the sulcus during WPT. PIPS is a not so well known phenomenon that happens with laser light. True, Er:YAG absorbs in water/hydroxyapatite and is the reason why it is used to cut hard tissue, but those higher setting are not what is being used with WPT.
With the Er:YAG, PIPS (photon-induced photo acoustic streaming) is particularly pronounced at 50μs pulses, 40Hz and 20mJ, which is only 0.80watts. These are very low settings with respect to the hard tissue settings of 50μs pulses, 15Hz, 300mJ which is 4.50watts (amazingly you can cut tooth structure without anesthetic because Er:YAG is considered a cold laser). What happens with PIPS is that the Er:YAG energy is absorbed in water, and the water explodes like a little nuclear bomb. This explosion is like what happens when a ship drops a depth-charge onto a submarine. The depth-charge doesn’t have to actually hit the sub, it just has to get close enough to concuss the hull and rupture it. This concussive force is what removes the calculus, detoxifies the root surface and kills the bacteria. The Nd:YAG PIPS on dark pigments also, just not with the force of the Er:YAG on water.
Dr. Colonna is right, studies are on the way. With more and more people purchasing the Er:YAG, I suppose many more studies will be done at research centers and “prestegiuos” universities around the world. I’m not sure what WPT will end up looking like in the long run, but you can bet it will be steered by scientific findings just like LANAP was, or it will die as a footnote. Please, please learn about the PIPS effect and understand what it can do before you dismiss it, or you will be left behind.
Mark Colonna, DDS says:
Dec 17, 2010
Mark,
I couldn’t have said it better than you. You get it. One thing I have to chime in on, when LANAP, or ANY other procedure is being researched, and studied, the people who are performing the scientific studies do NOT divulge their information until it is ready for publication. What the one doctor is saying is very false, and misleading, as he does NOT understand laser physics of the Er:YAG, and has NOT seen our histological, bacterial, or even confocal microscopical studies. They will be published soon enough. I just think it’s a shame that someone get’s bashed on their own blog, by such little understanding of really what is happening with the procedure.
You have seen things that you cannot divulge and we appreciate that you have kept to the task. Time will come my friend, and when it does…well, you know. By the way Mark, we will have some VERY exciting news regarding PIPS soon, and our studies that will be published in the first quarter of 2011. The calvary is coming!
Mark
Mark Kraver DDS says:
Dec 17, 2010
Thanks Mark! I’ll keep taking the “pot-shots” until then. You know many of these doctors that comment on this blog and other blogs I’ve seen don’t really know who Dr. Barr is, and what he has done for the field of laser dentistry. Maybe they should know that he was (one of the first) doctor(s) to show bone regeneration at the Academy of Laser Dentistry in 1992. In many ways, all laser dentists owe him a great deal of respect for his research and devotion to the field.
Robert Gregg, DDS says:
Dec 27, 2010
With an interest only in historical accuracy, and as someone who was at the early meetings of the “pre-ALD” days in 1990 when we were just a study club or the NAALD; and was at all of the meetings for a number of years, Bob Barr was not the first to show bone regeneration in 1992. The first to show bone regeneration was Hector Martinez from Monterrey Mexico at the Puerto Vallarta meeting in February 1991. Hector used a interesting method and material combination that anyone who was there would remember the formula and the tooth number….
I don’t recall that I ever saw Dr Barr show a single case of bone regeneration after that, and I was a member of the NAALD then ALD until around 2000.
Ron Schalter says:
Dec 27, 2010
Interesting discussion. Just to clarify for those who may not be aware and misinterpret- ‘You can definitely do LANAP with this machine.’
One needs to be licensed by Millennium Dental Technologies to preform LANAP.
Mark Kraver DDS says:
Dec 27, 2010
I want to make this perfectly clear, when I say someone can do LANAP with a Lares Nd:YAG laser, I am saying that if you have a license to do LANAP first. It was just an observation/correlation/comparison from what I see from the published YouTube videos of LANAP and my simple uninformed vision of what LANAP actually is. I am very sorry someone in the medical field has patented a procedure that can help so many needy people and holds it hostage to a licensing fee.
Robert Gregg, DDS says:
Dec 29, 2010
You paid for your dental educaion did you not? You paid for a dental license indirectly and or directly, did you not?
You may be sorry about the LANAP licensing fee, but we believe we have saved many patients from being severely injured by untrained clinicians who think they might like to attempt (experiment) LANAP with their diode (see Bornstein’s article in Dentistry Today) or an erbium that is not suitable for the protocol. All of which would have led by now to claims and complaints by copy-catters that “LANAP doesn’t work”.
Secondly, by licensing the protocol we have successfully protected the protocol from the research abuse that went on in the early 1990′s by the likes of Charles Cobb and his many papers claiming Nd:YAG burns roots and Doug Dederich who has claimed to this day that the penetration of an Nd:YAG leads to pulpal death.
I suggest one should know all the facts before jumping to conclusions about motive or purpose.
Mark Kraver DDS says:
Dec 30, 2010
Thank you for that explanation. I now understand.
Robert Barr says:
Dec 29, 2010
Mark, thanks for the support. Bob is right about Hector. What I showed in 1992 was laser alone bone regeneration. It was the first time a presentation was given at the ALD that showed bone regeneration with the laser only . It was done in a minimally invasive way with out laying a flap. It was done with the Nd:YAG laser only. We started from the top of the sulcus moving down to the bottom of the pocket removing the diseased epithelial lining and Biostimulating the periapical tissues. I’m disappointed that Bob Gregg didn’t come to any more of the presentations that Dr. Coluzzi and I gave at ALD over the next 5 to 6 years. I have educated and trained hundreds of doctors all over the world over the past 20 years in laser bone regeneration techniques using different laser wavelengths. I have hundreds of cases that show attachment and bone regeneration with the different wavelengths used in my charts. They all work if the Doctor adheres to the technique that was developed for that wavelength. Patient education, health and compliance is always a factor to evaluate when assessing ones results. It was with the pasted 20 years of experience with different laser wavelengths that W.P.T. was developed. Our first goal was to render the dentinal and cemental surface as undamaged as possible. The second goal was to remove the endotoxins and bacteria from the root surface making the most ideal surface for reattachment and bone regeneration. Hand instrumentation of the root surface removes the cementum and leaves a bacterial film behind with a less than desirable surface for healing. WPT addresses all these factors leaving the root surface ideal for reattachment and bone regeneration. It was founded on many sound laser principles that have been published over the years. The research that we are doing on WPT will be published soon and show the sound principles it is based on. As we all know, it takes a long time to get research published. To wrap this up, I would like to thank Bob, Dell and all the other research teams that have done so much to further laser dentistry. With out their dedicated work, laser dentistry would not be where it is today. As a member of the Laser Society which we all make up, I hope we all can work together to make Laser Dentistry the best that it can be and make it the standard of care.
Bob
Mark Kraver DDS says:
Dec 30, 2010
I think, Dr. Barr, that showing some of your cases would actually be a good idea. If your results could be seen then maybe people will realize how WPT actually works. If you can provide a URL link to a site with your cases posted or you can e-mail them to me, and I could post them for everyone to see.
Robert Gregg, DDS says:
Dec 29, 2010
P.S. Thank you Ron for that clarification, as well as you Mark.
F.Y.I. We are hard at work conducting RCT University and more human hisotological research to make the matter of licensing moot. We are seeing LANAP, as is our goal, adopted in the post graduate perio programs around dental schools across the country, and eventually, it is the universities that will be the custodians of LANAP. As it is, we collect no licensing fees or royalties. We only charge for hands-on training….the PerioLase MVP-7 is “free”.
The cost for hands-on training includes 3 live patients that the LANAP student treats over 12 months on E-2, 4, 5, AND the patients’ post op care for 12 months. Should we require doctors to do this independently, like at LVI or Panke or Spear where doctors must bring their own patients, pay their transportation and airfare, food, lodging, etc–the cost would well exceed what we charge for doing it on a large scale operation.
Mark Kraver DDS says:
Dec 30, 2010
I like that concept. Getting the PerioLase into perio grad programs is a great way to mainstream lasers into dentistry in general. Good idea!
Tell me Dr. Gregg, what if (hypothetically) some of this “independent” sound research on the various laser wavelengths shows that Er:YAG PIPS effect is actually good inside the diseased sulcus, would you then begin to make your own Er:YAG laser at Millennium Dental Technologies?
Harvey Shiffman DDS says:
Dec 22, 2011
good question mark, but unfortunately it was answered. Lanap was an incredible developement and i give huge kudos to bob and dell for all their work, but just like with anything else, new developments bring new and possibly better treatment protocols. as a PIPS and WPT trained dentist, i see on a daily basis as you do the benefits of what we are doing for our patients. enjoying your blog.
Harvey Shiffman DDS says:
Dec 22, 2011
should have been not answered sorry
dentist philadelphia says:
Mar 19, 2012
Thanks, this is really good blog. And truely i sometimes look here. thanks a lot
Scottie Cazzell says:
May 15, 2012
Fantastic blog you have here but I was wanting to know if you knew of any user discussion forums that cover the same topics discussed here? I’d really like to be a part of group where I can get feed-back from other knowledgeable people that share the same interest. If you have any recommendations, please let me know. Thanks!
Mark P Kraver DDS says:
May 15, 2012
Check out Facebook.