13/10/2009

THE HOLY GRAIL OF MODERN DENTAL PRACTICE.

LASERS IN DENTISTRY (A REVIEW)
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CONTENTS
INTRODUCTION  SIGNIFICANCE IN MODERN DENTAL PRACTICE  REVIEW OF HISTORY AND DEVELOPMENT  FUNDAMENTAL OF LASER PHYSICS AND ITS COMPONENTS

a)Laser principles b)Laser properties c)Measurements of laser d)Laser generation e)Beam Profile and Spot Geometry f) Power Density(PD)
2

Cont…
  

LASER DELIVERY SYSTEM LASER EMISSION MODE LASERS AND TISSUE INTERACTION
a)OPTICAL PROPERTIES OF TISSUE b)TISSUE EFFECT OF LASER IRRIDIATION

  

CLASSIFICATION OF LASERS TYPES OF LASERS SOFT AND HARD TISSUE APPLICATION OF LASERS IN DENTISTRY
1.Laser in endodontics 2.Laser in operative and esthetic dentistry

  

LASERS SAFTY IN DENTAL PRACTICE CONCLUSION REFRANCES

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INTRODUCTION
LASERS can be defined as 1. A device that utilizes the natural oscillations of atoms or molecules between energy levels for generating coherent electromagnetic radiation usually in the ultraviolet, visible, or infrared regions of the spectrum  -Merriamwebster.com 1. A device which amplifies electromagnetic energy at various optical frequencies into an extremely intense small and nearly non divergent beam of bright light of a single color. Capable of mobilizing intense heat and power when focused at a close range, it is used as tool in surgical procedure , in diagnosis and in physiological studies. 4

cont.
 To d a y

La se rs a re e m p l ye d fo r va ri u s o o p u rp o se s ra n g i g fro m n
Ømeasuring distances of the far planets, Øcreate laser guided warfare, Øentertainment, Øinstrumentation Øand even those that record the price of our groceries. And many more ……….

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6

CONT…
 But

out of all odds the main and most advantageous purposes of is found in the field of HEALTH CARE INDUSTRIES.

 

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SIGNIFICANCE IN MODERN DENTAL PRACTICE.

Today's dream and tomorrow's reality


lasers can be used to enhance the once clinical practice and the treatment out come also. Dentist should become laser literate, consumer wise and that’s how increasing the potential of its use in day to day clinical practice with patient acceptance. To understand the differences between variety of lasers and their vivid application. Understanding lasers in an easy and understandable
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Worldwide laser sales by application

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REVIEW OF HISTORY AND DEVELOPMENT

Use of light for treatment of various pathologies is referred to as phototherapy.


Ancient Greece  sun for heliotherapy, by exposure of the body to the sun for the restoration of health .


Late 1700s the Chinese used the sun to treat conditions such as rickets, skin cancer, and even psychosis.


In 1400 B.C. INDIANS used psoralens(a plant extract),to treat vitiligo.

10

cont…
 1903,

a Danish physician Niels Finsen used carbon arc phototherapy for the treatment of lupus vulgaris by using UV rays.

 

11

Foundation of laser development

In 1917 Albert Einstein, in his “The Quantum Theory of Radiation”, laid the foundation for the invention of the laser and its predecessor, the maser, In 1928, Rudolf W. Ladenburg confirmed the existence of stimulated emission and negative absorption. In 1939, Valentin A. Fabrikant predicted the use of stimulated emission to amplify "short" waves. In 1947, Willis E. Lamb and R. C. Retherford
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Development of the lasers

The earliest use of photochemotherapy, or the use of an exogenous photosensitizerto absorb light and render a therapeutic effect In 1974 it is evidenced that psoralens combination with exposure to ultraviolet radiation was indeed effective in the treatment of psoriasis and vitiligo. Theodore H. Maiman of Hughes Aircraft Corporation in 16 May 1960 developed the first laser, or “ MASER“ an acronym for "Microwave Amplification by Stimulated Emission of Radiation,". Snitzer in 1961 developed neodymium laser Carbon dioxide laser -Kumar Patel in 1964
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T h e o d o re H . M ai an m

Le o n G o l m a n d
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Cont…
  

In 1965 Taylor et al studied histological effect of laser on the pulp In 1968 Lobene et al used carbon dioxide laser in dentistry Weichman & Johnson 1971 used laser for the first time in sealing of the apical foramen in vitro by means of a high power-infrared (CO2) laser In 1974 Yamamoto et al used Nd:YAG laser for caries prevention In 1977 Lenz et al used laser for the first time in maxillofacial surgery

 

 

 

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R e f:- l se rs i d e n ti a n stry b y

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RECENT DEVELOPMENTS

1987 Meyer and mayer developed a Portable Laser 1990 FDI permitted the use of the same in the dentistry The FDA approved oral soft tissue surgery in 1995 and sulcular debridement in 1998 by means of a diode laser Hibst et al. 1999-2001 developed a novel laser 17 for caries detection (Diagnodent-KaVo,




FUNDAMENTAL LASER PHYSICS 
L  A  S  E  R

The word LASER is an acronym for Light Amplification by Stimulated Emission of Radiation.

Light Amplification by Stimulated Emission of Radiation
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UNDERSTANDING LIGHT
 

Form of electromagnetic energy that behave as a particle and a wave as well. light produced by a table lamp, for example, is usually a white diffused glow, although it is the sum of the many colors of the visible spectrum—violet, blue, green, yellow, orange, and red. A prism can be used to separate the individual colors in the same way that raindrops break up sunlight into the colors of a rainbow.


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AMPLIFICATION

The initial light is amplified to make a very bright compact beam

 

 

20

STIMULATED

means that the photons are amplified by stimulating an atom to release more photons. An atom can exist in an excited state, similar to a bow when it is stretched.

21

EMISSION
 

Refers to the giving of photons. The excited atom emits a photon when another photon comes by. Einstein(1917) Stimulated Emission.

22

RADIATION

For lasers, radiation refers to the PHOTONS which are being emitted.

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Properties of LASER light

Monochromatic (single wavelength) ( specific boundary) (in same phase)


 Collimation


 Coherency


 Efficiency

(how good it works)

Directional (narrow cone of divergence)
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monochromaticity
 Laser

light is one specific color, a property called monochromacity; in dental applications that color may be visible or invisible.

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collimation

Collimation refers to the beam having specific spatial boundaries, which insures that there is a constant size and shape of the beam emitted from the laser cavity. A dental x-ray machine produces radiation with this property.

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coherance

Coherency means that the light waves produced in the instrument are all the same. They are all in phase with one another and have identical wave shapes; that is, all the peaks and valleys are equivalent.

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Efficiency and its measurement

The clinically useful feature of laser is efficiency. Three measurements that can define the wave of photons in a laser. The first is velocity, which is the speed of light. The second is amplitude, which is the total height of the wave. It indication of the amount of intensity in the wave. The third property is wavelength, which is the distance between any two corresponding points on the wave on the horizontal axis.which is important in determining 28 how the laser light is delivered to the surgical site and to





Electromagnetic Waves
Wavelength

Amplitude

Velocity

Frequency is the number of complete oscillations of the wave per second.
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directionality

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Laser generation

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Components of Laser system
      

La si g a cti m e d i m . n ve u Energy or Pumping source.

Optical chamber.

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Lasing medium:
A

material, capable of absorbing the energy produced by an external extension source through the subatomic configuration of its component molecules, atoms or ions.  subsequently give off this excess energy as photons of light.


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Energy or pumping source
 An

energy source is used to excite or pump the atoms in the lasing medium to their higher energy levels that are necessary for production of laser radiation.

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Optical Chamber
 The

lasing medium is located within resonating chamber which has cylindrical structure with a fully reflecting mirror on one another.

 

37

Core cavity

The core cavity or the optical cavity is comprised of chemical elements, molecules, or compounds which is called the active medium, which can be container of gas, a crystal, or a solid state conductor. The other devices are either solid state semiconductor wafers made with multiple layers of metals such as gallium, aluminum, indium and arsenic. High Voltage Power Supply
cathode anode Beam output

 = atoms 

100% Reflective Mirror

Active Medium
98% Reflective Mirror
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Beam Profile and Spot Geometry
 

There are more photons concentrated in the core of the beam and that the light intensity diminishes at the edges. Often in a well-tuned cavity the transverse cross section (profile) is the normal gaussian curve. This is referred to as the TEMoo (transverse electromagnetic mode: 00), also called the "fundamental mode“) Other modes are possible such as the "Donut" mode (TEM10), which has a cold spot in the center.

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Power Density(PD)
 Power


 

density is simply the concentration of photons in a unit area. Watts per area in square centimeters. Therefore, PD = W/cm2
(This is the average PD. Notice from the beam profile that the PD in the center of the spot is higher and that at the edge of the spot it approaches 0).
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Cont…

The terms focused and defocused when working with lasers refers to the position of the focal point in relation to the tissue plane. working on tissue, the laser should always be used either with the focal point positioned at the tissue surface (in focus) or positioned above the tissue surface (defocused or out of focus). laser should never be positioned with the focal spot deep or within tissue


 When


 The
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Laser delivery system

Contact lasers
It works on the “hot tip” principal  It improves cutting efficiency for low-power instruments  Requires cleaning or cleaving the fiber to attain desired results

Non contact lasers
Noncontact surgery relies completely on the pigments and water present in the tissue.  Noncontact surgery requires significantly greater power settings than contact surgery.  The techniques and principles are similar, only the feel is different.  During noncontact surgery, the clinician 44 operates with the aid of an aiming beam or by

Laser delivery medium

 

Articulated arm- consist of a series of rigid hollow tubes with mirrors at each joint (called a knuckle) that reflect the energy down the length of the tube.

  

DISADVANTAGES 1. Bulky 2. Awkward three-dimensional maneuverability 3. Alignment of the mirrors 4. Articulated arm delivery systems are  noncontact systems 1.

2.
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   

Fiberoptic delivery system-The fiberoptic cables are attached to a small handpiece similar in size to a dental turbine. Advantages 1. Relatively flexible 2. Easy transmission of the laser energy throughout the oral cavity 3. Fiberoptic technology allows for contact with the target tissue Disadvantage 1. Costly 2.
3. 4.


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     

Hollow waveguide delivery system – waveguide is a single long, semiflexible tube, without knuckles or mirrors. The laser energy is transmitted along the reflective inner lumen of this tube and exits through a handpiece at the end of the tube Advantages 1. Can be used as contact and non contact  mode 1. Various attachments for hand piece Disadvantages 1. Available with co2 laser and erbium system only

 

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 


  


  

Air-cooled fiberoptic delivery system – This type of delivery system is unique to the erbium family of lasers. A conventional fiberoptic delivery system cannot transmit the wavelength of the erbium family of lasers, owing to the specific characteristics of the erbium wavelength. These special air-cooled fibers terminate in a handpiece with quartz or sapphire tips. These tips are used slightly (1–2 mm) out of contact with the target tissue.


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Laser Emission Modes

Emission of energy in 3 modalities

Continuous wave : Beam emitted at only one power level for as long as device is operated by pressing the foot switch 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 Free running pulsed mode: large peak energies are emitted for an extremely short time span followed by long time of which laser is off. It is 49 computer controlled.


50

Several means are available for achieving pulsed output from a continuous wave laser. These are: Mode locking Q switching to micro sec Cavity dumping Pulses from pico sec.



 



 

Pump pulsing

from one microsecond to

a large fraction of sec
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WHATS IN THE HAND OF OPERATOR?

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Tissue effects of laser irradiation
 Broadly

the tissue effects of lasers can be groups as.
1.Photo 2. 3.Photo 4. 5.Photo 6. 7.Photo chemical interaction thermal interactions mechanical interactions electrical interaction
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Photo Chemical Interactions:

Specific wavelength absolved by naturally occurring chromophores Wavelength specific light absorption substances are able to induce certain biochemical reactions at the cellular level. Photo Chemical interactions are subdivided into 1.Photodynamic Therapy



2.

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Photodynamic therapy Therapeutic use of lasers to induce reactions in tissues for treatment of pathologic conditions

        

Biostimulation The stimulatory effects of the laser light on biochemical & molecular processes that normally

55

Photo thermal Interactions:


Radiant energy absorbed by tissue -> transformed into heat energy which produces tissue effect. The amount of light energy absorbed in tissue depends on:

1.Wavelength of radiant energy from laser.

2.Laser parameters such as spot size, power density, pulse duration & frequency. 3.Optical properties of tissue.
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Laser heating and tissue temp

What Occurs when , if energy is absorbed
1.Hyperthermia- temp . Increase but not destroyed, tissue whitening or blanching 2.Coagulation –Irreversibly damages the tissue, by congealing tissue liquid into semisolid mass, good to archive homeostasis 3.Welding -Adherence of the layers because of stickiness due to the collagen molecule’s helical unfolding and intertwining with adjacent segments 4.Vaporization - tissue containing water is elevated to a temperature of 100 c, process also called as ablation 5.Carbonization - about 200 c, dehydrated 57

Thermal effects at different temp.
           

Temperature 37-50 60-70 70-80 100-150 >200

Tissue Effects Hyper thermia Coagulation, protein denaturation Tissue Welding Vaporization and ablation Carbonization & charring (As in DCNA 2004 vol.48;759)

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THE ZONE OF LASER INTERACTION WITH THE TISSUE

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Photo Mechanical & Photo Electrical Effects


Photon disruption or photo disassociation which is breaking apart of structures by lasers Photo acoustic effects which involve removal of tissue with shock wave generation Photo plasmolysis describes how tissue is removed through the formation of electrically charged ions & particles that exist in a semi gaseous high energy state.
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   

laser action manifests clinically as:

Photo ablation or removal of tissue by 1.Vaporization 2.Super heating of tissue fluids, 3.Coagulation, 4.Homeostasis 5.Photo pyrosis or burning away of

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Optical properties of tissue

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Absorption and laser interaction with hard tissue

Dental structures have different amount of water content,  Enamel being the least followed by Dentin, Bone, Calculus, Caries and Soft tissue  Dental lasers have a Photo thermal effect  At low temperatures below 100°C, the thermal effects denature proteins and produce hemolysis and they cause coagulation & shrinkage  Above 400°C, carbonization of organic materials occurs with onset of some inorganic materials 64  Between 400°C & 1200°C, inorganic

In general, shorter WL (500-1000 nm) are well absorbed in pigmented tissues and blood elements  Longer WL are more interactive with water and Hydroxyapatite  Co2 (10,600 nm) is well absorbed by water and has the highest affinity for Hydroxyapatite

Tissue Hemoglobin Melanin Hydroxyapatite WL

Feature Absorbed by Blue & Green WL Absorbed by short wavelengths Absorbed by a wide range of
65

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Classifications of lasers

In general lasers can be classified into no. of ways. But chiefly on the potential of the primary laser beam or the reflected beam to cause biologic damage to the eyes or skin. The ANSI Standard Z136.1-2000 documents set the standards for classification in the United States. OSHA and the American Conference of Governmental Industrial Hygienists also use this standard as a source. Other countries subscribe to these standards and have their own similar regulatory agencies.




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Based on the potential danger posed to the exposed skin and eye
 Class

I - Low powered lasers that are safe to view  Class IIa - Low powered visible lasers that are hazardous only when viewed directly for longer than 1000 sec.  Class IIb - Low powered visible lasers that are hazardous when viewed for longer than 0.25 sec.  Class IIIa-Medium powered lasers or systems that are normally not hazardous if viewed for less than 0.25 sec without magnifying optics.  Class IIIb-Medium powered lasers (0.5w max) that can be hazardous if viewed directly.
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Classification OF LASERS
 Based

on Active Medium
1.Solid State 2.Gas 3.Semiconductors 4.Excimer 5.Dye

 Mode

of action
1.Contact mode (focused or defocused) Ho:YAG ; Nd: YAG 2.Non-contact mode (focused or defocused) CO2 3. 69 4.

CONT…
 Based

as application
1.Soft tissue laser - Argon, Co2, diode; Nd:YAG. 2.Hard tissue laser - Er : YAG 3.Resin curing laser - Argon

  Based

on Level of energy emission:
1.Soft lasers (Low level energy): He-Neon; Ga-Arsenide. 2.Hard lasers (High level energy): Er:YAG laser ; Nd: YAG laser.

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71

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Diode 812nm Diode (980nm) ErCr:YSGG 2.78 µm Ex c i m e r KTP (532nm) Er:YAG ( 2.94µm) KrF (248nm) XeF(351 nm) CO2 (9.6 or 10.6µ ) m HeNe (632nm)

Ultraviolet

Visible

Infrared

100 nm 400 nm ArF (193nm) XeCl (308 nm)

Ruby (694nm) 750 nm Ho: YAG 10,000 nm Argon (514 nm) Nd: YAG (2,08 µm) (1,06 µm) Argon (488 nm)

γ -rays 10-12

x-rays

UV 10 - 9

visible IR microwaves 10 - 6 1 0 -3

radio waves 1

acoustic waves

103 wavelength, meters
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Laser Wavelengths Used in Dentistry
Argon laser


   

 

Active medium of argon gas that is energized by a high current electrical discharge. It is fiber optically delivered in continuous wave and gated pulsed modes The only available surgical laser device whose light is radiated in the visible spectrum. There are 2 emission wavelength used in dentistry:  488 nm, which is blue in color &  514 nm which blue green. 488 nm emission activate camphoroquinone(photo initiator), causing polymerization. The 514 nm wave length has its peak absorption in tissues containing hemoglobin, hemosiderin & melanin.Thus it has excellent haemostatic capabilities. 76

usages

Used in Surgical Endodontics Both can be used for caries detection Argon laser light illuminates the tooth, the disease area appears dark orange-red colored Neither wavelength is absorbed by dental tissues or water Their poor absorption by enamel and dentin is an advantage when used for incising and sculpting gingival tissues





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Diode laser

A solid active medium laser, manufactured from (Gallium arsenide) semi conductor crystals using combination of aluminum or indium, gallium, and arsenic.


Wavelengths for dental use range are 800 nm for active medium containing aluminum to 980 nm for active medium containing indium.


Optic fiber delivery system with contact mode.



All of diode wavelength are highly absorbed by pigmented tissue and are deeply penetrating
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Neodymium :YAG laser

  

Nd:YAG has a solid active medium, which is a garnet crystal combined with rare earth elements yttrium and aluminum, doped with neodymium ions. Operates at wavelength of 1064nm in a high inter pulsed wave form. It emits light in near invisible infrared area of spectrum. Fiber optic cable to divert the light to a hand piece & lens to produce free beam of laser light
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   

Common clinical applications are:  For cutting & coagulating of dental soft tissues & debridement.


 Offers good hemostasis during soft tissue procedures


 For attaining pulpal analgesia


Advantages:  Facilitates a clear operating field


 Flexible delivery system.

Disadvantage:  Is unnecessary collateral damage due to its depth of penetration.


 Wound healing in soft tissue will be delayed

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Holmium:YAG

 



solid crystal of yttrium aluminum garnet sensitized with chromium and doped with holmium and thulium ions Fiber optically delivered and free running pulsed mode Operates at a wavelength of 2100 nm and uses a pulsed waveform. It is absorbed by water 100 times greater than Nd: YAG At high peak powers, can abrade hard, calcified tissue. An aiming device is used, as the light produced is invisible.

     

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Erbium Family lasers

Erbium: YSGG (2780nm) with solid crystal of yttrium scandium gallium garnet doped with erbium & chromium Erbium : YAG (2940nm) has crystal of yttrium aluminum garnet doped with erbium . The delivery systems are a hollow wave guide and fiber optics in free running pulse mode. The highest absorption in water & have a high affinity for hydroxyapatite.
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 

 

Uses: Caries removal and Cavity preparation


In preparation of root canals.


Facial resurfacing,
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Carbon dioxide laser

It was developed by Patel in 1964. A gas active medium laser that incorporates a sealed tube containing a gaseous mixture with Co2 molecules pumped via electrical discharge current. Operates at wavelength of 10,600nm. It is operated in a gated wave form or continuous form through a hallow tube like wave guide. Wavelength is well absorbed by water. It can easily cut & coagulate soft tissue & has a shallow depth of penetration into tissue. Emits light in the invisible mid infrared portion.
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 

          

Uses:  Excision and ablation of various types of superficial lesions & for skin resurfacing



Excellent Hemostasis,

Advantages:  Clear field of view.


Post operative pain is minimal

Disadvantages:  Wound healing is delayed  Difficult to uses (articulated arm)

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newer lasers systems

KTP Lasers (excimers)
Modified version of Nd: YAG laser: Addition of frequently doubling crystal operates at 532nm. It uses fiber optic cable with a hand piece. It is similar to argon laser in absorption characteristics Used in the treatment of vascular & pigmented lesions, tattoo removal
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Flash Lamp pumped pulsed Dye Laser

Produces yellow visible light in 400–1000nm range & is commonly used at 510, 577, 585nm. The desired wavelength can be used for specific tissue to be removed, offering great flexibility 510 nm melanin can be targeted & various benign melanin containing tissues can be ablated 585nm targets oxy-hemoglobin with in vascular abnormities. Thus it is used in treatment of cancer, ablation of salivary 87





Copper Vapor Laser

Wavelengths of 511-578 nm. to both KTP & Argon lasers.

 Similar


 Its

medium is heated copper which produces copper gas. mode by fiber optic cable in pulsed


 Delivered


 Effective

in treatment of port wine stains or large superficial telangiectasias, nevi &

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Medical Applications of laser

Argon laser in ophthalmology 1968 Otorhinolaryngology Dermatology & plastic surgery Neurosurgery Urology Gastroinstestinal surgery
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Why to select laser for treatment?
 Patients

choice  Clinicians choice
Treatment outcome assessment  Utilizing benefits of lasers

 Patient

comfort & acceptance
 Reduced

postoperative complications  Hemorrhage control  Reduced need for postoperative analgesics
 Advantage

over the cold steel surgical procedure
1.Dry and bloodless surgery 2.Instant sterilization of the surgical site 3.Reduced bacteremia 4.Reduced mechanical trauma 5.Minimal postoperative swelling and scarring

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Types of Lasers

Hard lasers or high level lasers.
Cavity Preparation on tooth surface  Transillumination  Photo polymerization  Cortical bone ablation

  

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 Soft

tissue laser or low power
Tissue Effects Hyper thermia Desiccation protein denaturation Tissue Welding Vaporization and ablation Carbonization & charring (As in DCNA 2004 vol.48;759)
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Temperature 37-50 60-70 70-80 100-150 >200

Hard and soft tissue difference
 Hard

Lasers:
 Have

longer wavelength more then 450nm  Produces thermal effect, which cut the tissue by coagulation, vaporization & carbonization.  These lasers are used for surgical hard tissue applications.

 Soft

or low-level lasers
 Low

thermal energy wavelengths of less than about 450nm with minor temperature increase of less than 1C.  Stimulate circulation and cellular activity.  Anti-inflammatory,  Muscle relaxation,  Analgesia 93

Laser application in vivacity of dentistry

Biopsies Tongue lesions Aphthous ulcers Herpetic lesions Coagulation and hemostasis Exposure of implants Scaling and root planing
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Lasers in Endodontics

95

Laser in dentinal hypersentivity
 Rationale
 

for laser induced reduction in DH is based on 2 possible mechanisms
1st mechanism – implies direct effect of laser irradiation on the electric activity of nerve fibers within the dental pulp 2nd mechanism – modification of the tubular structure of dentin by melting and fusing of the hard tissue or smear layer and subsequent sealing of dentinal tubules

 

96

Lasers for treatment of DH are divided into 2 groups Low Output Power Lasers Output Power Lasers Helium – Neon Diode Nd:YAG Gallium-Aluminum-Arsenide diode

Middle

Co2

  

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Pulp Diagnosis
 Laser

Doppler flowmetry (LDF) was developed to assess blood flow in microvascular systems, e.g. in the retina, gut mesentery, renal cortex and skin (Morikawa et al. 1971, Riva et al. 1972)

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Helium – Neon and Diode laser at a low power of 1 or 2 mW of wavelength is 632.8 nm Laser beam is directed towards the tooth (to the blood vessels) Moving RBC causes the frequency of the laser beam to be Doppler shifted and some of the light be back scattered out of the tooth The reflected light is detected by the photocell on the tooth surface and its output proportional to the number and velocity of the blood cells. Advantages over EPT:
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Pulp Capping & Pulpotomy

The energy level of 1 W at 0.1 second exposure time with 1 second pulse intervals was applied to the exposed pulp Teeth were check for vitality after 6 and 12 months and 89.4% of the teeth retained their vitality Lasers can be used for direct or in direct pulp capping in cases of deep and hypersensitive cavities Co2 and Nd:YAG lasers are well absorbed by the hydroxyapatite of enamel and dentin, causing tissue ablation, melting and re-solidification
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Cleaning & Shaping of Root Canal System

Various laser systems can deliver the energy into the root canal using a thin optical fiber Various systems that have been used are
    


Nd:YAG Er,Cr:YSGG Argon Diode Er:YAG

 

 

It has been demonstrated in many studies that the laser radiation has the ability to remove debris and smear layer from the root canals It also has the potential to kill the microorganisms Bergman et al suggested that lasers is not an alternative to the conventional

102

Limitations for use in Root Canals

Emission of laser energy from the tip of optical fiber or the laser when directed into the root canal is not uniform There may be thermal damage to the periapical tissues May be hazardous when the tooth apex is near vital structures such as mandibular nerve or mental foramen Sterilization of root canals by lasers is
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Laser assisted Obturation

Aim of Obturation:  Eliminate all avenues of leakage  Seal the RC system from all ends Rationale in using lasers for obturation is 1. Irradiation can be used as a heat source for softening the GP 2. Conditioning of the dentin walls can also be done The clinical evidence from reported studies for the use of lasers in obturation is not sufficient. It has not been determined if the use of laser as a heat source is safe for the surrounding structures of the tooth as well as for other teeth A suitable wavelength has not been ascertained Effect on the sealer per se has to be determined

 

 

 

   
105

LASERS IN Retreatment

Rationale for using lasers in retreatment is ascribed to the need to remove foreign material, GP etc by softening it by heat (1340 nm) in used to remove GP and ZOE sealer Silver cones and separated instruments but lasers alone cannot remove all the obturating materials from the RC clinical advantage is that toxic solvents like xylene can be avoided
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 Nd:YAP


A

Lasers in Endodontic Surgery

Laser is used for the surgery as
1. a bloodless surgical field 2. the ability of the laser to vaporize tissue 3. coagulate and seal small blood vessels. 4. Irradiation causes, surface sterilization


The potential of the Er:YAG laser to cut hard dental tissues without significant thermal or structural damage eliminates the need for mechanical drills Clinical investigations into laser use for apicectomy began with the CO2 laser (Miserendino 1988), which was successful When the laser was used for resection it is found that
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Advantages

Cont…

1.Good hemostasis 2.Improved visualization of surgical site 3.Sterilization operative field 4.Reduced permeability of root surface dentin 5.Reduction in post operative pain 6.Reduced risk of contamination of surgical site by eliminating use of air turbines 7.Reports suggest that laser created wounds heal more quickly and produce less scar tissue than conventional scalpel surgery.

8.

Constraints
1.Time Consuming 2.Increase temperature 3.Cause irreversible pulpal damage 4.Needs precise execution

108

Other Endodontic uses
 CO2

and Nd:YAG lasers have been used for the attempted treatment of root fractures (Arakawa et al. 1996). However, after using various parameters, fusion of the fractured root halves was not achieved (Ar, CO2, Nd:YAG lasers) have been used successfully to sterilize dental instruments in shorter time. pulsed dye laser emitted at 504 nm was used for the removal of a calcified attached denticle (Rocca et al. 1994)


 Lasers


A

109

Lasers in Operative & Aesthetic Dentistry
 Lasers

have become a part of routine operative and aesthetic practice are five lasers that are currently in the armamentarium
1.Argon laser 2.Plasma arc laser 3.CO2 laser 4.Diode laser 5.Erbium family of lasers
110


 There

Argon lasers
 The

wavelength is absorbed by Hb


 This

attribute allows precision cutting, hemostasis & coagulation of vascular tissue of argon lasers have been used for curing composites (at low power achieving higher bond strength) fractuures in diagnosis of tooth
111


 Use


 Transillumination

Plasma Arc Curing (PAC)
 PAC

& Argon laser curing systems are used in rapid polymerization of composites  However they increase heat generation and thus causing polymerization shrinkage
  Bleaching 
112

of stained teeth

Co2 Lasers
 Used   Used

for vaporizing, cutting and coagulation of soft tissue more for soft tissue procedures which include gingival re-modelling and shaping in aesthetic dentistry (Perio-Aesthetics)

113

Diode Lasers
2

different WL are used  Ga-Al-As Laser (800 nm) & In-Ga-As (980 nm)  These are used in contact mode for cavity preparation, removal of bacterial contamination and coagulation of tissue  Also used for Diagnosis

114

Erbium Family
 Er

lasers are absorbed by Hydroxyapatite and water to cut soft tissue, tooth structure and bone (2940 nm) cuts teeth easily & quickly used for removal of caries
115


 Allows


 Er:YAG


 Also

Operative dentistry

Detection of caries


Surface etching.



Removing decay painlessly and atraumatically without affecting the surrounding healthy tissues.


For removal of defective restoration as composite, GIC, Compomer restorations quickly and easily without the use of analgesia.


 

Bleaching of teeth (Power Bleaching). Argon laser – alter surface characteristicsdecreased acid solubility


Nd:YAG laser- APF application after laser irradiation increased

Decay present on the facial of the maxillary left lateral incisor

The Erbium laser used to remove the decay . No anesthesia was required

After caries removal and preparation is complete

Definitive direct bonded restoration after preparation with the Erbium laser

Angle tip towards the buccal aspect Of the central groove, defocused, with VERY slow movement from mesial To distal create a initial groove.

Note penetration angled towards Buccal direction. Also note Conical concentration of laser Energy from end of tip.

Cut viewed from occlusal

Next, angle towards lingual, pass 3 times mesial to distal and open OTHER side of central groove

Again, note conical shape of cut Where laser energy is concentrated.

Finish prep by then going Straight down central groove, exposing Dentin , thereby opening up entire prep For ease of disease detection and Removal.

Etching

Laser etching has been evaluated as an alternative to acid etching of enamel and dentine. The Er:YAG laser produces micro-explosions during hard tissue ablation that result in microscopic and macroscopic irregularities However, it has been shown that adhesion to dental hard tissues after Er: YAG laser etching is inferior to that of conventional acid etching. The weaker bond strength of the composite to laseretched enamel and dentine is due to the presence of subsurface fissuring which is absent126 in conventional etched surfaces




Caries prevention

Laboratory studies have indicated that enamel surfaces exposed to laser irradiation are more acid resistant than non-laser treated surfaces (Watanabe et al., 2001; Arimoto et al., 2001) The degree of protection against caries progression provided by the one-time initial laser treatment was reported to be comparable to daily fluoride treatment by a fluoride dentifrice (Featherstone, 2000) It is believed that laser irradiation of dental hard tissues modifies the calcium to phosphate ratio, reduces the carbonate to phosphorous ratio, and leads to the formation of more stable and less 127 acid soluble compounds, reducing susceptibility



Laser Assisted Bleaching

Two laser-assisted whitening systems have been cleared by the FDA The laser enhances the activation of bleaching material, which then whitens the teeth The argon laser wavelength of 488 nm for 30 seconds to accelerate the activity of the bleaching gel After the laser energy is applied, the gel is left in place for three minutes, then removed. This procedure is repeated four to six times CO2 laser is employed with another peroxide- based solution to promote penetration of the bleaching agent into the tooth.
128





Dental Laser Safety
 Safety

is an integral part of providing dental treatment with lasers

  

3

aspects to safety:
Manufacturing process  Proper operation of the device  Personal protection

129

Regulatory Agencies
 American

National Standard Institute

(ANSI)
  Food   Center   Occupational

and Drug Administration (FDA)

for devices and Radiological Health (CDRH) safety health administration (OSHA)

130

Laser Classification
Class I II Laser Properties

(on bases of potential hazards)

Pose no health hazard e.g. CD Player, pointer Emit only visible light with low power output & do not pose any health hazards Maximum allowable output is 1 mW Emit any WL and have an output power of 0.5 W of visible light; In this laser light can be viewed only momentarily Caution label is present Hazardous to unprotected eye; Output power no greater than 0.5 W; eg. Argon Laser curing light; Eye protection is must Hazardous from direct viewing and may produce diffuse reflections; Output power more than 0.5 W; Can produce fire and severe skin reactions; Can ignite

IIIa

IIIb IV

The lasers used in dentistry fall in class IV category


The type of hazards can be grouped as :
1.Ocular hazards

2.
3.Tissue damage

4.
5.Reparatory depression

6.
7.Fire & explosion

8.
9.Electrical Shock
132

Fire & Explosion Hazards
Use only wet and fire retardant materials in operative field  Use non combustible anesthetics  Avoid alcohol based topical anesthetics  Avoid alcohol moistened gauze or cotton  Fire Extinguisher  Stay informed  Follow ANSI regulations and local body regulations

133

Guidelines
 Mention

outside  Door Switch  Fire hazards

134

Laser safety control measures & recommendation

ENGINEERING CONTROLS
       

ADMINISTRATIVE CONTROLS

Protective housing Interlocks Beam enclosures Shutters Service panels Equipment labels Warning system Key switch


Laser safety officer Standard operating procedures Out put limitations Training and education Maintenance and alignment Warning sign Protective devices Medical surveillance







Eye Protection
 In

1962, the awareness to eye protection began  Eye is a critical target for laser injury
  Class

III & IV lasers pose a threat to the

eye
  Proper 
136

eye wear is a must

Why the Eye ???

Cornea is made up of 90% Water Absorbs emissions from all lasers Can cause Corneal Burns Retinal damage occurs due to lasers with more depth if penetration and is absorbed into the pigments The eye is 100,000 times more vulnerable to injury than the skin WL from 400-1400 is dangerous Protective glasses must have an Optical Density of at least 4








137

Sterilization & Infection Control
 Fiber   Oil   The

optic cables & handpieces can be autoclaved in pouches based aerosols should not be used

wires and protective casing / housing should be wiped clean and not autoclaved
138

Recent advancement
 Waterlase

MD (All-Tissue Laser)

1.Works on teeth, gums and bone 2.FDA cleared for most clinical procedures of any dental laser 3.Cuts over 50% faster 4.Recent root canal clearance 5.Works on Hydrophotonics principle
1.It’s the interaction between laser energy and water 2.Most procedures can be performed without anesthesia 3.Can coagulate while cutting 139 4.Reduced healing time and tissue trauma

Cutting with Waterlase
Optimization of the cutting efficiency:
Air / Water balance

TOO little wa TOO m
•Water and Air settings in Spray should should be based on power settings and type of the tip

* charring * slo

Waterlase Hydrokinetic Cutting Mechanisms
O
Excitation of Water Molecules

H
Expansion

H

Laser + Water Spray

Photo-acoustic

Effective Tissue Cutting

BIOLASE Engineering

Length and Shape
750

WATERLASE (MD) TIPS Relative shapes of the tips, approximate beam divergence and radiation spot sizes (at 2-3 mm distance)

09/23/04

SAPPHIRE TIPS

(M)G6, (M)G4

750

600

(M)T4

(M)S75

400

750

750

(M)C6

(M)C12

1200

600

1200

1200

(M)C3 (cone side)

(M)C3 (flat side)

1200

300

1200

1200

QUARTZ TIPS

(M)Z2
240 460

(M)Z4

(M)Z3
380

(M)Z6

640

Laser technology in future

Caries detection and prevention
 

Tetra hertz pulse imaging


Endodontic canal lasing and curing Computer Aided Design/Manufacturing (CAD/CAM) Low Level Laser Therapy (LLLT) Holographic imaging

  

 

   

No cut ,no sew and no pain

But does not prove to be a holy grail

conclussion

Many ethical issue questioning the risk benefit ratio

Mostly a tool of dentist with golden spoon in mouth Patient pay capability is in question, as it is 10 times costly

Future is hopeful

As cost and the availability will be in reach of common man

As portability and versatility of the commercial products will increase 144

145

146

References and literature review

147

1.www.goolge.com 2.www.yahoo.com 3.www.pubmed.com

2000 and

148

THANK YOU FOR YOUR PATIENCE LISTENING

149

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