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Lasers in Endo
Lasers in Endo
Lasers in Endo
Historical Perspective Introduction Fundamentals of dental lasers Laser Physics Lasers in Endodontics
L A S E R
A laser is a device that transforms light of various frequencies into a chromatic radiation in the visible, infrared, and ultraviolet regions with all the waves in phase capable of mobilizing immense heat and power when focused at close range
Historical Perspective
Early 1900s Chinese & Egyptians (Phototherapy)
1960 Theodore Maiman 1965 Dr. Leon Goldman
1970s Nd:YAG
1982 - Pick, Frame & Pecaro 1987 Meyers Portable Laser
were the first to investigate the potential uses of the ruby laser in dentistry
They began their laser studies on hard dental tissues
Weichman & Johnson (1971) who attempted to seal the apical foramen in vitro by means of a high powerinfrared (CO2) laser
Fundamentals of Lasers
PHOTONS
Ground State Atoms are normal position Atoms are excited by an energy source and move to a
higher energy
As it reverts back to its ground state, energy is emitted
Spontaneous Emission
Results without external interference and forms waves that
are in phase
Light
Form of electromagnetic energy Laser light vs. Ordinary light Ordinary light is usually white diffused Sum of many colours of the visible spectrum Laser light Monochromacity
Coherency Same light waves All waves are in phase with one another (identical wave shapes)
Collimation Specific spatial boundaries Low Divergence Insures a constant shape & size of the beam
Amplification
Is a part of a process that occurs inside the laser An optical cavity is at the center of the laser device &
the core is comprised of chemical elements, molecules or compounds Active Medium Lasers are generically named for the material of the active medium Gas, Crystals or Semi-Conductors
characteristic wavelength
These ware amplified and filtered to make a coherent
beam
The effect of this energy depends on whether or not
Stimulated Emission
Quantum theory of Max Planck & Neils Bohr Smallest unit of energy It can be absorbed by electrons, cause brief excitation
Radiation
Refers to light waves produced by the laser as
electromagnetic energy
EM Spectrum entire range Wavelengths
Higher Photon energy can deeply penetrate biologic
Laser consists of a lasing medium contained with an optical cavity, with an external energy source to maintain a population inversion so that stimulated emission of a specific wavelength can occur, producing monochromatic, collimated and coherent beam of light
Active medium Gas, liquid or solid Contained in glass or ceramic tubes Energy Electric current Mirrors are added to each end to increase the back and
radiation
connected
Waveguide (Tube)
Fiber Optic
Advantages
Thinner & flexible Higher carrying capacity Less energy degradation Low power consumption Non inflammable Light weight
at one power
In Gated Pulse Mode, there are periodic alterations of
True Pulsed
In this large peak of energy of laser light is emitted for
Classifications:
Lasers are named according to:
Active medium Wavelength Delivery systems Emission modes Tissue absorption Clinical Application
Classifications:
I.
d)
e)
Nd: YAG
b)
Argon, Co2, diode; Nd:YAG. Hard tissue laser - Er : YAG Resin curing laser - Argon
YAG laser.
Wavelength
Argon
Active medium is Argon gas Fiber optically delivered Continuous wave & Gated Pulsed modes Only laser whose light is in the visible spectrum 2 wavelengths are used: 488 nm (Blue) 514 nm (Blue-Green)
in composite resins
The beam divergence of this blue light is used in non-
contact mode, produces excessive amount of photons thus providing curing energy
More strength in cured resin when compared to
water
Their poor absorption by enamel and dentin is an
Diode
Is a solid active medium laser
Manufactured from semiconductor crystals using
combinations of Al, In, Ga and Ar Available wavelengths are 800 nm (Al) to 980 nm (In), placing them at the beginning of the infra red spectrum Fiber optic delivered Continuous wave or Gated Pulse modes Used in Contact mode
fluorescence from carious tooth structure, which is reflected back into a detector device in the unit
This analyses and quantifies the
degree of caries
Neodynium:YAG (Nd:YAG)
Has a solid state active medium, which is a garnet
crystal combined with rare earth elements Yytrium & Aluminum doped with Neodynium Wavelength is 1064 nm Operate in free running pulsed mode with short pulse durations Delivered via fiber optic cable Contact mode
soft tissues
Energy is slightly absorbed by dental hard tissues but
there is little interaction between sound tooth structure following soft tissue surgery
Pigmented surface carious lesions can be vaporized
Holmium:YAG
Consists of a solid crystal of Yytrium, Aluminum
Garnet sensitized with Chromium and doped with Holmium and Thulium ions
Delivered via Fiber optic cable Free running pulsed mode Wavelength is 2100 nm Absorbed by water 1000 times more than Nd:YAG
Er Cr:YSGG
Erbium Chromium:Yytrium Scandium Gallium Garnet
Wavelength 2780 nm Delivered via fiber optics Free running pulsed mode Fiber cable diameter is much larger and requires an air
or water coolant
Er:YAG
Erbium: Yytrium, Aluminum Garnet
Wavelength is 2940 nm Delivered via hollow tube and fiber optic cable Free running pulsed mode
crystal and into water that is bound to the crystalline structures of tooth
Caries removal and tooth preparation can be easily
carried out
The increased water content in carious lesions allows
CO2
Gas active medium laser
Co2 pumped via electrical discharge
Wavelength is 10,600 nm
Well absorbed by all biological hard & soft tissues Can easily cut and coagulate soft tissue Has a shallow depth of penetration into tissue The laser energy is delivered by a hollow wave guide in a
application
suitable for cutting and drilling enamel & dentin as the damage to the dental pulp may occur
target tissue
Amount of energy absorbed by the tissue depends on
Reflection
Transmission
Scattering
Light travels in different directions, absorbed over a greater surface area Causes less thermal effect
Absorption
Absorbed by tissues and results and light energy is converted to thermal energy
Feature Absorbed by Blue & Green WL Absorbed by short wavelengths Absorbed by a wide range of WL
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 Photothermal effect
re-crystallize or vaporize
Hydroxyapatite
Co2 (10,600 nm) is well absorbed by water and has the
Lasers in Endodontics
Dentinal Hypersensitivity Pulp Diagnosis Pulp Capping & Pulpotomy Cleaning & Shaping of root canal systems
Sterilization
Endodontic Surgery
Dental Hypersensitivity
Characterized as short, sharp pain from exposed
dentin that occurs in response to provoking stimuli such as cold, heat or chemicals
Not ascribed to any other dental defect or pathology
diseases)
tubule
Oxalate salts Isobutyl cyanoacrylate Fluoride releasing resins
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
Nd:YAG Co2
anti-inflammatory effect
Have an ability to stimulate the nerve cells Senda et al were the first to apply He-Ne lasers Used a low power output of 6 mW which does not
pulp
claimed that the helium neon laser irradiation affects the electric activity (action potential) rather than A- or C-fiber nociceptors
transmission caused by diode laser irradiation blocking the depolarization of C-fiber afferents
on dentin
Microradiography and Electron probe analysis
irradiated dentin, recrystallization had occurred and dentin had changed to look like the original
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)
mW
Wavelength is 632.8 nm
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
tooth surface and its output proportional to the number and velocity of the blood cells
Advantages over EPT: Can be used in traumatized teeth Does not rely on painful sensation to determine vitality
dental material such as Calcium hydroxide or MTA is placed over a pulpal wound to encourage the formation of reparative dentin
Pulpotomy is defined as the surgical removal of the
coronal portion of the pulp by means of preserving the remaining radicular tissues
that no damage was detected in the radicular pulp. Charring, coagulation necrosis and degeneration of odontoblastic layer occurred, with no pulp damage
hydroxyapatite of enamel and dentin, causing tissue ablation, melting and re-solidification
These lasers do not cause any thermal damage to the
pulp tissue and do not increase the intra-pulpal temperature if used at the correct power, duration of time and intensity
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 cleaning & shaping, but can be used as an adjunct
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
the irradiation (side-firing), rather than direct emission through a single opening
The endodontic side firing spiral tip is designed to fit the
shape and volume of the root canals prepared by NiTi rotary instruments
molars and the teeth were then split and examined longitudinally
Efficient cleansing of the RC System is achieved
have been performed using CO2 (Zakariasen et al. 1986) and Nd:YAG lasers (Rooney et al. 1994, Ebihara et al. 1994, Fegan & Steiman 1995, Moshonov et al. 1995b, Goodis et al. 1995, Sekine et al.)
The Nd:YAG laser is more popular, because a thin
fibre-optic delivery system for entering narrow root canals is available with this device
308 nm (Stabholz et al. 1993), the Er:YAG laser emitted at 2.64 mm (Gomi et al. 1997), a diode laser emitting at 810 nm (Moritz et al. 1997a), and the Nd:YAP laser emitting at 1.34 mm (Blum et al. 1997) have also been used
All lasers have a bactericidal effect at high power that
bacterial contamination from the root canal to the patient and the dental team via the smoke produced by the laser, which can cause bacterial dissemination (Hardee et al. 1994)
Thus, precautions such as a strong vacuum pump
system must be taken to protect against spreading infections when using lasers in the root canal (McKinley & Ludlow 1994)
Sterilization of root canals by lasers is problematical
Ar laser emitting at 477 and 488 nm (Potts & Petrou 1990, 1991)
The results indicate that an Ar laser coupled to an optical fiber could become a useful modality in endodontic therapy Studies have been performed using the obturation material AH-26 & AH Plus (Zaman et al. 1994) and composite resin (Anic et al. 1995)
An SEM examination revealed that laterally compacted resin fillings showed fewer voids than those obtained by vertical compaction (Kitamura et al, 2005) Ar, CO2, and Nd:YAG lasers have been used to soften gutta-percha (Anic & Matsumoto 1995), and
results indicate that the Ar laser can be used for this purpose to produce a good apical seal
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
Retreatment
Rationale for using lasers in retreatment is ascribed to
the need to remove foreign material, GP etc by softening it by heat Farge et al used the Nd:YAP (1340 nm) Attempted to remove GP and ZOE sealer Silver cones and separated instruments They concluded that lasers alone cannot remove all the obturating materials from the RC
in 70% cases, while broken files in only 55% of the cases using the Nd:YAG laser
Removal of GP and files is always a challenge and
can be avoided
However the effects of the laser on the tissues and
foramen of freshly extracted teeth in which the pulp had been removed
Laser is used for the surgery, a bloodless surgical field
should be easier to achieve due to the ability of the laser to vaporize tissue and coagulate and seal small blood vessels
and sealed
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
1993, Wong et al. 1994), used the Nd:YAG laser and found that there was a reduction in the penetration of dye or bacteria within resected roots
When the laser was used for resection itself, either in
extracted human teeth in vitro (Maillet et al. 1996), found that tissue repairs was quicker when compared with those roots resected with a bur
Advantages
Good hemostasis
Improved visualization of surgical site Sterilization operative field
Constraints
Time Consuming
Increase temperature Cause irreversible pulpal damage
quickly and produce less scar tissue than conventional scalpel surgery.
However, contrary evidence from studies in pigs, rats
wounds have less tensile strength during the early phase of healing (Pick et al 1990)
human skin fibroblasts and showed that collagen production and DNA synthesis were delayed when the fibroblasts were exposed to Nd: YAG laser radiation
Crespi et al evaluated the effects of CO2 laser
treatment on fibroblast attachment to root surfaces and concluded that CO2 laser treatment in defocused, pulsed mode with a low power of 2W combined with mechanical instrumentation constitutes a useful tool to condition the root surface and increase fibroblast attachment to root surfaces
(Ref: Journal of Periodontology)
attempted treatment of root fractures (Arakawa et al. 1996). However, regardless of the re-approximation technique, laser type, energy, and other parameters used, fusion of the fractured root halves was not achieved
Lasers (Ar, CO2, Nd:YAG lasers) have been used
successfully to sterilize dental instruments (Adrian & Gross 1979, Hooks et al. 1980, Powell & Whisenant 1991).
lasers) are capable of sterilizing selected dental instruments; however, the argon laser was able to do so consistenly at the lowest energy level of 1 W for 2 min
A pulsed dye laser emitted at 504 nm was used for the
aesthetic practice
There are five lasers that are currently in the
armamentarium
Argon lasers
The wavelength is absorbed by Hb
This attribute allows precision cutting, hemostasis &
coagulation of vascular tissue Use of argon lasers have been used for curing composites (at low power achieving higher bond strength) Transillumination in diagnosis of tooth fractuures
polymerization of composites However they increase heat generation and polymerization shrinkage stresses Studies have shown that they exhibit a narrow spectral output and do not coincide with the spectral requirements of all restorative resins Bleaching of stained teeth
Co2 Lasers
Used for vaporizing, cutting and coagulation of soft
tissue
Used more for soft tissue procedures which include
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
Erbium Family
Er lasers are absorbed by Hydroxyapatite and water
Allows to cut soft tissue, tooth structure and bone Er:YAG (2940 nm) cuts teeth easily & quickly
The Erbium laser used to remove the decay. No anesthesia was required
Definitive direct bonded restoration after preparation with the Erbium laser
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
These micro irregularities make the enamel surface
hard tissues after Er: YAG laser etching is inferior to that obtained after conventional acid etching (Martinez-Insua et al., 2000)
The weaker bond strength of the composite to laser-
etched enamel and dentine to the presence of subsurface fissuring after laser radiation. This fissuring is not seen in conventional etched surfaces
The subsurface fissuring contributed to the high
prevalence of cohesive tooth fractures in bonding of both laser-etched enamel and dentine
Caries prevention
Studies examined the possibility of using laser to
tissues modifies the calcium to phosphate ratio, reduces the carbonate to phosphorous ratio, and leads to the formation of more stable and less acid soluble compounds, reducing susceptibility to acid attack and caries
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)
the FDA
The laser is used to enhance the activation of bleaching
three minutes, then removed. This procedure is repeated four to six times
the CO2 laser is employed with another peroxidebased solution to promote penetration of the bleaching agent into the tooth to provide bleaching below the surface
The entire clinical time for this system ranges from one
laser interactions with hard tissue and the lack of controlled clinical studies, CO2 laser-assisted bleaching is not recommended (FDA)
Based on previously accepted uses of argon lasers and
associated temperature-rise studies, the use of the argon laser in place of a conventional curing light may be acceptable if the manufacturers suggested procedures are carefully followed (FDA)
with lasers
3 aspects to safety: Manufacturing process Proper operation of the device Personal protection
Regulatory Agencies
American National Standard Institute (ANSI) Food and Drug Administration (FDA) Center for devices and Radiological Health (CDRH) Occupational safety health administration (OSHA)
Laser Classification
Class I II Laser Properties Pose no health hazard e.g. CD Player 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
IIIa
IIIb
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 inflammable devices
IV
field Use non combustible anesthetics Avoid alcohol based topical anesthetics Avoid alcohol moistened gauze or cotton Fire Extinguisher Stay informed Follow ANSI regulations
Guidelines
Mention outside
Door Switch Fire hazards
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 eye wear is a must
Vitreous Humor as well as the lens which lead to Aqueous Flare & Cataract formation Retinal damage occurs due to lasers with more depth if penetration and is absorbed into the pigments (Argon, Diode, He:Ne)
than the skin WL from 400-1400 Protective glasses must have an Optical Density of at least 4 For specific high WL lasers like Nd:YAG & Diodes, there are specific eye wear Eyewear is designed to have adequate protection for a wide range of WLs Regardless of protection, NEVER look directly into the laser beam
pouches
Oil based aerosols must not be used
The wires and protective casing / housing should be
In Conclusion
Lasers New face of Dentistry Diverse applications High Cost Treatment Planning Adverse Effects
References
Pathways of Pulp (9th Ed.) S.Cohen
Art & Science of Operative Dentistry Sturdevant Textbook of Endodontics (6th Ed.) Ingle