Received: 31 March 2023 | Revised: 15 June 2023 | Accepted: 30 July 2023

DOI: 10.1002/iid3.975

ORIGINAL ARTICLE

Analyze the clinical effect of YAG laser combined with

sodium hypochlorite in root canal treatment of pulpitis

Qiaolin Lin1 | Zhixin Li1 | Mingming Liu2

1
Department of Stomatology,
Shijiazhuang Fourth Hospital, Abstract
Shijiazhuang, China Objective: To compare and analyze the clinical therapeutic effects of sodium
2
Laboratory Center, The First Hospital of hypochlorite combined with Nd: YAG laser and sodium hypochlorite alone for
Hebei Medical University, Shijiazhuang,
China root canal disinfection in patients with pulpitis.
Methods: Patients with pulpitis were divided into control group and
Correspondence
observation group according to random number table method. Both groups
Mingming Liu, Laboratory Center, The
First Hospital of Hebei Medical received root canal treatment, while the control group received root canal
University, No.89 Donggang Rd, irrigation with 1% sodium hypochlorite. The observation group was irrigated
Shijiazhuang, Hebei 050000, China.
with 1% sodium hypochlorite combined with Nd: YAG laser. Periodontal
Email: [email protected]
index, inflammatory index, life quality score and bacterial infection clearance
Funding information rate of the two groups were compared before and 3 months after treatment.
Health and Medical Science Research
Results: The total effective rate of the observation group was 95.35%, which
Project of Hebei Province,
Grant/Award Number: 20231664 was higher than that of the control group 79.07% (p < .05). After 3 months of
treatment, the periodontal index and inflammation level of both groups
decreased, and the observation group was lower than that in the control group
(p < .05). The life quality score and infection clearance rate of observation
group were significantly higher than control group (p < .05).
Conclusion: Compared with root canal irrigation with 1% sodium hypo-
chlorite alone, sodium hypochlorite combined with Nd: YAG laser for root
canal disinfection can significantly improve the therapeutic effect, relieve
inflammatory reaction, and decrease bacterial infection.

KEYWORDS
Nd: YAG laser, periodontal index, pulpitis, root canal treatment, sodium hypochlorite

1 | INTRODUCTION are prone to symptoms such as spontaneous parochial

pain and temperature stimulation pain, which seriously
Pulpitis is a common and frequently occurring disease in affect patients' chewing function and daily diet. Gener-
dental clinics. About half of patients with pulp diseases ally, the damage caused by pulpitis is irreversible even
suffer from pulpitis. Pulpitis is a kind of dental pulp after the trigger of inflammation is removed, mainly
injury caused by bacterial infection, mechanical stimula- because the disease is usually accompanied by a loss of
tion, chemical stimulation and other factors.1 Patients the ability of an organism to regenerate dental pulp.2 The
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2023 The Authors. Immunity, Inflammation and Disease published by John Wiley & Sons Ltd.

Immun Inflamm Dis. 2023;11:e975. wileyonlinelibrary.com/journal/iid3 | 1 of 9

https://doi.org/10.1002/iid3.975
2 of 9 | LIN ET AL.

blood system and nervous system in healthy dental pulp The objective of this study was to explore the effect of
tissue can continuously supply nutrients to dental tissue Nd: YAG laser combined with sodium hypochlorite on
and transport unwanted metabolic wastes through apical root canal irrigation in pulpitis patients by evaluating the
foramina. At the same time, in addition to dental pulp changes of periodontal index and inflammatory factor
cells, there are many kinds of immune cells in healthy levels before and after treatment, so as to find an effective
dental pulp tissue, such as T lymphocytes and macro- root canal disinfection method in clinical practice.
phages, which can resist the invasion of foreign micro-
organisms and antigens.3,4 However, the occurrence of
pulpitis disrupted this stable environment. Therefore, 2 | MATERIALS AND METHODS
once pulpitis is found, it is advisable to seek treatment in
the stomatology department of the hospital immediately 2.1 | Study population and sample
to avoid damage to the integrity of the teeth. inclusion
At present, the commonly used clinical treatment of
pulpitis is root canal therapy after the infected root Pulpitis patients were selected and divided into control group
canals is completely removed.5 In most cases, root (n = 43) and observation group (n = 43) according to random
canal cleaning and shaping can be achieved by mechan- number table method. Inclusion criteria: (1) The affected
ical preparation.6 However, these instruments cannot teeth have spontaneous pain, hot and cold stimulation pain
reach all parts of the inner wall of the root canal, and or occlusion pain; (2) X‐ray examination confirmed lesion,
infected pulp and residual dentin debris still exist in alveolar bone resorption, and alveolar abscess; (3) The gums
the inaccessible areas.7 In the process of root canal are red and swollen, and the teeth are loose by I and II
treatment, most microorganisms in the diseased tooth degrees; (4) All patients had no treatment history of pulpitis.
root canal can be removed by root canal preparation Exclusion criteria: (1) Patients with unclear root canal
combined with irrigation solution, and subsequent drugs imaging and root canal blockage; (2) Patients with blood and
sealed in the root canal can completely kill the immune system diseases; (3) Severely malnourished patients;
remaining microorganisms and prevent the recurrence (4) Patients with periapical disease; (5) Patients with a
of inflammation. The ideal irrigation solution should history of maxillofacial surgery; (6) Patients suffering from
have the properties of antimicrobial activity, high mental illness or disorder of consciousness; (7) Patients
permeability, dissolving necrotic tissue, so as to clear allergic to the drugs used in this study; (8) Pregnant and
the lesions of root canal system of lesions, and be lactating women. All patients and their families in this study
nontoxic to periapical tissue.8 Presently, the commonly gave informed consent and this protocol was approved by
used root canal irrigation solution includes sodium the Ethics Committee of Shijiazhuang Fourth Hospital
hypochlorite, chlorhexidine, chloramine T, strong acid (Ethical number: 20200018).
electrolyte water, hydrogen peroxide solution, etc.9 As The sample size was estimated using PASS 11.0
the most widely used flushing solution, sodium hypo- software based on a 5% false‐positive error rate (α = 0.05,
chlorite has a remarkable effect in root canal therapy and bilateral) and 90% power (β = 0.1). A sample of at least 36
has become the “gold standard” of root canal flushing cases should be enrolled for each group. Assuming a
solution.10 Although sodium hypochlorite has excellent dropout rate of about 20%, a total of 86 patients should
bactericidal effect, conventional irrigation with low have been recruited in this trial (43 per group).
concentration cannot completely remove bacteria from
the dentin wall of root canal, which will undoubtedly
reduce the success rate of root canal treatment. 2.2 | Therapeutic method
Meanwhile, traditional syringe needle irrigation is
limited by complicated root canal anatomy and cannot Before treatment, all patients in both groups received routine
be completely rinsed.11 Recently, with the application of oral cleaning and took antibiotics to control the inflamma-
laser in endodontic treatment, the combination of laser tion. Both groups received one‐time root canal therapy. After
and flushing solution has been applied in clinics. Nd: the pulp was opened, the top of the pulp chamber was
YAG laser, with a wavelength of 1064 nm, can be removed with a slow ball drill to prevent external
strongly absorbed by water and hydroxyapatite in dentin contamination. After the root canal was cleaned, the root
to produce photothermal effects.12 Studies have shown canal length was measured and the root canal was prepared
that Nd: YAG laser combined with ordinary irrigation with Dentsply Protaper system (Dentsply Maillefer, Bailla-
solution cannot only significantly improve the steriliza- gues, Switzerland). The control group was given sodium
tion rate, but also effectively remove bacteria at different hypochlorite for root canal irrigation. The control group was
depths of dentin. given sodium hypochlorite (NaClO) for root canal irrigation,
LIN ET AL. | 3 of 9

that is, 1% NaClO was washed first, then 0.9% sodium reaction well, the remaining samples were added to each
chloride solution was washed. The observation group was well, and then 50 μL of biotin antibody working solution
treated with Nd: YAG laser combined with 1% NaClO for was added, covered with membrane plate, gently mixed
root canal irrigation. Set the Nd: YAG laser (1064 nm, 15 Hz, by shock, and incubated at 37°C for 30 min. Discard the
1.5 W) therapeutic instrument (France Guangtai Medical liquid in the plate, add washing liquid to each hole,
Company) to disinfection mode. The optical fiber was shake for 30 s, and repeat operation for 3 times. Then,
inserted 1 mm away from the root tip, and the root canal was chromogenic solution and the termination solution were
irradiated and disinfected from bottom to top. Each root added in turn, and the absorbance values of each hole at
canal was irradiated four times in different directions for 5 s 450 nm were measured with enzyme‐labeled marker to
each time, with an interval of 5 s. After irradiation calculate the sample concentration.
disinfection of each root canal, the exudation water was
sucked out with absorbent paper, and the root canal was
filled with hot gutta percha combined with i‐Rootsp paste 2.5 | Quality of life assessment
under pressure.
The standardized questionnaire SF‐36 scale was used to
assess patients' quality of life. The scale is used to assess
2.3 | Evaluation of periodontal index subjects' functional status, emotional health, and physical
health. Scores on each dimension of the SF‐36 scale ranges
Oral examination was performed before and 3 months after from 0 to 100, with higher scores indicating better quality
treatment to observe the periodontal index. Bleeding index of life.
(BI), with a score of 0−5. 0: no inflammation, no bleeding,
healthy gums; 1 point: no bleeding but inflammatory
changes in gingival color; 2 points: the gums are a little 2.6 | Comparison of bacterial infection
bleeding; 3 points: the bleeding spread along the gingival rates
margin; 4 points: the amount of bleeding is large and
overflows the gingival sulcus; 5 points: massive bleeding and Patients were examined for periodontal bacterial infec-
automatic bleeding. Plaque index (PLI), with a score of 0−5. tion before and 3 months after treatment. Bacterial
0: aseptic plaque on the patient's tooth surface; 1 point: there culture and drug sensitivity tests were carried out to
is a small amount of plaque on the gingival margin; 2 points: calculate bacterial infection rate and infection clearance
there are continuous plaque in the tooth neck, and the width rate. Infection clearance rate = (Number of cleared
of plaques is less than 1 mm; 3 points: there are many dental cases/total cases) × 100%.
plaques, and the coverage area attached to the tooth neck is
more than 1 mm and less than 1/3 of the tooth area; 4 points:
the attachment area of dental plaque accounts for 1/3 of the 2.7 | Therapeutic effect evaluation
entire tooth surface; 5 points: plaque attachment area is
more than 2/3 of the tooth surface. Gingival index, with a The evaluation standard of curative effect can be used to
score of 0−3. 0: the gingiva is healthy as a whole, without evaluate the therapeutic effect according to the marked
any abnormality; 1 point: there is mild inflammation and effect, effectiveness, and ineffectiveness. Effective: the clinical
edema in the gums; 2 points: the gums are red, with symptoms disappeared, the bite force and masticatory
moderate inflammation and moderate edema and bleeding; efficiency returned to normal, and the levels of various
3 points: there is severe inflammation, obvious swelling and indicators returned to normal. Palliative: clinical symptoms
severe bleeding in the gums. The higher the score of the were relieved, and the bite force, masticatory efficiency and
above periodontal index, the more serious the degree of various indexes were improved effectively. Useless: the
tooth pain and bleeding. clinical symptoms, bite force and masticatory efficiency have
not been alleviated or improved. Total effective rate =
(Marked effect + effectiveness)/total cases × 100.
2.4 | Enzyme linked immunosorbent
assay (ELISA)
2.8 | Data analysis
The levels of TNF‐α, IL‐6 and CRP were determined by
double‐antibody sandwich method according to the SPSS19.0 software was used for data analysis and processing.
instructions of ELISA Kit. The sample was diluted 1:1 Counting data is described in %. Kolmogorov‐Smirnov is
with 50 μL of specimen dilution and added to the applied to test whether the data confirms to the normal
4 of 9 | LIN ET AL.

distribution, and the data fitting the normal distribution was two groups was shown in Table 2. For both the control
described by mean ± standard deviation (SD). Levene group and the observation group, the periodontal index
method was used to check the uniformity of variance. score after treatment was significantly lower than that
Independent sample t test was used for intergroup compari- before treatment (Table 2, p < .01).
son, and paired t test was used for intragroup comparison.
p < .05 was considered statistically significant.
3.3 | Comparison of inflammatory index
before and after treatment
3 | RESUL TS
Before treatment, there was no significant difference in IL‐6,
3.1 | Comparison of baseline data TNF‐α and CRP between the control group and the
observation group (Figure 2A, p > .05). After treatment, the
General data of the control group and the observation group levels of IL‐6, TNF‐α and CRP in the observation group were
are summarized in Table 1. There were no statistically significantly lower than those in the control group
significant differences between the two groups in gender, (Figure 2B, p < .001). The results of intra‐group comparison
age, location of affected tooth and basic diseases (hyper- of inflammatory indicators showed that the concentration of
tension and diabetes), which was comparable (p > .05). inflammatory indicators were significantly lower after
treatment than before for both the observation group and
the control group (Table 3, p < .01).
3.2 | Comparison of periodontal index

The results of intergroup comparison of periodontal 3.4 | Comparison of patients' quality of

index between the two groups are shown in Figure 1. life before and after treatment
Before treatment, the periodontal index including PLI, BI
and GI scores of the control group and the observation Before treatment, there was no significant difference
group were nearly identical (Figure 1A, p > .05). After 3 between the control group and the observation group in
months of treatment, except BI score, the scores of PLI any item of the quality of life scores (Figure 3A, p > .05).
and GI in the observation group were significantly lower After treatment, the scores of all aspects of life quality in
than those in the control group (Figure 1B, p < .001). The the observation group were higher than those in the
intragroup comparison of periodontal index between the control group (Figure 3B, p < .001). The intragroup

TABLE 1 Basic clinical information of the subjects.

Items Control group (n = 43) Observation group (n = 43) T/χ2 p
Age (years) 51.60 ± 11.29 50.98 ± 10.72 1.82 .07
Gender (n/%) 0.42 .52
Male 24 (55.82) 21 (48.84)
female 19 (44.18) 22 (51.16)
Hypertension (n/%) 0.66 .42
yes 7 (16.28) 10 (23.26)
no 36 (83.72) 33 (76.74)
Diabetes (n/%) 0.72 .40
yes 2 (4.65) 4 (9.30)
no 41 (95.35) 39 (90.70)
Location of affected tooth (n/%) 0.81 .37
Premolar 17 (39.53) 18 (41.86)
Molar 26 (60.47) 25 (58.14)
Note: Data presentation: mean ± standard deviation or n/%. p < .05 is considered a significant difference.
LIN ET AL. | 5 of 9

F I G U R E 1 Detection of periodontal indicators. Assessment of PLI, BI and GI in control group (n = 43) and observation group (n = 43)
before (A) and after treatment (B). ***p < .001 versus Control group using independent sample t test. BI, bleeding index; GI, gingival index;
PLI, plaque index.

TABLE 2 Comparison of the periodontal clinical indexes between the two groups.
Control group (n = 50) Intervention group (n = 50)
Items Before After t p Before After t p
PLI 2.27 ± 0.80 1.30 ± 0.47 8.17 <0.01 2.40 ± 0.68 0.78 ± 0.33 14.93 <.01
BI 4.27 ± 0.41 2.55 ± 0.36 23.25 <0.01 4.23 ± 0.35 2.44 ± 0.52 21.19 <.01
GI 2.59 ± 0.66 1.46 ± 0.46 8.94 <0.01 2.60 ± 0.36 0.93 ± 0.15 19.61 <.01
Abbreviations: BI, bleeding index; GI, gingival index; PLI, plaque index.
Note: Data presentation: mean ± standard deviation. p < .05 is considered a significant difference.

F I G U R E 2 Detection of inflammatory indexes. Assessment of IL‐6, TNF‐α and CRP in control group (n = 43) and observation group
(n = 43) before (A) and after treatment (B). ***p < .001 versus Control group using independent sample t test. CRP, C‐reactive protein; IL‐6,
Interleukin‐6; TNF‐α, Tumor necrosis factor‐α.

comparison of quality of life scores showed that after 3.5 | Comparison of bacterial infection
treatment, the scores of the control group were improved before and after treatment
in all categories, but there were significant differences in
physiological function and emotional function (Table 4, The bacterial infection rate in both control and observa-
p < .05). However, for the observation group, compared tion groups decreased significantly after treatment
with the control group, the scores in all categories compared to before treatment (Table 5, p < .01). Addi-
increased after treatment (Table 4, p < .01). tionally, it can be observed that the infection clearance
6 of 9 | LIN ET AL.

TABLE 3 Comparison of levels of inflammatory mediators in root canal exudate between the two groups.
Control group (n = 43) Observation group (n = 43)
Indicators Before After t p Before After t p
IL‐6 (ng/mL) 4.37 ± 0.89 2.62 ± 0.87 8.01 <0.01 4.72 ± 1.30 1.86 ± 0.52 14.17 <.01
TNF‐α (ng/mL) 6.56 ± 1.13 4.15 ± 1.03 10.43 <0.01 6.63 ± 1.27 2.44 ± 0.50 19.38 <.01
CRP (mg/mL) 3.48 ± 0.27 2.03 ± 0.20 27.20 <0.01 3.50 ± 0.25 1.09 ± 0.10 56.54 <.01
Note: Data presentation: mean ± standard deviation. p < .05 is considered a significant difference.

F I G U R E 3 Quality of life assessment. Assessment of SF‐36 score in control group (n = 43) and observation group (n = 43) before
(A) and after treatment (B). ***p < .001 versus Control group using independent sample t test.

TABLE 4 Comparison of quality of life scores between the two groups.

Control group (n = 43) Observation group (n = 43)
Items Before After t p Before After t p
General health 68.40 ± 6.98 70.40 ± 5.43 −1.43 0.16 68.51 ± 7.31 80.16 ± 9.68 −5.40 <.01
Role physical 63.12 ± 3.87 67.30 ± 5.47 −3.93 <0.01 64.06 ± 5.06 77.26 ± 7.88 −8.72 <.01
Physiological function 66.16 ± 6.35 68.67 ± 5.44 −1.90 0.06 63.77 ± 6.83 75.79 ± 5.48 −9.05 <.01
Body pain 72.12 ± 6.36 74.47 ± 6.46 −1.98 0.05 71.65 ± 6.51 79.51 ± 4.87 −6.88 <.01
Mental health 75.79 ± 4.56 75.49 ± 5.47 0.29 0.77 75.65 ± 4.93 79.95 ± 3.97 −4.47 <.01
Function of emotion 69.58 ± 5.52 72.47 ± 5.08 −2.44 0.02 68.74 ± 5.69 79.77 ± 7.70 −6.89 <.01
Note: Data presentation: mean ± standard deviation. p < .05 is considered a significant difference.

TABLE 5 Comparison of the periodontal clinical indexes between the two groups.
Control group (n = 43) Observation group (n = 43)
Items Before After χ 2
p Before After χ2 p
Bacterial infection rate 39 (90.70%) 9 (25.71%) 42.43 <.01 40 (93.02%) 2 (5.00%) 67.20 <.01
Infection clearance rate 30 (30%) 38 (52.6%) 10.90 <.01
Note: Data presentation: n/%. p < .05 is considered a significant difference.
LIN ET AL. | 7 of 9

T A B L E 6 Effect of different treatment methods on patients For complicated root canal procedures, it is necessary
with acute pulpitis. to use effective antibacterial solution in the root canal. In
Control Observation the process of root canal therapy, the ideal root canal
group group washing agent can effectively kill bacteria, dissolve
Items (n = 43) (n = 43) χ2 p necrotic tissue, lubricate the root canal, and remove the
Useless 9 (20.93%) 2 (4.65%) 5.11 .02 smear layer, which is the key to the success of root canal
treatment.15,16 As the most commonly used irrigating
Palliative 10 (23.26%) 14 (32.56%)
agent in root canal irrigation, NaClO not only has
Effective 24 (55.81%) 27 (62.90%)
excellent antibacterial effect, but also has the advantages
Total effective 34 (79.07%) 41 (95.35%) of high irrigation efficiency, low surface tension, and
rate dissolving interstitial fluid and protein. In solution,
Note: Data presentation: n/%. p < .05 is considered a significant difference. NaClO dissociates into hypochlorous acid and hypo-
chlorite, which kill bacteria by affecting their metabo-
lism. Studies have shown that the bactericidal effect of
rate in the observation group is significantly higher than NaClO was gradually enhanced with the increase of the
that of the control group (Table 5, p < .01). concentration. When the concentration is higher than
0.05%, it will cause changes in cell vacuoles, but the
antibacterial effect will be greatly weakened when the
3.6 | Comparison of therapeutic efficacy concentration is too low.17 Currently, the optimal
between the two groups concentration of NaClO for root canal irrigation has
not been determined in clinic, and the common
After treatment, the total effective rate was 95.35% concentrations are 1%, 2.5%, and 5.25%.18 5.25% NaClO
(41 cases) in the observation group, which was higher will not only damage periapical tissues, but also cause
than that of the control group (79.07%, 34 cases) chemical burns once it comes into contact with oral soft
(Table 6, p < .05). tissues.19 Considering the safety problem, 1% NaClO was
selected in this study. At present, to improve the efficacy
of irrigating agent, laser washing technology is gradually
4 | DISCUS SION emerging in people's field of vision. Nd: YAG laser, as a
solid‐state laser, can convert spectral energy into heat
At present, the main clinical treatment of pulpitis is root energy, remove most bacteria in root canal through
canal treatment, which can achieve good results.13 The thermal damage, and inhibit inflammatory reaction,
root canal treatment of pulpitis requires the thorough which plays a good clinical role in the treatment of
removal of residual tissue and debris in the root canal pulpitis.20,21 Bergmans et al. showed that the dentin disc
system, as well as the effective elimination of bacteria with a thickness of 1 mm was inoculated with actinomy-
and their complex product.13 However, the structure of ces and streptococcus in the same proportion, and after
the root canal system is relatively complex, and other three times of irradiation with 1.5w Nd: YAG laser, it was
areas except the principal root canal are irregular, found that the morphology of bacteria gradually changed
which increases the difficulty of root canal treatment. with the increase of irradiation times, and finally the
During the preparation of the root canal, part of the wall bacteria were completely destroyed.22 The pulp tissue
of the root canal was difficult to be reached by and periodontal tissue are anatomically communicating
instruments, so the removal of bacteria and their with each other, and there are mixed infections
products was not complete. The residual bacteria after dominated by anaerobic bacteria in both the periodontal
the filling of the root canal was the main cause of the pocket and the infected pulp.23 The inflammation and
failure of the root canal and the recurrence of periapical immune response caused by them are similar. In this
inflammation.14 Root canal flushing solution plays an study, after laser‐assisted root canal cleaning, the
important role in reducing bacteria in irregular areas of periodontal index of patients, including PLI, BI, GI,
root canal, improving the success rate of root canal and the levels of inflammatory indicators IL‐6, TNF‐α,
treatment, and promoting the healing of peri‐root and CRP, were all lower than those of the 1% NaClO
tissue. In this study, it was found that Nd: YAG laser group, which further indicating that the periodontal
combined with 1% NaClO irrigation is better than 1% recovery and inflammation inhibition of patients after
NaClO alone in reducing periodontal index, relieving laser‐assisted root canal therapy were better than those in
inflammatory response, improving quality of life and 1% NaClO alone. The above results also indicate that the
reducing microbial infection. periodontal problems of the patients have been alleviated
8 of 9 | LIN ET AL.

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