Lasers Med Sci
DOI 10.1007/s10103-013-1321-6
ORIGINAL ARTICLE
Effects of Er:YAG and Er,Cr:YSGG laser irradiation
on the adhesion to eroded dentin
Thaysa Monteiro Ramos & Thayanne Monteiro Ramos-Oliveira &
Patricia Moreira de Freitas & Nilton Azambuja Jr &
Marcella Esteves-Oliveira & Norbert Gutknecht &
Carlos de Paula Eduardo
Received: 2 July 2012 / Accepted: 15 April 2013
# Springer-Verlag London 2013
Abstract Limited information is available regarding the ad-
hesion to eroded dentin. This study aims to evaluate the effect
of different surface treatments on eroded dentin morphology
and on microtensile bond strength (μTBS) of adhesive sys-
tems to this substrate. Ninety-six extracted third molars were
randomly divided into eight groups (n=12) according to the
type of surface treatment and the adhesive system: G1=
Control+Clearfil SE Bond [SE], G2=Diamond bur [DB]+
SE, G3=Er:YAG laser (60 mJ, 2 Hz, 0.12 W, 19.3 J/cm2)+
SE, G4=Er,Cr:YSGG laser (50 mJ, 30 Hz, 1.5 W, 4.5 J/
cm2)+SE, G5=Control+Single Bond [SB], G6=DB+SB,
G7=Er:YAG+SB, G8=Er,Cr:YSGG+SB. The erosive cy-
cling was performed by immersion in 0.05 M citric acid (pH
2.3, 10 min, 6x/day) and in supersaturated solution (pH 7.0,
1 h, between acid attacks), during 5 days. Blocks of composite
were bonded to the samples according to the manufacturers'
instructions. After 24 h-storage in distilled/deionized water
(37 °C), stick-shaped samples were obtained and submitted
to μTBS test. Each surface treatment was analyzed under
scanning electron microscopy (n=4) and the bond strength
values (megapascal) were analyzed by two-way ANOVA and
Tukey tests (α=0.05). All surface treatments lead to changes
T. M. Ramos (*) : T. M. Ramos-Oliveira : P. M. de Freitas :
N. Azambuja Jr : C. de Paula Eduardo
Special Laboratory of Lasers in Dentistry (LELO),
Department of Restorative Dentistry, School of Dentistry,
University of São Paulo (USP), Av. Prof. Lineu Prestes,
2227—Cidade Universitária,
05508-000 São Paulo, SP, Brazil
e-mail: thaysamramos@hotmail.com
M. Esteves-Oliveira : N. Gutknecht
Department of Operative Dentistry, Periodontology and Preventive
Dentistry (ZPP), RWTH Aachen University, Pauwelsstr. 30,
52074 Aachen, Germany
on eroded dentin. G4 showed the highest bond strength mean
(28.3±9.2 MPa), which was statistically significant higher
than all the other groups (p<0.05). The surface treatment with
Er,Cr:YSGG laser irradiation (4.5 J/cm2/50 mJ/30 Hz/140 μs)
prior to bonding with a self-etching adhesive system signifi-
cantly increases adhesion to eroded dentin, as compared to
conventional treatment.
Keywords Dentin . Erosion . Microtensile bond strength .
Er:YAG laser . Er,Cr:YSGG laser . SEM
Introduction
In the last decade, the improvement in life quality and
longevity, and the consequent longer maintenance of the
teeth in the oral cavity, significantly increased the preva-
lence and severity of tooth wear in the world population. In
addition to that, the combination of factors—such as higher
consumption of acidic foods, stress facing the increased
requirements of the labor market and the presence of psycho-
somatic eating disorders and gastro-esophageal—transformed
dental erosion in a disorder of great concern to dentists [1] and
also in an important and increasing issue worldwide addressed
by the researchers [2].
Defined as a localized, chronic, irreversible, and patho-
logical loss of dental hard tissue due to chemical mecha-
nisms that dissolve the mineralized portion of the tooth,
dental erosion does not involve acids derived from oral
bacteria, such as the dental caries, but, chelating substances
and acids derived from the diet, medication and occupation-
al intrinsic sources [3–5]. Thus, it has a complex and mul-
tifactorial etiology with interplay between several chemical,
biological, and behavioral factors [5, 6].

When the erosive wear is at an advanced level with involve-
ment of the dentin of the tooth's structural integrity and
compromising the aesthetics, it is necessary to perform a restor-
ative treatment [5, 7] to reduce thermal sensitivity, prevent pulpal
involvement, abrasion by toothpastes, further acid erosion, food
impaction, discomfort of the tongue and cheeks, and especially
to restore the aesthetics and increase the tooth resistance [8, 9].
With the development of adhesive systems and within the
concepts of minimally invasive restorative treatment [10],
the direct composite restorations are conservative proce-
dures that can rehabilitate teeth affected by erosion [7] and
must provide enough bond strength to the tooth to support
the incident forces at oral environment.
High power lasers have been introduced in dentistry as an
alternative to carry out cavity preparations and to promote
chemical/morphological changes on the tooth surface.
Erbium lasers (Er:YAG and Er,Cr:YSGG) have been con-
sidered the most promising lasers to be used on mineralized
tissues because both wavelengths show high absorption by
water and hydroxyapatite. These lasers act at the dental hard
tissue through explosive “thermo-mechanical” ablation. In
this mechanism, the water molecules contained between the
hydroxyapatite crystals absorbs the incident radiation and
the water vaporization results in increased internal pressure
and microexplosions leading to a substrate ejection in the
form of inorganic particles and to a precise irradiated tissue
removal [11–14]. Studies have evaluated the effect of erbi-
um lasers in surface morphology of dentin, and they have
shown an irregular appearance, without smear layer, with
open dentinal tubules and prominent peritubular dentin,
with a microretentive morphological pattern possibly favor-
able to bonding procedures [15–18].
However, contradictory findings about the effectiveness
of adhesion to previously irradiated substrate have also been
reported in the scientific literature, probably due to lack of
standardization of the studies and different parameters,
methodologies, substrates, and adhesives. Some studies
show a reduction in bond strength of resin to dentin because
depending on the energy density used, the thermo-
mechanical effects of the laser may cause denaturation of
the collagen fibrils [19, 20], lead to the formation of
microcracks [21, 22] and of an acid-resistant surface with
granular structures. Also, some authors reported a carbon-
ized or melted surface that has possibly impaired the adhe-
sive system infiltration and hybrid layer formation and lead
to lower tensile bond strength [20, 23–25].
Dental erosion involves complex histological changes in
the dentin. The continuous exposure to acids results in a
fully demineralized outer surface, followed by a partially
demineralized dentin zone, until an internal, sound layer and
not affected by the acid, is reached [5, 26, 27].
Different surface treatments create different substrates to
be restored. In adhesive dentistry, the effectiveness of
Lasers Med Sci
adhesive systems depends largely on the characteristics of
the prepared tooth surface [28, 29]. Although there are studies
with the use of lasers for the dentin treatment prior to adhesive
procedures, until now, there are no reports about adhesion to
eroded substrate, following the pretreatment of the dentin
surface with high power lasers. It is thus of great clinical
relevance to study the bond strength and surface morphology
of the dentin subjected to erosive challenge and irradiated with
Er:YAG or Er,Cr:YSGG lasers before the restorative proce-
dure, since it may indicate the adhesive system and surface
treatment best suited to the eroded dentin.
The aim of this in vitro study was to evaluate the effect of
different surface treatments (diamond bur, Er:YAG and
Er,Cr:YSGG laser irradiation) on eroded dentin morphology
and the microtensile bond strength (μTBS) of adhesive
systems to this treated substrate.
Material and methods
Ethical aspects
This study was approved by the Research Ethics Committee
of the School of Dentistry of the University of São Paulo
(CEP-FOUSP No. 41/11) and by the National Committee of
Ethics in Research (CONEP—Protocol No. 452/2011).
Samples preparation
One hundred and four freshly extracted human third molars
were stored in 0.5 % chloramine solution at 4 °C until the
beginning of the experiment. They were hand scaled and
cleaned with pumice slurry. Eight teeth were used for scan-
ning electron microscopy (SEM) analysis of the dentin
surface and the remaining teeth (96) were destined for the
microtensile bond test.
The oclusal enamel was removed with a low-speed dia-
mond saw (Isomet, Buehler Ltd., IL, USA) and the exposed
superficial dentin surfaces were submitted to polishing
(Ecomet 3—Buehler Ltd, Lake Buff, IL, EUA) with wet #
120, 240, 400, and 600-grit silicon carbide sandpaper discs
for 60 s each to remove remaining enamel, to plane the
surface, and to create a standardized smear layer.
To ensure the standardization of the exposed dentin
surface, in which the surface treatments were performed,
an area was delimitated using a small square piece of
adhesive tape of approximately 5 × 5 mm, which was
attached to the dentin's surface. The sample was complete-
ly coated with an acid-resistant varnish, and after drying,
the adhesive tape was removed using a scalpel, and the
surface was cleaned with wet cotton in distilled/deionized
water to remove any remnants.
Lasers Med Sci
Erosive cycling
This study used an in vitro cyclic re- and demineralization
model of erosion, proposed by Ganss et al. [30]. The sam-
ples were mounted side-by-side in wax (Epoxiglass, São
Paulo, Brazil) on a flat plastic, and they were transposed
to the different solutions to ensure constant immersion
times. The erosive pH cycling was performed during 5 days
by immersion in 0.05 M citric acid (pH 2.3, 10 min,
6×/day). Between acid attacks, the specimens were im-
mersed for 60 min in supersaturated solution (pH 7.0)
consisting of 1.5 mmol/L CaCl2, 1.0 mmol/L KH2PO4,
and 50 mmol/L NaCl [31], at room temperature (25 °C),
under constant agitation (30 rpm) on a shaker. During the
remaining time of the erosive cycling, the specimens also
were stored in supersaturated solution until the beginning of
the experiment at the following day. The solutions were
renewed everyday, and the pH of the solutions was checked
at the beginning and at the end of each experimental day.
Surface treatments
The control groups (G1 and G5) were submitted to polishing
with wet silicon carbide sandpaper discs and to the erosive
cycling. The experimental groups were treated as follows:
& Groups G2 and G6: the treatment was performed with
diamond bur (no 2135 FF, KG Sorensen, Barueri, São
Paulo, Brazil) in a high-speed dental handpiece (Kavo
do Brasil, Joinville, Brazil) with water spray, to remove
a thin layer of the surface modified by the erosive
cycling. The active tip was positioned parallel to the
surface and activated for 5 s. Due to their inherent wear
and short durability, new burs were used after every five
preparations.
& G3 and G7: The Er:YAG laser used to treat the samples
surface was the Key Laser II (Kavo, Germany),1 which
operates at a wavelength of 2.94 μm and pulse duration
of 150 – 250 μs. The handpiece 2058 (spot size of
0.63 mm) was positioned perpendicular to the target
area of the dentin surface, with working distance of
12 mm (focused mode) and water spray of nearly
5 mL/min. The irradiation was performed manually
during 3 min, scanning the surface in both directions
(vertical and horizontal). To ensure this distance be-
tween dentin and radiation tip by hand irradiation, an
endodontic file was fixed at the handpiece and a distance
of 12 mm was kept from the dentin surface during all the
procedures. Before and during the sample irradiation,
the output power of the laser beam was measured with a
1
Er:YAG laser: Property of Special Laboratory of Lasers in Dentistry
(LELO-FOUSP) (FAPESP grant-97/10823-0).
power meter (GS™ FieldMaster Power, Energy
Analyzer, Coherent, Inc., Germany), and no power loss
was found. The parameters used were: energy per pulse
of 60 mJ, repetition rate of 2 Hz, 2 pulses per second,
power of 0.12 W and energy density of 19.3 J/cm2, as it
has shown to cause good marginal quality and sufficient
microtensile bond strength [32, 33].
& G4 and G8: The Er,Cr:YSGG laser used in this study
was the Waterlase MD (Biolase Technology Inc., San
Clemente, CA, USA),2 which emits at a 2.78-μm wave-
length. It has fixed pulse duration for hard tissues of
140 μs. The irradiation was performed in both vertical
and horizontal directions, using 70 % of water spray and
65 % of air spray. The sapphire tip MC12 was posi-
tioned perpendicular to the dentin surface, with working
distance of 2 mm, determining a beam diameter of
1.2 mm and water flow of nearly 14.5 mL/min. To
ensure this distance, the same approach was performed
for Er:YAG laser irradiation, differing only at the work-
ing distance (2 mm). Before and during the samples
irradiation, the output power of the laser beam was
measured with a power meter (GS™ FieldMaster
Power, Energy Analyzer, Coherent, Inc., Germany) and
was found an average power loss of 25 %. After a pilot
study investigating the effects over the surface, the set of
parameters that did not cause excessive tissue removal
or brown discoloration of the surface was chosen. The
energy per pulse was of 50 mJ, measured output power
of 1.5 W, repetition rate of 30 Hz, and calculated energy
density of 4.5 J/cm2.
Adhesive and restorative procedures
An etch-and-rinse adhesive system (Single Bond, 3M ESPE,
St. Paul, MN, USA) or a self-etching adhesive system
(Clearfil SE Bond, Kuraray Medical Inc., Osaka, Japan)
was applied to the pre-treated dentin surface according to
manufacturers' instructions. Then, resin composite blocks
(shade A3, Filtek Z250, 3M ESPE, Dental Products, St.
Paul, MN, USA) with dimensions of ≈5×5×5 mm were
bonded to the samples, also according to the manufacturer's
instructions. Each increment of ≈1 mm thick was light cured
for 20 s using a halogen lamp (model Degulux Soft-Start,
Degussa Dental GmbH & Co. KG, Hanau, Germany). The
light intensity was monitored by means of radiometer
(Curing Light Meter 105, Demetron Research Corporation,
USA), remaining in the range between 450 and 500 mW/
cm2.
2
Er,Cr:YSGG laser: Property of Department of Operative Dentistry,
Periodontology and Preventive Dentistry, RWTH Aachen University,
Aachen, Germany.
 Lasers Med Sci

Microtensile bond strength test Microscopy Ltd., Cambridge, England) at a magnification

of 1.000× and 3.000×.
The μTBS was determined using the protocol described by The sites of analysis were the surface appearance and the
Sano et al. [34] and modified by Shono et al. [35]. After aspects of the peritubular and intertubular dentin, dentin
bonding procedures and the storage in distilled–deionized tubules entrance, absence or not of the smear layer, and
water at 37 °C for 24 h, the 96 restored teeth were sectioned collagen fibrils appearance.
in “x” and “y” directions, perpendicular to the adhesive
interface, using an Isomet saw, yielding stick-shapped sam-
Statistical analysis
ples with a cross-sectional area of approximately 1.0 mm2.
The cross-sectional area of each stick was measured with a
Ninety-six restorations on human teeth were used as exper-
digital caliper and recorded for the calculation of the bond
imental units. Two variation factors were considered: adhe-
strength. The sticks were fixed to the Geraldeli's Jig with
sive system at two levels of variation (Single Bond and
cyanoacrylate resin (Super Bonder; Loctite, São Paulo,
Clearfil SE Bond) and type of surface treatment at four
Brazil) and accelerator (Loctite 7452, São Paulo, Brazil)
levels of variation (control, diamond bur, Er:YAG and
and submitted to a microtensile force in a universal testing
Er,Cr:YSGG laser irradiation). This study represented a
machine (Kratos, Model IKCL3-USB, São Paulo, Brazil)3
2×4 factorial design. The quantitative variable was the
running at a crosshead speed of 0.5 mm/min until fracture.
μTBS values in megapascal. As the Kolmogorov–Smirnov
Means (megapascal) of the sticks were calculated for each
test confirmed the normal distribution of all groups, the
restored tooth.
bond strength data were analyzed by two-way ANOVA
For the failure mode analysis, each stick-shaped sample
and Tukey's multiple comparison tests (α=0.05), using the
was stained for 5 min with 2 % Ponceau S dye [36]. It was
statistical software Minitab, version 16.0.
evaluated at a magnification of 40× using an optical micro-
scope (Miview Digital Microscope, Cosview Technologies
Co.,Ltd., Bantian, Longgang Dist., China) and classified as
Results
adhesive—interfacial failure, cohesive—failures either
within the resin composite or adhesive layer or as mixed
Scanning electron microscopy
failure—simultaneous adhesive and cohesive failure in
dentin.
Morphological analysis of the specimens showed different
characteristics according to the surface pre-treatment, as
Scanning electron microscopy described below:
& Control group: The effect of the erosive cycling allowed
For the surface morphological analysis, eight human third
the observation of a surface with demineralized organic
molars were selected. A flat occlusal dentin surface was
matrix without smear layer and open dentinal tubules
exposed, roots were removed, and samples were polished
(Fig. 1). As the acid removes inorganic structure of the
as described for the μTBS test. Disks of approximately
dentin surface, the peritubular dentin was fully
2 mm thick were divided, providing 16 halves of dentin.
demineralized and the intertubular dentin exhibited a
The samples were randomly distributed in four groups (n=
porous and rough appearance with exposed collagen
4), according to the surface treatment after the erosive
fibrils network (black arrows).
cycling: control, diamond bur, Er:YAG, and Er,Cr:YSGG
& Diamond bur group: It was possible to notice that the
laser irradiation.
samples which were treated with diamond bur exhibited
The specimens were immersed in 2.5 % glutaraldehyde
a surface with smear layer, obliterated dentinal tubules
solution for 24 h at 4 °C. After fixation, they were rinsed
and a rough appearance caused by the mechanical action
with sodium phosphate buffer at pH 7.2 in three baths of
of the diamond corns (Fig. 2).
5 min each. Then, the specimens were dehydrated in as-
& Er:YAG laser irradiation: The eroded dentin treated with
cending alcohol concentration (25 %, 50 %, 75 %, 95 %,
Er:YAG laser showed a surface without smear layer with
100 %), dried with hexamethyldisilazane (HMDS) for
disrupted tissue and demineralized collagen fibrils. In
30 min, and air dried at room temperature for 24 h. After
some areas, as illustrated in Fig. 3, it was possible to
mounting on stubs and sputter-coating with gold (MED 010,
verify an irregular dentin appearance, suggesting char-
Balzers, BAL-TEC, Furstentum, Liechtenstein), each spec-
acteristics of ablation, with open dentinal tubules and
imen was observed by SEM (LEO 435 VP, LEO Electron
prominent peritubular dentin.
3
Universal testing machine belong to Department of Dental Materials, & Er,Cr:YSGG laser irradiation: The eroded dentin sam-
School of Dentistry, University of São Paulo. ples which were subjected to surface treatment with the
Lasers Med Sci
Fig. 1 SEM of the eroded dentin surfaces pre-treated only with Grit Sic Paper (control group) (a 1,000×, b 3,000×)
Er,Cr:YSGG laser showed an irregular and rough sur-
face, with open dentinal tubules and prominent
peritubular dentin without smear layer (Fig. 4).
Microtensile bond strength test
The μTBS data expressed as mean and standard deviation
(SD) are shown in Table 1.
Among all the experimental groups, G4 (Er,Cr:YSGG
laser+Clearfil SE Bond) presented the highest bond strength
value (28.26±9.22 MPa), being significantly different from
all the other groups.
Regarding the self-etching adhesive system (Clearfil SE
Bond), there was no significant difference between groups G1
(control—17.01±7.31 MPa), G2 (diamond bur—21.02±
9.72 MPa), and G3 (Er:YAG laser—19.67 ± 5.62 MPa).
However, when using the total etch adhesive system (Single
Bond), no significant statistical differences were found be-
tween the control group (G5) and erbium-irradiated groups
(G7 and G8). However, the Er:YAG laser-treated samples
Fig. 2 SEM of the eroded dentin surfaces pre-treated with diamond bur (a 1,000×, b 3,000×)
(G7—16.00±5.63 MPa) revealed higher microtensile bond
strength when compared to the diamond bur group (G6).
It was observed that the difference between the adhesive
systems occurred only when the Er,Cr:YSGG laser and
diamond bur were used, both with higher bond strength
values achieved with the self-etching adhesive system
(Clearfil SE Bond). When considering the dentin surface
treatment without any treatment or with the Er:YAG laser
irradiation, there were no significant differences between
both adhesive systems (Clearfil SE Bond and Single Bond).
In all groups, the failure mode was predominantly adhe-
sive (between adhesive and dentin), followed by mixed
failure and cohesive failure (Fig. 5).
Discussion
The increased occurrence of dental erosion combined with
the lack of research on bonding to eroded dentin and the
possible benefits of treatment with erbium lasers, led to the
decision to carry out this in vitro study.

Fig. 3 SEM of the eroded dentin surfaces pre-treated with Er:YAG laser irradiation (a 1,000×, b 3,000×)
In this study, the diamond bur was considered as the
conventional treatment since it consists on the most used
rotary instrument in the oral cavity. Recently introduced in
dentistry for the purpose of ablating mineralized tissue,
Er:YAG and Er,Cr:YSGG lasers were also studied, since
little is known about its effects on eroded dentin surfaces.
The irradiation parameters proposed were lower than those
reported by previous studies [17, 20, 23–25, 37, 38] since
our goal was to modify the eroded dentin surface, without
necessarily promoting its ablation or a cavity formation.
Different surface treatments had led to distinct morpho-
logical characteristics of the eroded dentin surface. Eroded
dentin showed a disorganized surface with exposed and
demineralized organic matrix, without smear layer and open
dentinal tubules. These findings corroborate with other stud-
ies in the literature [5, 27, 39]. The conventionally prepared
dentin surface (i.e., diamond bur prepared surfaces) showed
a thick smear layer obliterating the entrance of the dentinal
tubules, while the irradiated dentin revealed an irregular
surface without smear layer, with open dentin tubules and
prominent peritubular dentin, suggesting a microrretentive
Fig. 4 SEM of the eroded dentin surfaces pre-treated with Er,Cr:YSGG laser irradiation (a 1,000×, b 3,000×)
Lasers Med Sci
morphology favorable to bonding procedures [15, 17, 18,
23, 36, 38].
Regarding the adhesion to eroded dentin surfaces, the
morphological analysis of the treated surfaces revealed
some interesting aspects that could positively favor the
adhesive procedures. Furthermore, the bond strength evalu-
ation between the dental substrate and the adhesive systems
revealed important data that should be considered before the
restorative treatment on eroded dentin.
Erosion was shown to negatively affect the bond
strength, as also reported previously by Zimmerli et al.
[40]. This can be explained by the presence of denatured
collagen, which develops an unfavorable adhesion [41]. For
both adhesive systems evaluated, the adhesion to dentin was
compromised, even though the self-etching adhesive system
has revealed a tendency to provide better results. It was
verified that the irradiated dentin on which the total etch
system—Single Bond—was applied showed the lowest
bond strength values. It can be hypothesized that the re-
duced interfibrillar space generated after the laser treatment
[20, 42], associated to the effects of the dentin exposure to
Lasers Med Sci

Table 1 Mean (MPa) and standard deviation (SD) values of the attached to collagen and are available to interact with the
microtensile bond strength test
monomer that infiltrates in this region [45].
Surface treatment Mean±SD (MPa) Among the treatments proposed for eroded dentin, the
Er,Cr:YSGG laser with the parameters studied associated
G1 (Control+SE) 17.0±7.3BC with the self-etching adhesive system showed the best re-
G2 (Diamond bur+SE) 21.0±9.7B sults of bond strength. Based on bond strength values and on
G3 (Er: YAG laser+SE) 19.7±5.6B the morphological evaluation of the dentin surfaces, it can
G4 (Er,Cr: YSGG laser+SE) 28.3±9.2A be suggested that the energy deposited on the surface was
G5 (Control+SB) 11.2±5.8CD able to remove the dentin layer modified by erosion and
G6 (Diamond bur+SB) 9.9±5.8D exhibit a dentin surface more favorable to adhesion, without
G7 (Er: YAG laser+SB) 16.0±5.6BC affecting negatively the dentin substrate, as reported by
G8 (Er,Cr: YSGG laser+SB) 15.4±7.9BCD other authors [17, 23–25, 46].
*
Regarding Er:YAG and diamond bur treatment with self-
Different upper letters indicate significant statistical difference be-
tween groups (p<0.05)
etching adhesive, the morphological changes and the lower
values of bond strength, when compared to Er,Cr:YSGG
treatment, suggest that these surface treatment were not able
phosphoric acid, has compromised the complete adhesive to cause appropriate modifications of the eroded tissue. It
penetration and, consequently, hindered the formation of an seems that the collagen fibrils' disorganization of the soft-
adequate hybrid layer. It is presumed that the application of ened and demineralized dentin was not removed neither
phosphoric acid on eroded dentin results in a fully modified by the pretreatments. On the other hand, it is
demineralized outer zone that gradually becomes more min- important to notice that for the etch-and-rinse adhesive, the
eralized until it achieves a normal mineralized dentin in its situation is different. Here, only the Er:YAG laser irradiation
inner portion [40] and may not have a homogeneous infil- caused bond strength values which are statistically signifi-
tration of the total-etch adhesive system. cantly higher than the bur treatment, probably indicating a
On the other hand, the self-etching adhesive system pro- better interaction between the dentin surface modifications
vided better adhesion to eroded dentin. Clearfil SE Bond has caused by the Er:YAG laser irradiation with this kind of
an acidic primer, which promotes demineralization and the adhesive system. Detailed chemical and structural analysis
simultaneous infiltration of the hydrophilic monomer in the of the irradiated surfaces could help clarify the adhesion
demineralized dentin, preventing the formation of characteristics and mechanism in future studies.
deprotected collagen layer, as it happens when using the Although the erbium lasers have similar wavelengths, the
phosphoric acid [41, 43]. This suggests that the mechanism mechanism of absorption and the action on dental tissues are
of action of Clearfil SE Bond is actually more favorable [40, different. So it is very important to notice that the direct
43, 44], possibly due to the micromechanical bonding, the comparison of the two laser systems is not possible since the
uniformity of the hybrid layer formed, and the presence of aim of this study was to understand the effect of laser
10-MDP monomer that has the ability to promote a chem- parameters which were previously successful in sound den-
ical bond between the adhesive components and the calcium tin [15, 29, 33, 36, 37, 46 and pilot study—unpublished
ions of the residual hydroxyapatite. As its acidic primer is data] in a more complex substrate as the eroded dentin. The
weak, a few remnants of crystals of hydroxyapatite are limitation of this approach is that it is not possible to identify
why one laser system performed better than the other (e.g.
Er,Cr:YSGG laser was better because of the lower energy
density). However, it has the positive effect that we could
identify that for the Er:YAG laser an adjustment of the laser
parameters is necessary when changing from sound to erod-
ed dentin, and the same is not necessary for the Er,Cr:YSGG
laser, as long as a self-etching adhesive system and the
parameters of this study are used.
Adhesion was the highest when the eroded dentin sur-
faces were pre-treated with the Er,Cr:YSGG laser before the
self-etching adhesive application. The results of all groups
involving self-etching adhesive, independent of the kind of
treatment, were higher than the etch-and-rinse system (p=
Fig. 5 Prevalence (in percent) of the failure mode in each experimental 0.000). However, even among the groups treated with self-
group etching, which had already high bond strength values, the

pre-treatment with the Er,Cr:YSGG laser resulted in signifi-
cantly higher bond strength means (p=0,002). So it is clear
that the adhesion of the self-etching adhesive to eroded dentin
was significantly improved in relation to pre-treatments with a
diamond bur, Er:YAG laser irradiation (60 mJ, 2 Hz, 19 J/
cm2), or to surfaces receiving no pre-treatment at all.
It is also important to mention that the most of the studies
published until now regarding bonding to laser-treated dentin
showed bond strength values which were not better but only
not statistically significant different from the treatment with
burs [15, 29, 36, 37, 46]. Thus, this is the first time that a set of
laser parameters caused statistically significant higher bond
strength to eroded dentin than the conventional treatment.
This may represent an improvement in adhesion of a great
clinical relevance and should be for sure further investigated
in more complex long-term and clinical models.
Conventionally, the use of diamond burs are the first
choice for the conservative approach of non-carious lesions,
being able only to remove the surface layer of the soften
substrate and cause minimal roughness [40]. Nevertheless,
under the conditions proposed in this study, the use of
diamond bur did not favor the adhesion procedure. The
electron micrographs suggest that the diamond bur led to
the formation of a thick smear layer and maybe the weak
acid primer of the self-etching adhesive system (Clearfil SE
Bond) was not able to modify the smear layer and cause
demineralization of the dentin, hampering the hybrid layer
formation and the penetration of the resin into the tubules.
Another relevant consideration about the use of laser
irradiation on eroded vital tooth is its antibacterial effect.
Dental erosion lesions are not usually associated with the
presence of bacteria, but rather due to the high acidity of
exogenous or endogenous solutions to which the tooth sur-
face is exposed. However, even in this situation, the expo-
sure of dentinal tubules can allow the presence of
microorganisms. Considering this possibility, many studies
have shown that erbium-laser-irradiation with reasonable
settings have the potential for microbial reduction due to
the temperature rise during irradiation. Thus, it is believed
that when erbium lasers are used with appropriate parame-
ters and water/air cooling, they can provide a surface more
favorable to bonding of composites and also microbial re-
duction, without compromising pulp vitality. It is important
to highlight that the irradiation with erbium lasers should be
done with caution, since the greater the depth of the lesion to
be restored, the greatest is the attention that should be given
to the water/air cooling parameters, in order to avoid irre-
versible damage to the pulp. Our SEM images exhibited a
clean eroded dentin surface proving that erbium laser irra-
diation caused the smear layer removal and the elimination
of microorganisms at the dentin outer surface. So, consider-
ing that dentinal tubules are open just shortly before adhe-
sive restoration of these defects, it is believed that laser
Lasers Med Sci
irradiation is an important tool to promote bacterial reduc-
tion, improving the prognosis of dental treatments [13, 47].
A prevalence of adhesive failures was found in all exper-
imental groups. However, laser-irradiated groups also
showed mixed failures, as found by Moretto et al. [20],
and cohesive failures in dentin, suggesting the existence of
microcracks in the subsurface, which are not completely
infiltrated by the resin monomer and create a weak zone
below the interface [21, 22, 48, 49]. The current findings on
the adhesion to eroded are innovative, considering that, up
to the present, there are still no reports in the literature
regarding the treatment with high power lasers—Er:YAG
and Er,Cr:YSGG—on eroded surfaces.
Although the conventional treatment exists and is proved
to be effective, the laser treatment on eroded surfaces re-
vealed to be promising. The laser, as a new technology, has
been introduced in various specialties of Dentistry and
Medicine, with perspectives of expansion of its use in clin-
ical practice. Moreover, it is a treatment that has major
advantages for the erosion lesions: selective removal of
demineralized tissue, possible low-intensity laser effects on
irradiated tissue [50], and greater acceptance by the patient.
The bond strength values obtained when associating the
Er,Cr:YSGG laser treatment to the use of a self-etching
adhesive system was close to 30 MPa, while the other
treatments showed values close or lower than 20 MPa.
Finally, different surface treatments may affect bonding
performance of adhesive systems to dentin. It is important to
highlight that in the present study, just one irradiation pa-
rameter was used for each type of laser. Thus, further
laboratorial and clinical, longitudinal and multicenter stud-
ies with eroded dentin are necessary to assess new parame-
ters of Er:YAG and Er,Cr:YSGG laser irradiation. Also, the
acid etching conditioning time and the adhesive system to
be applied on the eroded and irradiated surface should be
considered in future investigations.
Conclusions
Within the limits of this in vitro study and considering the
parameters selected for dentin irradiation, it was possible to
conclude that the surface treatment with Er,Cr:YSGG laser
irradiation (4.5 J/cm2, 50 mJ, 30 Hz, 140 μs), prior to
bonding with a self-etching adhesive system, significantly
increases adhesion to eroded dentin, as compared to con-
ventional treatment. It is yet unclear whether other combi-
nations of Er:YAG laser parameters could achieve the same
results, and this should be tested in future studies.
Acknowledgments The authors would like to thank the Coordenação de
Aperfeiçoamento de Pessoal de Ensino Superior (CAPES), the Fundação
de Amparo à Pesquisa do Estado de São Paulo (FAPESP—grant 2011/
Lasers Med Sci
02925-6) and the Conselho Nacional de Desenvolvimento Científico e
Tecnológico (CNPq—Grant 305574/2008-6) for their financial support
and the Departament of Dentistry, Departament of Dental Materials and
LELO–FOUSP. This study is part of a research cooperation between the
RWTH University of Aachen (Germany) and the University of São Paulo
(Brazil). The contents of this study are based on the dissertation submitted
by TM Ramos to the Faculty of Dentistry, the University of São Paulo for
partial fulfillment of the degree of Master of Dentistry.
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