LASERS USED IN OPERATIVE

DENTISTRY AND ENDODONTICS

BY DR SAKSHI TYAGI
 CONTENTS
Introduction
History of lasers
Components of lasers
Classification of lasers
Types of lasers
Application of lasers in operative dentistry
Application of lasers in endodontics
Conclusion
Refrences
 INTRODUCTION
Dentistry has advanced a lot.

Among various advances, one which have good scope of

improvement is the use of lasers in dentistry.

Recent advances in laser technology will bring revolution in

dentistry.

Laser is an acronym for Light Amplification by Stimulated

Emission of Radiation.
HISTORY OF LASERS IN DENTISTRY
1960-first laser
1993 Nd:YAG Laser
1993 Kinetic Cavity Preparation
1994 CO2 Laser, Argon Laser
1996 Laser welder
1997 Nd:YAP Laser
1998 Er:YAG Laser

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

investigate the use of the ruby laser in dentistry by working
on dental hard tissues 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 power-infrared (CO2) laser.

COMPONENTS OF LASER
* There are 3 main parts of laser delivery system.

(1).LASING OR ACTIVE MEDIUM

Laser Delivery Systems

Articulated arms
Hollow Waveguide or Tube
Glass fiber optic cable
Flexible Hollow Waveguide (Tube)
It 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.

Er:YAG, CO2
 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
manner.

Argon , Diode , Nd:YAG

Laser Emission Modes
Two modes :
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.

Free running pulsed mode or True Pulsed, large peak of

energy of laser light is emitted for a very short time

Classification of lasers
Lasers are named according to:
Acc to ANSI and OSHI
Acc to wavelength
Acc to material
Acc to penetration
Acc to pulsation
Acc to mode of action

According to ANSI and OSHA classification

Class I Low intensity , Safe use

Class II Low intensity ,

 Hazardous when view over 1000 sec
Class IIa Low intensity
Hazardous when view more then 0.25 sec
Class III Medium intensity
Hazardous when viewd less then 0.25 sec of
magnification optics
Class IV High intensity
produce occular and skin hazards

According to wavelength
400 um (uv)
400-700 um (invisible)
700 um to micro spectrum (infrared)
According to material
Solid State
Gas
Semiconductors
Excimer
Dye

According to penetration
(1).HARD LASERS OR HIGH LEVEL LASERS

- Longer wavelength

- Cuts the tissue by ablation.

 - Used for tooth & bone applications.

(2).SOFT LASERS OR LOW LEVEL LASERS

- Low energy wavelengths

- Cuts tissues by coagulation,vapourisation & carbonisation.

According to pulsation
1. Pulsed Short duration ,not continous
2. Non pulsed Long duration , continous

According to mode of action

Contact mode (focused or defocused) - Ho:YAG ;
Nd: YAG
Non-contact mode (focused or defocused) - CO2

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
USES: CURING , SOFT TISSUE DESENSITIZATION

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
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
Use hard tissue

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
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

KTP[POTASIUM-TITANYL PHOSPHATE] LASER

HELIUM-NEON[He-Ne]

RUBY LASER

EXCIMER LASER

Effects of lasers
Effects on tissues on certain temperatures
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

APPLICATION OF LASERS IN OPERATIVE

DENTISTRY
* DIAGNOSIS OF DENTAL CARIES
(A).INFRARED LASER FLUORESCENCE
[DIAGNODENT]

- Diagnodent is an instrument, recently designed to facilitate

the detection of dental caries.
- Used for detection of caries on occlusal & smooth surface.

(B).LASER INDUCED FLUORESCENCE

- Kutsch in 1992,illuminated carious & non carious tissue with

argon laser along with dark field photography.

- He reported that while illuminating, carious lesion

has clinical appearance of dark,fiery,orange-
red colour.

* CAVITY PREPARATION WITH LASER

- NUMBER OF STUDIES HAVE BEEN PERFORMED FOR
THE USE OF Er:yag LASER FOR CAVITY
PREPARATION.

- Results of studies says that little or no noticeable pulp

reaction is produced while preparing the cavity with Er:yag
laser.

- It is safe & can be used for cavity preparation.

 MECHANISM OF ACTION
Carbonate is lost from carbonated appetite mineral of tooth
during laser irradiation

(B). DIODE LASER

- A true laser light produced from a solid state

source.

- It is ultra fast, taking 3 to 5 sec. to activate

bleaching agent.

- This type of lasers produce no heat.

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
PHOTOPOLYMERIZATION OF COMPOSITE RESIN
WITH LASER

- Argon lasers are used for this purpose.

- For polymerization of camphorquinone Activated composite

resin, the argon laser increases

~ The depth of cure

~ The diametric tensile strength
~ Adhesive bond strength
~ Degree of polymerization of materiels.

LASERS IN ENDODONTICS
Dentinal Hypersensitivity
Pulp Diagnosis
Pulp Capping & Pulpotomy
Cleaning & Shaping of root canal systems
Sterilization
Endodontic Surgery

Dentin Hypersensitivity
 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

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

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)

 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

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

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 camphorquinone-activated

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

Endodontic Surgery
 The goal of endodontic surgery is to eliminate the disease and
prevent its recurrence. Surgical options should be considered
only when better results cannot be achieved by non-surgical
treatment.
The first attempt to use a laser in endodontic surgery was
performed by Dr. Weichman He attempted to seal the apical
foramina of extracted teeth from which the pulps had been
extirpated. The apices of those specimens were irradiated
using a high power CO2 laser.

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
Duclos et al. used a CO2 laser to perform apicoectomies in
patients and advocated the use of a mini contra-angle head
for efficient delivery of the laser irradiation at a 90 angle to
the root apexes of teeth in the posterior areas

Recently it has been reported that when using an Er:YAG

laser in a low output power in apical surgery, it was possible
to resect the apex of extracted teeth. Smooth and clean
resected surfaces devoid of charring were observed.
It was also found that although the cutting speed of the
Er:YAG laser was slightly slower than conventional high-
speed burs, absence of discomfort and vibration and less
 chance for contamination at the surgical site, as well as
reduced risk of trauma to adjacent tissues may compensate
for the additional time required

Miserendino used a CO2 laser to irradiate the apex of a tooth

during apicoectomy. He described the advantages associated
with laser application for periapical surgery such as improved
hemostasis and concurrent visualization of the operative
field.
He also emphasized the potential sterilizing effect of the
contaminated root apex as well as the reduction in
permeability of the root surface dentin. Moreover, he
described re-crystallization of the apical root dentin that
appeared to be smooth and suitable for placement of an apical
filling material.

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
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 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)

ADDITIONAL BENEFITS
A. Minimises patient fear of the drill.

B. No irritating sound like traditional drills.

C. The cavity with laser preparation appears open,patent,fresh &

devoid of all debris.

D. Mono-infection with Enterococcus faecalis is avoided- hence

sterile cavity.

E. Melts the dentin & blocks the tubules,thus hydrodynamic

theory of dentin sensitivity is ruled out.
ADVANTAGES OF LASERS
(1).Minimal damage to surrounding tissues.

(2).Haemostatic effect by sealing blood vessels.

(3).Reduction of postoperative inflammation & edema.

(4).Little postoperative scarring.

DISADVANTAGES OF LASERS

(1).Laser beam could injure the patient or operator

By direct beam or reflected light, causing retinal
burns.
(2).It available only at big hospital & treatment is
very expensive.

(3).Specially trained person is needed.

CONCLUSION
* Dental lasers are now well established instruments. Ongoing
research is showing the many benefits of laser therapy.
* The ability to perform less invasive procedures with greater
patient comfort makes laser dentistry something the modern
practitioner should consider.
* A thorough understanding of laser physics and biological
effects is mandatory for any provider.
* Comprehensive beginner and ongoing training is imperative
to use these devices effectively and safely
REFERENCES
Pathways of Pulp S.Cohen
Art & Science of Operative Dentistry Sturdevant
Textbook of Endodontics Ingle