May 25, 2020
Allen Honigman, DDS, MS
Marty Klein: Welcome to Dentistry for the New Millennium. I’m Marty Klein, Training Manager at the Institute for Advanced Laser Dentistry, and today we’re speaking with Dr. Allen Honigman from Scottsdale, Arizona. Dr. Honigman is a graduate of the University of Texas Health Science Center as well as UCLA for his periodontal residency. He’s published articles both on the LANAP and LAPIP protocols and serves as a certified instructor with the IALD. Today we’ll talk about how and when he first started using his PerioLase MVP-7 and dive into the LAPIP Protocol and discuss how the ability to treat ailing and failing implants has changed the way he practices. Okay, Dr. Honigman, thanks for joining me.
Dr. Allen Honigman: Nice to be here, Marty.
MK: First, just a little background for yourself. When and why did you start using the PerioLase MVP-7 in the first place?
AH: Well, I’m a periodontists out of Scottsdale, Arizona. I have been practicing since ’93. Back in 2000…I think it was 2006 actually, I started hearing more and more about this PerioLase and LANAP, etc. I talked to some doctors, and basically, I was looking for a way to treat my patients rather than the traditional surgery and bone regeneration that I was taught at my residency at UCLA. I wanted to try to find a way to treat my patients because I found that a lot of patients weren’t coming in and asking to have their gums cut. So started looking more into LANAP and the PerioLase. I actually started talking with Dr. Bob Gregg, one of the founders and developers of LANAP, and decided in August of 2006 to take the plunge. Since that day I really haven’t looked back, and my patients have been happy. I’ve been happy. I see a high success rate in terms of patient acceptance of treatment, but also more importantly, a higher success rate in the positive outcomes on treatment of periodontal disease.
MK: And you became a certified instructor not too long after that, I want to say. What was your decision to go right into teaching others?
AH: Well, I’ve always liked teaching. I was head of the perio undergraduate program at Case Western Reserve University before I started doing LANAP. I decided I liked the procedure so much I wanted to teach other doctors and kind of spread the gospel of it because I really wanted other doctors to see what I had seen in their patients too. So in 2009 I became a certified instructor.
MK: All right. Now I know you’re well known for using the PerioLase a lot around implants, and I want to ask a little bit more about that. First, if you could, just give us a quick definition of LAPIP.
AH: Well, LAPIP stands for Laser Assisted Peri-Implantitis Protocol, and it’s actually an offshoot of the LANAP Protocol except we do it around implants instead of teeth. It’s basically almost the same protocol, except we’re just watching how many joules we put in, how much energy we’re putting in the implant because the implant is made of titanium and it’s a metal and so we don’t want to overheat the mental, so we will watch the number of joules and allow things to cool down before we proceed through the procedure. Basically, once you learn LANAP you’ve already learned LAPIP too.
MK: And I understand peri-implantitis is a pretty big deal. Could you expand on that a little bit?
AH: Sure. Peri-implantitis… No one really thought that implants we’re gonna have these types of problems back when implants were first inserted, you know, started being used more regularly in practices with patients because they don’t get cavities, they don’t need root canals, and never have sensitivity, and everyone thought, “Oh, they last forever.” I think what happened was we didn’t predict that they would start seeing peri-implantitis like basically periodontal disease around implants. As more and more general dentists were trained and more periodontists were trained and oral surgeons were trained on how to do implants, you saw more and more peri-implantitis occurring because people didn’t know really how often to bring the patients in for recalls or how to clean them. There were problems with cemented crowns that were starting to be put on implants. The cement was running down under the gum line, and basically, that’s kind of like calculus, so we started seeing more and more bone loss and infections around implants as time went on. Patients have a lot of money invested in these implants, and they want to try to keep them, so peri-implantitis has become a bigger part of a lot of practices now around the world, actually.
MK: So when you’re treating peri-implantitis, how do you measure the success of the treatment?
AH: Well, you know, it’s interesting, because when implant companies measure the success rate of their implants all they’re really saying is, “Is the implant still in the patient’s mouth or not?” They’re not really looking at the bone loss, etcetera. They’re saying, “Okay, well, after five years, the implant was still the patient’s mouth, so it’s a success. We have a higher success rate.” So how do I measure success? Success is based on, to me, if the implant is still in the patient’s mouth, if it’s stable, if there’s really no infection around the implant, the supporting gum tissue is still intact and it’s healthy, it’s pink, and it’s not bleeding, patient can maintain it. Some doctors will say, “Well, unless I get bone all the way up to the top where it’s supposed to be – that’s my only criteria for success.” Which I think is wrong. I think if you have a healthy periodontium or gingival supporting structure around the implant and, like I said, if it’s still stable and maintainable, then that’s a successful outcome. You know, some doctors were or are very quick to extract the implant out, and that could be more expensive for the patient. And actually, it could be more traumatic for the patient than actually just trying to save the implant where it is.
MK: So I know you’ve done a lot of these cases. Is there a particular case that stands out or a couple of cases that really prove to you that this is a viable treatment option for peri-implantitis?
AH: I think there are actually two cases that kind of stand out in my head. There’s one case that, both were actually anterior cases. What’s interesting is a lot of doctors don’t like to treat the anterior cases with traditional surgical methods because if things go south, they could go south quickly. The patient could end up with a much more aesthetic problem than the original problem was, what the original peri-implantitis was.
So there was one case that I had. The patient came in for the regular maintenance, and my hygienist noticed on the two front implants there was some infection going on, so she brought it to my attention. I told the patient, “Look, you have an infection going on around your implants. You have some bone loss, and we really kind of have to treat this as soon as possible.” I happened to have opening in my schedule that afternoon. The patient came back that afternoon. We treated the patient for her two implants, probably about 1/2 hour-40 minutes, because I like to take pictures for presentations and things.
So it took about, you know, 30-40 minutes to do the case. Over time the patient came back in, you know, for a couple post op checks, then over time we kind of followed the case. What was nice was after five months, well, actually, after a month we saw the infection go away, the tissue looked much healthier. After the course of five months, we saw a nine millimeter pocket that was bleeding a lot and had puss coming out, go down to a three millimeter pocket. The bone actually regenerated in the area where she had lost the bone, which was nice. That was, to me, the added bonus. We’ve been following the patient over the course of the last 5-6 years and the bone is still there, the pocket has never returned, and the aesthetics are fantastic. So, for a very short type of appointment, where I didn’t have to make sure that I had the bone graft material or the membranes or any other materials that a lot of doctors used to try to treat peri-implantitis, I could do this in a very non-traumatic way. We got a great result, the patient maintained her aesthetics, and the implants are still in place.
The other case that I had was actually when I first started doing LAPIP, where I had a young man come in and he had the implant placed and restored less than a year ago, and he already had 50% bone loss around the implant. The original periodontist was going to flap the whole case open, like open the whole case up and see what was going on, and then make a decision from there, which is kind of exploratory surgery. I don’t know about you or the listeners out there, but I’m not into a lot of exploratory surgery. I like to try to make decisions, what’s going on before I start cutting a patient open. So I talk to the patient. I said, “Look, I have this procedure, my laser-based procedure that we might be able to treat this, get this infection down, and see where we go from there.” So he end up going with me. We ended up doing the case probably less than, you know, like 30-40 minutes to do the case. And after about a month we saw the infection go away. We saw the tissue infection resolve, the tissue looked great. And what was nice was we didn’t get any recession. So what he started with is pretty much what he ended with. Over the course of a few years, we followed the case, and the pocket stayed stable, the tissue stayed healthy. We didn’t, which was interesting, we didn’t get the bone to come all the way back to top because I think he just lost the bone. It actually was due to some cement under the crown when it was cemented in place. So that’s what kind of happened there: that was the impetus for the original disease. But the implant was stable. We didn’t get the bone regeneration wanted, but the aesthetics were fine, the pockets were fine, the tissue was firm. And so we had a successful case on anterior implant that a lot of doctors probably would have extracted, tried to graft again, and would have been the aesthetic nightmare for the patient and probably cost a lot more money than what we charge for the patient anyway.
So two cases of anterior implants, both saved! One we got bone regeneration and pocket depth reduction and no infection. The other one we didn’t get the bone regeneration, but we got the pocket depth reduction, and we got healthy tissue also. So again, both successful cases in their own right.
MK: Right. So, those are great, great examples, but I also want to make sure we’re realistic. And could you speak a bit about how often LAPIP is successful? I mean, is that a standard result, or are there times that sometimes it doesn’t save the implant as intended?
AH: Well, you know, that’s interesting, because I’ve been kind of looking at some cases that I didn’t get exactly the results I wanted, or we had to take the implant out. I think LAPIP works in the majority of cases. I think it’s a great first-line treatment because it’s non-traumatic, it gets rid of the infection very quickly, and then allows you to reevaluate the case over time to see if the retreatment is necessary, or maybe the implant has to come out. I’ve had a couple cases that the, you know, we did LAPIP once, we let it heal, we did our maintenance on our patients, and we just didn’t get the result we wanted. So we tried again. That’s nice thing about LAPIP, and LANAP actually, is because we’re not removing tissue, we’re not losing tissue. We could retreat these patients again and see what we can get.
And one case comes to mind where the patient had severe bone loss around the implant. Ideally, probably, if the patient would have seen nine other periodontists or oral surgeons, they probably would have recommend to take the implant out. I gave it a chance because we have the LAPIP procedure in our armamentarium. Over the course of a year or year and 1/2, it just never resolved and the infection kept coming back, so we ended up taking the implant out. But it was hopeless, I think was a hopeless case to begin with. I think LAPIP itself was the Hail Mary Pass. Now what’s interesting is, I just saw a case this past week where we did LAPIP. It seemed to resolve a bit, then I saw her again for her last maintenance, and the infection came back again. I told the patient, “Well, you know, we’re gonna have to take the implant out or we can try the laser, the LAPIP procedure again.” We opted to try it again to see what would happen, because we have nothing to lose and everything to gain.
What was interesting was, the common thing between the two cases were: one, they were both lower posterior implants, but the other thing was, they didn’t have a large amount, they didn’t have really any, attached gingiva around them. I’m starting to come up with, I guess, my own little hypothesis that the amount of attached gingiva that is present or thick tissues that is present around the implants is very important to the success of really any peri-implantitis treatment, whether it’s LAPIP or traditional surgery. So I have a feeling that the more cases I see, I’m gonna be looking more for the attached gingiva, for the thicker tissue around the implant on dealing with how successful the case is gonna be. Now, mind you, in both cases the amount of bone loss was severe, like I said, LAPIP was the Hail Mary here to see if we can save the implant, and, we’ll go from there and see what’s going on. So does it work 100% of time? Well, nothing works 100% time except extraction of teeth or implants, but I think the LAPIP protocol itself is a great way to at least give the implants a chance in cases where you say, “I don’t know what’s gonna happen. Let’s see what happens in this case,” where you would normally try to take the implant out. If the implant is loose, though – kind of like flapping in the breeze loose, it’s time to take the implant out, I think. I think it’s a much more predictable procedure. Then graft the case and then go from there.
MK: Very good. Well, that’s a fair statement, I suppose. Dr. Honigman, thanks for your time this morning. I know you’re teaching some LANAP clinicians today, so I’ll let you get going to do that. And again, thanks for thanks for being here.
AH: Always a pleasure, Marty. Thanks a lot.
MK: If you’re interested in more information about the LANAP or LAPIP articles discussed in this podcast, you can visit LANAP.com and click on the Research tab at the top.