Review

Lasers In Endodontics
Sebeena Mathew 1, Deepa Natesan Thangaraj2
1

Reader, Department of Conservative Dentistry and Endodontics, KSR Institute of Dental Science and Research Senior Lecturer, Department of Dental Materials, KSR Institute of Dental Science and Research

ABSTRACT: The main aim of this review article is to give an update on lasers in endodontics. This review goes on to explain about the transition from Ruby lasers to YSGG lasers, the effects of laser on tissue, laser delivery systems and emission modes and about the use of lasers in endodontics. Key words: Laser, endodontics, pulp, disinfection.

Address for correspondance : Dr Sebeena Mathew M.D.S. Reader, Department of Conservative Dentistry and Endodontics, KSR Institute of Dental Science and Research, KSR Kalvinagar, Thokkavadi Post, Thiruchengode, Namakal Dist- 637215. Phone Number: 9443737737. E- mail: [email protected]

Introduction Lasers have made considerable progress in various fields of dentistry. Studies continue to be conducted in order to make maximum use of properties of the existing lasers in the field of endodontics. With all the research and progress that is being made there is a fair chance for lasers gaining prominence over conventional methods that are used in endodontics. Lasers In Endodontics 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 a phase capable of mobilizing immense heat and power when focused at a close range. The word LASER is an acronym for "Light Amplification by Stimulated Emission of Radiation". Dental lasers are named from chemical elements, molecules, or compounds that compose the core, or active medium, that is stimulated. This active medium can be a combination of gas, solid crystal rod, or a solid-state electronic device. Gas-active medium lasers are argon and carbon dioxide. Solid semiconductors are made with metals such as gallium, aluminum, and arsenide. Solid rods of garnet crystal are generally made from yttrium and aluminum, to which are added elements chromium, (1) neodymium, holmium, or erbium.

From Ruby Lasers To YSGG Using a theory that was postulated by Einstein, Theodore Maiman created a device in 1960 where a crystal medium was stimulated by energy and radiant laser light was emitted from the crystal. The first laser was a ruby laser. The first lasers to be marketed for intraoral use were CO2 lasers. Dr Terry Meyers and his brother William, an ophthalmologist, selected the Nd:YAG laser for experiments on the removal of incipient caries. They developed the first true laser system which according to the text books and published literature sparked the dental laser revolution. In May 1997, Premier Laser obtained the first marketing clearance from the U.S. F.D.A to cut enamel and dentin in adults using an Er:YAG laser. In 1998, BIOLASE obtained marketing clearance for cutting hard tissue in adults using an all new laser designed by the company exclusively for use in dentistry. BIOLASE's first YSGG laser, called the Millenium, used a patented combination of YSGG laser energy, water and air to safely and effectively ablate enamel and dentin in adults. Researchers at BIOLASE had also worked on soft tissue with the YSGG laser with the water spray minimized or turned off, the laser could effectively cut and coagulate soft tissue with more control, and in many cases, much faster. By 2000, expanded FDA clearances for soft tissue indications had been
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Lasers In Endodontics

Sebeena Mathew & Deepa Natesan Thangaraj

obtained by BIOLASE and clinicians were able to work across both hard and soft tissue. Also in 2000, BIOLASE released its second YSGG laser the Waterlase. It got clearance from FDA for complete laser endodontics (2002), apicoectomy (2002), cutting and shaving of oral 2 tissues (2003). Effects Of Laser On Tissue Lasers have four different interactions with the target tissue. These interactions will depend on the optical properties of the tissue. Photobiologic Interactions The first effect is reflection, which is simply a beam redirecting itself off the tissue surface, having no effect on the target tissue. The second interaction is absorption of laser energy by the intended target tissue. This effect is desirable and the amount of energy that is absorbed by the tissue depends on the tissue characteristics, such as pigmentation and water content, and on the laser wavelength and emission mode. Argon has a high affinity for melanin and haemoglobin in soft tissue. The third interaction is transmission of the laser energy directly through the tissue with no effect on the target tissue. The fourth interaction is scattering. Scattering of the reflected light weakens the intended energy and possibly produces no useful biological effect. Photochemical Interactions The basic principle of photochemical process is that specific wavelengths of laser light are absorbed by naturally occurring chromophores which are able to induce certain biochemical reactions. Photosensitive compounds when exposed to laser energy can produce a single oxygen radical for disinfection of endodontic canals.3 Photothermal Interactions The radiant energy absorbed by tissue substances are transformed into heat energy, which produce the tissue effect. Photomechanical and photo electrical interactions These include photodisruption, photoplasmolysis and photoacoustic interactions. In photoacoustic effects, the pulse of laser energy on the

dental tissues can produce a shock wave. When this shock wave explodes or pulverizes the tissue, it creates an abraded crater. Photoelectrical effect includes photo plasmolysis, which describes how the tissue is removed through formation of electrically charged ions. Laser Energy And Tissue Temperature

Table -1 Effect Of Laser Energy On Tissue Temperature and the Observed Effects:

Table -1 shows that when the target tissue containing water is elevated to a temperature of 100C, vaporization of the water within the tissue occurs, a process called ablation. Soft tissue is composed of a high percentage of water, hence excision of soft tissue commences at this temperature. 0 At temperatures below 100C and above 60 C, proteins begin to denature without any vaporization of the underlying tissue. This is useful in surgically removing granulomatous tissue, because if the tissue temperature is controlled, the biologically healthy portion would remain intact. If the tissue temperature is raised to 200C, it is dehydrated and then burned and carbon is the end product. Carbon absorbs all wavelengths so heat sinks in as lasing continues. This causes a great deal of collateral thermal trauma to a wide area. Pulsing ensures that the target tissue has time to cool before the next amount of laser energy is emitted. Laser Delivery Systems And Emission Modes Two delivery systems are used in dental lasers. One has a flexible hollow wave-guide or tube that has an internal mirror finish. The laser energy is reflected along this tube and exits through a hand piece at the surgical end, with the beam striking the tissue in a noncontact fashion. The second delivery system is a glass fiber optic cable. It is pliable and comes in sizes ranging
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Lasers In Endodontics

Sebeena Mathew & Deepa Natesan Thangaraj

from 200 to 1000 . Although the glass fiber is encased in a resilient sheath, it can be somewhat fragile and cannot be bent into a sharp angle. The fiber fits snugly into the hand piece with the bare end protruding or, in some cases, with an attached glass like tip. This fiber tip can be used in contact or noncontact mode. Clinically a laser used in contact can provide easy access to otherwise difficult to- reach areas of tissue. In noncontact, the beam is aimed at the target, some distance away from it. This modality is useful for following various tissue contours, but the loss of tactile sensation demands that the surgeon pays close attention to the tissue interaction with laser energy. Most of the invisible lasers are equipped with a separate aiming beam. The aiming beam is delivered coaxially along the fiber or wave guide and shows the operator the exact spot where the laser energy is focused. Lasers with shorter emission wavelengths such as argon, diode and Nd:YAG can be designed with small, flexible glass fibers. A laser such as the Er:YAG presents challenges to fiber technology because the wavelength is large and does not fit into the crystalline molecules of the conducting glass fiber easily. The largest wavelength, CO2, is too large for glass and has to be conducted in a hollow tube. Low level laser therapy (LLTP), cold or soft laser, or laser biostimulation involves the application of monochromatic and coherent light to injuries and lesions to stimulate healing. Helium-Neon diode, Gallium-Arsenide and Gallium-Aluminum- Arsenide are soft tissue lasers. Hard tissue lasers are those that produce immediate visible effects on irradiated tissues. The three main types of hard tissue Lasers are Argon laser, CO2 laser and Nd:YAG laser. A high power of about 3 W or more is used. The laser device can emit the light energy in one of the three basic modes. One being the continuous wave. Here, the beam is emitted at one power level continuously as long as the device is activated, by pressing the foot switch. The second is the Gate pulsed mode meaning there are periodic alternations of the laser energy being on and off, similar to a blinking light. This mode is achieved by the opening and closing of a mechanical shutter in front of the beam path of a continuous wave emission. The duration of on and off times of this type of laser normally is as small as a few milli seconds.

The third is the free -running pulsed mode. Here, large peak energies of laser light are emitted for an extremely short time span, usually microseconds, followed by a relatively long time in which the laser is off. I) Diagnosis Of Pulp Vitality By Laser. A. Laser Doppler flowmetry Laser Doppler Flowmeter was developed by Tenland in 1982 and later by Hollway in 1983.This method uses Helium-Neon and diode lasers at a lower power of 1 or 2 mW. Laser Doppler flowmetry is a noninvasive method of assessing and accurately measuring the rate of blood flow in a tissue. The pulp is a highly vascular tissue and cardiac blood flow in the supplying artery is transmitted through pulsations. These pulsations are apparent on the laser doppler monitor of vital teeth and absent in the nonvital teeth. The blood flux level is much higher in vital than non vital teeth. Currently, the vitality can be 4 interpreted from a signal on the screen. B. Heat stimulation by Laser (Thermal testing): The laser stimulation method by pulsed Nd:YAG laser has been used in order to check the vitality of the pulp and is better tolerated than guttapercha.5 Differential diagnosis of pulpitis by laser stimulation a) Normal pulp and acute pulpitis When normal pulp is stimulated by the pulsed Nd:YAG laser at 2W and 20 pulses per second (pps) at a distance approximately 10 mm from the tooth surface, pain is produced within 20 to 30 seconds and disappears a couple of seconds after the laser stimulation is stopped. In the case of acute pulpitis the pain is induced immediately after laser application and continues for more than 30 seconds after stopping the laser stimulation. b) Acute serous pulpitis and acute suppurative pulpitis Differential diagnosis of acute serous pulpitis and acute suppurative pulpitis can be obtained by combining the measurement of electric current resistance of caries and the pain duration induced by laser stimulation. If the electric current resistance is
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greater than 15.1 m? and the patient experiences continuous pain for more than 30 seconds, the diagnosis is acute serous pulpitis .When the value of resistance is less than 15.0 m? and there is continuous pain for more than 30 seconds, the diagnosis is acute suppurative pulpitis. Caries impedence of less than 15.0 m? indicates that no hard healthy dentin exists between the caries and the pulp chamber. II) Lasers In Pulp Capping A. Accesory treatment by laser for Indirect Pulpcapping Pulsed Nd:YAG laser is used and black ink applied on the tooth surface. Air spray cooling is needed to prevent pulp damage resulting from the laser energy provided by 2W and 20pps for less than 1 second to the area. CO2 laser can also be used. In some cases, it is recommended that this laser be used with 38% silver ammonium solution. These treatments should be performed under local anesthesia. B. Direct pulp capping by laser CO2 laser irradiation is performed at 1 or 2W after irrigating with 8% sodium hypoclorite and 3%hydrogen peroxide for more than 5 minutes. Calcium hydroxide paste must be used to dress the exposed pulp after laser treatment, after which the cavity should be tightly sealed with cement such as polycarboxylate cement. Pulsed Nd:YAG, argon, semiconductor diode, and Er:YAG can also be used. III) Laser Ablation And Accessory Treatment For Vital Pulp Amputation The lasers used are CO2, pulsed Nd:YAG, He, Ne and low power semiconductor diode lasers and middle power semiconductor diode lasers.CO2 laser usage is time consuming and pulp tissue may be damaged due to several exposures.Pulsed Nd:YAG causes damage to the pulp tissue and thereby showed a low success rates so it should be used only for pulp hemostasis,sedation,antinflammatory effects, and stimulation of remaining pulpal cells. IV) Laser In Analgesia Certain wavelengths of laser energy interfere with the sodium pump mechanism, change cell membrane permeability, alter temporarily the

endings of sensory neurons, and block depolarization of C and A fibers of the nerves. In this area the pulsed Nd:YAG laser has commanded the most attention. The use of lasers in endodontic therapy has been extensively studied for the past 15 years and proven to have many advantages over conventional methods. Results suggest that the laser is an effective tool for removal of debris, the smear layer and obturation materials, as well as being an effective disinfection tool. Indications And Contra Indications Of Laser Support In Endodontics Laser-supported endodontic treatments should be favored when treating patients that show one or several of the following symptoms. - Teeth with a purulent pulpitis or pulp necrosis - Teeth, of which crown and root pulp show gangrenous changes. - Teeth with peri-apical lesions (peri-apical gap from 1mm, up to granulomas with a diameter of 5mm and more) (Smith et al., 1993, Kovacs et al.,1993,Schroeder,1983) - Teeth with a peri-apical abscess - Teeth with lateral canals that lead to periodontal involvement. - Absorption of the apex caused by inflammation or trauma - Teeth that have been treated for at least three months without success (with alternating rinsing and medicinal inlays). Clear contra-indications for performing a lasersupported endodontic treatment are very advanced periodontitis, a deep crown or root fracture on the tobe-treated tooth, and when obliterated root canals are 6 diagnosed on the endodontically treated teeth. V) Lasers In Root Canal Treatment. a) Laser in access cavity preparation and root canal orifice enlargement The primary use of lasers in Endodontics is focused on eradicating microorganisms in the root channel, especially in the lateral dentinal tubuli. Er,Cr:YSGG (2780nm) and Er:YAG (2940nm) can be used for access cavity preparation, root canal shaping 7 and cleaning . b) Root canal wall preparation by lasers Lasers that are used are Er:YSGG (2780nm), Er:YAG(2940nm) and Nd:YAG(1064 nm).
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Sebeena Mathew & Deepa Natesan Thangaraj

Procedure The length of the root canal, obtained through the X-ray ,is transferred to the fiber-optical wave guide to ensure that the flexible 200m fiber reaches the apex. The laser is activated only after the fiber reaches the apex and the fiber is guided in an apical to coronal direction with rotary movements and in contact with the root canal wall.6 When the laser fiber is unable to be inserted into the canals, reamers and files are to be used, followed by lasers. Smear layer is completely removed and dentinal tubuli are for the most part closed if pulsed Nd:YAG laser is applied at 15 Hz / 1.5 W settings. Er:YAG laser removes the smear layer completely and the dentinal tubuli remain open. c) Root canal sweeping and irrigation with lasers Straight, slightly curved and wide canals are indicated for this treatment. Pulsed Nd:YAG, Er:YAG and Nd:YAG are recommended. Along with lasers, 5.25% Sodium hypochlorite or 14% EDTA must be used along laser irradiation. d) Laser application for removing pulp remnants and debris at the apical foramen. The effects of pulsed Nd:YAG laser when used on the apical foramen include sterilization,removal of pulp remnants,control of hemorrhage, and stimulation of cells surrounding the root apex as well as debridement on the surface. e) Sterilization or disinfection of infected canals. The laser is an effective tool for killing microorganisms because of the laser energy and wavelength characteristics. Infected canals are an indication for this treatment but its difficult in extremely curved and narrow canals. Pulsed Nd:YAG, argon, semiconductor diode, CO2, Er:YAG are considered for this treatment. Gutknecht et al, 1996 achieved an average of 99.92% bactericidal reduction in root canal using the pulsed Nd:YAG laser with standard settings of 15 Hz at 100 mJ =1.5 W, repeated four times for 5-8 seconds. In Photoactivated disinfection, tolonium dye is applied to the infected area and light is transmitted into the root canals at the tip of a small flexible optical fiber that is attached to a disposable hand piece. Laser emits 100mW and does not generate sufficient heat to harm the adjacent tissues.8

L. Bergmans et al did a study on the effect of photoactivated disinfection on endodontic pathogens ex vivo. They concluded that photoactivated disinfection is not an alternative but a possible supplement to the existing protocols for root canal 9 disinfection. f) Obturation using gutta-percha or resin by laser Gutta-percha is thought to be melted by laser heat energy. Anic and Matsumoto10,11 attempted to investigate whether it is possible to perform the root canal filling using sectioned gutta-percha segments and a pulsed Nd:YAG laser. This was shown to be possible by vertical condensation method, but the technique required too much time. g) Removal of temporary cavity sealing materials,root canal sealing materials, and fractured instruments in root canals. According to experimental results, it was easy to remove temporary cavity sealing materials made of zinc oxide, eugenol , or gutta-percha by pulsed Nd:YAG, Er:YAG, and Er,Cr:YSGG lasers; root canal sealing material made of resin or gutta-percha by pulsed Nd:YAG and Er:YAG lasers; and fractured reamers or files in slightly curved and wide root canals. In fine and strongly curved canals, however, there were many cases in which laser tips perforated the canal wall. VI) Laser In Apicoectomy, Retrograde And Endodontic Apical Cavity Preparation, And Periapical Curretage Advantages of laser over scalpel are greater precision, a relatively bloodless and post surgical course, sterile surgical area, minimal swelling and scarring, coagulation, vaporization and cutting, minimal or no suturing and much less or no post 12 surgical pain. Permeability of dentin exposed by apicoectomy is one of the causes of endodontic surgery failure because microleakage and bacterial contamination trigger inflammation. The use of lasers resulted in smoother surfaces and more homogenous dentin fusion and recrystallization, which occluded tubules and decreased permeability.13 Daniel humberto et al in their laser study found the following techniques to reduce dye leakage and thereby concluded them to be good.
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Sebeena Mathew & Deepa Natesan Thangaraj

Apicoectomy with burs and treatment of apical surface with Nd:YAG laser; Apicoectomy with bur, root end cavity preparation with ultrasound, filling with MTA; treatment of apical surface with CO2 laser; and apicoectomy with Er:YAG laser and treatment of 14 apical surface with Nd:YAG laser. The advantages of Er:YAG laser over burs are better visibility; accurate apical resection; no contact; removal of lesion in a shorter time by vaporization; hemostasis; no vibration or discomfort and minimal pain and less bacterial risk of trauma to adjacent tissues. While using Er,Cr:YSGG laser the clinician uses a single instrument for all major steps of an apicoectomy procedure, including flap preparation, cutting bone ,amputating root tip, removing pathologic tissue and hyperplastic tissue from around the site and preparing the site for retrofill amalgam or composite. VII) Laser Treatment Of Periapical Lesions Of Sinus Tract Laser therapy is recommended for cases for which apicoectomy or periapical curettage cannot be performed, or for which standard endodontic treatment cannot be performed, because of deep post in the root canal. This treatment can be performed to accelerate wound healing in combination with endodontic or surgical treatment. Pulsed Nd:YAG and CO2 lasers are recommended for these treatments. For the pulsed Nd:YAG laser, 2 W and 20pps are the recommended parameters and the fiber tip must be inserted into the tract and drawn slowly from the root apex to the exit through the sinus tract. This treatment generally is performed three or four times during one visit. When using the CO2 laser, the exit of drainage must be ablated as deeply as possible at 1 or 2 W and under air cooling or local anesthesia. The aforementioned laser treatments are performed once or twice a week until the sinus tract disappears. Laser Safety The operator should be well trained to use a laser device. The operator, patient and the surgical team should wear protective eyewear so that any reflected energy does no damage. The surgical environment must have a warning sign and limited access. High volume suction must be used to evacuate the plume formed by tissue ablation, and normal infection protocol should be followed. The laser should be in good working condition.

Benefits Of Lasers Ability to selectively and precisely interact with diseased tissues, allows the surgeon to reduce the amount of bacteria and other oral pathogens in the surgical field and incase of soft-tissue procedures, achieve good hemostasis with reduced need for sutures. Osseous tissue removal and contouring proceed easily with the Erbium family of laser instruments. While using YSSG laser dramatic reduction of pain in most cases reduces the need for injected anesthesia. Disadvantages Of Lasers High cost, accessibility to the surgical area can be a problem with the existing delivery system and the clinician must prevent overheating the tissue and guard against the possibility of surgically produced air embolisms that could be produced by excessive air and water used during the procedure. Erbium lasers cannot remove metallic restorations. No single wavelength will treat all dental disease. Conclusion Laser energy requires some procedures to be performed differently than with conventional instrumentation, but the indications for laser use continue to expand and further benefit patient care. References
1. Donald J.Coluzzi: An overview of laser wavelengths used in dentistry. DCNA. 2000; 44(4). 2. James Jesse, Sandip Desai, Patrick Oshita:The evolution of lasers in dentistry: Ruby to YSGG. The academy of dental therapeutics and stomatology. 3. Academy of laser dentistry.2008; 1-18 4. N i s h a G a r g a n d A m i t G a r g -Te x t b o o k o f endodontics 5. Koukichi-Matsumoto: Lasers in Endodontics: DCNA. 2000; Vol 44(4): 889-906 6. Nobert Gutknecht: Lasers in endodontics. Journal of laser and health academy. 2008; Vol 4; 1-5 7. Erin Koci et al: Lasers in dentistry. An evidenced based clinical decision making update: Pakistan oral and dental journal. 2009; Vol29 (2): 409- 423 8. Robert Pong-Yin Ng: Sterilization in root canal treatment: current advances. Hong kong dental journal.2004; 1: 52-57 9. L.Bergmans et al: Effect of photo activated disinfection on endodontic pathogens ex vivo. EJ. 2007; Vol 41(3): 227-239
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Sebeena Mathew & Deepa Natesan Thangaraj

10. Anic I, Matsumoto K: Comparison of the sealing ability of laser softened, laterally condensed and low temperature thermoplasticized gutta- percha.J of Endod .1995; 21:464-469 11. Anic I, Matsumoto K: Dentinal heat transmission induced by a laser-softened gutta percha obturation technique .Journal of Endod. 1995; 21:470-474

12. K.Gorkhay et al: Effects of oral soft tissue produced by a diode laser in vitro. Lasers in Surgery and medicine 1999; 25:401-406 13. Lee B.S: Ultra structural changes of human dentin after irradiation by Nd:YAG laser. Lasers Surg Med.2002; 30(3): 246-252 14. Daniel Humberto Pozzo et al: CO2, Er: YAG andNd:YAG lasers in endodontic surgery. J appl Oral Sci.2009; 17(6):596-599

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