255

Intrapulpal Temperatures During

Pulsed Nd:YAG Laser Treatment
of Dentin, In Vitro
Joel M. White, * Mark C. Fagan,f and Harold E. Goodis*

Lasers are being used for soft tissue removal, caries removal, and treatment of
root surface sensitivity. One concern for laser safety is that the heat produced at the
irradiated root surface may diffuse to the pulp causing irreversible pulpal damage. To
test this heat diffusion, copper-constantan thermocouples were inserted into the radicular
pulp canals of extracted teeth. Simulating direct exposure which might occur during
gingival excision, superficial caries removal, and modification of the dentin surface for
treatment of root surface sensitivity, a 2 mm2 area of the external root surface was
uniformly irradiated with a pulsed Nd:YAG laser using a 320 µ diameter fiber optic
contact probe. Power was varied from 0.3 to 3.0 W with frequencies of 10 and 20 Hz.
Temperature changes during cavity preparations using a high speed handpiece with air
coolant were also recorded. Repeated measures ANOVA ( <0.05) indicated that intra-
pulpal temperatures increased as a function of power, frequency, and time. Intrapulpal
temperatures decreased as remaining dentin thickness (0.2 to 2.0 mm) increased for each
laser parameter. Irradiation of dentin using a Nd:YAG pulsed laser, within the treatment
times, powers, and frequencies with adequate remaining dentin thickness, as outlined in
this paper, should not cause devitalizing intrapulpal temperature rises. J Periodontol
1994;65:255-259.

Key Words: Laser therapy; lasers; dental pulp disease/etiology; heat/adverse effects.

Laser systems are currently being investigated for a variety
of applications in dentistry. These procedures include caries
removal,1,2 periodontal pocket reduction,3 reduction of root
surface sensitivity, excision of neoplastic tissue,4 excision
of gingival hyperplastic tissue,5 and as an adjunct in root
canal therapy.6,7 The effect of laser radiation on target tis-
sue is largely dependent upon the wavelength of the laser
and the characteristic absorption of the particular tissue.8
Other laser parameters contributing to the effect on the amount
of energy emitted to a surface are power (watts), exposure
duration (seconds), pulsed versus continuous wave, and en-
ergy density (Joules/cm2). As a laser beam strikes a tissue
surface, the light energy can be effected in three ways:
reflected, transmitted, or absorbed.9 Of the three, the changes
in tissues are largely due to the absorbed energy which is
a thermal process.
If the magnitude of absorbed radiation is high, regardless
of the type of oral tissue, the temperature rise from such
an interaction can heat tissue to its vaporization state, thus
causing complete ablation of the absorbing surface.4 As
"Department of Restorative Dentistry, University of California, San Fran-
cisco, CA.
'Department of Stomatology.
laser radiation intensity and subsequent surface temperature
of dentin increases, it is possible to melt the hydroxyapatite
structure which, upon cooling, can resolidify forming hy-
droxyapatite crystals larger than the initial structure.10 In-
vestigations into this recrystallization of dentin have shown
that a glazed, non-porous surface can be produced which
may partially or totally obliterate dentinal tubules.6,7,10 Since
the blocking of dentinal tubules has been implicated in treating
dentinal sensitivity by theoretically decreasing hydraulic
conductance,11 investigators have logically proposed the use
of lasers in dentinal sensitivity therapy.
Because the interaction of the laser with tooth surfaces
liberates heat, investigations into the diffusion of heat across
dentin and its effect on pulpal tissue are particularly im-
portant. Historically, intrapulpal tissue damage caused by
temperature increases have been based primarily on the in
vivo work of Zach and Cohen.12,13 Their experimental method
used continuously applied heat by a hot soldering iron to
the crowns of monkey teeth for a length of time which
increased intrapulpal temperatures. They described demon-
strable but reversible histological pulpal changes with tem-
perature increases of 3.3°C. As temperatures increased to
5.6°C loss of vitality in 15% of test teeth was seen.
Using histologie methods, attempts have been made to
 J Periodontol
256 INTRAPULPAL TEMPERATURE DURING PULSED ND:YAG March 1994

define laser induced pulpal damage as a function of the Table 1. Nd:YAG Laser Parameters Used on Dentin (energy per
pulse =
mj/pulse, mj =
millijoules, s =
second)
energy density (Joules/cm2) from the direct exposure on
dentin and enamel surfaces in vivo.1417 Direct measure- Watts (W) Hertz (Hz) mj/pulse
ments of intrapulpal temperature changes in vitro induced 0.3 10 30
by laser irradiation have also been determined.18 21 Due to 0.5 10 50
the recent advances in laser technology, particularly pulsed 0.7 10 70
fiberoptic delivery, results of these earlier investigations are 1.0 10 100
limited because they must be interpreted independently and 1.0 20 50
categorized by the specific laser parameters and delivery 2.0 20 100
system used. Additionally, the methodologies used did not 2.5 20 125
address remaining dentin thickness, an important parameter
3.0 20 150
of heat conduction.
The purpose of this investigation was to quantify the
intrapulpal temperature changes following pulsed Nd:YAG
laser irradiation of different thickness of dentin. The data and 0.2 (±/ 20%) were determined using a measur-
mm
are necessary to determine those energy levels which the ing microscope (20 x ) with a digital recorder.11 The radio-
—

Nd:YAG laser can be used safely in soft tissue, superficial graphic measurements determined the placement of the
caries removal, and dentin sensitivity applications. thermocouples. Remaining dentin thickness was further
verified, after testing, by direct measurement of the teeth.
MATERIALS AND METHODS

Tooth Preparation Temperature Measurements

Extracted single-rooted teeth were scaled to remove all root
surface debris and stored in an aqueous 0.2% thymol so-
lution until used. Teeth were chosen for their straight root
morphology which facilitated uniform root canal shaping
for placement of thermocouples. The root canals were shaped
to a diameter slightly larger than the thermocouple.
Throughout, the root canals were irrigated copiously with
5.2% sodium hypochlorite and a final rinse of 0.5 M EDTA
(pH 7.4) was used to remove the smear layer created during
canal preparation.
To obtain a uniform outer root surface, the buccal and
lingual root surfaces were ground using a heatless wheel
stone and planed flat with #600 grit sand paper. This pro-
cedure removed at least 0.5 mm in depth of the root surface
to assure complete removal of root cementum. Finally, the
smear layer created during outer root surface preparation
was removed by rinsing with a 0.5 M EDTA (pH 7.4)
solution for 2 minutes.
In order to maximize temperature transference between
the thermocouple and the dentinal wall, the canals of the
teeth were filled with a thermal conducting paste.*
Dentin Thickness Measurements
Radiographs of the teeth, with the flat outer surfaces per-
pendicular to type E radiographie film,8 were taken using
a long cone paralleling technique. The teeth were placed
directly on the film to control magnification error. A Wil-
liams periodontal probe with 1 mm gradations was placed
next to the teeth to verify absence of magnification error.
Remaining dentin thicknesses (RDT) of 2.0, 1.5, 1.0, 0.5,
*Omegatherm 201, Omega Engineering, Inc., Stamford, CT.
5Eastman Kodak, Rochester, NY.
Test teeth with copper-constantan thermocouples,1 inserted
in the root canal space to the desired RDT, were placed
horizontally into a 37°C water bath with the dentin surface
to be exposed to laser energy above the water level. The
thermocouples were attached to a flat bed recorder.11 A pulsed
Nd:YAG laser,* with emission wavelength of 1064 nm, a
pulse duration of 150 microseconds, and 320 µ diameter
fiber optic contact probe was used on the root surfaces. The
probe was continuously moved in both mesial-distal and
apical-coronal directions, uniformly covering a 2 mm2 (1
mm 2 mm) area for 30 seconds.
A total of 8 laser parameter combinations (Table 1) were
used, ranging from a low energy of 0.3W, 10 Hz to the
highest energy of 3W, 20 Hz, producing energy densities
between 37.5-187.5 J/cm2. Each laser parameter was re-
peated 3 times using a different tooth for each repetition.
A total of 120 teeth were used. Temperature rises (°C) at
10, 15, and 30 second intervals were collected.
Pulpal temperature measurements were also taken in teeth
during cavity preparation with a high speed handpiece and
air coolant. Using a 557 carbide bur, preparations were cut
into the dentin of three teeth ranging from 0.65 to 1.0 mm
± 0.2 mm of the pulp for a time of 20 seconds.
Statistics
Repeated measures ANOVA ( <0.05) statistical analysis
of the data was performed in order to determine the effects
of independent variables (RDT, power, frequency, time) on
pulpal temperature rise.
'Gaentner Scientific Corp., Chicago, IL.
"Linseis Inc., Princeton, NJ.
'Sunrise Technologies, Fremont, CA.
 Volume 65
Number 3 WHITE, FAGAN, GOODIS 257

Table 2. Pulpal Temperature Rise with 0.2 mm Remaining Dentin Table 3. Pulpal Temperature Rise with 2.0 mm Remaining Dentin
Thickness (Hz = frequency, mj/pulse = energy per pulse) Thickness (Hz = frequency, mj/pulse = energy per pulse)

Watt Hz mJ/pulse Time (s) Temp Rise (°C ± S.D) Watt Hz mJ/pulse Time (s) Temp RiseA (°C ± S.D.)
0.3 10 30 10 9.3 ±3.0 0.3 10 30 10 1.1 ±0.1
15 12.8 ±3.7 15 1.5 ±0.3
30 17.1 ±3.4 30 2.2 ±0.4
0.5 10 50 10 20.2 ±4.4 0.5 10 50 10 2.1 ±0.6
15 22.5 ±3.3 15 2.8 ±0.9
30 27.9 ±4.7 30 4.3 ±1.1
0.7 10 70 10 25.7 ±4.5 0.7 10 70 10 2.8 ±0.9
15 31.7±5.2 15 4.0±1.3
30 43.2 ±10.3 30 5.8±0.8
1.0 10 100 10 1.0 10 100 10 4.0±1.6
15 15 5.3±1.8
30 30 7.7 ±2.4
1.0 20 50 10 1.0 20 50 10 4.3±1.4
15 15 5.8±1.4
30 30 8.4 ±2.3
2.0 20 100 10 2.0 20 100 10 13.4 ±2.5
15 15 18.3±4.3
30 30 27.5 ±5.9
2.5 20 125 10 2.5 20 125 10 13.0±7.1
15 15 16.4±7.9
30 30 21.3±15.2
3.0 20 150 10 3.0 20 150 10 11.2 ±7.5
15 15 15.0±8.9
30 30 22.9 ±10.7

RESULTS a function of RDT, time of exposure, and laser parameter.

The intrapulpal temperature increases for each laser param- In all cases, regardless of laser power or repetition rate,
eter at 0.2 mm and 1.0 mm RDT are given in Tables 2 and when RDT increased the pulpal temperature was less with
3. These represent the minimum and maximum RDT in- lowest temperatures recorded at 2.0 mm RDT. When RDT
vestigated. Some of the test conditions, especially as RDT was less then 1.0 mm, the pulpal temperature rise was more
decreased, resulted in temperature rises greater than 50°C pronounced. As power and repetition rate increased the pul-
which were not recorded (N). Above this level there was pal temperature rise also increased. As exposure time in-
carbonization and charring of the dentin surface. Generally, creased the pulpal temperature rise also increased (Figs. 2,
as laser power increased the variation in the temperature 3, and 4). Temperature results at each dentin thickness
rise also increased. These variations occurred because there grouped by time interval (10, 15, 30 seconds) showed sig-
was an observed ablation of the root surface resulting in nificant differences (P <0.01) with the mean pooled effect
difficulty in maintaining a constant dentin thickness be- for 10 Hz and 20 Hz being 8.4 and 10.5°C, respectively.
tween the laser and the thermocouple.
The fastest rate of temperature rise occurred during the Temperature Rise (Celsius)
initial laser exposure at times less than 10 seconds. The
temperature continually increased throughout the 30-second
test time and did not reach steady state. When the laser and
drill were removed from the tooth, the pulpal temperature
decreased and returned to baseline temperatures.
For the drill, the mean temperature increase at the 10-
second interval was 1.2±2.1°C, at 15 seconds the mean
was 3.3 ± 1.6°C, and at 20 seconds the mean was 4.7 ± 2.3°C.
The standard deviation found for the drill samples may be
a result of the difficulty in achieving a uniform RDT during -¡-,-1
cavity preparation. Statistical analysis comparing these re- 5 10 '15 20 25 30 35
sults to the laser found no significant difference (P <0.05) Time (sec)
between the drill and the 0.3, 0.5, and 0.7 W (10 Hz) laser Figure 1. Pulpal temperature rise comparing air cooled drill to laser
parameters (Fig. 1). power at 10 Hz and 1 mm RDT (mean and standard error).
Figures 2, 3, and 4 show the pulpal temperature rise as -m- drill -*- 0.3W, 10Hz 0.5W, 10Hz -±- 0.7W, 10Hz -e^l.OW, WHz
 J Periodontol
258 INTRAPULPAL TEMPERATURE DURING PULSED ND:YAG March 1994

0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 2.2 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 2.2
Remaining Dentin Thickness (mm) Remaining DentinThickness (mm)

Figure 2. Pulpal temperature rise at 10 seconds as a function of Nd:YAG Figure 4. Pulpal temperature rise at 30 seconds as a function of Nd.YAG
laser parameters and remaining dentin thickness (W watts, Hz
= = laser parameters and remaining dentin thickness (W watts, Hz =

frequency) [mean and standard error]. frequency) [mean and standard error].
—

-x- 0.3W, 10Hz -A- 0.5W, 10Hz -x- 0.3W, 10Hz 0.5W, 10Hz
-+-0.7W, 10Hz -e-l.OW, 10Hz -w-l.OW, 20Hz -+-0.7W, 10Hz -ß-LOW, 10Hz - -l.OVV, 20Hz
-*-2.0W,20Hz -m-2.5W,20Hz -#- 3.0W, 20Hz -K-2.0W, 20Hz -m-2.5W,20Hz -#- 3.0W, 20Hz

These data showed that increasing the repetition rate, pulses
per second (Hz), increased the intrapulpal temperature rise.
DISCUSSION
It is possible that accidental or intentional exposure of den-
tin surfaces to laser energy may cause pulpal damage if
temperature rise is sufficiently high. Zach and Cohen13 re-
port pulpal temperature rises of 5.6°C caused loss of pulpal
vitality in 15% of the teeth tested. Temperature rises in
excess of this value are unacceptable due to the potential
for loss of pulpal vitality. The data from this study indicate
that laser-induced temperature rises may damage pulpal tis-
sues when RDT is less than 1 mm. The temperatures de-
termined in this study using the pulsed fiberoptic delivered
Nd:YAG laser at low power, repetition rates, and exposure
heat.13,22'23 As power, repetition rates, and exposure times
increase, the pulpal temperature rise also increases to levels
which may cause detrimental pulpal effects. RDT is an
insulator of heat applied to the surface of teeth.24 This study
demonstrates there is not a significant pulpal risk due to
temperature rise when a 2 mm2 dentinal surface is exposed
to a pulsed NdrYAG laser for less than 10 seconds when 1
mm of remaining dentin is present and laser parameters do
not exceed 1.0 W and 10 Hz. Since one cannot directly
measure the remaining dentin thickness in vivo, it is im-
portant that the operator choose laser parameters below these
safety limits. The operator must judge the dentin thickness
and adjust the laser settings based on clinical experience
and other factors such as the presence of attrition, abrasion,
or erosion on the root surface. Other reasons for adjusting

times are similar to other dental procedures which produce energy may be the overall size of the tooth and the area to
be treated. If the area is different or the treatment time
váries from those used in this study, the laser parameters
Temperature Rise (Celsius) should be adjusted accordingly. Similarly, if the Nd:YAG
beam is de-focused, emitted energies could probably be
40 slightly increased due to the decreased energy density on
the root surface.
Launay et al.25 reported that the C02 laser increased sur-
face and intra-pulpal temperature more than the NdrYAG
laser, but did not account for RDT. In a similar study,
which accounted for RDT, the C02 laser had high intra-
pulpal temperatures with adverse dentin surface changes.26
Zach and Cohen12'13 used an experimental model that uti-
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 2.2
lized a soldering iron tip placed against the teeth which
Remaining Dentin Thickness (mm)
varied by as much as 122°F (50°C). This is a large surface
Figure 3. Pulpal temperature rise at 15 seconds as a function of Nd:YAG temperature variation when trying to quantify temperatures
laser parameters and remaining dentin thickness (W watts, Hz
= =
diffusing across a material in a given time and it would be
frequency) [mean and standard error]. ideal to have greater control over the surface temperature.
- - 0.3W, 10Hz 0.5W, 10Hz With laser energy, it is possible to emit a precise, constant
-+-0.7W, 10Hz -&-1.0W, 10Hz - -l.OW, 20Hz energy to a given surface and the work of Zach and Cohen
-m-Z0W, 20Hz -m-2.5W,20Hz -#- 3.0W, 20Hz has been repeated using Nd:YAG laser applied energy.27
 Volume 65
Number 3
Although the surface temperatures achieved with laser ex-
posure much higher than the soldering iron, the thermal
are
penetration depth is much lower due to the smaller surface
area and pulsed delivery of the laser as compared to the
large area and continuous exposure of the soldering iron
tip.
The energy transmitted through the dentin and absorbed
by the thermocouple may have increased recorded temper-
atures in our study. This study employed a shield of the
thermocouple to minimize this effect. While it is recognized
that a limitation of this study is the thermocouple, the data
reported are the maximum thermal measurements possible
in an in vitro system. In vivo intrapulpal temperature rises
of an accidental exposure of dentin during soft tissue laser
excision or intentional exposure for the treatment of dentin
sensitivity may be lower due to an intact periodontal liga-
ment, bone, and pulpal circulation all of which may reduce
temperature effects. The experimental design of this study
included straight, single-rooted teeth. The pulpal tempera-
ture rises that would be seen in multiple rooted teeth (bi-
cuspids and molars) would be expected to be less due to
the increase in mass of the tooth structure.
Clinical investigations are needed to determine the ef-
fectiveness of the Nd:YAG laser for the treatment of root
surface sensitivity. These investigations should include de-
termination of pulpal vitality before and after laser expo-
sure. If during cutting and coagulation of intraoral soft tis-
sue using the Nd:YAG laser, the dental practitioner suspects
accidental exposure of the root surface, the surface must be
examined and pulpal vitality tests carried out to evaluate
the accidental exposure.
The results of this study demonstrate that pulsed fiber-
optic delivered Nd:YAG laser energy applied to root sur-
faces, when used within the parameters described here, should
not cause irreversible damage to the pulp from heat diffusion.
Acknowledgments
The authors wish to thank Drs. Gary Armitage and E. Jack
Taggart for their support and advice. We recognize the
contributions of Larry Watanabe for temperature measure-
ment design, Kim Tran and Paul Lancour for data entry
and graphics, and Marianne Ashton for formatting the man-
uscript. This work was supported by NIH/NIDR grant R29
DE09941. The Nd:YAG laser used in this study was pro-
vided, through a research agreement, by Sunrise Technol-
ogies, Inc, Fremont, CA.
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Send reprint requests to: Dr. Joel M. White, UCSF, D-3252, Box 0758,
San Francisco, CA 94143.
Accepted for publication September 14, 1993.