Considering the Patient with the MMPPI & PROMs

September 21, 2020

Considering the Patient with the MMPPI & PROMs

Robert Levine, DDS


Marty Klein:  Welcome to Dentistry for the New Millennium. I’m Marty Klein, Training Manager at the Institute for Advanced Laser Dentistry. My guest today is Dr. Robert Levine, a periodontist in Philadelphia, Pennsylvania. Dr. Levine earned his DDS degree at Temple University and his certificate and Periodontics from the University of Pennsylvania, School of Dental Medicine. He is presently a clinical professor in postgraduate periodontics and dental implantology at Temple University, along with several other faculty appointments. Dr. Levine continues to lecture extensively, both domestically and internationally. Today we’ll talk about his road to using the PerioLase MVP-7 for the LANAP protocol, the patient’s role in making clinical decisions, and different ways in which to score periodontal disease. Dr. Levine, thank you for joining me today.

Dr. Robert Levine:  Marty, thank you for having me.

MK: I first want to talk about your original road to LANAP. You were trained in 2013, so let’s start with telling me how you got to that point in your awareness of LANAP and your decision to get trained.

RL:  I think the big thing was the study that was published in ’14, which I heard about at the AAP meetings. Lead author David Harris and friends, Ray Yukna, Harry Greenwell, Pinelopi Xenoudi were on the study that looked at LANAP versus modified Widman or surgical flap and scaling and root planing. The thing that kept coming back to me was the patients’ reported outcomes that they really had very little discomfort. So, besides having similar results in the study between the categories of the surgery as well as the LANAP. So that was something I’m always looking for, a benefit for my patients from a standpoint of comfort and maintaining teeth. Being a periodontist, I was born to keep teeth.

MK: Did you have any experience with lasers up to that point?

RL:  I had very little experience with lasers. I was sitting on the fence like many of us, for probably a few years, before I made the decision to go with Millennium and the LANAP protocol. It really was that study of Marc Nevins, whom I know as well, published histology, along with Ray Yukna, so there was really, in my circles, and being a member of the Southern Academy of Perio, one of the few Yankees in Southern Academy of Perio, and I found that at least I think was about 50% at the time were LANAPers at the time. Some of my close friends, Colin Richman, Phyllis Cook, and others had been using it and really expressed the benefits to their patients, and these are people that I trust.

MK: It sounds like it was a combination of due diligence with literature but also colleagues who are recommending it directly to you. Were those two things you’d say the tipping point?

RL:  Really important for that is people I trust, people that I know, and the literature is really important as a periodontist who’s involved with a lot of teaching.

MK: You mentioned the patient specifically. That’s refreshing for me, a non-clinician, to hear that one of the big reasons or things that you look for with new technology is the patient experience, is that accurate?

RL:  Correct. My partner, Phil Fava, and I, we did an in-office study early on our first 75 cases of LANAP. I think there were 50 of those and 25 (around there) with LAPIP – which is laser therapy around failing implants – and we found that 90% of our patients on a scale of 1 to 10  had 0 or 1 out of 10 discomfort, which was amazing. This is basically what we read in the Harris study, was that the patient-reported outcome measures were very good when it came to this procedure, with similar benefits of doing surgery, versus not. What we have seen is that (and a lot of it has to do with very minimal postoperative recession we see in LANAP) we have very little root sensitivity post-surgery. So these are things that my patients really over the years – and I’m a graduate from the mid-eighties and perio program, so we would see a lot of root sensitivity. We’d see patients dropping out of treatment, not wanting to continue full-mouth periodontal surgery. Where now we’re doing full-mouth LANAP in one sitting and our patients do very well during it, as well as the postoperative scale of 1 to 10. Again, 90% of our patients scaled a 0 or 1 out of 10, and ones that scaled higher were actually patients that the occlusion really need to be looked at more diligently from our standpoint.

MK: You’ve talked about the patient experience and how comfortable it is for patients, which is great, but I would imagine too from your perspective, you also need the clinical outcome to deliver as well. Has that been your experience?

RL:  Yes, it has been with LANAP, especially. Talking about LAPIP, we could talk about that as well, between cemented restorations and screw-retained restorations. But with LANAP I’m getting a real good consistency with what we’re doing, but as periodontists I mean we really trained very diligently in scaling and root planing, as well as occlusal equilibration. So these are two of the really major forms of how we’re treating these patients to get the results we’re looking at. So the root anatomy is really important to know prior, the ability to get into furcations – and Millennium has some great tips, these ball tips that we use to get into furcations.

So it’s really meticulous scaling and root planing, occlusal therapy, and knowing how to do definitive occlusal adjustments (which is ongoing with our patients) that get the results that we see, which is really clinical attachment improvement, reduction in probing depths, and reduction in mobility. I always like to say when I’m speaking, my mentor, Mort Amsterdam (who passed a couple summers ago), he would be a very major proponent of LANAP because of what we’re doing in saving teeth number one, as well as our attention to the occlusal as well as the inflammatory lesions that we’re dealing with. A very good friend of mine, PD Miller, who everybody in periodontics and dentistry knows, he states that teeth are not lost to periodontal disease; they are lost to titanium. That can’t be truer than what we’re seeing today with teeth being removed, which we are presently saving. So as a LANAP clinician I’m very proud, and I’m proud to be a periodontist. I feel that I’m saving a lot more teeth and we’re making patients really a lot happier because of that.

MK: You mentioned PD Miller just then, and I was about to ask here about something that you’ve worked on extensively with him, and I hope you’d give us just a small summary of the MMPPI as a way that it scores periodontal disease. I’d like for you to give us a little bit about that and how it dovetails with the LANAP treatment.

RL:  Yeah, I know PD very, very well. PD published an evidence-based scoring index to determine the periodontal prognosis on molars, back in 2014, in the Journal of Perio. It won the JD Power award in periodontology in 2015, meaning it was the best clinical study in our profession for the year of 2014. That is where he got the MMPPI, The Miller-McIntyre Periodontal Prognosis Index. The index is based on scoring the worst molar that we are going to keep in the mouth, so I usually take it maxillary second molar scores the highest. There are seven very important categories or criteria that we look at, including age, smoking, diabetes, the molar type, probing depth, furcations, and mobility. We come up with a 15- and a 30-year prognosis for the whole mouth based on the one molar. It’s very powerful because we present this. We use this for healthy patients, and we use this for diseased patients, and it reinforces for the healthy patient that whatever they’ve been referred to us for, they’re not going to go down a road of losing more teeth or needing more tissue grafts or whatever. In the advanced cases, they realize that they go through the LANAP procedure they had the value of being able to keep their teeth at a high prognosis of 15 or 30 years. So I feel, PD feels, that the routine use of the MMPPI should become the standard of care when treating all patients. It really has helped us significantly to improve case acceptance and follow-up care to whatever we are looking for. We use this in periodontal maintenance for all patients. We used it in initial presentation consultations with the patient. We scan it, we give it to them so they could tell their friends and family also what we’re doing. We are now really with this perio-systemic link, we are the physicians of the mouth, us as dentists, as periodontists.

MK: Thank you. There’s another webinar that you completed for us recently on PROM, Patient-Reported Outcome Measures. Can you compare PROM with the MMPPI or those totally separate concepts?

RL:  It’s really totally separate concepts. The PROMs, or the Patient-Reported Outcome Measures, is based on some early studies on locator attachments in dentistry by Jocelyne Feine and others up in McGill University. It’s really looking at the patient’s quality of life quotient. Everybody wants it, but what is it? Someone’s quality of life is the extent to which their life is comfortable or satisfying, truly the general wellbeing of a person or society, defined in terms of health and happiness rather than socio-economic status.

So I was involved with the ITI, which is the International Team for Implantology, and I was in a group called Patient-Reported Outcome Measures, focusing on aesthetics of implant & tooth-supported fixed dental prosthesis. We did systemic systematic reviews, and our conclusion was that we should be doing these Patient-Reported Outcome Measures for all clinical procedures that we’re doing. The webinar I did was regarding this and the PROMs. I kind of made reference to briefly when we started. We see the really incredible problems with patients when it comes to the LANAP procedure and the post-op discomfort is minimal, root sensitivity is almost negligible, so it really is beneficial. We came up with a study, Colin Richman and I really kind of put our heads together. Again, Colin was one of my really close friends from many years back, and we got to talking. He was one of my mentors when it came to becoming LANAP clinician. We got together an independent survey of satisfaction of LANAP users. We sent out to over 2000, I believe, LANAPers worldwide. We sent it out like five different times. We got the response from over 500 which was, I believe, the largest independent survey that’s been done. We’ve submitted to a journal that is in the midst of hopefully accepting it for publication. What we found were some very interesting results: 77% treat more patients because they offer the LANAP protocol, so about three quarters of the respondents said that, 85% felt that it increased personal satisfaction after adding LANAP treatment. 74% said more natural teeth are being saved as mentioned prior, and this is where we see the PROMs. We see less gum recession and postoperative discomfort compared to osseous surgery. As a periodontist, I mean, these are things that I’ve I always thought about, and this is now something that we’re able to publish – that this is what the vast majority of the LANAP clinicians are seeing.

What I see clinically also, and we documented studies, 90% of the patients are more willing to accept LANAP over traditional surgery, and I see this all the time. I get patients off the Internet, 50% of our patients in private practice come off the Internet, and many of them are calling because they know that we treat patients with this procedure, with the LANAP protocol. 91% of the patients are more likely to refer others, which is obviously a practice builder, and 94% of the patients are satisfied overall with the post-LANAP protocol and this includes post-op discomfort. Fewer complications; decreased need for opioids. So again, going back to, and I sum it up with the Patient-Reported Outcome Measures are tremendous, and it’s like what I reported in my own patients, over 90% of the patients had little (0 or 1) out of 10 discomfort post LANAP or LAPIP.

MK: Those are all fantastic figures, and I know you mentioned that this paper is in the process of being published, this independent satisfaction survey. Dr. Richman, when he was on our podcast, did talk about it a little more. For those of you who have not heard it, please go download Dr. Richman’s episode. I also want to mention back with the PROMs webinar that you did, that that is available for any listener that would like even more about that at Just one last question for you:  you have brought up patients a lot, and I know that that’s a particular interest of yours in terms of the patient’s role in clinical decisions. Can you expand on that a little more just philosophically, what the role of the patient is when deciding the treatment plan?

RL:  Well, this is how the MMPPI and the LANAP procedure really tie in. The MMPPI gives the patient the ability to really understand what we’re talking about because we go through all of the numbers. We come up with the prognosis for that one tooth, say it’s tooth number two (which is second molar), and it reflects against the whole mouth’s prognosis. We give a target goal of less than a five, so they may start out with a score of 11 for various reasons: There may be mobility of the tooth, pocketing, furcations, so forth, they may be a smoker. We motivate these patients from a health standpoint to do what needs to be done to get a better MMPPI in the future. So the patients accept the LANAP procedure because they understand the benefits of their health. They understand the benefits of improving the MMPPI. And there’s no question the difference between the LANAP protocol and conventional osseous surgery is like night and day. Again from the standpoint of post-operative complications, postoperative sensitivity, and discomfort, it’s very easy to educate the patient on the benefits of LANAP, and the acceptance rate is extremely high.

MK: Very good. Well, I finally want to give a plug to your website for listeners who would like to know more about you or your practice in the Philadelphia area, and that is I invite you, the listener, to subscribe to this podcast so that you don’t miss any episodes wherever you download your podcasts or at Dr. Levine, thank you again for being my guest today.

RL:  Marty, thank you so much for inviting me. You have a great day.