LASERS IN

ENDODONTICS
Light Amplification by Stimulated Emission of Radiation.
 Introduction
n 1917 -stimulated emission was predicted by Einstein

n In 1955 Gordon introduces simulated emission of microwave

n 1957, Theodore Maiman , a scientist with the Hughes Aircraft

Corporation, developed the first working laser device” MASER “, .
MASER stands for “Microwave amplification by stimulated
emission of Radiation which emitted a deep red-colored beam from
a ruby crystal.

q 1964 : Nobel prize for development of LASER was awarded to

Townes, Basov, Prokhoror).

§ Dr Leon Goldman , a dermatologist who had been experimenting

with tattoo removal using the ruby laser, focused two pulses of that
red light on a tooth of his dentist brother in 1965. The result was
painless surface crazing of the enamel.
n Frame , Pecaro , and Pick cited the benefits of CO2 laser treatment
of oral soft-tissue lesions and periodontal procedures.

n A portable tabletop model was made available in 1987, and 2 years

later Myers and Myers received the US- FDA permission to sell a
dedicated dental laser, a Nd:YAG

n 1971: Andrian et al confirmed extensive pulpal injury & destruction

with ruby laser.

n 1972 : Stern et al used CO2 laser for hard tissues for sealing of pit &
fissures, the welding of ceramic materials to enamel or the
prevention of caries .

n 1974: Yamamoto & Ooya used for first time neodymium laser to
vital oral tissue in experimental animals and said NdYAG was
effective tool for inhibiting the formation of caries.
n 1977: The first reported application of a laser for maxillofacial
surgery by Lenz (Argon).

n 1985: The properties of improved hemostasis afforded through

tissue ablation with CO2 were first recognized & applied to
periodontal surgery by Pick.

n 1987: FDI gave first approval for laser use in surgery to Pfizer laser
company (CO2 laser unit)(Also Stewart et al used CO2 laser for
surface such as pits & fissures)

n 1988 : Enamel etching was done by Cooper.

 LASER PHYSICS
Light Amplification by Stimulated Emission of Radiation
Properties of Laser

• Monochromatism

• Coherence

• Collimation

• Efficiency

Velocity, Amplitude, Wavelength

 Spectrum of laser

λ > 300 nm - less photon energy - cause excitation and heating

λ < 300 nm - higher photon energy – penetrate tissues & produce
charged atoms and molecules
 Types of lasers used
ArF Excimer 193nm
KrF Excimer 248nm
XeCl Excimer 308nm
Frequency doubled Alexandrite 377nm
Krypton ion 407nm
Argon ion 488, 514.5nm
Dye 507-510nm
Frequency doubled Nd:YAG 532nm
diode 600-908nm
Gold vapor 630nm
Ar pumped dye 630nm
Cu vapor pumped dye 632nm
He-Ne 694.3nm
Ruby 800-830nm, 904-950nm
Diode (GaAlAs, GaAs) 1.053µm
Nd:YLF 1.053µm
Nd:YAG 1.064µm
Nd:YAP 1.34µm
Ho:YAG 2.94µm
Er:YSGG 2.79µm
Er:YAG 2.94µm
Free electron 3.0, 6.1, 6.45µm
CO2 9.3, 9.6, 10.6µm
Laser delivery systems

0.5-1.0mm

Articluated arms
n Flexible hollow waveguide or tube that has an interior mirror finish.
n The laser energy is reflected along this tube and exits through a
handpiece at the surgical end with the beam striking the tissue in a
non-contact fashion.
n An accessory tip of sapphire or hollow metal can be connected to the
end of the waveguide for contact with the surgical site.
n Glass fiber optic cable which cable can be more pliant than the
waveguide, has a corresponding decrease in weight and resistance to
movement, and is usually smaller in diameter (200–600 µm).

n Though the glass component is encased in a resilient sheath, it can

be fragile and cannot be bent into a sharp angle.

n This fiber system can be used in contact or noncontact mode. Most

of the time it is used in contact fashion, directly touching the surgical
site. Contact lasers system offer an advantage of tactile sense.
Hand held laser
LASER DELIVERY SYSTEM
CO2 Mirror system
Er:YAG Mirror system
Ho:YAG Fiber system
Nd:YAG Fiber system
Diodes Fiber system
HeNe Fiber system
Dyes Fiber system
Ar ion Fiber system
Excimer Mirror system & Fiber
system
 LASER EMISSION MODES
• Continuous mode

• Gated Pulse mode

• Free running pulsed mode

n Continuous wave : Beam emitted at only one power level for as long
as device is operated by pressing the foot switch. Ex, Diode, CO2

n 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.
Ex, Diode, CO2

n Free running pulsed mode: This is unique in that large peak energies
are emitted for an extremely short time span (in microsecond)
followed by long time of which laser is off. It is computer controlled.
Ex: Nd:YAG, Er:YAG
Laser–tissue interaction
absorption Photothermal effect

transmission Photochemical effect

reflection Photoaccoustic effect

scattering Photoelectrical effect

Laser energy and tissue temperature
n photothermal ( the conversion of light energy into heat)

Thermal effect of laser on tissues

degree of temperature rise and the

corresponding reaction of the
interstitial and intracellular water

emission mode, the power

density, and the time of exposure

Hy
Coagula Vapourizati
per Soft
tion, on
the tissue
protein (ablation)
rmi edge
denatur
a( welding (Spallation)
ation
37- (70- ( 100-
(60-
50º 80ºC) 150ºC)
70ºC)
Photochemical effect

n Photodynamic theraphy
n Tissue flourscence
n Curing of composites

Photoaccoustic effect

n Conversion of heat energy produced by light into sound waves due

to pressure variation

Photoelectrical effect
n Photo plasmolysis – tissue removed by the electrically charged ion
particles in a semi-gaseous high energy state.
 Classification:
n Based on the active medium

v Solid - Ruby, Nd YAG, Diode- electricity / light

v Gas - CO2 , Argon, Krypton - electricity
v Liquid - Dye, Jello- light

n Depending on wave length

v Hard Lasers- infrared spectrum (> 700nm) E.g.CO2 , Nd:YAG, Argon

v Soft Lasers – UV & visible light ( 140-400nm )E.g. HeNe, Diode.
n Based on safety procedure:
n Class I : safe under all conditions – CD player- max output -1/10 mW

n Class II: no health hazard -– visible low power laser – scanner in

supermarket, small laser pointers , 1mW

n Class IIIA: extension of class II with power output is < 0.5 W. It will not
harm unprotected eye

n Class IIIB: upper continuous power output is > 0.5 W.. It will harm
unprotected eye
n Class IV: output more than 0.5 W either continuous or pulsed
emission. used for cutting & drilling. Hazard to eye, skin

FDA has cleared four types of lasers for dental use:

n carbon dioxide,
n Nd:YAG,
n argon, and
n holmium:YAG.
CO2 Lasers:
n gas-active medium laser, hollow tube-like waveguide in continuous or
gated pulsed mode delivery system

n noncontact fashion that has an advantage when treating movable oral

structures, such as the tongue and floor of the mouth

n It has a shallow depth of penetration into tissue, which is important

when treating mucosal lesions.

n It has the highest absorption in hydroxyapatite of any dental laser.

n Therefore, tooth structure adjacent to a soft-tissue surgical site must be
shielded from the incident laser beam; usually a metal instrument placed
in the sulcus provides the protection.

n The continuous wave emission limit hard-tissue applications because

carbonization and crazing of tooth structure can occur.
 Neodymium:YAG Laser:
n solid active medium, which is a garnet crystal combined with rare earth
elements yttrium and aluminum, doped with neodymium ions.

n free-running pulsed mode with short pulse durations in the hundreds of

microseconds.

n Nd:YAG laser energy is slightly absorbed by dental hard tissue, but there is
little interaction with sound tooth structure, allowing soft tissue surgery
adjacent to the tooth to be safe and precise.

n Pigmented surface carious lesions can be vaporized without removing the

healthy surrounding enamel.

n When used in a noncontact, defocused mode, this wavelength can

penetrate several millimeters, which can be used for procedures such as
hemostasis, treatment of aphthous ulcers, or pulpal analgesia
Diode Laser:
n solid active medium laser, manufactured from semiconductor
crystals using some combination of aluminum or indium, gallium, and
Arsenic.

n Al - 800nm : In- 980nm

n continuous wave (Air water coolant) and gated pulsed modes

n contact with soft tissue for surgery /non contact for deeper coagulation.

n Smaller size & portable (major advantage )

n Some clinicians prefer to initiate the end of the fiber with a small
amount of carbon pigment and refer to this as a ‘‘hot tip.’’ This
method focuses a large amount of laser energy at the contact point and
accelerates tissue incisions
n Less by dental tissue of enamel , dentin so Soft tissue surgeries can be
done around tooth

n Diagnodent for caries detection

n Low level laser therapy (LLLT) can provide biostimulation and pain
relief.

n The diode is an excellent soft tissue surgical laser and is indicated for
cutting and coagulating gingiva and mucosa and for sulcular
debridement.
Argon Lasers:
n continuous wave and gated pulsed modes

n Only available surgical laser device whose light is radiated in the

visible spectrum.

n There are two emission wavelengths used in dentistry:

n Blue-488 nm, and blue green -514 nm,.

n Can be used as curing light (488-nm emission is the wavelength

needed to activate camphoroquinone,)
n Acute inflammatory periodontal disease and highly vascularized lesions,
such as a hemangioma, are ideally suited for treatment by the argon
laser.

n The poor absorption into enamel and dentin is advantageous when using
this laser for cutting and sculpting gingival tissues because there is
minimal interaction and thus no damage to the tooth surface during
those procedures.

n Both wavelengths can be used as an aid in caries detection.

n When the argon laser light illuminates the tooth, the diseased, carious
area appears a dark orange-red color and is easily discernible from the
surrounding healthy structures
Ho:YAG lasers:
n It contains a solid crystal of yttrium aluminum garnet sensitized with
chromium and doped with holmium and thulium ions.

n fiberoptically delivered in free-running pulsed mode.

n However, as a soft-tissue instrument it does not react with hemoglobin

or other tissue pigments .

n The holmium laser is frequently used in oral surgery for arthroscopic

surgery on the TMJ and has many medical applications .
The Erbium Family:
n Two distinct lasers

v Er:YAG (2940nm) - hollow wave guide or a fibreoptic system

v Er,Cr:YSGG (2780nm)- only use fibreoptic.

Both wavelengths are emitted in a free-running pulsed mode.

n Laser tip size 0.5micrometer

n Air water spray for dental use

n Highest absorption in water & high affinity for hydroxyapetite

n Vaporization of water causes expansion causing surrounding material

to explode away
n Caries removal and tooth preparation are easily accomplished.

n Additionally, sound tooth structure can be better preserved when the

carious material is being ablated ; the increased water content in dental
caries allows the laser to preferentially interact with that diseased tissue .

q The healthy enamel surface can be modified for increased adhesion

of restorative material by exposing it to the laser energy .

q The current indication for use of these lasers dictates that they not be
used for removal of amalgam or other metal.

q However, the non-interaction with precious metal and fused porcelain

allows the practitioner to remove caries surrounding these restorations
without any damage.

n The advantage of erbium lasers for restorative dentistry is that a carious

lesion in close proximity to the gingiva can be treated and the soft tissue
recontoured with the same instrumentation
n For endodontics, removal of pulpal tissue and dentin is easily
accomplished with these wavelengths .

There are three challenges,

n One is to maintain the water spray during the hard-tissue ablation

so that the temperature of the target tissue and surrounding
structures is kept from being elevated.

n The second is to design a flexible and durable fiber to conduct the

laser energy.

n Third is most tips are end cutting, and shaping the canal space
requires a side-cutting accessory, which is not possible.
 Dental applications of laser
n Cutting and coagulation.
n Stimulation of healing.
n Analgesia.
n Surface modification.
n Exposing unerupted teeth or decay.
n Implant exposure
n Tuberosity reduction.
n Periodontal / endodontic disinfections.
n Incision / excision procedures.
n Treatment of leukoplakia.
n Treatment for soft tissue lesion
Soft tissue Applications
n Pre-impression troughing.
n Gingivectomy / gingivoplasty.
n Frenectomy.
n Operculectomy.
n Crown lengthening.
n Biopsy

Other Applications
n Sterilization.
n Incision and drainage of abscesses.
n Providing pain relief by coagulating the surface of apthous ulcers.
n Cold sores can be coagulated but the laser from vaporization is
highly infectious material and suction is mandatory.
Uses in conservative dentistry:

n Caries detection & prevention with laser energy

n Dentin desensitization
n Cavity preparation using lasers
n Laser etching
n Polymerization of composite resins
n Laser tooth whitening
n Composite curing

Lasers in endodontics

n Dentinal hypersensitivity and modification of the dentin structure

n Pulp diagnosis (LDF).
n Pulp capping and pulpotomy
n Cleaning and shaping of root canal system
n Photodynamic therapy
Dentinal hypersensitivity and modification of the dentin structure
n Grossman outlined the requirements for the treatment of this condition:
therapy should be nonirritating to the pulp, be relatively painless on
application, be performed easily, act rapidly, be effective
for a long period of time, be devoid of staining effects, and be
consistently effective.
Two groups:
n low output power lasers (helium-neon and gallium/ aluminum/arsenide
[diode])
n middle output power lasers (Nd:YAG and carbon dioxide [CO2])
Possible suggested mechansim:
n depressed nerve transmission caused by the diode laser irradiation
blocking the depolarization of C-fiber afferents.
n higher levels of calcium and phosphorus in the fused or recrystallized
dentin walls of the crater compared with levels in normal dentin
n Decreased permeability of laser-treated dentin caused by fusion of the
smear layer into the dentinal tubules or narrowing of the dentinal
tubules
 Pulp diagnosis
Laser Doppler flowmetry
n DOPPLER SHIFT --the frequency shift that a wave undergoes when emitted
from an object that is moving away from or towards an observer. It manifests
itself, as example, in the increase in the pitch of the siren of an ambulance, when
this vehicle moves towards an observer (Riva 2001).

n LDF an optical measuring method that enables the number and velocity of
particles conveyed by a fluid flow to be measured.

n The particles (1–20 μm) must be big enough to scatter sufficient light for signal
detection but small enough to follow the flow faithfully (Durst et al. 1976,
Durrani & Greated 1977, Drain 1980, Bonner & Nossal 1990,Albrecht et al. 2003).

n It was developed to assess blood flow in microvascular systems, also can be used
for diagnosis of blood flow in the dental pulp.

n This technique uses helium-neon and diode lasers (632.8 nm) at a low power
of 1 or 2 mW . Other wavelengths of semi-conductor laser have also been
used: 780 nm and 780–820 nm (Kimura et al. 2000).
n Laser light is transmitted to the dental pulp by means of a fibre optic probe
placed against the tooth surface (Gazelius et al. 1986, Bonner & Nossal 1990)
n Two equal-intensity beams (split from a single beam) intersect across the
target area.
n The scattered light beams from moving red blood cells will be frequency-shifted
whilst those from the static tissue remain unshifted in frequency (Gazelius et al.,
Bonner & Nossal, Rowe & Pitt Ford 1990).
n The reflected light, composed of Doppler-shifted (light reflected by a moving
object is Doppler-shifted) and unshifted light, is returned by an afferent fibre
within the same probe to photodetectors in the flowmeter and a signal is
produced (Bonner & Nossal 1990, Roeykens et al. 1999).
n The photodetectors convert the interference pattern arising from the mixing of
shifted and unshifted light into a semiquantitative measurement of blood flow,
termed the Flux signal, which is measured in arbitrary units.
n The received signal is calculated with a preset algorithm in the LDF machine
(Roebuck et al. 2000, Berman & Hartwell 2006) .

n The LDF output signal or Flux can be simplified as a function of the product of red
blood cells’ concentration as well as their mean velocity (Gazelius et al. 1986,
Bonner & Nossal 1990, Rowe & Pitt Ford 1990,).

v In fact, Flux is the number of moving red blood cells per second times their
mean velocities (Berman & Hartwell 2006).

v When used to assess the vitality of teeth, the size of the Flux signal obtained from
a healthy vital control tooth can be compared with that of the suspected
nonvital tooth.

q The Flux signal from a tooth with a vital pulp should be greater than from a tooth
with a nonvital pulp (Roebuck et al. 2000).

q It should be emphasized that the optical properties of a tooth change when the
pulp becomes necrotic and this can produce changes in the LDF signal that are
not due to differences in blood flow, as discussed by Soo-ampon et al. (2003).
 Indications:
n Estimation of the pulpal vitality

n Periapical radiolucencies may have nonendodontic origins, so application of

vitality tests,

n Pulp testing in children: sensibility tests are not reliable in children

n Laser Doppler flowmetry can help monitor age-related changes in PBF

n Laser Doppler flowmetry can be used for monitoring of reactions to electrical

(Raab et al. 1988) or thermal pulp stimulation (Andersen et al. 1994,
Mavropoulos et al. 1995, Goodis et al. 2000)

n Monitoring the effect of exercise, local or systemic pharmacological agents ,

orthodontic procedures (McDonald & Pitt Ford 1994, Barwick & Ramsay 1996)
on PBF .

n Monitoring of revascularization of replanted teeth (Mensdorff-Pouilly et al. 1995,

Yanpiset et al. 2001, Ritter et al. 2004):
 ADVANTAGES
v It does not rely on the occurrence of painful sensation to determine the
vitality of a tooth

v Teeth of recent trauma , in line orthognathic surgery (lost nerve supply but
intact blood supply).

n used for patients who have difficulties in communicating or for young

children whose responses may not be reliable

DISADVANTAGES
n presence of mineralized tissues that limit the penetration of the laser
beam into the tooth.1

n differences in sensor output and inadequate calibration by the

manufacturer may dictate the use of multiple probes for accurate
assessment. 6
n information provided by LDF can be ambiguous and must be interpreted
with care (Matthews & Vongsavan 1993).7
n For example, in acute pulpitis, in which the vascularity of the pulp is increased
and the concentration of red cells is above 1%, an increase in PBF can result in a
decrease in the signal. This indicates that LDF values must be interpreted with
caution (Vongsavan & Matthews 1993a,b).8

n It is susceptible to extraneous noise, such as loud sounds (i.e. vibrations) or

movement near or in the apparatus itself. 5

n It may also be sensitive to contamination from blood flow in adjacent tissues.

Lower levels of reliability or technical difficulties, including the potential
confounding factor that some signals originate from the periodontal tissue. 4

n It may be contraindicated in some heavily restored teeth 2 and teeth with vital
apical pulp tissue, because LDF probes detect only coronal PBF (Edwall et al.
1987).3

q equipment costs.9
 Reliability of LDF

n It is highly reliable, but only under specific and carefully controlled

conditions (Evans et al. 1999).

n Several studies have suggested a reliability of greater than 80–90% for

LDF assessment of vitality (Wilder-Smith 1988, Ingo´lfsson et al. 1994a,
Hartmann et al)

n Whilst LDF has proved effective and reliable for some body tissues
(Belcaro et al. 2000, Braverman 2000, Tabrizchi & Pugsley 2000), the
limited translucency and multiple reflectance of teeth have cast doubt
upon its validity to assess the condition of the pulp (Ikawa et al. 1999).

n The use of a dual-probe LDF system has been suggested to increase

reliability (Roeykens et al. 1999, Roebuck et al. 2000).
 probe design
Agerelated probe holder
Changes characteristics

gingival
isolation
intake of drugs, devices

Factors influencing the results flowmeter

characteristics

tooth
discolouration,
stress,
mineralization
of enamel and
dentine
heartbeat-
synchronous
oscillations,
the temperature of the environment, the
position and the resting status of the patient,
the position of the probe
 Pulp analgesia:
n Nd:YAG recommended

n 100mJ , 10-15 pps , 3-4 mins

n Proposed mechanism
n Hyper stimulation of nerve endings

n Stimulation resulting in endorphin secretion within gray matter

of posterior pulp horns
 Pulp capping and pulpotomy
n DPC - CO2 - Moritz et al .,

n IPC - CO2 laser, pulsed Nd:YAG -tissue ablation, melting, resolidification

n Melcer et al., showed that the CO2 laser - new mineralized dentin
formation without cellular modification of pulpal tissue

n Shoji et al., Charring, coagulation necrosis, and degeneration of the

odontoblastic layer occurred, without damage to radicular portion of the
pulp.
Shaping the root canal system
n The emitted energy can be delivered into the root canal system by a thin
optical fiber (Nd:YAG, erbium,chromium:yttrium-scandium-gallium-
garnet [Er,Cr:YSGG], argon, and diode) or by a hollow tube (CO2 and
Er:YAG). (WATERLASE)

Suggested mechanism:
n Potential bactericidal effect
n ability to remove debris and the smear layer

Limitation:
n The emission of laser energy from the tip of the optical fiber or the laser
guide is directed along the root canal and not necessary laterally to the
lateral root canal walls ( Matsumoto et al.,).

n thermal damage to the periapical tissues potentially is possible

especially near the AF
RC Lase
n Stabholz et al., new endodontic tip used Er:YAG laser system
gained approval by FDA for use on hard dental tissues .

n An endodontic tip that allows lateral emission of the irradiation

(side-firing), rather than direct emission through a single opening
at its far end.

n This new endodontic side-firing spiral tip (RCLase; Lumenis, Opus

Dent, Israel) was designed to fit the shape and the volume of root
canals prepared by nickel-titanium rotary instrumentation.

n a spiral slit located all along the tip. The tip is sealed at its far end,
preventing the transmission of irradiation to and through the apical
foramen of the tooth
 CLEANING OF ROOT CANAL SYSTEM
Photodynamic therapy
n The mechanism of action of PDT occurs when dye, acting as a
photosensitizing agent, absorbs photons from the light source, and their
electrons enter an excited state, also known as triplet state.
n In the presence of a substrate, such as oxygen, the photosensitizer,
when return to its basic state, transfers the energy to substrate, forming free
radicals of high cytotoxicity, such as superoxides and singlet oxygen.
n These highly reactive species can cause serious damage to microorganisms
through irreversible oxidation of cellular components, causing damage to
the cell membrane, to mitochondria, to nucleus, and to other microbial cell
components.
n The type I reaction involves the transfer of electrons from excited
photosensitizer molecules of the substrate, leading to production of free
radicals that react rapidly with oxygen, resulting in the production of
superoxide, hydroxyl radicals and hydrogen peroxide.
n In the type II reaction, the excited photosensitizer transfers energy to
oxygen, leading to the production of electronically animated molecules
known as singlet oxygen.
LASER OXYGEN SUBSTRATE PHOTOSENSITIZER

PDT produces cytotoxic effects on subcellular organelles and molecules. Its

effects are targeted on mitochondria, lysosomes, cell membranes and nuclei
of tumor cells. Photosensitizer induces apoptosis in mitochondria and
necrosis in lysosomes and cell membranes.
Photosensitizers
n Photosensitizers can also be activated by low power visible light at a
specific wavelength. Activation of the photosensitizer is dependent on
the total light dose, the dose rates, the depth of light penetration and
the localization of target area.

Dyes: Chlorines:
Monoterpene:
vTricyclic dyes with vChlorine e6,
Azulene.
different meso-atoms vStannous (IV) chlorine e6
vMethylene blue, vChlorine e6-2.5 N-methyl-d-
vToluidine blue O glucamine, polylysine
Xanthenes:
vAcridine orange; vPolyethyleneimine
Erythrosine
vPhthalocyanines — conjugates of chlorine e6
aluminum disulfonated
phthalocyanine and
Porphyrins:
vCationic Zn (II) -
v Hematoporphyrin HCl,
phthalocyanine
v Photofrin
v 5 aminolevulinic acid (ALA),
vBenzoporphyrin derivative
Optimal Properties of a Photosensitizer
Highly selective and activated by light between 630 nm and 700 nm.

Photochemically efficient, and resonant with the wavelength emitted by the

light source

Low toxicity and fast elimination from skin and

epithelium.

Absorption peaks in low-loss transmission window of biological tissues.

Optimum ratio of the fluorescence quantum yield to the interconversion

quantum yield.

High quantum yield of singlet oxygen production in vivo.

High solubility in water, injection solutions and blood substitutes.

Storage and application light stability.

n Burns et al., showed that tolonium chloride (25 g/mL) used with
632.8 nm laser energy reduced the viability of S.mutans, S.sobrinus,
Lactobacillus casei, and A. viscosus.

n Vaziri et al., combination of NaOCl 2.5% and PDT using toluidine blue
at a concentration of 15 μg/mL and diode LASER with 200 mW/cm2 of
power and a wavelength of 625 nm -eliminate totally Enterococcus
faecalis.

n Fimple et al., increasing the concentration of methylene blue and the

light energy fluence (J/cm²), -- an increase in the antibacterial capacity
of PDT.

n Garcez et al., showed that endodontic treatment alone reduced

90% of bacteria, whereas PDT alone reduced it by 95% & combination
of these two reduced bacteria by 98%.
PHOTON INDUCED PHOTOACOUSTIC STREAMING(PIPS)
n A novel nonablative, 9-mm long, 600-µm diameter quartz tapered tip with
the polyamide sheath stripped 3 mm from its end.
n Erbium:Yttrium Aluminium Garnet (Er:YAG) laser to deliver shockwaves
throughout the root canal system.
n PIPS uses extremely low energy levels (< 20 mJ) and short microsecond
pulse rates (50 µs at a wavelength of 2,940 nm) to create peak power spikes
that generate a profound shockwave which travels 3-dimensionally
throughout the root canal system.
n inducing a photomechanical event rather than thermal.
n Critical to the success of the system is having a sufficient volume and
constant flow of irrigant available to allow a “sonic boom” effect to ripple
throughout the root canal system.
n Application of the PIPS laser activation protocol involves holding the
probe stationary in the coronal aspect of the preparation only, unlike
negative pressure or ultrasonic devices, with the access cavity chamber
filled with irrigant.

n This application allows the irrigants used to stream 3-dimensionally to all

internal aspects of the canal system, even into the distant apical portion.
Since PIPS has been shown to be effective in this movement, irrespective
of depth of probe penetration, the necessity to enlarge and potentially
over instrument the apical third, as is often necessary with other irrigation
techniques to achieve sufficient volume of irrigant, is avoided.

n This has significance in permitting minimally invasive preparations in

canals of all curvatures.

n 100% elimination of E faecalis in the PIPS/hypochlorite

 Obturation of root canal system
n The rationale in introducing laser technology to assist in obturating
the root canal system is based on two major assumptions:

n the ability to use the laser irradiation as a heat source for softening
the gutta-percha to be used as obturating material
n and for conditioning the dentinal walls before placing an obturating
bonding material.

n The first laser-assisted root canal filling procedure involved using the
wavelength of Argon 488 nm laser.

n This wavelength that can be transmitted through dentin was used to

polymerize a resin that was placed in the main root canal.
 Endodontic surgery
n The goal of all endodontic surgery is to eliminate the disease and to
prevent it from recurring
n Egress of irritants from the root canal system into the periapical tissues is
n considered the main cause of failure following apicoectomy and
retrograde filling.
n It is assumed that the irritants penetrate mainly through a gap present
between the retrograde filling and the dentin.
n Consequently, many efforts have been made to improve the adaptation of
retrofilling material to the dentin.
n A second possible pathway for irritants to invade the periapical tissues is
through the dentin of the cut root surface after apicoectomy and
retrograde filling.
q It was shown that the dentin of apically resected root is more
permeable to fluids than the dentin of nonresected roots. There are
n large numbers of exposed dentinal tubules on the cut root surface;
n CDJ - 13,000 dentinal tubules/mm2
n Miserendino -CO2 laser – recrystallization - smooth and suitable for
placement of retrograde filling material.

n Miserendino suggested mechanism :

improved hemostasis

concurrent visualization of the operative field

potential sterilization of the contaminated root apex,

potential reduction of the permeability of the root surface dentin,

a reduction in postoperative pain

reduced risk of surgical site contamination by eliminating the use of

aerosol producing air turbine handpieces
Caries detection
n Benedello and Antonson - CO2
n Sandstorn, Mansson- Argon
n Koning - krypton ion
n Lussi - diode - 655 nm

Laser fluorescence method

n The tooth is illuminated with a broad beam of blue green light of 488-
nm wavelength from an argon ion laser.
n The fluorescence of the enamel, occurring in the yellow-green region, is
observed through a yellow high-pass filter to exclude the tooth-
scattered blue laser light.
n Demineralised areas appear dark.

n Hibst and Gall systematically studied this phenomenon and their work
culminated in the development of a commercial device,Diagnodent,
KaVo in Germany that is in use in several European countries .
n This utilizes an In:Ga:As:P diode laser emitting at 655 nm to detect
occlusal caries.
Diagnodent
n Red Diode laser( 600-700 nm)
n Flourescence resulting from red light ( 655nm )
n Signal comes out as a number on instrument on a scale of 0 – 99
n The laser light emitted by DIAGNOdent is absorbed by both inorganic
and organic components in the tooth. Some of this light is re-emitted as
near infra-red fluorecent light.
n A high-pass filter removes reflected light and ambient light (from daylight
and operatory lighting), such that only near infrared light (>680 nm) will
pass
n The fluorecent light increases when the carious process progresses into
the tooth substance.
n This allows to detect caries by fluorescence intensity which is analyzed
and quantified (Hibst and Gall, 1998).
5 – 25 – initial lesion in enamel
25 – 35 – initial lesion in dentin
>35 – advanced lesion
n The fluorescent molecules responsible for the increase of fluorescence
in carious tissue seem to be porphyrins, mainly proto-porphyrin IX.
These porphyrins could be synthesized as metabolic by-products by
several microorganisms in carious lesions.

n As well as the DIAGNOdent “Classic” system, the DIAGNOdent Pen and

the In:Ga:As:P diode laser part of the KEY3 system (KaVo, Biberach,
Germany) also use the same LF diagnostic approach and use identical
laser illuminators, detectors, and processing software.
n Lussi et al., later reported the use of a modified sapphire tip with the
DIAGNOdent, for detection of proximal caries.

n Sainsbury has reported that the DIAGNOdent system could be

adapted for the detection of bacteria in the pulp chamber and
root canal.

n He identified that healthy dental pulp soft tissues and healthy dentine
give minimal infrared emissions, whilst strong emissions occurred
from canals which had been infected with bacteria either in vivo or in
vitro.

n Recently modified tips with a honeycomb fiber design had been

reported by R.George and Walsh (REF). This honey comb fiber is
expected to be better for detection of fluorescence within the root
canal when compared to a conical tip, because it emits and collects
light from both lateral and forward directions .
 Poor
Caliberation

Degradation of
optical path due to
autoclaving the tip Probe tip
or optical fiber angulation

contamination
of optical path
due to debris
on tip Interference
of ambient
light

Filling
material Moisture,
interference saliva
interference

Calculus, plaque, stain

interference
Quantitative Light induced fluorescence
n QLF device (Folke Sundstrom, ) used for diagnostic purposes in
monitoring dental caries, bacterial activity, stains, plaque, calculus and
mineral content of teeth including white spot lesions; for either dental
researches or clinical applications.
n when illuminating teeth with a specific light spectrum in the blue
region, teeth gave off a green fluorescence, based on this notification,
QLF was built since sound teeth produced green fluorescent light also
carious lesions gave less intense green fluorescence because carious
lesion structure scattered the absorbed light more often than sound
teeth structure which giving what was so called autofluorescence
image of teeth.
n xenon arc-lamp- IO mirror-CCD Camera- Computer
n cannot detect secondary caries
Optical Coherence Tomography
n Optical coherence tomography is an imaging technique that is capable of
two-dimensional or three-dimensional images of subsurface tissue.
n OCT is based on confocal microscopy and low coherence
interferometry.
n OCT a tool for noninvasive evaluation of tissue microstructure by
providing high spatial resolution 10–20 m and real-time, two dimensional
depth visualization. The principle of OCT is similar to B-mode ultrasound
imaging, except that OCT uses near infrared NIR light instead of sound.
n Near-infrared light penetrates deeply into tissue, making it useful for
imaging of internal structure.
n The majority of the light, however, is highly scattered as it penetrates into
the tissue. These scattered photons dominate in most imaging
applications, leading to blurred images.
n By using a white light Michelson interferometer as a gate, OCT detects
only the unscattered "ballistic" photons and is thus able to generate high
resolution images. In addition, heterodyning techniques are used to detect
very low levels of reflected light from the tissue.
n Laser light -1310 nm.It is able to detect carious lesions in the enamel,
hidden lesions in occlusal surfaces and to produce an image that shows
Caries prevention with laser energy

n Mechanism two folds:

n Specific effects of irradiation interacting with dental hard tissue.

n ON ENAMEL: increased Ca/P , more uniformly roughened,
high degree of acid resistance hence more caries resistant

n Efficient conversion of light to heat resulting in increased

resistance of tooth material to dissolution by acid.

n Fried et al reported CO2 laser removing carious lesion & inhibiting

caries progression
Cavity preparation using lasers
n CO2 laser
n ArF Excimer laser
n Nd:YAG
n Er lasers
n First in vivo application Goldman, 1965 a pulsed ruby laser used
n Use rubber dam or metal matrix to protect adjacent tooth.
n Disposable or reusable cutting tips of various diameters
n Used in contact or non contact position on the tissue.-If patient is
uncomfortable during the procedure - decrease the hertz, energy, and
move the cutting tip from the contact mode, to a non-contact mode.
n Direct water stream to the target tissue-Always keep operation area wet
n Always keep tip moving to provide effective ablation and better cooling
n For wide cut, constantly move tip over the surface.
n For deep cut , constantly move tip up and down (pumping)
n Ablating and preparing an irregular cavity - Ideal for placement of
composite or glass ionomer restoration

n RECOMMENDED SETTING FOR THE Er : YAG laser are as follows

ENERGY (Mj) PULSE / SEC (Hz)
Caries 100-200 10
Enamel 200-250 15
Dentin 150-200 10
Etching 30-50 15
The lasers have FDA clearance to do the following:
n Remove caries
n Remove enamel
n Remove dentin
n Remove cement
n Remove composite
n Remove glass ionomer
n Ablate soft tissue with no hemostasis
Laser etching
n More effective than acid etching

n CO2 laser
n XeCl Excimer
n Hydrogen fluoride laser
n Er:YAG in defocused mode

n Bubble like inclusions produced on enamel surface

n Featherstone , surface melt layer increase bond strength of composite

by 300%.

n Shiriati et al., lasing before placing composite on GIC increases bond

strength
Polymerization of composite resins
n One of FDA approved restorative application

n Ar laser common

n Advantages( Kelsey ):

n Increased compressive, tensile, transverse flexural strength &

improved flexural modules
n More with microfilled than hybrid
n More homogenous resin
n Restorations more resistant to deformation
n Exposure time 25% of VLC, i.e. 10 sec
n Reduced polymerization shrinkage
n Reduced post op sensitivity
Laser tooth whitening

n Officially started in 1996 with the approval of Ion Laser Technology

n Ar & Co2 laser with patented chemicals
n Isolation & protection of soft tissue
n Initial Ar followed by CO2 laser ---- KTP laser
Lower Level Laser Therapy:
n Therapeutic laser treatment, also referred to as low-level laser
therapy (LLLT), offers numerous benefits. Along with the primary
benefit of being nonsurgical, it promotes tissue healing and reduces
edema, inflammation and pain.
n Smaller less expensive & operate in milliwatt range, 1-500 milliwatts.
n ‘Soft lasers’, ‘Low Intensity Level Lasers’
n Therapy being called ‘Biostimulation’ or ‘Biomodulation’
n Visible & infrared spectrum ( 600- 900 nm )
n HeNe (Helium-Neon) laser,CO2 laser ( 10600nm) & Nd:YAG
(1064nm), GaAlAs (gallium-aluminum-arsenide; 780–890 nm),
InGaAlP (indium-gallium-aluminium-phosphide; 630–700 nm) diode
n lasers being used successfully.
n The principle of using LLLT is to supply direct biostimulative light
energy to the bodys cells. Cellular photoreceptors (eg, cytochrome c
oxidase) can absorb low-level laser light and pass it on to mitochondria,
which promptly produce the cells fuel, ATP and resulted in increased cell
activity , angiogenesis & collagen synthesis and change in inflammatory
mediators level
n Enhanced synthesis of endorphin, decreased c-fiber activity, bradykinin,
and altered pain threshold

n Treatment of pain, wound healing & inflammation

n Dentinal hypersensitivity
n Herpes simplex
n Mucositis
n Pain
n Paresthesia
n Sinusitis
n TMD
n Tinnitus / vertigo
n Trigeminal neuralgia
n Apthae
Laser effects on Dental Hard Tissues :
ON ENAMEL: increased Ca/P , more uniformly roughened, high degree
of acid resistance hence more caries resistant

CO2 Laser
n Micro-cracks, necrosis & carbonization unavoidable
n Steam & vapor cause cracks in enamel & dentin
n Drying causes the increase in micro hardness of dentin
n Fusion of apatite crystals to a glaze like material( tricalcium phosphate)

Er:YAG Laser

n 1-3mm zone of necrosis in dentin with water cooling

n Deeper cavities, areas of carbonization & microcracks
n Ablating enamel always cracks & deep zones of debris

Er:YSSG Laser
n Er:YAG >> Er: YSSG
 Ho:YAG & Tm:YAG lasers
n Without cooling intensive carbonization
n Zones of necrosis & some microcracks below the carbonized surface

Nd:YAG lasers
n Low absorption in water, therefore the laser power diffuses deeply
through the enamel and dentin and finally heats the pulp
n In dentin zones of debris and carbonization are surrounded by all areas
of necrosis even, when low pulse energies are used
n Micro cracks appear when energies above a threshold of 100 mJ pulse
are used.

Excimer lasers
n No pathologic changes after the ablation of dental tissue with 193 nm
ArF Excimer lasers
n The ablation effects of dental hard tissues are predictable.

ON PULP: produce more heat on pulp Continuous wave>> pulsed CO2

Hazards :
n Environmental hazards
n Combustion hazards
n Electrical hazards

Environmental hazards
n Potential inhallation of airborn biohazardous materials in the form of
smoke or plume
n Toxic dyes & solvents
n Greatest producers of smoke – CO2 ,Er, Nd:YAG

Combustion hazards
n Flammable solids ( cloths, paper, plastics)
n Gases (O2, N2)

Electrical hazards
n Electrical shock
n Electrical fire
n Explosion
Measures to control hazards:
n ANSI & OSHA – 4 categories:

n Engineering control
n Personal protective equipment
n Administrative & procedural control
n Environmental control

Engineering control

n Protective housing
n Interlocks
n Beam enclosures
n Shutters
n Service panels
n Equipment labels
n Warning system
n Key switch
 Personal protective equipment
n Eye wear
n Clothing
n Surgical masks
n Screens & curtains

Administrative & procedural control

n Laser safety office
n Standard operating procedures
n Output limitations
n Training & education
n Thorough knowledge of laser operation
Environmental control

n Proper ventilation
n High volume evacuation
n Recirculating air filtration system
n Adequate suction
n Changing filters of evacuating system
n Laser filtration masks
n Caps & gowns
Conclusion
n As with any clinical procedure, before treatment is initiated, the
dentist must make a correct diagnosis and outline a treatment plan
that addresses the patient’s needs .
n Generally, a specific laser device is maximized for diagnosis or for
use in soft or hard tissues. It is common to find lasers that are good
for use in soft tissues with some hard tissue applications.
n Especially its improved disinfection efficacy, more effective root
canal cleaning, reduction of permeability, reduction of micro-
leakage, and elimination of the need to use toxic solvents represent
the main advantages for patients and dentists.