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Introduction Laser is an acronym, which stands for Light Amplification by Stimulated Emission of Radiation. Several decades ago, the laser was a death ray, the ultimate weapon of destruction, something you would only find in a science fiction story. Then lasers were developed and actually used, among other places, in light shows. The beam sparkled, it showed pure, vibrant and intense colors. Today the laser is used in the scanners at the grocery store, in compact disc players, and as a pointer for lecturer and above all in medical and dental field. The image of the laser has changed significantly over the past several years. With dentistry in the high tech era, we are fortunate to have many technological innovations to enhance treatment, including intraoral video cameras, CAD-CAM units, RVGs and air-abrasive units. However, no instrument is more representative of the term high-tech than, the laser. Dental procedures performed today with the laser are so effective that they should set a new standard of care. This presentation intends to discuss the role of lasers in dentistry.
History of Lasers • The first working laser was produced by TH Maiman 35 years ago He described a laser based on a ruby crystal pumped by a high-power flash lamp which produced deep red visible light at two wavelength. • Approximately, the history of lasers begins similarly to much of modern physics, with Einstein. In 1917, his paper in Physikialische Zeil, “Zur Quantern Theorie der Strahlung”, was the first discussion of stimulated emission. • In 1954 Townes and Gordon built the first microwave laser or better known as ‘MASER’ which is the acronym for ‘Microwave Amplification by Stimulated Emission of Radiation’ • In 1958, Schawlow and Townes suggest the possibility to use this stimulated emission for light amplification. • In May 1960, Theodore Maimen at Hughes Aircraft company made the first laser. He used a ruby as the laser medium.
• One of the first reports of laser light interacting with tissue was from Zaret; he measured the damage caused by lasers incident upon rabbit retina and iris. • In 1961, the first gas laser was developed by Javan et al in 1961. This was the first continuous laser and used helium – neon. • In 1964, the Nobel Prize for the development of the laser was awarded to Townes, Basor and Prokhovov in 1964. • The neodymium – doped (Nd): glass laser was developed in 1961 by Snitzer. • In 1964 Nd: YAG was developed by Geusic.
The CO2 laser was invented by Patel et al in 1965.
• 1975 – Excimer Laser developed by ‘AYCO’.
Polanyi in 1970 applied CO2 laser clinically.
• In 1990 Ball suggested opthalmologic application of ruby laser.
• The use of low-power lasers has recently become known as “Low Intensity Laser Therapy” (LILT) qualities which distinguish it as a laser light i.e. 1. Coherence
Unlike white light, which is scattered, laser light energy travels in a specific wavelength and in a predictable patterns. ↓ i.e. it is coherent 2. Monochromatic
Since lasers are coherent, each traveling in a specific wavelength from uv to infrared, lasers express one colour ↓ i.e. they are monochromatic 3. Laser light also travels in a collimated or parallel, beam and is therefore highly directional.
Other Terminologies When lasers first appeared as clinical tools, they were divided into 2 groups Related to their observed Hard Produces immediate observable effects on the tissues irradiated These terms are generally falling from use and it is probably better now to talk only of High-power is the one capable of producing 3W and more Laser Physics Laser is a device that converts electrical or chemical energy into light energy. In contrast to ordinary light that is emitted spontaneously by excited atoms or molecules, the light emitted by laser occurs when an atom or molecule retains excess energy until it is stimulated to emit it. The Low-power produces upto 1000 mw (LILT) Soft interaction with the tissue Appeared to cause no visible change in the tissue at the time of lasing
radiation emitted by lasers including both visible and invisible light is more
generally termed as electromagnetic radiation. The concept of stimulated emission of light was first proposed (1917) by Albert Einstein. He described three processes: 1. Absorption 2. Spontaneous emission 3. Stimulated emission. Einstein considered the model of a basic atom to describe the production of laser. An atom consists of centrally placed nucleus which contains positively charged particles known as protons, around which the negatively charged particles. i.e. electrons are revolving. When an atom is struck by a photon, there is an energy transfer causing increase in energy of the atom. This process is termed as absorption. The photon then ceases to exist, and an electron within the atom pumps to a higher energy level. This atom is thus pumped up to an excited state from the ground state. In the excited state, the atom is unstable and will soon spontaneously decay back to the ground state, releasing the stored energy in the form of an emitted photon. This process is called spontaneous emission.
If an atom in the excited state is struck by a photon of identical energy as the photon to be emitted, the emission could be stimulated to occur earlier than would occur spontaneously. This stimulated interaction causes two photons that are identical in frequency and wavelength to leave the atom. This is a process of stimulated emission. Laser Design All lasers have similar fundamental elements: A. Lasing Medium Which maybe solid, a liquid / gas Maiman’s laser used a solid medium – ruby crystal. As a rule, the lasing medium gives its name to the laser e.g. Ruby laser (solid) Nd :YAG (solid) Dye laser (liquid)
CO2 (gas) and Argon (gas)
Semi-conductor lasers B. Energy Source The atoms or molecules of the lasing medium need to be excited so that protons of laser light are emitted. The energy for this maybe provided
by an electric discharge, high powered xenon-flash lamps or even another laser. C. Optical resonator / housing tube Is an arrangement of mirrors which both amplify the effect of the laser and ensure that when the light does emerge from the laser, it possesses the unique. Laser Light Delivery Light can be delivered by a number of different mechanisms. Several years ago a hand held laser meant holding a larger, several hundred pound laser usually the size of a desk, above a patient. Although the idea was comical at the time, it is becoming more feasible as laser technology is producing smaller and lighter weight lasers. In the more future it is probable that hand held lasers will be used routinely in dentistry. 1. Articulated arms Laser light can be delivered by articulated arms, which are very simple but elegant devices. Mirrors are placed at 45o angles to tubes carrying the laser light. The tubes can rotate about the normal axis of the mirrors. This results in a tremendous amount of flexibility in the arm and in delivery of the laser light. This is typically used with CO2 laser. The arm
does have some disadvantages that include the arm counter weight and the limited ability to move in a straight line. 2. Optical Fiber Laser light can be delivered by an optical fiber, which is frequently used with near infrared and visible lasers. The light is trapped in the glass and propagates down through the fiber in a process called total internal reflection. Optical fibers can be very small. They can be either tenths of micrnos or greater than hundreds of microns in diameter. Advantages of optical fiber is that they provide easy access and transmit high intensities of light with almost no loss but have two disadvantages. Disadvantages (1) The beam is no longer collimated and coherent when emitted from the fiber which limits the focal spot size. (2)The light is no longer coherent.
Mode of Delivery of Laser Once the laser is produced, its output power may be delivered in the following modes. Continuous wave: When laser machine is set in a continuous wave mode the amplitude of the output beam is expressed in terms of watts. In this mode the laser emits radiation continuously at a constant power levels of 10 to 100 w. Eg: CO2 laser Chopped: The output of a continuous wave can be interrupted by a shutter that “chops” the beam into trains of short pulses. The speed of the shutter is 100 to 500ms. Gated: The term superpulsed is used to describe the output of a gated high peak power laser with a short pulse duration, typically between hundreds of microseconds (1ms = 1x10-6 sec.). The pulse produced during superpulsing can have a repitition rate of 50 to 250 pulses per second that permits the laser output to appear almost continuous during use. Pulsed: Lasers can be gated or pulsed electronically. This type of gating permits the duration of the pulses to be compressed producing a
corresponding increase in peak power, that is much higher than in commonly available continuous wave mode. Super pulsed: The duration of pulse is one hundredth of microseconds. Ultra pulsed: This mode produces an output pulse of high peak power that is maintained for a longer time and delivers more energy in each pulse than in the superpulsed mode. The duration of the ultra pulse is slightly less. Q-scotched: Even shorter and more intense pulse can be obtained with this mode. Several hundreds of millijoules of energy can be squeezed into nano second pulses. Flash-Lamp pulsing: In these systems, a flash – lamp is used to pump the lasing medium, usually for solid state lasers. Focusing Lasers can be used in either a focussed mode or in a defocused mode. A focussed mode is when the laser beam hits the tissue at its focal points or smallest diameter. This diameter is dependent on the size of lens
used. This mode can also be referred as cutting mode. Eg. While performing biopsies. The other method is the defocused mode. In which the mode is moved away from the total plane. This beam size that hits the tissue has a greater diameter, thus causing a wider area of tissue to be vaporized. However, laser intensity / power density is reduced. This method is also known as ablation mode. Eg. In Frenectomies; In removal of inflammatory papillary hyperplasias. In contact mode, the fibre handpiece is placed in contact to the tissue whereas in the non-contact, the handpiece is placed away from the target tissue. Contact and Non contact modes In contact mode, the fiber tip is placed in contact with the tissue. The charred tissue formed on the fiber tip or on the tissue outline and increases the absorption of laser energy and resultant tissue effects. Char can be eliminated with a water spray and then slightly more energy will be required to provide time efficient results. Advantage is that there is control feed back for the operator.
Non contact mode: Fiber tip is placed away from the target tissue. In the non contact mode the clinician operates with visual control with the aid of an aiming beam or by observing the tissue effect being created. So generally laser can be classified as Dental Lasers Those work in both Solely in the non contact mode Eg: CO2 Laser Types I. Based on wavelength. 1. Soft lasers 2. Hard lasers II. Based on the lasing medium Lasers can be classified according to the state of the active medium i.e., 1. Solid eg: Nd:YAG, Diode 2. Liquid eg: Dye
Contact & focussed
Non contacted & defocused
Eg: Argon, Ho : YAG, Nd:YAG
Gas eg: CO2, Argon, Er:YAG
III. Based on the potential danger posed to the exposed skin and to the unaccomodated eye. I. Based on wavelength: Soft Lasers: Soft lasers are lower power lasers; with a wave length around 632mm. Eg. He-Ne, Diode. These are employed to relieve pain and promote healing eg. In Apthous ulcers. Hard lasers: Lasers with well known laser systems for possible surgical application are called as hard lasers. Eg: CO2, Nd: YAG, Argon, Er:YAG etc. CO2 Lasers The CO2 laser first developed by Patel et al in 1964 is a gas laser and has a wavelength of 10,600 nanometers or 10.6 µ deep in the infrared range of the electromagnetic opectrum.
CO2 lasers have an affinity for wet tissues regardless of tissue color. The laser energy weakens rapidly in most tissues because it is absorbed by water. Because of the water absorption, the CO 2 laser generates a lot of heat, which readily carbonizes tissues. Since this carbonized or charred layer acts as a biological dressing, it should not be removed. They are highly absorbed in oral mucosa, which is more than 90% water. High absorption in small volume results although their penetration depth is only about 0.2 to 0.3nm. There is no scattering, reflection, or transmission in oral mucosa. Hence, what you see is what you get. CO2 lasers reflect off mirrors, allowing access to difficult areas. Unfortunately, they also reflect off dental instruments, making accidental reflection to non-target tissue a concern. CO2 lasers can not be delivered fiber optically Advances in articulated arms and hollow wave guide technologies, now provide easy access to all areas of the mouth. Regardless of the delivery method used, all CO2 lasers work
in a non-contact mode.
Of all the lasers for oral use, CO2 is the fastest in removing
tissue. As CO2 lasers are invisible, an aiming Helium – neon (He
Ne) beam must be used in conjunction with this laser. Nd: YAG Laser: Here crystal of Ytrium – aluminum – garnet are doped with neodymium. Nd: YAG laser, has wavelength of 1,064 nm (0.1064 µ ) placing it in the near infrared range of the magnetic spectrum. It is not well absorbed by water but are attracted to pigmented
tissue. Eg: haemoglobin and melanin. Therefore various degrees of optical scattering and penetration to the tissue, minimal absorption and no reflection. • Nd: YAG lasers work either by a contact or non-contact mode. When working on tissue, however, the contact mode in highly recommended. • The Nd:YAG laser is delivered fiber optically and many sizes of contact fibers are available. 1. Carbonized tissue remnants often build up on the tip of the contact fiber, creating a ‘hot tip’. This increased temperature
enhances the effect of the Nd:YAG laser, and it is not necessary to rinse the build up away. 2. Special tips, the coated sapphire tip, can be used to limit lateral thermal damage. 3. A helium-neon-aiming beam is generally used with Nd: YAG wavelength. Penetration depth is ~ 2 to 4m, and can be varied by upto 0.5-4mm
in oral tissues by various methods. • A black enhancer can be used to speed the action. • The Nd-YAG beam is readily absorbed by amalgam, Ti and nonprecious metals, requiring careful operation in the presence of these dental material. Uses: Soft tissue removal Haemostasis Coagulation
Argon Lasers • Argon lasers are those lasers in the blue-green visible
spectrum (thus they can be seen). • They operate at 488nm(blue) or 514.5nm (green), or 496nm
(blue/green) ARGON is easily delivered fiber optically. • Argon lasers have an affinity for darker colored tissues and
also a high affinity for haemoglobin, making them excellent coagulators. Thus argon lasers focused on bleeding vessels stop the haemorrhage. It is not absorbed well by hard tissue, and no particular care is needed to protect the teeth during surgery. In oral tissues there is no reflection, some absorption and
some scattering and transmission – travel fiber-optically is unaffected by H2O. • • Argon lasers work both in the contact and non contact mode Like, Nd: YAG lasers, at low powers argon lasers suffer from and need sweeping motion to avoid tissue from
accumulating on the tip. • Enhances are not needed with Argon lasers.
Argon lasers also have the ability to cure composite resin, a
feature shared by none of the other lasers. Argon is highly absorbed by Hb, strongly absorbed by
melanin and poorly absorbed by H2O. • The blue wavelength of 488 nm is used mainly for composite
curing, while the green wavelength of 510nm is mainly for soft tissue procedures and coagulation. Erbium: YAG laser
Is a promising laser system because the emission wave length
coincides with the main absorption peak of water, resulting in good absorption in all biological tissues including enamel and dentin. This is the 1st Laser to be cleared by the FDA on May 7, 1997 for use in preparing human cavities. Have a wavelength of 2.94 µ m. A number of researchers have demonstrated the Er: YAG
lasers ability to cut, or ablate, dental hard tissue effectively and efficiently. The Er: YAG laser is absorbed by water and
hydroxyapatite, which particularly accounts for its efficiency in cutting enamel and dentin. • A variety of restorative materials such as Zn phosphate, Zn
carboxylate, glass ionomer cements and silver amalgam can be effectively removed by the Er: YAG cases. • Pulpal response to cavity preparation with an Er: YAG laser
was minimal, reversible and comparable with pulpal response created by a high-speed drill. • Er: YAG can also be used for bone ablation and has
indications in soft tissue surfaces where no coagulation effect is desired such as removal of hyperplastic gingival tissue, periodontal surgery and abrasion of large benign lesions of the oral mucosa and skin. Ho: YAG laser [Holmium YAG lasers] • crystal • • Has a wavelength of 2,100 nm Delivered through a fiber optic carrier. Is thallium and holomium doped, chromium sensitized YAG
• • •
A He-Ne laser is used as an aiming light Dragability is less compared to Nd: YAG and argon lasers Like Nd: YAG, can be used in both the contact and non-
contact modes and are pulsed lasers. • Ho: YAG laser has an affinity for white tissue and has ability
to pass through water and acts as a good coagulator.
Laser – tissue interaction
Scattered Absorbed Transmitted When laser strikes a tissue surface, it can be reflected, scattered, absorbed or transmitted. Reflection: Reflected light bounces off the tissue surface and is directed outward. Because the energy dissipates so effectively after reflection, there is little danger of damage to other parts of the mouth.
It also limits the amount of energy that enters the tissue. Scattering: occurs when the light energy bounces from molecule to molecule within the tissue. It distributes the energy over a larger volume of tissue, dissipating the thermal effects. Absorption: occurs after a characteristic amount of scattering and is responsible for the thermal effects within the tissue. Transmission: Light can also travel beyond a given tissue boundary. This is known as transmission. • It irradiates the surrounding tissue and must be quantified. • The distance the energy transmits into the tissue is called penetration depth. • Co-agulation where as depth is the deepest level where alterations in the tissue will occur because of the laser’s energy E.g. CO2, Nd-YAG and Argon have similar co-agulation depths but different penetration depths.
Naturally, the temperature and tissue effects are greatest near the light source and decrease exponentially as tissue depth increases. °C >175 100-150 90-100 70-80 60 50 37 Lasers and soft tissues • The absorption of laser light by different elements of tissue is extremely wavelength dependent. • H2O, a major constituent of soft tissue strongly absorbs wavelengths of 2nm / above and therefore these penetrate little in soft tissues, the greater part of which is made up of H2O. Hard tissues Many researchers felt that lasers were obvious replacement for the dental drill, as • Lasers are ‘non-contact’ and their use produces much less vibration than conventional drills. J/cm2 >5000 1000-5000 1000 500 200 10 0 Tissue effect Rapid cutting Carbonization Vaporization Welding Co-agulation Hyperthermia Normal
• They are much quieter than drills, usually producing only a muted ‘popping sound’ which is generally well-tolerated. • They can sterilize as they cut. • They can also be used to seal tissues at the periphery of the cut. Therefore cut dentinal tubules were sealed rather than left-open as pathways for micro-organisms, reducing the possibility of postoperative hypersensitivity. 1. Thermal effects: The best known laser effect in dentistry is the thermal vaporization of tissue by absorbing laser light i.e. the laser energy is converted into thermal energy or heat that destroys the tissues. From 45o – 60 o >60 o At 100 o C >300 o C Above 300°-800° denaturation occurs coagulation and necrosis water inside tissue vaporizes carbonization and later phyrolysis with vaporization of bulky tissues. used to cut cavities.
When the high peak-power of a pulsed – laser is greater, a superheated gas called the ‘plasma’ may form.
↓ Which can absorbed the incoming laser beam, allowing less energy to reach the surface. This hot plasma, can then quickly conduct heat to the tissues surfaces and causes ablation and severe heating which can lead to tissue damage. Flowing water down the fiber and onto the tissue has been used in an attempt to control this plasma (which pulsed Nd-YAG). 2. Mechanical effects / Effect of heat build-up High energetic and short pulsed laser light can lead to a fast heating of the dental tissues in a very small area. The energy dissipates explosively in a volume expansion that may be accompanied by fast shock waves. These shock waves lead to mechanical damage of the irradiated tissue. Histologic Results: A. With continuous wave and pulsed CO2 lasers. When continuous wave and pulsed CO2 lasers were used, structural changes and damage in dental hard tissue were reported. 1. Microcracks.
2. Zones of necrosis and carbonization are unavoidable. Because of drying effects 3. The microhardnes of dentin increases. The crystalline structure of hydroxyapatite changes and a transformation of apatite 4. Tricalcium phosphate takes place. B. Nd: YAG Lasers The Nd: YAG laser shows low absorption in water as well as in hydroxyapatite. Therefore the laser power diffuses deeply through the enamel and dentin and finally heats the pulp. In dentin, at the laser impact, zones of debris and carbonization are surrounded by an area of necrosis can be seen. Microcracks appear when energies above a threshold of 100mj / pulse are used. But the appearance and the extent of the side effects are not predictable. C. Er: YAG Laser In dentin, shallow cavities were surrounded by a zone of necrosis of 1-3µ m thickness when water-cooling systems were used. In deeper cavities, areas of carbonization and microcracks were observed. Ablating enamel always cracked and deep zones of debris appeared.
D. Excimer Lasers No pathologic changes in the tissue layers adjacent to the dissected areas were found after the ablation. The ablation effects of dental hard tissues are predictable. Compared to conventional diamond and burs, however, the effectiveness is low. Thermal side effects increase as photon energies of excimer lasers decrease. Laser Effects On Dental Pulp: Recent histologic evidence suggests that a normal odontoblast layer, stroma and viable epithelial root sheath can be retained following laser radiation provided damage threshold energy densities are not exceeded. If pulp temperatures are raised beyond the 5°C level, research has shown that the odontoblasts layer may not be present. Characteristics of the dentinogenesis process related to root development, predentin and reparative dentin formation, dentinal bridge presence, typically reflect the overall trauma that has been induced in the odontoblasts. Laser in Restorative Dentistry and Endodontics
Lasers find numerous applications in restorative dentistry and endodontics ranging from prevention of caries to antibacterial action in root canals. 1. Prevention of carries: • Yamamoto and Ooya used Nd-YAG laser at energy densities
of 10 to 20 J/cm2 and demonstrated that the lased enamel surface was more resistant to in vitro demineralization than non lased enamel. • Stern and Sognnaes demonstrated in vivo that enamel
subjected to 10 to 15 J/cm² Ruby laser showed a greater resistance to dental caries than the controls. • Stern concluded that energy levels below 250 J/cm² did not
permanently alter the pulp but necrosis could occur when energy level, reached 1800 J/cm² or higher. • Lobene and Colleagues in their experiment with CO2 laser,
observed that CO2 irradiation to tooth enamel caused small amounts of hydroxyapatite to be converted to more insoluble calcium orthophosphate apatite. This paved the way for widespread use of laser in prevention of caries.
Another study, laser dentin closed resembled e.g. because of
increase in Ca and phosphate contents. • Lasers can be thus used for removal of incipient caries,
sealing pits and fissures. The CO2 and Nd:YAG lasers can remove the organic and inorganic debris found in pits and fissures. Following the removal a synthetic hydorxyapatite compound is attached to enamel using the laser. Power densities used are low and it did not alter the health of pulp tissue. • In 1985 Terry Myers used Nd:YAG laser for debrident of
incipient caries. • When a topical fluoride treatment was performed after argon
laser conditioning of enamel, an even more dramatic reduction in enamel acid demineralization was observed. CO2 lasers: Florin has shown that a continuous wave CO2 laser homogenesizes the enamel surface by melting structural elements. The tissue in the laser – induced zones of fusion was harder than adjacent, un-irradiated enamel, which would increased the caries resistance.
Argon: • Argon irradiation of root surfaces significantly increased the resistance of cementum and underlying dentin to continual artificial caries attack. • Lased cementum and dentin seem to have an increased affinity for uptake of fluoride, phosphorous and calcium ions. 2. Diagnosis: Lasers can be used to detect incipient carious lesion which cannot be diagnosed clinically and radiographically. Transilliumination using lasers is used for this purpose. The lesion appears as a distinct dark red area easily differentiated from the rest of the sound tooth structure. Decalcified area appears as a dull, opaque, orange color. Also enamel fractures and recurrent decay around metallic and resin restoration can be diagnosed. • Quantitative measurement of the fluorescence emission pattern induced by laser, the technique of laser-induced fluorescence, has been used in the assessment of caries. • This non-destructive method is more effective than microradiography.
Cavity preparation: The use of lasers for cavity preparation has been under scrutiny for 20yrs as many investigators found that pulpal necrosis would occur with use of lasers. The reasons for necrosis are: 1. The heat produced 2. Total power output (J/cm²) The search for laser that can be used to cut hard tissues begun in 1964 by Dr. Leo Goldman who used laser on his brother Bernard’s teeth. The subsequent search included many laser wavelengths such as CO2 but its disadvantages include cracking with flaking of enamel surface. Nd:YAG 10 J/cm² has shown to inhibit incipient carious lesions but at higher densities it causes irreversible pulpal damage. Other lasers such as Ho: YAG, ArF, Nd:YLF and Er: YAG have been investigated. Er: YAG at the wavelength of 2.94µ m has shown most promising results. A number of researchers have demonstrated the Er:YAG laser’s ability to cut or ablate dental hard tissues effectively and efficiently. The Er:YAG laser is absorbed by water and hydroxyapatite, which partially accounts for its efficiency in cutting enamel and dentin.
It has generally been assumed that if pulpal
temperature rises less than 5.5°C, the procedure would be safe and would not cause irreversible histologic damage to the pulpal tissues. Researchers who conducted in vivo animal studies reported that the pulpal response to cavity preparation with an Er:YAG laser was minimal, reversible and comparable with the pulpal response created by a high speed drill. • The temperature rise with these type of laser was less
than 3°C. • Moreover, a water coolent can be used which not only
cools the tooth during ablation but also increase the efficiency of ablation. • In a study by Timothy Smith, patients reported little or
no pain during the treatment with dental laser. With many people reporting fear of pain as their chief reason for not seeking dental care, lasers may offer a more acceptable treatment technique. Etching the Enamel:
The laser absorbed by enamel causes the enamel surface to be heated to a high temperature, generating micro cracks in the surface and thus aids in enhancing adhesion of composite to the tooth structure. The surfaces appear similar to acid etched surfaces. The Nd:YAG laser is not readily absorbed but absorption can be increased by using a dye on enamel surface.
Curing of Composites and GIC: Currently, photoactivated dental resins employ a diketone, such as camphoroquinone, and a tertiary amine reducing agent to initiate polymerization. This photoinitiator system is sensitive to light in blue region of the visible spectrum with broad peak activity in the 480nm region. The argon laser’s monochromatic wavelengths of 488nm and 514.5nm have been shown to be effective in the initiation of polymerization of dental resins. Advantages: • Enhanced physical properties like increased tensile strength
due to enhanced or more thorough polymerization. • Improved adhesion
Reduced microleakage Reduced exposure time. Argon laser polymerization requires
a 10sec cure cycle while visible light activation usually takes approximately 40sec. • The polymerization of light activated bases and or liners can
also be accomplished with the argon laser. Advantages : A wide varity of fiber sizes provides access to all location of cavity preparation. Pit and Fissure Sealant Therapy: Advantages are similar to those offered for curing composite resins. Bleaching: Lasers also find use in bleaching of vital and non-vital teeth. Two-laser assisted whitening systems have been cleared by the FDA. The laser is used to enhance the bleaching material. e.g. i) Argon of 488 nm for 30 sec to accelerate the activity of its bleaching gel.
ii) Both Argon and CO2 are used. CO2 is employed with another peroxide based solution to promote penetration of the bleaching agent into the tooth to provides bleaching below the surface. Treatment of fractured teeth: Lasers have the potential to fuse the segments of fractured teeth. Pulpotomy: Recent development. Removal of Old restoration: • Composites and cements can be ablated. • Gold crowns and cast fillings cannot be removal as laser beam is reflected. • Ceramics cannot be ablated.
Lasers in endodontics
1. Diagnosis of blood flow in the dental pulp Laser Doppler Flowmetry (LDF) was developed to assess blood flow in microvascular system e.g. retina, skin. This original technique utilized a light beam from a He-Ne laser emitting at 032.8nm, which when scattered by moving red cells, underwent a frequency shift, according to the Doppler principle. A fraction of the light back-scattered from the
illuminated area was frequency shifted in this way. This light was detected and processed to produce a signal that was a function of the red cell flux. • Other wavelengths of semiconductor lasers have also been used : 780 nm and 180-820nm. • In general, infra-red (780-910nm) has a greater ability to penetrate enamel and dentin than shorter wavelength red light (632.8nm). • Non laser light (576nm) has also been used for the detection of pulpal perfusion. • Lasers are usually at a low-power level of 1-2 mW and no reports on pulp injury by this method have been reported. • Another diagnostic application of lasers in endodontics is the application of an excimer laser system emitting at 308nm for residual tissue detection within the canals. 2. Dentinal hypersensitivity: To date, most of the therapies for this, have failed to satisfy one or more of the criteria like, non-irritant to the pulp painless on application
easily carried out rapid in action be effective for a long time but some authors report that lasers may now provide reliable and reproducible treatment, documenting success rates of upto 90%
The lasers used for the treatment of dental hypersensitivity are divided into two groups: low output power lasers e.g. He-Ne Gallium / Al / arsenide (Ga Al As) Mechanism causing a decrease in hypersensitivity is mostly unknown, but it is thought that the mechanism for each laser is different. a) In the case of low output-power lasers – A small fraction of the laser’s energy is transmitted through enamel and dentine to reach the pulp tissue. • He-Ne laser irradiation may affect the electric activity / action potential / and not affect peripheral Ag or C-fiber nociceptors. Using CO2 at moderate laser energies, mainly sealing of dentinal tubules is achieived, as well as reduction of permeability. CO2 laser irradiation may cause dentinal dessication, yielding temporary clinical relief of dentinal hypersensitivity. • The sealing depth achieved by Nd:YAG laser irradiation on dentinal tubules measured less than 7nm. middle output power lasers e.g. Nd-YAG - CO2
Note: It is necessary to consider the severity of dentinal hypersensitivity before laser use. 3. Pulp capping and pulpotomy
Melcer et al (1987) first described laser treatment of exposed pulp tissues using the CO2 laser in dogs to achieve hemostasis.
• Lasers facilitate pulpal healing after irradiation at 2W for 2s. CO2 laser was found to be a valuable aid in direct pulp capping in human patients (Moritz 1998). Ist laser pulpotomy using CO2 on dogs by Shoji (1985). No detectable damage was observed in the radicular patients of irradiated pulps with the CO2 laser. Wound healing of the irradiated pulp seems to be better than that of controls at 1 week, and dentine bridge formation in the irradiated pulp was stimulated at 4 and 12 after operation. • If a laser is used for these procedures, a bloodless field would be easier to achieve due to the ability of the laser to vaporize tissue and coagulate and seal small blood vessels. • Moreover, the treated wound would be sterilized.
• No laser damage was found in tissues, with the presence of secondary dentine and a regular odontoblast layer by Wilder Smith et al (1997). Lasers used for this are mainly CO2 and Nd:YAG. Note: An approximate parameter should be selected as if the laser energy is too strong, the treatment will be unsuccessful. 4. Modification of root canal walls • Laser removes the smear layer and replaces it with an uncontaminated chemical sealant, or sealing it by melting the dentinal surface. • Using CO2 laser irradiation, the dentine permeability was reduced and a wide range of morphological changes were observed by (Tanji 1994). • Nd:YAG within fiber / fiber optic laser was used to seal the entrance to the root canal at the apex of the tooth in vitro (Weichman 1972). • First, debris and smear layer were removed using appropriate laser parameters and dentin permeability was reduced.
• Since absorption of Nd:YAG laser irradiation is enhanced by black ink, it potential laser effects on root canals. Argon laser irradiation can also achieve an efficient clearing effect on instrumented root canal surfaces. The effect of the laser irradiation was enhanced in the presence of Ag(NH3)2F. Others lasers used – Er:YAG Potassium titanye phosphate (KTP) Xenon chloride (XeCl) Ar-Fluoride (F) excimer laser HO:YAG Note: The removal of smear layer and debris is possible however, it is hard to clean all the walls, because the laser is emitted straight ahead, making it almost impossible to clean or irradiate the lateral root canal walls. 5. Sterilization of root canals • The Nd:YAG laser is more population for this, because a thin fibre-optic delivery systems for entering narrow root canals is available with this device. Others are : XeCl, Er:YAG, a diode laser • All the lasers have a bactericidal effect at high power that is dependent on each laser.
• There appears to exist a potential for spreading bacterial contamination from the root canal to the patient and the dental team via the smoke produced by the laser, which can cause bacterial dissemination (Hardee et al 1994). Note: Precautions such as a strong vacuum pump system must be taken to protect against spreading infections when using lasers in the root canal (McKinley 1994). Also, sterilization of root canals by lasers is problematic since thermal injury to periodontal tissues is possible. 6. Root canal shaping and obturation • Using an Er:YAG laser, root canal orifices were prepared, after irradiation by an Er:YAG laser, the root canal surface appeared smooth under SEM. Root canal cleaning and shaping was achieved by Nd:YAG laser clean and regular root canal walls achieved. • The photopolymerization of camphoroquinone – activated resins for obturation is possible using an Argon laser emitting at 477 and 488 nm.
• The results indicate than an Argon laser coupled to an optical fibre could become a useful modality in endo therapy. • AH-26 and composite resin have been used as obturating materials (AMC 1795) and SEM examinations revealed fewer voids in laterally compacted resin fillings than in vertical compaction. Argon, CO2 and Nd:YAG lasers have been used to soften guttapercha and results (Anic 1995) indicate that the Argon laser can be used for this purpose to produce a good apical seal. Note: It is hard to irradiate root canal walls; as after laser irradiation, walls are rough and uneven. Therefore it is necessary to improve the fibre tip and the method in order to irradiate all areas of root canal walls. 7. Effect on periodontal tissues • The threshold level for bone survival 47°C for 1 min. • No adverse effects on periodontal tissues by lasers were observed if appropriate parameters were selected. Laser systems operate in various modes, such as continuous wave, pulsed, chopped-wave and Q-switched.
• To minimize the rise in tissue temperature within the target and around areas, use of the Q-switched nanosound pulsed mode is beneficial. 8. Full root canal treatment • Clinical follow-up examination of infected teeth at 3-6 months after laser irradiation and root canal filling revealed that postoperative discomfort or pain in the laser treated group was significantly reduced compared to the non-laser treated group (Koba, 1995, 1999). • The immediate drying of Nd:YAG laser maybe due to the evaporating effect of irradiation on the exudates leaving the suspended materials to precipitate inside the canals followed by hemostatic and healing effect with subsequent inhibition of the inflammatory condition of the periapical lesion. Note: It is useful to use lasers as an adjacent during conventional treatment, but it is not possible to use lasers alone for treatment. 9. Apicoectomy: Because of the high heat energy generated by the use of laser, better sealing ability of hydroxyapatite to the root apex was detected.
• If a laser is used for the surgery, a blood less surgical field should be easier to achieve due to the ability of the laser to vaporize tissue and co-agulate and seal small blood vessels. • If the cut surface is irradiated, the surface is sterilized and sealed. Moreover, the potential of the Er:YAG laser to cut hard dental tissues without significant thermal or structural damage would eliminate the need for mechanical drills. • The use of Er:YAG laser resulted in improved healing and diminished post-operative discomfort (Komori 1996, 1997). With other lasers like CO2 and Nd:YAG did not improve the healing process. Note: It take more time to perform with lasers when compared to more conventional methods. • Use of Er:YAG laser for retrograde cavity preparation showed that the working time with the Er:YAG laser is significantly less than with ultrasonic tools.
10. Other applications for endodontic treatment -
For treatment of root fractures But fusion was not achieved (Arakawa 1996). To sterilize dental instruments (Ar, CO2, Nd:YAG) Argon laser was able to do so consistently at the lowest energy level of 1w for 2 min.
Laser Hazards and Laser Safety: The subject of dental laser safety is broad in scope, including not only an awareness of the potential risks and hazards related to how lasers are used, but also a recognition of existing standards of care and a thorough understanding of safety control measures. Laser Hazard Class for according to ANSI and OSHA Standards: 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. Class IV - High powered lasers (>0.5W) that produce ocular, skin and fire hazards.
The types of hazards can be grouped as follows: 1. Ocular injury 2. Tissue damage 3. Respiratory hazards 4. Fire and explosion 5. Electrical shock 1. Ocular Injury: Direct emission Reflection
Potential injury to the eye can occur either by direct emission from the laser or by reflection from a specular (mirror like) surface or high polished, convex curvatured instruments. Damage can manifested as injury
to sclera, cornea, retina and aqueous humor and also as cataract formation. The use of carbonized and non-reflective instruments has been recommended. 2. Tissue Hazards: Laser induced damage to skin and other non target tissues can result from the (1) thermal interaction of radiant energy with tissue proteins. Temperature elevation of 21°C above normal body temp (37°C) can produce cell destruction by denaturation of cellular enzymes and structural proteins. (2) Tissue damage can also occur due to cumulative effects of radiant exposure. Although there have been no reports of laser induced caroinogenesis to date, the potential for mutagenic changes, possibly by the direct alteration of cellular DNA through breaking of molecular bonds, has been questioned. The terms photodisruption and photoplasmolysis have been applied to describe these type of tissue damage. 3. Respiratory: Another class of hazards involves the potential inhalation of airborne biohazardous materials that may be released as a result of the
surgical application of lasers. Toxic gases and chemical used in lasers are also responsible to some extent. During ablation or incision of oral soft tissue, cellular products are vaporized due to the rapid heating of the liquid component in the tissue. In the process, extremely small fragments of carbonized, partially carbonized, and relatively intact tissue elements are violently projected into the area, creating airborne contaminants that are observed clinically as smoke or what is commonly called the ‘laser plume’. Standard surgical masks are able to filter out particles down to 5µ m in size. Particle from laser plume however may be as small as 0.3µ m in diameters. Therefore, evacuation of laser plume is always indicated with a “Smoke Evacuator”. 4. Fire and Explosion Flammable solids, liquids and gases used within the clinical setting can be easily ignited if exposed to the laser beam. The use of flameresistant materials and other precautions therefore is recommended. Flammable materials found in dental treatment areas.
Clothing Paper products Plastics Waxes and resins 5. Electrical Hazards: These can be: -
Ethanol Acetone Methylmethacrylate Solvents
Oxygen Nitrous oxide General anesthetics Aromatic vapors
electrical shock hazards electrical fire or explosion hazards
Summary of laser safely control measures recommended by ANSI Engineering controls: Protective housing Interlocks Beam enclosures Shutters Service panels Equipment tables Warning systems
Key switch Administrative controls: Laser safety officer Standard operating procedures Output limitations Training and education Medical surveillance Personal protective equipment: Eye wear Clothing Screens and curtains Special controls: Fire and explosion Repair and maintenance
Conclusion Laser has become a ray of hope in dentistry. When used efficaciously and ethically, lasers are an exceptional modality of treatment for many clinical conditions that dentists treat on daily basis. But laser has never been the “magic wand” that many people have hoped for. It has got its own limitations. However, the futures of dental laser is bright with some of the newest ongoing researches. Once, our knowledge about optimal laser parameters for each treatment modality is complete, lasers can be developed that will provide dentists with the ability to care for patients with improved techniques. References
St underwent (3rd Ed.).
Lasers in Endodontics – a review (IEJ, 33 : 173-185). DCNA 2000 (Lasers and light amplification in dentistry).
INTRODUCTION HISTORY OF LASERS LASER PHYSICS AND DESIGN MODE OF DELIVERY OF LASER TYPES OF LASER LASER INTERACTION WITH BIOLOGIC TISSUE
AND ITS EFFECTS APPLICATION OF LASERS IN DENTISTRY CONSERVATIVE ENDODONTIC LASER HAZARDS
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