Review

Lasers In Endodontics
Sebeena Mathew , Deepa Natesan Thangaraj
1 2
1
2
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
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: matsden@gmail.com
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.
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,
(
neodymium, holmium, or erbium.
1)
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 CO lasers. Dr Terry Meyers and his
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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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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
t o i nduce cert ai n bi ochemi cal react i ons.
Photosensitive compounds when exposed to laser
energy can produce a single oxygen radical for
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disinfection of endodontic canals.
Photothermal Interactions
The radiant energy absorbed by tissue
substances are transformed into heat energy, which
produce the tissue effect.
Photomechanical and photo electrical interactions
T h e s e i n c l u d e p h o t o d i s r u p t i o n ,
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 shows that when the target tissue
containing water is elevated to a temperature of
100ºC, 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 100ºC 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 200ºC, 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
Table -1
Effect Of Laser Energy On Tissue Temperature
and the Observed Effects:
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from 200 to 1000 µ. 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
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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 gutta-
5
percha.
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.
CO laser can also be used. In some cases, it is
2
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
CO laser irradiation is performed at 1 or 2W
2
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 CO , pulsed Nd:YAG, He,
2
Ne and low power semiconductor diode lasers and
middle power semiconductor diode lasers.CO laser
2
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
â
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 laser-
supported endodontic treatment are very advanced
periodontitis, a deep crown or root fracture on the to-
be-treated tooth, and when obliterated root canals are
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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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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 200µm 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
6
in contact with the root canal wall.
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, CO , Er:YAG are
2
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
8
heat to harm the adjacent tissues.
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
10,11
heat energy. Anic and Matsumoto 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
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surgical pain.
Permeabi l i t y of dent i n 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
13
tubules and decreased permeability.
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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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 CO laser;
2
and apicoectomy with Er:YAG laser and treatment of
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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
CO lasers are recommended for these treatments.
2
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 CO laser, the exit of drainage
2
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. Ni s ha Gar g and Ami t Gar g-Text book of
endodontics
5. Kouki chi -Mat sumot o: Lasers i n Endodont i cs:
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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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: CO , Er: YAG andNd:YAG
2
lasers in endodontic surgery. J appl Oral Sci.2009;
17(6):596-599
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