The use of lasers for ENAP and gingival curettage should be evaluated in light of the available evidence...

Statement Regarding Use of Dental Lasers for Excisional New Attachment Procedure (ENAP)

Evaluation of studies and evidence available.

A recent commercial advertisement describes a "revolutionary . . . breakthrough in periodontal surgery that regenerates new attachment" through the application of "a patented Laser ENAP procedure."1 Despite FDA approval for sulcular debridement, the use of lasers for ENAP and gingival curettage as proposed in the advertisement and several recent journal articles 2-8 should be evaluated in light of the available evidence.

The ultimate applicability for a specific treatment modality must be based on scientific evidence and critical review of the literature. As noted in the 1996 World Workshop in Periodontics, an evidence-based approach involves systematic evaluation of available information, where randomized, controlled, double-blind studies are more relevant than uncontrolled case reports. The latter studies rarely present concurrent controls and therefore the effectiveness of treatment is likely to be overestimated.9

The ENAP was first described in 1976 as "a definitive subgingival curettage performed with a knife."10 Like subgingival curettage, the ENAP results in "a long, thin epithelial attachment and a minimal amount of connective tissue attachment."11 The only published human clinical study comparing gingival curettage to the ENAP found no significant differences in probing depth reduction or gains in attachment.12

It should be noted that the preponderance of evidence indicates that curettage fails to achieve any clinical result that cannot be accomplished by routine scaling and root planing.13-16 The Academy is not aware of any published data that indicates that the ENAP laser procedure is any more effective for these purposes than traditional scaling and planing.17-27

To date, there are only four published human studies involving a total of 57 patients that have evaluated the effects of subgingival laser application.4, 5, 17, 18 All four papers report reductions in putative periodontal pathogenic microbes following laser treatment. Two of the papers also reported laser induced root damage.4, 17 The remainingtwo papersdid not evaluate treated teeth for root damage.5 Elimination of pocket epithelium by gingival curettage, ENAP or other internal bevel incision designs appears not only nearly impossible but unnecessary for long-term therapeutic goals.28-30 In addition, there are no published data that demonstrate that either curettage or ENAP are effective in periodontal regeneration. To the contrary, there is peer reviewed evidence, both in vivo and in vitro, that use of lasers for ENAP procedures and/or gingival curettage may place patients at risk for damage to root surfaces and subjacent alveolar bone 31, 32 that, in turn, could render these tissues incompatible to normal cell attachment and healing.

In conclusion, The Academy is not aware of any randomized blinded controlled longitudinal clinical trials, cohort or longitudinal studies, or case-controlled studies indicating that "laser ENAP" or "laser curettage" offers any advantageous clinical result not achieved by traditional periodontal therapy. Moreover, published studies suggest that use of lasers for ENAP procedures and/or gingival curettage could render root surfaces and adjacent alveolar bone incompatible with normal cell attachment and healing.

References

  1. Millennium Dental Technologies, Inc. Dent Prod Report 1999;33 (May):40.
  2. Epstein SR. Curettage revisited: laser therapy. Pract Periodontic Aesthet Dent 1992;4:27-32.
  3. Gold SI, Vilardi MA. Pulsed laser beam effects on gingiva. J Clin Periodontol 1994;21:391-396.
  4. Ben Hatit Y, Blum R, Severin C, Maquin M, Jabro MH. The effects of a pulsed Nd:YAG laser on subgingival bacterial flora and on cementum: an in vivo study. J Clin Laser Med Surg 1996;14:137-143.
  5. Neill ME, Mellonig JT. Clinical efficacy of the Nd:YAG laser for combination periodontitis therapy. Pract Periodontic Aesthet Dent 1997;9(suppl):1-5.
  6. Gregg RH, McCarthy DK. Laser ENAP for periodontal bone regeneration. Dent Today 1998;17 (5):88-91.
  7. Gregg RH, McCarthy DK. Laser ENAP for periodontal ligament regeneration. Dent Today 1998;17 (11):86-89.
  8. Gregg RH, McCarthy DK. Laser economics: periodontal therapy. Dent Economics 1998;88:42-44.
  9. Cobb CM. Non-surgical pocket therapy: mechanical. Ann Periodontol 1996;1:443-490.
  10. Yukna RA, Bowers GM, Lawrence JJ, Fedi PF, Jr. A clinical study of healing in humans following the excisional new attachment procedure. J Periodontol 1976;47:696-700.
  11. Yukna RA. A clinical and histologic study of healing following the excisional new attachment procedure in Rhesus monkeys. J Periodontal 1976;47:701-709.
  12. Borghetti A, Ranchain D. ENAP ou curetage aveugle? Etude biométrique.J Parodontol 1984;4:189-195.
  13. Echeverria JJ, Caffesse RG. Effects of gingival curettage when performed 1 month after root instrumentation. A biometric evaluation. J Clin Periodontol 1983;10:277-286.
  14. Ramfjord SP, Caffesse RG, Morrison EC, et al. Four modalities of periodontal treatment compared over 5 years. J Clin Periodontol 1987;14:445-452.
  15. Lindhe J, Nyman S. Scaling and granulation tissue removal in periodontal therapy. J Clin Periodontol 1985;12:374-388.
  16. Kalkwarf KL. Tissue attachment. In: Proceedings of the World Workshop in Clinical Periodontics. American Academy of Periodontics. 1989;V1-V23.
  17. 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.
  18. Mortiz A, Schoop U, Goharkhay K, Schauer P, Doertbudak O, Wernisch J and Sperr W. 1998. Treatment of periodontal pockets with diode laser. Lasers Surg. Med., 22, 302-311.
  19. Tewfik HM, Garnick JJ, Schuster GS, Sharawy MM. Structural and functional changes of cementum surface following exposure to a modified Nd:YAG laser. J Periodontol 1994;65:297-
  20. Trylovich DJ, Cobb CM, Pippin DJ, Spencer P, Killoy WJ. The effects of the Nd:YAG laser on in vitro fibroblast attachment to endotoxin-treated root surfaces. J Periodontol 1992;63:626-632.
  21. Morlock BJ, Pippin DJ, Cobb CM, Killoy WJ, Rapley JW. The effect of Nd:YAG laser exposure on root surfaces when used as an adjunct to root planing. J Periodontol 1992;63:637-641.
  22. Spencer P, Trylovich DJ, Cobb CM. Photoacoustic FTIR spectroscopy of lased cementum surfaces. J Periodontol 1992;63:633-636.
  23. Spencer P, Cobb CM, McCollum MH, Wieliczka DM. The effects of CO2 laser and Nd:YAG with and without water/air surface cooling on tooth root structure: Correlation between FTIR spectroscopy and histology. J Periodont Res 1996;31:453-462.
  24. Thomas D, Rapley JW, Cobb CM, Spencer P, Killoy WJ. Effects of the Nd:YAG laser and combined treatments on in vitro fibroblast attachment to root surfaces. J Clin Periodontol 1994;21:38-44.
  25. Gopin BW, Cobb CM, Rapley JW, Killoy WJ. Histologic evaluation of soft tissue attachment to CO2 laser treated root surfaces: an in vivo study. Int J Periodontol Restor Dent 1997;17:317-325.
  26. Cobb CM, Spencer P, McCollum MH. Histologic comparison of the CO2 and Nd:YAG lasers with and without water/air surface cooling on tooth root structure. SPIE (Society of Photo-Optical Instrumentation Engineers) 1995;2394:662-667.
  27. Radvar M, Creanor SL, Gilmour WH, et al. An evaluation of the effects of an Nd:YAG laser on subgingival calculus, dentine and cementum. An in vitro study. J Clin Periodontol 1995;22:71-77.
  28. Litch JM, O'Leary TJ, Kafrawy AH. Pocket epithelium removal via crestal and subcrestal scalloped internal bevel incisions. J Periodontol 1984;55:142-148.
  29. Svoboda PJ, Reeve CM, Sheridan PJ. Effect of retention of gingival sulcular epithelium on attachment and pocket depth after periodontal surgery. J Periodontol 1984;55:563-566.
  30. Pippin DJ. Fate of pocket epithelium in an apical positioned flap. J Clin Periodontol 1990;17:385-391.
  31. Krause LS, Cobb CM, Rapley JW, Killoy WJ, Spencer P. Laser irradiation of bone. I. An in vitro study concerning the effects of the CO2 laser on oral mucosa and subjacent bone. J Periodontol 1997;68:872-880.
  32. Friesen LR, Cobb CM, Rapley JW, Forgas-Brockman L, Spencer P. Laser irradiation of bone. II. Healing response following treatment by CO2 and Nd:YAG lasers. J Periodontol 1999;70:75-83.

This statement was developed by the Committee on Research, Science and Therapy and approved by the Board of Trustees of The American Academy of Periodontology in August 1999, as a statement for the profession. This statement is based on the published studies referenced at the end of this statement. However, there may be unpublished studies of which the Academy is unaware.

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