LASERS IN ENDODONTICS AND CONSERVATIVE DENTISTRY

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LASER
‡ An acronym for Light Amplification by the Stimulated Emission of Radiation.. ‡ A device that creates a uniform and coherent light that is very different from an ordinary light bulb.

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‡ Also can be described as a device for generating a high-intensity, ostensibly parallel beam of monochromatic(single wavelength) electromagnetic radiation. ‡ Laser light can be focused down to a tiny spot as small as a single wavelength.
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A bit of history
‡ The possibility of stimulated emission predicted by Einstein-1917.. ‡ Based on work of Gordon in 1955 & Schawlow n Townes in 1958, MAIMAN created the 1st operatinal laser in 1960, a ruby laser emitting a brillant red beam of light..
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‡ photo of the development of the helium-neon laser taken at AT&T's Bell Laboratories in 1964.
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THE LASER
‡ Basic components.. ‡ An ACTIVE LASING MEDIUM :- cn be a solid, liquid or gas ‡ Enclosed within a LASER CAVITY bounded by two perfectly parallel reflectors(mirrors) ‡ PUMP SOURCE ± high energy radiation pumped into the active rxdentistry.net medium

‡ POPULATION INVERSION :condition when energyfrom pump source is absorbed by active medium until the majority of atoms, ions or molecules are raised to their upper energy state.. ‡ And this condition is NECESSARY to generate laser light..

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‡ TWO PARALLEL REFLECTORS ± situated at end of laser cavity act to constarin light along n within the axis of cavity.. ‡ So light is repeatedly bounced b/w the reflectors ‡ One of the mirrors is only partially reflective, enabling some of the light to escape the cavity as a beam of laser rxdentistry.net light..

‡ Working of laser

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‡ Working of laser

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Advantages of lasers in general
‡ Processing of matter without contact. ‡ High working speed ‡ Outstanding precision
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Benefits
‡ Soft, quiet, vibration-free operation ‡ As fast as the high-speed turbine ‡ CO2 laser cuts and coagulates soft tissue without bleeding ‡ No risk of cross-infection
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‡ Sterilization of operating field ‡ Fewer cracks than with turbine ‡ Multiple quadrant dentistry ‡ No need for etching ‡ Pulsing minimizes charring and thermal necrosis
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LASER DENTISTRY
Lasers are still in the pioneering stage, but there are many current uses.. There are three types of Dental lasers: ‡ Surgical Laser (soft tissue) ‡ Curing Laser ‡ Tooth Laser (hard tissue)
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SURGICAL LASER (soft tissue)
This laser replaces traditional surgery for many gum and soft tissue dental applications and is gentler than traditional surgical procedures. This laser used for : ‡ Improve treatment results for gum disease ‡ Contour gums for smile enhancement ‡ Surgically correct oral abnormalities
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‡ Surgically assist in arresting herpes lesions and canker sores ‡ Assist in biopsies ‡ Treat infant tongue/frenum problems which can hinder proper chewing/sucking ‡ Treat child/adult frenum problems which can cause speech impediments, gum disease, and teeth to grow apart rather than together
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CURING LASER
‡ This laser spectrum light source is used for rapid teeth whitening and placing all toothcolored restorations (fillings) and repair procedures. ‡ Bonds created by this advanced instrument result in dentistry that is twice as strong !
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‡ The light source increases gradually during the curing process to create the best bond available in dentistry today. ‡ Appointment length is also reduced because it is 500% more powerful than standard equipment. ‡ Less than 1% of dental offices nationwide have this instrument, making it one of the newest tools in dentistry..
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‡ TOOTH LASER (hard tissue) Third type of laser is used to remove cavities. But since this laser cannot be used on existing metal fillings, we use micro dentistry.. ‡ MICRO DENTISTRY one of the greatest advancements in the field of dentistry. ‡ offers the ultimate flexibility and capability. It is also the most tooth conservative dentistry available.
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‡ About 50% of cavities are candidates for this technique and there is no drilling, no needle, no extra fee, and no pain! ‡ And because this process is so efficient, it reduces appointment length.
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Hard tissue applications
‡ Desensitize exposed root surfaces ‡ Diagnosis of non-cavitated caries ‡ To arrest demineralization and promote remineralization of enamel. ‡ Debond ceramic orthodontic brackets. rxdentistry.net

DIAGNOdent Caries Detector
‡ The DIAGNOdent can find cavities that other dental instruments can miss. ‡ The device is designed as an adjunct to a traditional oral examination in the detection of occlusal decay. Teeth that are suspicious for caries are ideal candidates for survey with the device
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‡ ‡ ‡ ‡

Key Benefits: A laser examination tool for the early detection of caries. Even very small lesions can be detected at the earliest stages. Over 90% accurate! Earlier treatment - Better outcomes
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‡ Diagnodent is a pen-like probe that sends a safe, painless laser beam into the tooth. A numeric display & alarm signals when there are signs of hidden decay.
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‡ These pictures show how the Diagnodent finds cavities that other dental instruments can miss.
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How it works....
‡ The Diagnodent device measures laser fluorescence within the tooth structure. ‡ As the incident laser light is propagated into the site, two-way hand-piece optics allows the unit to simultaneously quantify the reflected laser light energy. ‡ At the specific wavelength that the device operates (655 nm), clean healthy tooth structure exhibits little or no fluorescence, resulting in very low scale readings on the display. ‡ Carious tooth structure exhibits fluorescence, proportionate to the degree of caries, resulting in elevated scale readings on the display rxdentistry.net

‡ Roughen tooth surfaces ,in lieu of acid etching in preparation for bonding procedure

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‡ ‡ ‡ ‡

Treatment of dentin hypersensitivity.. In bleaching Adhesion of pit & fissure sealant Most obvious application ± controlled removal of dental enamel, dentin, bone or cementum.

‡ Replacement of dental drill is a real possibility for the future.rxdentistry.net

Soft tissue aplications
‡ 1968 ± use of carbon dioxide laser ± in oral and maxillofacial surgery ± Goldman et all. ‡ Restricted mostly to incising and excising masses from the mucosa and gingiva in oral cavity. ‡ Vaporize exces tissue as in gingivoplasty, gingivectomyy and labial /lingual frenectomy.
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‡ Remove or reduce hyperplastic tissue. ‡ Remove and control hemorraging of vascular lesions such as hemangiomas. ‡ In endodontics

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LASER TYPE CO2

Characteristics of surgical lasers SPECTRAL
WAVEL ENGTH MODE
REGION 10,600nm Midinfrared

TYPICAL MAX POWER

100w CW& CW Gated &superp ulsed Pulsed 15Wavg Near Holmiu 2,100 infrared . nm m CW & 100W Nd:YAG 1,064 Near infrared pulsed CW nm rxdentistry.net

800Near 890nm infrared KTP/KD 532nm visible P Argon 488/514 Visible nm Excimer 190nm Ultaviol ArF-XeCl et Erbium: 308nm Ultraviol YAG(Er: et rxdentistry.net YAG) Diode

CW Pulsed CW Pulsed Pulsed

>50W 25Wavg . 20W 550mJ 250mJ

Carbon dioxide Laser
‡ Co2 gas as lasig /active medium

‡ Delivery system ² uses an articulated arm
(a series of hollow tubes connected together through a series of six to eight articulating mirrors). ‡ USEDcutting & vaporising tissue in open proceures or in procedures where rigid endoscopyis acceptable.. rxdentistry.net

Cavity preparation
‡ Efect of ruby laser radiation on enamel ± Goldman, Stern & Sognnaes, 1964 ‡ Carbondioxide laser ± Lobene et all 1968 ‡ Nd:YAG laser ± Yamamoto & Ooya 1974 ‡ Argon laser ± Goodman & Kaufmann 1977
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‡ In removal of enamel n dentin ± thermal side effect occoured.. ‡ Superpulsed carbon dioxide laser ± removal of dentin without thermal side effect possible. ‡ Transversal stimulation or carbon dioxide TEA (the Alexandrit laser with double frequency) ± most efficent carb.dioxide laser for dental hard tissue ablation.
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‡

‡

Clinical perespactive of lasers increased by introduction of Er:YAG, Er, Er:YSGG lasers have advatages of - reduced thermal effects - creating precise contour of the section zone.
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‡ Also in meantime new lasers -Nd:YAG -excimer -holmium -argon -diode
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Speed of preparation
‡ In thermomechanical , micro-abrasion like explosion ± much less energy is needed. ‡ If soft tissue is softened by caries,the laser ablation rate increases« ‡ Rough surfaces produced by laser ablation provide good retension
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‡ Dentin surfaces r less rough aftr ablation and hence less problamatic. ‡ High bond n shear strength can be achieved with simple defocused radiation.. ‡ For conditioning less time is needed than when etching conventionaly..
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‡ Drying the surface with laser is very quick , efficent and gentle. ‡ Erbium laser has bactricidal abilities. ‡ Bcz high surface temperature can be achieved for a short time by subalative irradiation.. ‡ Irridation of caries by a sequence of laser pulses leads to consecuetive dessication and sterlization.
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‡ The Er:YAG laser can be used to disinfect cavity prep , in case of residual bacteria contaminating, otherwise intact enamel or dentin, or in fissures prior to sealing.

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Dentin hypersensitivity
‡ Best results obtained whn affected areas exposed to co2 , Nd:YAG, Er:YAG, Diode laser radiation ‡ Colojoara et al showed that dentin hypersensitivity can be reduced without any damages to pulp vitality by using co2 laser.. ‡ They also showed that when using co2 laser , in parallel direction with dentin tubules, the desensiting effect ws obvious aftr three exposures. rxdentistry.net

Dental material curing
‡ The first materials introduced in 1970¶s (photopolymerised composites) wr cured by ultraviolet light.. ‡ Power et al showed that an argon laser requires shorter curing times & th ematerials dentin bond strength was stronger whn compared with laser.
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‡ Variables that control the depth &extent of cure include - time of exposure - composite material - wavelength - intensity of light - particle size of filler
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‡ Current reserches report that used at the power of 250 +/- 50 mW for 10sec per increment , ‡ the argon laser provides good curing of light activated restorative material in shorter period of time with equal or better physical properties than the conventional halogen curing light..
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LASER TEETH WHITENING ( bleaching)
‡ With today's technology, laser teeth whitening through the use of the Diode Laser is the quickest and most dramatic way to brighten your smile if porcelain laminates are not an option. ‡ All tooth whitening procedures use hydrogen peroxide or carbamide peroxide to bleach out stains on your tooth enamel, but this is where the similarity ends when comparing standard bleaching procedures such as whitening performed with a light cure to laser whitening.
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‡ Laser whitening is superior to all other whitening techniques since ‡ 1.laser whitening products contain the highest concentration of peroxide 2.the laser provides the highest light intensity available 3.the procedure is done in the office at chairside ‡ thus allowing us to concentrate in those areas of your mouth where the type and location of discoloration is worse. Laser technology allows us to whiten your teeth with amazing results in just one hour! rxdentistry.net

Whitening techniques will vary with every individual depending on:
1.the type of stain on your teeth 2.where the stain is located 3.the amount of time the whitening gel is used 4.the peroxide concentration in the whitening gel 5.the intensity of the light activating the whitening gel
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Bleaching
‡ In Laser-Assisted Tooth Whitening, the laser enhances the effect of bleaching agents for faster, more comfortable and more effective results. ‡ By stimulating the bleaching gel to react faster, the bleaching agent (mainly peroxide) spends less time on the tooth. This leads to increased comfort levels, a reduction in reaction from gums both during and after treatment, and improved results over non-laser treatments

‡

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Hazards of lasers
‡ Types of hazards Ocular hazards # injury to eye ± direct emission or by reflection from mirror like surface. # irreversible retinal burns- by conversion of incident radiation to heat energy.
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Tissue damage
* damage to skin & other non-target tissue result from thermal interaction of energy with tissue proteins * temperature elevations can produce denaturation of cellular enzymes &structural proteins which interrupt basic metabolic processes
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3. Environmental hazards
‡ Are referred to as non-beam hazards ‡ Capable of producing smoke , toxic gases and chemicals. ‡ Laser plume ± composed of vaporised water (steam), carbon particles, cellular products..
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‡ The greatest producers of smoke are co2, erbium lasers followed by Nd:YAG Lasers..

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Mechanical efects
‡ High energetic & short pulsed laser light lead to a fast heating of dental tissue. ‡ Energy dissipates explosively in vol of expansion ± accompanied by fast shockwaves.. ‡ The shockwaves lead to high pressure ±destroy or damage adjacent tissue.
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Effects on dental pulp
‡ Characteristically pulp tissue cannot survive environment of elevated temp for protracted periods when tooth structure is irridated with lasers. ‡ Use of combination of air and water spray before during or immediately after laser irridation may be more effective..
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4. Combustion hazards
‡ Flammable solids , liquids, gases used within the surgical setting can be easily ignited if exposed to laser beam..

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5. Electrical hazards
‡ Can be in form of - electric shock - fire - explosion

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Thremal effects of laser irradation
‡ Temperature < 60 celcius ~ tissue hyperthermia ~ enzymatic changes ~ edema ‡ Temperature > 60 celcius ~ protein denaturation
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‡ Temperature < 100 celcius ! Tissue dehydration ! Blanching of tissue ‡ Temperature > 100 celcius ! Super heating ! Tissue ablation&shrinkage
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Fire & electrical control measures
‡ Operatory must be dry ‡ Control panel & its electrical power unit should be protected from any kind of splashing..

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Control of air borne contamination
‡ Can cause charring ‡ Coagulation of blood elements

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Procedural control
‡ Highly reflective instruments & those with mirror surfaces should be avoided. ‡ Tooth protection is needed, whenever , the beam is directed at angles other than parallel to the tooth surface. ‡ A no.7 wax spatula can be inserted into gingival sulcus to serve as an effective shield for teeth
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‡ If anesthesia is required in place of standard PVC tubes , rubber or silastic tubes should be used. ‡ For further protection tube should be wraped with an aluminium tape.

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EYE PROTECTION

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LASER PLUME
‡ The plume from a laser ablation deposition: A Nd:YAG laser hits ZnTe

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‡ The 514nm line of the cw laser, a few 100 mW, going through a prism. Do not try this at home!

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A CASE STUDY
‡ Figure 1A² Maxillary left first permanent molar with occlusal enamel hypoplasia

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‡ Figure 1B² Waterlase MD. used to remove (ablation).

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‡ Completed cavity preparation after using Waterlase MD

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‡ Completed restoration with resinomer

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THANX !
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