13/10/2009

THE HOLY GRAIL OF MODERN DENTAL PRACTICE.

LASERS IN DENTISTRY
(A REVIEW)
1
CONTENTS
 INTRODUCTION
 SIGNIFICANCE IN MODERN DENTAL PRACTICE
 REVIEW OF HISTORY AND DEVELOPMENT
 FUNDAMENTAL OF LASER PHYSICS AND ITS
COMPONENTS
a)Laser principles
b)Laser properties
c)Measurements of laser
d)Laser generation
e)Beam Profile and Spot Geometry
f) Power Density(PD)

2
 Cont…
 LASER DELIVERY SYSTEM
 LASER EMISSION MODE
 LASERS AND TISSUE INTERACTION
a)OPTICAL PROPERTIES OF TISSUE
b)TISSUE EFFECT OF LASER IRRIDIATION
 CLASSIFICATION OF LASERS
 TYPES OF LASERS
 SOFT AND HARD TISSUE APPLICATION OF LASERS IN
DENTISTRY
1.Laser in endodontics
2.Laser in operative and esthetic dentistry
 LASERS SAFTY IN DENTAL PRACTICE
 CONCLUSION
 REFRANCES 3
INTRODUCTION
 LASERS can be defined as
1. A device that utilizes the natural oscillations of
atoms or molecules between energy levels for
generating coherent electromagnetic radiation
usually in the ultraviolet, visible, or infrared
regions of the spectrum
 -Merriam-
webster.com
1. A device which amplifies electromagnetic energy at
various optical frequencies into an extremely
intense small and nearly non divergent beam of
bright light of a single color. Capable of
mobilizing intense heat and power when focused
at a close range, it is used as tool in surgical
procedure , in diagnosis and in physiological
studies. 4
 cont.
 To d a y La se rs a re e m p lo ye d fo r va rio u s
p u rp o se s ra n g in g fro m
Ømeasuring distances of the far planets,
Øcreate laser guided warfare,
Øentertainment,
Øinstrumentation
Øand even those that record the price of
our groceries. And many more ……….

5
6
 CONT…

 But out of all odds the main and most

advantageous purposes of is found in
the field of HEALTH CARE INDUSTRIES.


7
SIGNIFICANCE IN MODERN DENTAL PRACTICE.


Today's dream and tomorrow's
reality


 lasers can be used to enhance the once clinical practice

and the treatment out come also.


 Dentist should become laser literate, consumer wise and

that’s how increasing the potential of its use in day to
day clinical practice with patient acceptance.


 To understand the differences between variety of lasers

and their vivid application.


 Understanding lasers in an easy and understandable 8

 Worldwide laser sales by
application

9
REVIEW OF HISTORY AND DEVELOPMENT
 Use of light for treatment of various pathologies is
referred to as phototherapy.


 Ancient Greece  sun for heliotherapy, by exposure of
the body to the sun for the restoration of health .


 Late 1700s the Chinese used the sun to treat conditions
such as rickets, skin cancer, and even psychosis.


 In 1400 B.C. INDIANS used psoralens(a plant 10
extract),to treat vitiligo.
 cont…
 1903, a Danish physician Niels Finsen
used carbon arc phototherapy for the
treatment of lupus vulgaris by using
UV rays.


11
Foundation of laser development
 In 1917 Albert Einstein, in his “The Quantum
Theory of Radiation”, laid the foundation for
the invention of the laser and its predecessor,
the maser,

 In 1928, Rudolf W. Ladenburg confirmed the
existence of stimulated emission and
negative absorption.

 In 1939, Valentin A. Fabrikant predicted the use
of stimulated emission to amplify "short"
waves.

In 1947, Willis E. Lamb and R. C. Retherford 12

Development of the lasers

 The earliest use of photochemotherapy, or the use of an exogenous
photosensitizerto absorb light and render a therapeutic effect

 In 1974 it is evidenced that psoralens combination with exposure to
ultraviolet radiation was indeed effective in the treatment of
psoriasis and vitiligo.

 Theodore H. Maiman of Hughes Aircraft Corporation
 in 16 May 1960 developed the first laser, or “ MASER“ an acronym for
"Microwave Amplification by Stimulated Emission of Radiation,".

 Snitzer in 1961 developed neodymium laser

 Carbon dioxide laser -Kumar Patel in 1964
 13
 T h e o d o re H . Le o n G o ld m a n
M a im a n
14
 Cont…
 In 1965 Taylor et al studied histological effect of laser
on the pulp


 In 1968 Lobene et al used carbon dioxide laser in

dentistry


 Weichman & Johnson 1971 used laser for the first time
in sealing of the apical foramen in vitro by means of
a high power-infrared (CO2) laser


 In 1974 Yamamoto et al used Nd:YAG laser for caries

prevention


 In 1977 Lenz et al used laser for the first time in

maxillofacial surgery 15

R e f:- la se rs in d e n tistry b y 16
RECENT DEVELOPMENTS
 1987 Meyer and mayer developed a Portable
Laser

 1990 FDI permitted the use of the same in the
dentistry

 The FDA approved oral soft tissue surgery in
1995 and sulcular debridement in 1998 by
means of a diode laser

 Hibst et al. 1999-2001 developed a novel laser
for caries detection (Diagnodent-KaVo, 17
FUNDAMENTAL LASER
PHYSICS
 The word LASER is an acronym for Light
Amplification by Stimulated Emission
of Radiation.
 L Light
 A Amplification by
 S Stimulated
 E Emission of
 R Radiation

18
UNDERSTANDING LIGHT
 Form of electromagnetic energy that behave as a particle and a
wave as well.
 light produced by a table lamp, for example, is usually a white
diffused glow, although it is the sum of the many colors of the
visible spectrum—violet, blue, green, yellow, orange, and red.
 A prism can be used to separate the individual colors in the
same way that raindrops break up sunlight into the colors of a
rainbow.





19
AMPLIFICATION
 The initial light is amplified to make a very
bright compact beam







20
STIMULATED

 means that the photons are amplified by

stimulating an atom to release more
photons.
 An atom can exist in an excited state,
similar to a bow when it is stretched.


21
EMISSION
 Refers to the giving of photons.
 The excited atom emits a photon when
another photon comes by.
 Einstein(1917) Stimulated Emission.

22
RADIATION

 For lasers, radiation refers to the PHOTONS

which are being emitted.

23
 Properties of LASER light

 Monochromatic (single wavelength)


 Collimation ( specific boundary)

 Coherency (in same phase)

 Efficiency (how good it works)

 Directional (narrow cone of divergence)

24
monochromaticity
 Laser light is one specific color, a
property called monochromacity; in
dental applications that color may be
visible or invisible.


25
collimation
 Collimation refers to the beam having specific
spatial boundaries, which insures that there
is a constant size and shape of the beam
emitted from the laser cavity. A dental x-ray
machine produces radiation with this
property.


26
coherance
 Coherency means that the light waves
produced in the instrument are all the same.
They are all in phase with one another and
have identical wave shapes; that is, all the
peaks and valleys are equivalent.


27
Efficiency and its measurement

 The clinically useful feature of laser is efficiency.

 Three measurements that can define the wave of photons
in a laser.

 The first is velocity, which is the speed of light.

 The second is amplitude, which is the total height of the
wave. It indication of the amount of intensity in the
wave.

 The third property is wavelength, which is the distance
between any two corresponding points on the wave on
the horizontal axis.which is important in determining
how the laser light is delivered to the surgical site and to
28
 Electromagnetic Waves

Wavelength
Amplitude

Velocity

Frequency is the number of complete oscillations

of the wave per second.

29
directionality

30
Laser generation

31
32
33
Components of Laser system


 La sin g a ctive m e d iu m .

 Energy or Pumping source.

 Optical chamber.


34
Lasing medium:
A material, capable of absorbing the
energy produced by an external
extension source through the
subatomic configuration of its
component molecules, atoms or ions.
 subsequently give off this excess energy
as photons of light.



35
Energy or pumping source
 An energy source is used to excite or pump
the atoms in the lasing medium to their
higher energy levels that are necessary
for production of laser radiation.


36
Optical Chamber
 The lasing medium is located within
resonating chamber which has cylindrical
structure with a fully reflecting mirror on
one another.


37
Core cavity
 The core cavity or the optical cavity is comprised of chemical
elements, molecules, or compounds which is called the active
medium, which can be container of gas, a crystal, or a solid
state conductor.
 The other devices are either solid state semiconductor wafers
made with multiple layers of metals such as gallium, aluminum,
indium and arsenic.


High Voltage Power Supply

 = atoms

 cathode anode Beam output

Active Medium
100% Reflective Mirror 98% Reflective Mirror 38
39
Beam Profile and Spot Geometry
 There are more photons concentrated in the core of the beam
and that the light intensity diminishes at the edges.
 Often in a well-tuned cavity the transverse cross section (profile)
is the normal gaussian curve. This is referred to as the TEMoo
(transverse electromagnetic mode: 00), also called the
"fundamental mode“)
 Other modes are possible such as the "Donut" mode (TEM10),
which has a cold spot in the center.


40
Power Density(PD)

 Power density is simply the

concentration of photons in a unit
area. Watts per area in square
centimeters. Therefore,
 PD = W/cm2


 (This is the average PD. Notice from the

beam profile that the PD in the center of
the spot is higher and that at the edge of
the spot it approaches 0).
41
 Cont…
 The terms focused and defocused when
working with lasers refers to the position
of the focal point in relation to the tissue
plane.

 When working on tissue, the laser should
always be used either with the focal point
positioned at the tissue surface (in focus)
or positioned above the tissue surface
(defocused or out of focus).

 The laser should never be positioned with
the focal spot deep or within tissue 42
43
Laser delivery system
 Contact lasers
 It works on the “hot tip” principal
 It improves cutting efficiency for low-power
instruments
 Requires cleaning or cleaving the fiber to attain
desired results


 Non contact lasers

 Noncontact surgery relies completely on the
pigments and water present in the tissue.
 Noncontact surgery requires significantly
greater power settings than contact surgery.
 The techniques and principles are similar, only
the feel is different.
 During noncontact surgery, the clinician
operates with the aid of an aiming beam or by44
Laser delivery medium
 Articulated arm- consist of a series of rigid hollow
 tubes with mirrors at each joint (called a knuckle)
 that reflect the energy down the length of the tube.


 DISADVANTAGES
1. Bulky
2. Awkward three-dimensional maneuverability
3. Alignment of the mirrors
4. Articulated arm delivery systems are
 noncontact systems
1.
2.
45


 Fiberoptic delivery system-The fiberoptic cables are attached

to a small handpiece similar in size to a dental turbine.
 Advantages
1. Relatively flexible
2. Easy transmission of the laser energy throughout the oral
cavity
3. Fiberoptic technology allows for contact with the target
tissue
 Disadvantage
1. Costly
2.
3.
4.

46
 Hollow waveguide delivery system –
 waveguide is a single long, semiflexible
 tube, without knuckles or mirrors.
 The laser energy is transmitted along the
 reflective inner lumen of this tube and
 exits through a handpiece at the end of
 the tube
 Advantages
1. Can be used as contact and non contact
 mode
1. Various attachments for hand piece
 Disadvantages
1. Available with co2 laser and erbium system only


47
 Air-cooled fiberoptic delivery system –
 This type of delivery system is unique to the
 erbium family of lasers.
 A conventional fiberoptic delivery system
 cannot transmit the wavelength of the
 erbium family of lasers, owing to the specific
 characteristics of the erbium wavelength.
 These special air-cooled fibers terminate in
 a handpiece with quartz or sapphire tips.
 These tips are used slightly (1–2 mm) out
 of contact with the target tissue.



48
Laser Emission Modes
 Emission of energy in 3 modalities


 Continuous wave : Beam emitted at only one

power level for as long as device is operated
by pressing the foot switch


 Gated pulse Mode: Periodic attenuations of laser

energy being on & off similar to blinking light.
The duration is as small as a few mille sec

 Free running pulsed mode: large peak energies
are emitted for an extremely short time span
followed by long time of which laser is off. It is
49
computer controlled.
50
 Several means are available for achieving pulsed
output from a continuous wave laser. These are:

 Mode locking


 Q switching Pulses from pico sec.



to micro sec
 Cavity dumping


 Pump pulsing from one microsecond to



a large fraction of sec

51
WHATS IN THE HAND OF OPERATOR?

52
Tissue effects of laser irradiation
 Broadlythe tissue effects of lasers can
be groups as.
1.Photo chemical interaction
2.
3.Photo thermal interactions
4.
5.Photo mechanical interactions
6.
7.Photo electrical interaction

53
Photo Chemical Interactions:


 Specific wavelength absolved by naturally occurring
chromophores

 Wavelength specific light absorption substances are
able to induce certain biochemical reactions at the
cellular level.

 Photo Chemical interactions are subdivided into

1.Photodynamic Therapy
2.
54
 Photodynamic therapy
 Therapeutic use of lasers to induce reactions in
tissues for treatment of pathologic conditions


 Biostimulation
 The stimulatory effects of the laser light on
biochemical & molecular processes that normally 55
Photo thermal Interactions:

 Radiant energy absorbed by tissue -> transformed

into heat energy which produces tissue effect.


 The amount of light energy absorbed in tissue

depends on:


 1.Wavelength of radiant energy from laser.


 2.Laser parameters such as spot size, power density,
pulse duration & frequency.


 3.Optical properties of tissue.

 56
Laser heating and tissue temp
 What Occurs when , if energy is absorbed
1.Hyperthermia- temp . Increase but not
destroyed, tissue whitening or blanching
2.Coagulation –Irreversibly damages the
tissue, by congealing tissue liquid into
semisolid mass, good to archive
homeostasis
3.Welding -Adherence of the layers because of
stickiness due to the collagen molecule’s
helical unfolding and intertwining with
adjacent segments
4.Vaporization - tissue containing water is
elevated to a temperature of 100 c,
process also called as ablation
5.Carbonization - about 200 c, dehydrated 57
Thermal effects at different temp.
 Temperature Tissue Effects


 37-50 Hyper thermia



 60-70 Coagulation, protein denaturation



 70-80 Tissue Welding



 100-150 Vaporization and ablation



 >200 Carbonization & charring

 (As in DCNA 2004 vol.48;759)

58
THE ZONE OF LASER INTERACTION WITH THE TISSUE

59
Photo Mechanical & Photo Electrical Effects


 Photon disruption or photo disassociation which is
breaking apart of structures by lasers

 Photo acoustic effects which involve removal of
tissue with shock wave generation

 Photo plasmolysis describes
 how tissue is removed through
 the formation of electrically
 charged ions & particles that exist
 in a semi gaseous high energy state.
60
laser action manifests clinically as:

 Photo ablation or removal of tissue

by
1.Vaporization
2.Super heating of tissue fluids,
3.Coagulation,
4.Homeostasis
5.Photo pyrosis or burning away
of
61

Optical properties of tissue

62
63
Absorption and laser interaction with hard
tissue

 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 Photo thermal effect
 At low temperatures below 100°C, the thermal
effects denature proteins and produce
hemolysis and they cause coagulation &
shrinkage
 Above 400°C, carbonization of organic
materials occurs with onset of some inorganic
materials
 Between 400°C & 1200°C, inorganic 64
 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


Tissue Feature
Hemoglobin Absorbed by Blue & Green WL
Melanin Absorbed by short wavelengths
Hydroxyapatite Absorbed by a wide range of
WL 65

66
Classifications of lasers
 In general lasers can be classified into no. of ways.

 But chiefly on the potential of the primary laser
beam or the reflected beam to cause biologic
damage to the eyes or skin.

 The ANSI Standard Z136.1-2000 documents set the
standards for classification in the United States.

 OSHA and the American Conference of
Governmental Industrial Hygienists also use this
standard as a source. Other countries subscribe
to these standards and have their own similar
regulatory agencies. 67
 Based on the potential danger
posed to the exposed skin and eye
 Class I - Low powered lasers that are safe to
view
 Class IIa - Low powered visible lasers that are
hazardous only when viewed directly for
longer than 1000 sec.
 Class IIb - Low powered visible lasers that are
hazardous when viewed for longer than
0.25 sec.
 Class IIIa-Medium powered lasers or systems
that are normally not hazardous if viewed
for less than 0.25 sec without magnifying
optics.
 Class IIIb-Medium powered lasers (0.5w max)
that can be hazardous if viewed directly. 68
Classification OF LASERS
 Based on Active Medium
1.Solid State
2.Gas
3.Semiconductors
4.Excimer
5.Dye
 Mode of action
1.Contact mode (focused or defocused) -
Ho:YAG ; Nd: YAG
2.Non-contact mode (focused or defocused) -
CO2
3.
4. 69
 CONT…
 Based as application
1.Soft tissue laser - Argon, Co2, diode;
Nd:YAG.
2.Hard tissue laser - Er : YAG
3.Resin curing laser - Argon


 Based on Level of energy emission:

1.Soft lasers (Low level energy): He-Neon;
Ga-Arsenide.
2.Hard lasers (High level energy): Er:YAG
laser ; Nd: YAG laser.
70

71
72
 Diode 812nm
Diode (980nm)
ErCr:YSGG 2.78 µm
Ex c i m e r KTP (532nm) Er:YAG ( 2.94µm)
KrF (248nm) XeF(351 nm) HeNe (632nm) CO2 (9.6 or 10.6µm)

Ultraviolet Visible Infrared

100 nm 400 nm Ruby (694nm) 750 nm Ho: YAG 10,000 nm
ArF (193nm) XeCl (308 nm) Argon (514 nm) Nd: YAG (2,08 µm)
Argon (488 nm) (1,06 µm)

γ -rays x-rays UV visible IR microwaves radio waves acoustic waves

10-12 10 - 9 10 - 6 1 0 -3 1 103 wavelength, meters

73
74
75
Laser Wavelengths Used in Dentistry

Argon laser


 Active medium of argon gas that is energized by a high

current electrical discharge.
 It is fiber optically delivered in continuous wave and gated
pulsed modes
 The only available surgical laser device whose light is
radiated in the visible spectrum.
 There are 2 emission wavelength used in dentistry:
 488 nm, which is blue in color &
 514 nm which blue green.
 488 nm emission activate camphoroquinone(photo initiator),
causing polymerization.
 The 514 nm wave length has its peak absorption in tissues
containing hemoglobin, hemosiderin & melanin.Thus it has
excellent haemostatic capabilities. 76
usages
 Used in Surgical Endodontics

 Both can be used for caries detection

 Argon laser light illuminates the tooth, the disease
area appears dark orange-red colored

 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 77
Diode laser
 A solid active medium laser, manufactured from (Gallium arsenide)
semi conductor crystals using combination of aluminum or
indium, gallium, and arsenic.


 Wavelengths for dental use range are 800 nm for active medium
containing aluminum to 980 nm for active medium containing
indium.


 Optic fiber delivery system with contact mode.


 All of diode wavelength are highly absorbed by
 pigmented tissue and are deeply penetrating

 78
Neodymium :YAG laser

 Nd:YAG has a solid active medium,

 which is a garnet crystal combined with
 rare earth elements yttrium and aluminum,
 doped with neodymium ions.

 Operates at wavelength of 1064nm in a high inter pulsed
wave form.

 It emits light in near invisible infrared area of spectrum.

 Fiber optic cable to divert the light to a hand piece & lens
to produce free beam of laser light
 79


 Common clinical applications are:

 For cutting & coagulating of dental soft tissues & debridement.

 Offers good hemostasis during soft tissue procedures

 For attaining pulpal analgesia

 Advantages:
 Facilitates a clear operating field

 Flexible delivery system.


 Disadvantage:
 Is unnecessary collateral damage due to its depth of penetration.

 Wound healing in soft tissue will be delayed
 80
Holmium:YAG
 solid crystal of yttrium aluminum
 garnet sensitized with chromium
 and doped with holmium and thulium ions
 Fiber optically delivered and free running
 pulsed mode
 Operates at a wavelength of 2100 nm
 and uses a pulsed waveform.


 It is absorbed by water 100 times greater than Nd: YAG



 At high peak powers, can abrade hard, calcified tissue.



 An aiming device is used, as the light produced is

invisible. 81
Erbium Family lasers

 Erbium: YSGG (2780nm) with solid crystal of yttrium

scandium gallium garnet doped with erbium &
chromium

 Erbium : YAG (2940nm) has crystal of yttrium
aluminum garnet doped with erbium .

 The delivery systems are a hollow wave guide and
fiber optics in free running pulse mode.

 The highest absorption in water & have a high
affinity for hydroxyapatite.

82



Uses:


 Caries removal and Cavity preparation


 In preparation of root canals.


 Facial resurfacing,

 83
Carbon dioxide laser
 It was developed by Patel in 1964.

 A gas active medium laser that incorporates a sealed tube
containing a gaseous mixture with Co2 molecules pumped via
electrical discharge current.

 Operates at wavelength of 10,600nm.

 It is operated in a gated wave form or continuous form through a
hallow tube like wave guide.

 Wavelength is well absorbed by water.

 It can easily cut & coagulate soft tissue & has a shallow depth of
penetration into tissue.

 Emits light in the invisible mid infrared portion.
84

Uses:


 Excision and ablation of various types of superficial

lesions & for skin resurfacing

 Excellent Hemostasis,


Advantages:


 Clear field of view.


 Post operative pain is minimal

Disadvantages:


 Wound healing is delayed

 Difficult to uses (articulated arm) 85
newer lasers systems
KTP Lasers (excimers)



 Modified version of Nd: YAG laser:

 Addition of frequently doubling crystal operates at 532nm.

 It uses fiber optic cable with a hand piece.

 It is similar to argon laser in absorption characteristics

 Used in the treatment of vascular & pigmented lesions,
tattoo removal
86

Flash Lamp pumped pulsed Dye Laser


 Produces yellow visible light in 400–1000nm range & is
commonly used at 510, 577, 585nm.

 The desired wavelength can be used for specific tissue to
be removed, offering great flexibility

 510 nm melanin can be targeted & various benign
melanin containing tissues can be ablated

 585nm targets oxy-hemoglobin with in vascular
abnormities.

 Thus it is used in treatment of cancer, ablation of salivary 87
Copper Vapor Laser
 Wavelengths of 511-578 nm.


 Similar to both KTP & Argon lasers.


 Its medium is heated copper which
produces copper gas.

 Delivered by fiber optic cable in pulsed
mode

 Effective in treatment of port wine stains or
large superficial telangiectasias, nevi & 88
Medical Applications of laser
 Argon laser in ophthalmology 1968

 Otorhinolaryngology

 Dermatology & plastic surgery

 Neurosurgery

 Urology

 Gastroinstestinal surgery
 89
Why to select laser for treatment?
 Patients choice
 Clinicians choice
 Treatment outcome assessment
 Utilizing benefits of lasers

 Patient comfort & acceptance

 Reduced postoperative complications
 Hemorrhage control
 Reduced need for postoperative analgesics

 Advantage over the cold steel surgical

procedure
1.Dry and bloodless surgery
2.Instant sterilization of the surgical site
3.Reduced bacteremia
4.Reduced mechanical trauma
5.Minimal postoperative swelling and scarring 90
Types of Lasers

 Hard lasers or high level lasers.

 Cavity Preparation on tooth surface
 Transillumination

 Photo polymerization

 Cortical bone ablation

91
 Soft tissue laser or low power
Temperature Tissue Effects

37-50 Hyper thermia

60-70 Desiccation protein denaturation

70-80 Tissue Welding

100-150 Vaporization and ablation

>200 Carbonization & charring

(As in DCNA 2004 vol.48;759)

92
Hard and soft tissue difference
 Hard Lasers:
 Have longer wavelength more then 450nm
 Produces thermal effect, which cut the tissue
by coagulation, vaporization & carbonization.
 These lasers are used for surgical hard tissue
applications.


 Soft or low-level lasers

 Low thermal energy wavelengths of less than
about 450nm with minor temperature
increase of less than 1C.
 Stimulate circulation and cellular activity.
 Anti-inflammatory,
 Muscle relaxation,
 Analgesia 93

 Laser application in vivacity of dentistry
 Biopsies

 Tongue lesions

 Aphthous ulcers

 Herpetic lesions

 Coagulation and hemostasis

 Exposure of implants

 Scaling and root planing 94
Lasers in Endodontics

95
Laser in dentinal hypersentivity
 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


 96
Lasers for treatment of DH are divided into 2 groups

Low Output Power Lasers Middle

Output Power Lasers
Helium – Neon Diode

Nd:YAG
Gallium-Aluminum-Arsenide diode Co2


97
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)


98
 Helium – Neon and Diode laser at a low power of 1 or
2 mW of 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: 99

100
Pulp Capping & Pulpotomy
 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
 101
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
102
 is not an alternative to the conventional
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

 Sterilization of root canals by lasers is 103
104
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

1. Irradiation can be used as a heat source for softening the GP
2. Conditioning of the dentin walls can also be done

 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
105
LASERS IN Retreatment
 Rationale for using lasers in retreatment is
ascribed to the need to remove foreign
material, GP etc by softening it by heat

 Nd:YAP (1340 nm) in used to remove GP
and ZOE sealer Silver cones and
separated instruments but lasers alone
cannot remove all the obturating
materials from the RC

A clinical advantage is that toxic solvents
like xylene can be avoided
 106
Lasers in Endodontic Surgery
 Laser is used for the surgery as
1. a bloodless surgical field
2. the ability of the laser to vaporize tissue
3. coagulate and seal small blood vessels.
4. Irradiation causes, surface sterilization

 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

 When the laser was used for resection it is found that 107
 Cont…
 Advantages
1.Good hemostasis
2.Improved visualization of surgical site
3.Sterilization operative field
4.Reduced permeability of root surface dentin
5.Reduction in post operative pain
6.Reduced risk of contamination of surgical site by
eliminating use of air turbines
7.Reports suggest that laser created wounds
heal more quickly and produce less scar
tissue than conventional scalpel surgery.
8.
 Constraints
1.Time Consuming
2.Increase temperature
3.Cause irreversible pulpal damage 108
4.Needs precise execution
Other Endodontic uses
 CO2 and Nd:YAG lasers have been used for
the attempted treatment of root fractures
(Arakawa et al. 1996). However, after
using various parameters, fusion of the
fractured root halves was not achieved

 Lasers (Ar, CO2, Nd:YAG lasers) have been
used successfully to sterilize dental
instruments in shorter time.

A pulsed dye laser emitted at 504 nm was
used for the removal of a calcified
attached denticle (Rocca et al. 1994) 109
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
1.Argon laser
2.Plasma arc laser
3.CO2 laser
4.Diode laser
5.Erbium family of lasers

110
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 111
Plasma Arc Curing (PAC)
 PAC & Argon laser curing systems are
used in rapid polymerization of
composites
 However they increase heat generation
and thus causing polymerization
shrinkage


 Bleaching of stained teeth


112
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)


113
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


114
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 115
Operative dentistry
 Detection of caries

 Surface etching.

 Removing decay painlessly and atraumatically without affecting

 the surrounding healthy tissues.

 For removal of defective restoration as composite, GIC, Compomer

restorations quickly and easily without the use of analgesia.

 Bleaching of teeth (Power Bleaching).



 Argon laser – alter surface characteristics- decreased acid solubility



 Nd:YAG laser- APF application after laser irradiation increased
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
Angle tip towards the buccal aspect
Of the central groove, defocused, with
VERY slow movement from mesial
To distal create a initial groove.
Note penetration angled towards
Buccal direction. Also note
Conical concentration of laser
Energy from end of tip.
Cut viewed from occlusal
Next, angle towards lingual, pass
3 times mesial to distal and open
OTHER side of central groove
Again, note conical shape of cut
Where laser energy is concentrated.
Finish prep by then going
Straight down central groove, exposing
Dentin , thereby opening up entire prep
For ease of disease detection and
Removal.
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

 However, it has been shown that adhesion to dental
hard tissues after Er: YAG laser etching is inferior
to that of conventional acid etching.

 The weaker bond strength of the composite to laser-
etched enamel and dentine is due to the
presence of subsurface fissuring which is absent126
in conventional etched surfaces
Caries prevention
 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)

 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 127
acid soluble compounds, reducing susceptibility
Laser Assisted Bleaching
 Two laser-assisted whitening systems have been cleared by the
FDA

 The laser enhances 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

 CO2 laser is employed with another peroxide- based solution to
promote penetration of the bleaching agent into the tooth.
 128
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
129
Regulatory Agencies
 American National Standard Institute
(ANSI)


 Food and Drug Administration (FDA)



 Center for devices and Radiological

Health (CDRH)


 Occupational safety health

administration (OSHA) 130
 Laser Classification (on bases of potential hazards)

Class Laser Properties

I Pose no health hazard e.g. CD Player, pointer
II Emit only visible light with low power output & do not
pose any health hazards
Maximum allowable output is 1 mW
IIIa 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
IIIb Hazardous to unprotected eye; Output power no greater
than 0.5 W; eg. Argon Laser curing light; Eye
protection is must
IV 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
The lasers used in dentistry fall in class IV category


 The type of hazards can be grouped as :

1.Ocular hazards
2.
3.Tissue damage
4.
5.Reparatory depression
6.
7.Fire & explosion
8.
9.Electrical Shock 132
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 and local body

regulations
 133
Guidelines
 Mention outside
 Door Switch

 Fire hazards

134
Laser safety control measures & recommendation

ENGINEERING

ADMINISTRATIVE


CONTROLS CONTROLS

 Protective housing  Laser safety officer

 Interlocks  Standard operating
procedures
 Beam enclosures 
 Shutters  Out put limitations

 Service panels  Training and education

 Equipment labels  Maintenance and alignment

 Warning system  Warning sign

 Key switch  Protective devices


 Medical surveillance
Eye Protection
 In1962, 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


136
Why the Eye ???
 Cornea is made up of 90% Water

 Absorbs emissions from all lasers

 Can cause Corneal Burns

 Retinal damage occurs due to lasers with more depth if
penetration and is absorbed into the pigments

 The eye is 100,000 times more vulnerable to injury than the skin

 WL from 400-1400 is dangerous

 Protective glasses must have an Optical Density of at least 4 137
Sterilization & Infection Control
 Fiberoptic cables & handpieces can be
autoclaved in pouches


 Oil based aerosols should not be used



 The wires and protective casing /

housing should be wiped clean and not
autoclaved

138
Recent advancement
 Waterlase MD (All-Tissue Laser)
1.Works on teeth, gums and bone
2.FDA cleared for most clinical procedures
of any dental laser
3.Cuts over 50% faster
4.Recent root canal clearance
5.Works on Hydrophotonics principle
1.It’s the interaction between laser energy
and water
2.Most procedures can be performed
without anesthesia
3.Can coagulate while cutting
4.Reduced healing time and tissue trauma 139
 Cutting with Waterlase
Optimization of the
cutting efficiency: Air / Water balance

TOO little
TOO wam
•Water and Air settings in
Spray should should be
based on power settings
and type of the tip
* charring
* slo
 Waterlase Hydrokinetic
Cutting Mechanisms
O
Excitation of
Water Molecules
H
H
Expansion
Effective
Laser + Water Tissue
Spray Photo-acoustic Cutting
 BIOLASE Engineering
WATERLASE (MD) TIPS 09/23/04

Relative shapes of the tips,

Length approximate beam divergence
and radiation spot sizes

and
(at 2-3 mm distance)

Shape SAPPHIRE TIPS

(M)G6, (M)G4

750 600

(M)T4 (M)S75

750 400 750 750

(M)C6 (M)C12

1200 600 1200 1200

(M)C3 (cone side) (M)C3 (flat side)

1200 300 1200 1200

QUARTZ TIPS

(M)Z2 (M)Z4

240 460

(M)Z3 (M)Z6

380 640
Laser technology in future

 Caries detection and prevention

 Tetra hertz pulse imaging


 Endodontic canal lasing and curing



 Computer Aided Design/Manufacturing (CAD/CAM)


 Low Level Laser Therapy (LLLT)


 Holographic imaging




  No cut ,no sew and no pain

conclussion
But does not prove to be a holy grail
 Many ethical issue questioning the risk benefit ratio
 Mostly a tool of dentist with golden spoon in mouth
 Patient pay capability is in question, as it is 10 times
costly
 Future is hopeful
 As cost and the availability will be in reach of common
man
 As portability and versatility of the commercial products
will increase144
145
146
 References and
literature review

147
 1.www.goolge.com
2.www.yahoo.com
3.www.pubmed.com

148
2000 and
THANK YOU FOR YOUR
PATIENCE -
LISTENING

149