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Lasers in Endodontics & Conservative Dentistry

Historical Perspective Introduction Fundamentals of dental lasers Laser Physics Lasers in Endodontics

Operative & Aesthetic Dentistry


Dental laser safety

L A S E R

Light Amplification by Stimulated Emission of Radiation

A laser is a device that transforms light of various frequencies into a chromatic radiation in the visible, infrared, and ultraviolet regions with all the waves in phase capable of mobilizing immense heat and power when focused at close range

Historical Perspective
Early 1900s Chinese & Egyptians (Phototherapy)
1960 Theodore Maiman 1965 Dr. Leon Goldman

1970s Nd:YAG
1982 - Pick, Frame & Pecaro 1987 Meyers Portable Laser

Stern & Sognnaes (1964) and Goldman et al (1964)

were the first to investigate the potential uses of the ruby laser in dentistry
They began their laser studies on hard dental tissues

by investigating the possible use of a ruby laser to reduce subsurface demineralization


The first laser use in endodontics was reported by

Weichman & Johnson (1971) who attempted to seal the apical foramen in vitro by means of a high powerinfrared (CO2) laser

Fundamentals of Lasers

Light beam is composed of packets of energy known as

PHOTONS
Ground State Atoms are normal position Atoms are excited by an energy source and move to a

higher energy
As it reverts back to its ground state, energy is emitted

Spontaneous Emission
Results without external interference and forms waves that

are in phase

Light
Form of electromagnetic energy Laser light vs. Ordinary light Ordinary light is usually white diffused Sum of many colours of the visible spectrum Laser light Monochromacity

Coherency Same light waves All waves are in phase with one another (identical wave shapes)

Collimation Specific spatial boundaries Low Divergence Insures a constant shape & size of the beam

Efficiency Most useful feature Provides thermal energy

Amplification
Is a part of a process that occurs inside the laser An optical cavity is at the center of the laser device &

the core is comprised of chemical elements, molecules or compounds Active Medium Lasers are generically named for the material of the active medium Gas, Crystals or Semi-Conductors

Gas Co2 & Argon


Solid state semi conductors : With metals like Gallium, Aluminum, Indium, Arsenic With solid rods of garnet crystal growth with various combinations of Yytrium, Aluminum, Scandium, Gallium and then doped with elements of Chromium, Neodynium or Erbium.

The crystal or gas is excited to emit photons of a

characteristic wavelength
These ware amplified and filtered to make a coherent

beam
The effect of this energy depends on whether or not

the WL of the energy is absorbed by the surface or not

Stimulated Emission
Quantum theory of Max Planck & Neils Bohr Smallest unit of energy It can be absorbed by electrons, cause brief excitation

and then the quatum is released Process called as Spontaneous Emission

Radiation
Refers to light waves produced by the laser as

electromagnetic energy
EM Spectrum entire range Wavelengths
Higher Photon energy can deeply penetrate biologic

tissues and produce charged atoms and molecules

All dental lasers have emission wave lengths of 0.5m

(500 nm) to 10.6m (10,600 nm)


Within the visible or invisible infrared non-ionizing

EM range & emit thermal radiation


The dividing line between ionizing and non-ionizing

portion is on the junction of ultraviolet and visible violet light

Laser consists of a lasing medium contained with an optical cavity, with an external energy source to maintain a population inversion so that stimulated emission of a specific wavelength can occur, producing monochromatic, collimated and coherent beam of light

Active medium Gas, liquid or solid Contained in glass or ceramic tubes Energy Electric current Mirrors are added to each end to increase the back and

forth movement of photons


Thus increasing the stimulation of emission of

radiation

Laser Delivery Systems


Coherent, Collimated beam of laser light must be delivered to the target tissue Two delivery systems that are employed
Hollow Waveguide or Tube Glass fiber optic cable

Flexible Hollow Waveguide (Tube)


Has an interior finish mirror
Laser energy is reflected along this tube and exits

through a hand piece


Strikes the tissue in a non-contact manner An accessory tip of sapphire or hollow metal can be

connected

Glass Fiber optic cable


More flexible than waveguide
Less weight and less resistance in movement

Smaller diameter (200-600 m)


Glass component is encased in a resilient sheath Fragile & cant be bent in sharp angles Used in contact and non-contact mode

Glass Fiber (Flexible) Argon Diode Nd:YAG Er Cr:YSGG Er:YAG CO2

Waveguide (Tube)

Fiber Optic

Advantages
Thinner & flexible Higher carrying capacity Less energy degradation Low power consumption Non inflammable Light weight

Laser Emission Modes


Dental lasers can emit light energy in 2 modalities Constant ON Pulsed ON/OFF
In Constant or Continuous Wave, the beam is emitted

at one power
In Gated Pulse Mode, there are periodic alterations of

laser energy (Blinking light)

This is achieved by the opening and closing of a

mechanical shutter in front of the beam path of a continuous wave emission


All surgical lasers that operate in continuous wave

have this gated pulse feature


Third mode is termed Free running pulsed mode or

True Pulsed
In this large peak of energy of laser light is emitted for

a very short time

What does the Operator control?

Level of applied power (Power Density)

Total energy to be delivered (Energy density)

Rate & Duration of exposure (Pulse Repetition)

Mode of energy delivery

Lasers Used in Dentistry

Classifications:
Lasers are named according to:
Active medium Wavelength Delivery systems Emission modes Tissue absorption Clinical Application

Classifications:
I.

Based on Active Medium


a) b) c)

d)
e)

Solid State Gas Semiconductors Excimer Dye


a)

II. Mode of action


Contact mode (focused or defocused) - Ho:YAG ;

Nd: YAG
b)

Non-contact mode (focused or defocused) - CO2

III. Based as application


a) Soft tissue laser b) c)

Argon, Co2, diode; Nd:YAG. Hard tissue laser - Er : YAG Resin curing laser - Argon

IV. Based on Level of energy emission:


a) Soft lasers (Low level energy): He-Neon; Ga-Arsenide. b) Hard lasers (High level energy): Er:YAG laser ; Nd:

YAG laser.

Wavelength

Argon
Active medium is Argon gas Fiber optically delivered Continuous wave & Gated Pulsed modes Only laser whose light is in the visible spectrum 2 wavelengths are used: 488 nm (Blue) 514 nm (Blue-Green)

488 nm emission is used to activate camphoroquinone

in composite resins
The beam divergence of this blue light is used in non-

contact mode, produces excessive amount of photons thus providing curing energy
More strength in cured resin when compared to

conventional blue light


Shorter curing time

514 nm has its peak absorption in tissues containing Hb,

Hemosiderin and Melanin


Has excellent hemostatic capabilities
Small diameter flexible glass fiber is used for delivery Used in contact mode Used in Surgical Endodontics Acute inflammatory Periodontal conditions and highly

vascularized lesions such as Hemangioma

Neither wavelength is absorbed by dental tissues or

water
Their poor absorption by enamel and dentin is an

advantage when used for incising and sculpting gingival tissues


Minimal interaction and no damage to tooth surface Both can be used for caries detection Argon laser light illuminates the tooth, the disease

area appears dark orange-red colored

Diode
Is a solid active medium laser
Manufactured from semiconductor crystals using

combinations of Al, In, Ga and Ar Available wavelengths are 800 nm (Al) to 980 nm (In), placing them at the beginning of the infra red spectrum Fiber optic delivered Continuous wave or Gated Pulse modes Used in Contact mode

Diode WL are highly absorbed by pigmented tissue and

deeply penetrating, though hemostasis is not as rapid as with Argon laser


Poorly absorbed by tooth tissues Soft tissue surgeries can be performed near tooth Causes a rapid increase in temperature thus, surgical site

needs to be air or water cooled


Diode is an excellent soft tissue surgical laser Small size & Portable

Diagnodent (Kavo) is a visible red

diode with a WL of 655 nm and 1 milliwatt power


This red energy excites

fluorescence from carious tooth structure, which is reflected back into a detector device in the unit
This analyses and quantifies the

degree of caries

Neodynium:YAG (Nd:YAG)
Has a solid state active medium, which is a garnet

crystal combined with rare earth elements Yytrium & Aluminum doped with Neodynium Wavelength is 1064 nm Operate in free running pulsed mode with short pulse durations Delivered via fiber optic cable Contact mode

Laser light is highly absorbed by melanin

Clinical applications include cutting and coagulating

soft tissues
Energy is slightly absorbed by dental hard tissues but

there is little interaction between sound tooth structure following soft tissue surgery
Pigmented surface carious lesions can be vaporized

without removing the healthy surrounding enamel

Holmium:YAG
Consists of a solid crystal of Yytrium, Aluminum

Garnet sensitized with Chromium and doped with Holmium and Thulium ions
Delivered via Fiber optic cable Free running pulsed mode Wavelength is 2100 nm Absorbed by water 1000 times more than Nd:YAG

Using peak powers it can ablate hard calcified tissues


As a soft tissue laser instrument it does not react with

Hb or other tissue pigments


Used more in TMJ disorders and Orthopedic cases

The Erbium Family


2 distinct lasers
Erbium Chromium: YSGG Erbium:YAG

Er Cr:YSGG
Erbium Chromium:Yytrium Scandium Gallium Garnet
Wavelength 2780 nm Delivered via fiber optics Free running pulsed mode Fiber cable diameter is much larger and requires an air

or water coolant

Er:YAG
Erbium: Yytrium, Aluminum Garnet
Wavelength is 2940 nm Delivered via hollow tube and fiber optic cable Free running pulsed mode

These 2 WLs have the highest absorption in water and

have high affinity for hydroxyapatite


The laser couples into hydroxyl radical in the apatite

crystal and into water that is bound to the crystalline structures of tooth
Caries removal and tooth preparation can be easily

carried out
The increased water content in carious lesions allows

the laser to preferentially interact with diseased tissue

This is the most efficient laser for drilling and cutting

enamel as its energy is well absorbed by hydroxyapatite

CO2
Gas active medium laser
Co2 pumped via electrical discharge

current and is present in a sealed tube

Wavelength is 10,600 nm

Delivered via hollow tube or wave guide


Continuous or Gated pulsed mode

Well absorbed by all biological hard & soft tissues Can easily cut and coagulate soft tissue Has a shallow depth of penetration into tissue The laser energy is delivered by a hollow wave guide in a

non contact fashion


This WL has the highest absorption in hydroxyapatite of

any dental laser


Thus tooth must be protected during soft tissue

application

Its high thermal absorption makes the CO2 laser less

suitable for cutting and drilling enamel & dentin as the damage to the dental pulp may occur

(Ref: Seltzer & Bender, Quintessence 2002)

Laser Tissue Interaction


Laser light has four different interactions with the

target tissue
Amount of energy absorbed by the tissue depends on

the tissue characteristics such as pigmentation and water content

Little or no absorption No thermal effect on Tissue

Light transfers to tissue without any interaction & injury

Reflection

Transmission

Scattering
Light travels in different directions, absorbed over a greater surface area Causes less thermal effect

Absorption
Absorbed by tissues and results and light energy is converted to thermal energy

Tissue Hemoglobin Melanin Hydroxyapatite

Feature Absorbed by Blue & Green WL Absorbed by short wavelengths Absorbed by a wide range of WL

Dental structures have different amount of water content, Enamel being the least followed by Dentin, Bone, Calculus, Caries and Soft tissue Dental lasers have a Photothermal effect

At low temperatures below 100C, the thermal effects

denature proteins and produce hemolysis


They cause coagulation & shrinkage

Above 400C, carbonization of organic materials

occurs with onset of some inorganic materials


Between 400C & 1200C, inorganic constituents melt,

re-crystallize or vaporize

In general, shorter WL (500-1000 nm) are well

absorbed in pigmented tissues and blood elements


Longer WL are more interactive with water and

Hydroxyapatite
Co2 (10,600 nm) is well absorbed by water and has the

highest affinity for Hydroxyapatite

Lasers in Endodontics
Dentinal Hypersensitivity Pulp Diagnosis Pulp Capping & Pulpotomy Cleaning & Shaping of root canal systems

Sterilization
Endodontic Surgery

Dental Hypersensitivity
Characterized as short, sharp pain from exposed

dentin that occurs in response to provoking stimuli such as cold, heat or chemicals
Not ascribed to any other dental defect or pathology

Can be attributed to non carious tooth loss (Wasting

diseases)

Various treatment modalities

Blocking the dentinal fluid flow


Application of various agents to exposed dentinal

tubule
Oxalate salts Isobutyl cyanoacrylate Fluoride releasing resins

Reduce Neuronal Responsiveness 5% Potassium Nitrate & 10% Strontium Nitrate

Laser as a treatment modality


Rationale for laser induced reduction in DH is based

on 2 possible mechanisms
1st mechanism implies direct effect of laser

irradiation on the electric activity of nerve fibers within the dental pulp
2nd mechanism modification of the tubular structure

of dentin by melting and fusing of the hard tissue or smear layer and subsequent sealing of dentinal tubules

Lasers for treatment of DH are divided into 2 groups:


Low Output Power Lasers Middle Output Power Lasers

Helium Neon Diode Gallium-Aluminum-Arsenide diode

Nd:YAG Co2

Low output lasers were used by Kimura et al for their

anti-inflammatory effect
Have an ability to stimulate the nerve cells Senda et al were the first to apply He-Ne lasers Used a low power output of 6 mW which does not

affect the morphology of dentin and enamel


It allows a small fraction of the energy to reach the

pulp

The mechanism of action is not clear but it was

claimed that the helium neon laser irradiation affects the electric activity (action potential) rather than A- or C-fiber nociceptors

Gallium-Aluminum-Arsenide diode have 3 WL (780,

830 & 900 nm)


Matsumoto et al applied an output of 30 mW in a

continuous wave for 0.5 3 mins


The analgesic effect was due to a depressed nerve

transmission caused by diode laser irradiation blocking the depolarization of C-fiber afferents

In 1972, Kantola et al used a Co2 laser to create craters

on dentin
Microradiography and Electron probe analysis

revealed higher levels of Ca & P in the fused or recrystallized dentin


At a 1 year follow up, it was observed that in laser

irradiated dentin, recrystallization had occurred and dentin had changed to look like the original

(Ref: IEJ, 33, 173185, 2000)

Pulp Diagnosis
Laser Doppler flowmetry (LDF) was developed to

assess blood flow in microvascular systems, e.g. in the retina, gut mesentery, renal cortex and skin (Morikawa et al. 1971, Riva et al. 1972)

Helium Neon and Diode laser at a low power of 1 or 2

mW
Wavelength is 632.8 nm

Laser beam is directed towards the tooth (to the blood

vessels)
Moving RBC causes the frequency of the laser beam to

be Doppler shifted and some of the light be back scattered out of the tooth

The reflected light is detected by the photocell on the

tooth surface and its output proportional to the number and velocity of the blood cells
Advantages over EPT: Can be used in traumatized teeth Does not rely on painful sensation to determine vitality

(REF: Australian Dental Journal 2003;48:3.)

Pulp Capping & Pulpotomy


AAE defines Pulp capping as a procedure in which a

dental material such as Calcium hydroxide or MTA is placed over a pulpal wound to encourage the formation of reparative dentin
Pulpotomy is defined as the surgical removal of the

coronal portion of the pulp by means of preserving the remaining radicular tissues

Pulp Capping & Pulpotomy


Melcer et al used Co2 lasers & demonstrated new

mineralized dentin formation without cellular modifications in pulpal tissues

Shoji et al used Co2 lasers in different WL and reported

that no damage was detected in the radicular pulp. Charring, coagulation necrosis and degeneration of odontoblastic layer occurred, with no pulp damage

Jukic et al used Co2 and Nd:YAG lasers on exposed pulp

tissue and reported that a dentinal bridge was formed

Moritz et al used Co2 laser for direct pulp capping

The energy level of 1 W at 0.1 second exposure time

with 1 second pulse intervals was applied to the exposed pulp


Teeth were check for vitality after 6 and 12 months and

89.4% of the teeth retained their vitality


Lasers can be used for direct or in direct pulp capping

in cases of deep and hypersensitive cavities -

Co2 and Nd:YAG lasers are well absorbed by the

hydroxyapatite of enamel and dentin, causing tissue ablation, melting and re-solidification
These lasers do not cause any thermal damage to the

pulp tissue and do not increase the intra-pulpal temperature if used at the correct power, duration of time and intensity

Cleaning & Shaping of Root Canal System


Various laser systems can deliver the energy into the

root canal using a thin optical fiber


Various systems that have been used are Nd:YAG Er,Cr:YSGG Argon Diode Er:YAG

It has been demonstrated in many studies that the

laser radiation has the ability to remove debris and smear layer from the root canals
It also has the potential to kill the microorganisms Bergman et al suggested that lasers is not an

alternative to the conventional cleaning & shaping, but can be used as an adjunct

Limitations for use in Root Canals


Emission of laser energy from the tip of optical fiber or

the laser when directed into the root canal is not uniform
There may be thermal damage to the periapical tissues May be hazardous when the tooth apex is near vital

structures such as mandibular nerve or mental foramen

Stabholz et al developed a new endodontic tip that can be

used with Er:YAG laser

It is delivered via a hollow tube allows lateral emission of

the irradiation (side-firing), rather than direct emission through a single opening
The endodontic side firing spiral tip is designed to fit the

shape and volume of the root canals prepared by NiTi rotary instruments

The tip is sealed at its far end, preventing irradiation to

the periapical tissues


In a recent study, the efficacy in smear & debris

removal of the side firing tip was compared to ProTaper


The RCLase Side firing tip was used in extracted

molars and the teeth were then split and examined longitudinally
Efficient cleansing of the RC System is achieved

Researcher Moritz et al Mehl et al Fogel & Pashey Takeda et al Sousa-Neto et al

Laser Diode & Nd:YAG Er:YAG Diode Er:YAG Co2

Sample 220 90 E.coli & Staph aureus Smear Layer removal; 60 40

Sterilization of root canals


Numerous studies into the sterilization of root canals

have been performed using CO2 (Zakariasen et al. 1986) and Nd:YAG lasers (Rooney et al. 1994, Ebihara et al. 1994, Fegan & Steiman 1995, Moshonov et al. 1995b, Goodis et al. 1995, Sekine et al.)
The Nd:YAG laser is more popular, because a thin

fibre-optic delivery system for entering narrow root canals is available with this device

Many other lasers such as the XeCl laser emitting at

308 nm (Stabholz et al. 1993), the Er:YAG laser emitted at 2.64 mm (Gomi et al. 1997), a diode laser emitting at 810 nm (Moritz et al. 1997a), and the Nd:YAP laser emitting at 1.34 mm (Blum et al. 1997) have also been used
All lasers have a bactericidal effect at high power that

is dependent on each laser

There appears to exist a potential for spreading

bacterial contamination from the root canal to the patient and the dental team via the smoke produced by the laser, which can cause bacterial dissemination (Hardee et al. 1994)
Thus, precautions such as a strong vacuum pump

system must be taken to protect against spreading infections when using lasers in the root canal (McKinley & Ludlow 1994)
Sterilization of root canals by lasers is problematical

since thermal injury to periodontal tissues is possible

Laser assisted Obturation


Aim of Obturation: Eliminate all avenues of leakage Seal the RC system from all ends
Rationale in using lasers for obturation is that the

irradiation can be used as a heat source for softening the GP


Conditioning of the dentin walls can also be done

The photo-polymerization of camphorquinoneactivated resins for obturation is possible using an

Ar laser emitting at 477 and 488 nm (Potts & Petrou 1990, 1991)
The results indicate that an Ar laser coupled to an optical fiber could become a useful modality in endodontic therapy Studies have been performed using the obturation material AH-26 & AH Plus (Zaman et al. 1994) and composite resin (Anic et al. 1995)

An SEM examination revealed that laterally compacted resin fillings showed fewer voids than those obtained by vertical compaction (Kitamura et al, 2005) Ar, CO2, and Nd:YAG lasers have been used to soften gutta-percha (Anic & Matsumoto 1995), and

results indicate that the Ar laser can be used for this purpose to produce a good apical seal

The clinical evidence from reported studies for the use

of lasers in obturation is not sufficient


It has not been determined if the use of laser as a heat

source is safe for the surrounding structures of the tooth as well as for other teeth
A suitable wavelength has not been ascertained Effect on the sealer per se has to be determined

Retreatment
Rationale for using lasers in retreatment is ascribed to

the need to remove foreign material, GP etc by softening it by heat Farge et al used the Nd:YAP (1340 nm) Attempted to remove GP and ZOE sealer Silver cones and separated instruments They concluded that lasers alone cannot remove all the obturating materials from the RC

Yu et al were able to remove the entire filling material

in 70% cases, while broken files in only 55% of the cases using the Nd:YAG laser
Removal of GP and files is always a challenge and

lasers can only assist


A clinical advantage is that toxic solvents like xylene

can be avoided
However the effects of the laser on the tissues and

surrounding teeth remains to be studied

Lasers in Endodontic Surgery


Weichman & Johnson attempted to seal the apical

foramen of freshly extracted teeth in which the pulp had been removed
Laser is used for the surgery, a bloodless surgical field

should be easier to achieve due to the ability of the laser to vaporize tissue and coagulate and seal small blood vessels

If the cut surface is irradiated, the surface is sterilized

and sealed
The potential of the Er:YAG laser to cut hard dental

tissues without significant thermal or structural damage eliminates the need for mechanical drills
Clinical investigations into laser use for apicectomy

began with the CO2 laser (Miserendino 1988), which was successful

The use of this laser seals the dentinal tubules in the

apical portion of the root and sterilizes the surgical site


On, extracted teeth (Stabholz et al. 1992 Arens et al.

1993, Wong et al. 1994), used the Nd:YAG laser and found that there was a reduction in the penetration of dye or bacteria within resected roots
When the laser was used for resection itself, either in

extracted human teeth in vitro (Maillet et al. 1996), found that tissue repairs was quicker when compared with those roots resected with a bur

Advantages
Good hemostasis
Improved visualization of surgical site Sterilization operative field

Reduced permeability of root surface dentin


Reduction in post operative pain Reduced risk of contamination of surgical site by

eliminating use of air turbines

Constraints
Time Consuming
Increase temperature Cause irreversible pulpal damage

Needs precise execution


Increased cost of treatment

Healing after Laser Surgery


Reports suggest that laser created wounds heal more

quickly and produce less scar tissue than conventional scalpel surgery.
However, contrary evidence from studies in pigs, rats

and dogs indicate that the healing of laser wounds is delayed


More initial tissue damage may result, and that

wounds have less tensile strength during the early phase of healing (Pick et al 1990)

Abergel et al (1984) experimented with cultured

human skin fibroblasts and showed that collagen production and DNA synthesis were delayed when the fibroblasts were exposed to Nd: YAG laser radiation
Crespi et al evaluated the effects of CO2 laser

treatment on fibroblast attachment to root surfaces and concluded that CO2 laser treatment in defocused, pulsed mode with a low power of 2W combined with mechanical instrumentation constitutes a useful tool to condition the root surface and increase fibroblast attachment to root surfaces
(Ref: Journal of Periodontology)

Other Endodontic uses


CO2 and Nd:YAG lasers have been used for the

attempted treatment of root fractures (Arakawa et al. 1996). However, regardless of the re-approximation technique, laser type, energy, and other parameters used, fusion of the fractured root halves was not achieved
Lasers (Ar, CO2, Nd:YAG lasers) have been used

successfully to sterilize dental instruments (Adrian & Gross 1979, Hooks et al. 1980, Powell & Whisenant 1991).

Results indicated all three lasers (Ar, CO2, Nd:YAG

lasers) are capable of sterilizing selected dental instruments; however, the argon laser was able to do so consistenly at the lowest energy level of 1 W for 2 min
A pulsed dye laser emitted at 504 nm was used for the

removal of a calcified attached denticle (Rocca et al. 1994)

Lasers in Operative & Aesthetic Dentistry


Lasers have become a part of routine operative and

aesthetic practice
There are five lasers that are currently in the

armamentarium

Argon lasers
The wavelength is absorbed by Hb
This attribute allows precision cutting, hemostasis &

coagulation of vascular tissue Use of argon lasers have been used for curing composites (at low power achieving higher bond strength) Transillumination in diagnosis of tooth fractuures

Plasma Arc Curing (PAC)


PAC & Argon laser curing systems have rapid

polymerization of composites However they increase heat generation and polymerization shrinkage stresses Studies have shown that they exhibit a narrow spectral output and do not coincide with the spectral requirements of all restorative resins Bleaching of stained teeth

Co2 Lasers
Used for vaporizing, cutting and coagulation of soft

tissue
Used more for soft tissue procedures which include

gingival re-modelling and shaping in aesthetic dentistry (Perio-Aesthetics)

Diode Lasers
2 different WL are used
Ga-Al-As Laser (800 nm) & In-Ga-As (980 nm) These are used in contact mode for cavity preparation,

removal of bacterial contamination and coagulation of tissue Also used for Diagnosis

Erbium Family
Er lasers are absorbed by Hydroxyapatite and water
Allows to cut soft tissue, tooth structure and bone Er:YAG (2940 nm) cuts teeth easily & quickly

Also used for removal of caries (excavation)

Decay present on the facial of the maxillary left lateral incisor

The Erbium laser used to remove the decay. No anesthesia was required

After caries removal and preparation is complete

Definitive direct bonded restoration after preparation with the Erbium laser

Etching
Laser etching has been evaluated as an alternative to

acid etching of enamel and dentine. The Er:YAG laser produces micro-explosions during hard tissue ablation that result in microscopic and macroscopic irregularities
These micro irregularities make the enamel surface

micro retentive and may offer a mechanism of adhesion without acid-etching

However, it has been shown that adhesion to dental

hard tissues after Er: YAG laser etching is inferior to that obtained after conventional acid etching (Martinez-Insua et al., 2000)
The weaker bond strength of the composite to laser-

etched enamel and dentine to the presence of subsurface fissuring after laser radiation. This fissuring is not seen in conventional etched surfaces
The subsurface fissuring contributed to the high

prevalence of cohesive tooth fractures in bonding of both laser-etched enamel and dentine

Caries prevention
Studies examined the possibility of using laser to

prevent caries (Hossain et al., 2000; Apel et al., 2003)


It is believed that laser irradiation of dental hard

tissues modifies the calcium to phosphate ratio, reduces the carbonate to phosphorous ratio, and leads to the formation of more stable and less acid soluble compounds, reducing susceptibility to acid attack and caries

Laboratory studies have indicated that enamel

surfaces exposed to laser irradiation are more acid resistant than non-laser treated surfaces (Watanabe et al., 2001; Arimoto et al., 2001)
The degree of protection against caries progression

provided by the one-time initial laser treatment was reported to be comparable to daily fluoride treatment by a fluoride dentifrice (Featherstone, 2000)

(Ref: Archives of Orofacial Sciences 2006; 1: 1-4)

Laser Assisted Bleaching


Two laser-assisted whitening systems have been cleared by

the FDA
The laser is used to enhance the activation of bleaching

material, which then whitens the teeth


The argon laser wavelength of 488 nm for 30 seconds to

accelerate the activity of the bleaching gel


After the laser energy is applied, the gel is left in place for

three minutes, then removed. This procedure is repeated four to six times

Another system uses both the argon and CO2 lasers in

the bleaching process


The argon laser is used as previously described, then

the CO2 laser is employed with another peroxidebased solution to promote penetration of the bleaching agent into the tooth to provide bleaching below the surface
The entire clinical time for this system ranges from one

hour to three hours

Laser-assisted tooth bleaching, however, still poses a

number of unanswered questions


Because of continuing concerns and unknowns about

laser interactions with hard tissue and the lack of controlled clinical studies, CO2 laser-assisted bleaching is not recommended (FDA)
Based on previously accepted uses of argon lasers and

associated temperature-rise studies, the use of the argon laser in place of a conventional curing light may be acceptable if the manufacturers suggested procedures are carefully followed (FDA)

Dental Laser Safety


Safety is an integral part of providing dental treatment

with lasers
3 aspects to safety: Manufacturing process Proper operation of the device Personal protection

Regulatory Agencies
American National Standard Institute (ANSI) Food and Drug Administration (FDA) Center for devices and Radiological Health (CDRH) Occupational safety health administration (OSHA)

Laser Classification
Class I II Laser Properties Pose no health hazard e.g. CD Player Emit only visible light with low power output & do not pose any health hazards Maximum allowable output is 1 mW Emit any WL and have an output power of 0.5 W of visible light; In this laser light can be viewed only momentarily Caution label is present

IIIa

IIIb

Hazardous to unprotected eye; Output power no greater than 0.5 W; eg. Argon Laser curing light; Eye protection is must
Hazardous from direct viewing and may produce diffuse reflections; Output power more than 0.5 W; Can produce fire and severe skin reactions; Can ignite inflammable devices

IV

Fire & Explosion Hazards


Use only wet and fire retardant materials in operative

field Use non combustible anesthetics Avoid alcohol based topical anesthetics Avoid alcohol moistened gauze or cotton Fire Extinguisher Stay informed Follow ANSI regulations

Guidelines
Mention outside
Door Switch Fire hazards

Eye Protection
In 1962, the awareness to eye

protection began
Eye is a critical target for laser

injury
Class III & IV lasers pose a threat

to the eye
Proper eye wear is a must

Why the Eye ???


Cornea is made up of 90% Water
Absorbs emissions from all lasers Cause Corneal Burns

Holium and Erbium lasers affect the Aqueous and

Vitreous Humor as well as the lens which lead to Aqueous Flare & Cataract formation Retinal damage occurs due to lasers with more depth if penetration and is absorbed into the pigments (Argon, Diode, He:Ne)

The eye is 100,000 times more vulnerable to injury

than the skin WL from 400-1400 Protective glasses must have an Optical Density of at least 4 For specific high WL lasers like Nd:YAG & Diodes, there are specific eye wear Eyewear is designed to have adequate protection for a wide range of WLs Regardless of protection, NEVER look directly into the laser beam

Sterilization & Infection Control


Fiber optic cables & handpieces can be autoclaved in

pouches
Oil based aerosols must not be used
The wires and protective casing / housing should be

wiped clean and not autoclaved

In Conclusion

Lasers New face of Dentistry Diverse applications High Cost Treatment Planning Adverse Effects

Worldwide laser sales by application

( Ref: Journal of Laser Application, Feb 2005)

References
Pathways of Pulp (9th Ed.) S.Cohen
Art & Science of Operative Dentistry Sturdevant Textbook of Endodontics (6th Ed.) Ingle

DCNA 2000, 2005


Journal of Endodontics International Endodontic Journal Journal of American Dental Association British Dental Journal