Historical Perspective Introduction Fundamentals of dental lasers Laser Physics Lasers in Endodontics Operative & Aesthetic Dentistry Dental laser safety
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
y Early 1900 s y 1960 y 1965 y 1970 s y 1982 y 1987
Chinese & Egyptians (Phototherapy) Theodore Maiman Dr. Leon Goldman Nd:YAG Pick, Frame & Pecaro Meyer s Portable Laser
were the first to investigate the potential uses of the ruby laser in dentistry
Weichman & Johnson (1971) who attempted to seal the apical foramen in vitro by means of a high powerinfrared (CO2) laser
Fundamentals of Lasers
y Atoms are excited by an energy source and move to a higher energy y As it reverts back to its ground state, energy is emitted Spontaneous Emission y 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
y Is a part of a process that occurs inside the laser y An optical cavity is at the center of the laser device &
the core is comprised of chemical elements, molecules or compounds Active Medium y Lasers are generically named for the material of the active medium y Gas, Crystals or Semi-Conductors
y Gas
y Solid state semi conductors : y With metals like Gallium, Aluminum, Indium, Arsenic y With solid rods of garnet crystal growth with various combinations of Yytrium, Aluminum, Scandium, Gallium and then doped with elements of Chromium, Neodynium or Erbium.
characteristic wavelength
y These ware amplified and filtered to make a coherent
beam
y The effect of this energy depends on whether or not
Stimulated Emission
y Quantum theory of Max Planck & Neils Bohr y Smallest unit of energy y It can be absorbed by electrons, cause brief excitation
Radiation
y Refers to light waves produced by the laser as
electromagnetic energy
y EM Spectrum entire range Wavelength s y 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
y Active medium
Electric current
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
y In Gated Pulse Mode, there are periodic alterations of
True Pulsed
Lasers Used in
entistr
Classifications:
y Lasers are named according to:
Active medium Wavelength eliver s stems Emission modes Tissue absorption Clinical Application
Classifications:
I.
Nd: YAG
b)
Argon, Co2, diode; Nd:YAG. Hard tissue laser - Er : YAG Resin curing laser - Argon
YAG laser.
Wavelength
Argon
y Active medium is Argon gas y Fiber optically delivered y Continuous wave & Gated Pulsed modes y Only laser whose light is in the visible spectrum y 2 wavelengths are used: y 488 nm (Blue) y 514 nm (Blue-Green)
in composite resins
y The beam divergence of this blue light is used in non-
contact mode, produces excessive amount of photons thus providing curing energy
y More strength in cured resin when compared to
y 514 nm has its peak absorption in tissues containing Hb, Hemosiderin and Melanin y Has excellent hemostatic capabilities y Small diameter flexible glass fiber is used for delivery y Used in contact mode y Used in Surgical Endodontics y Acute inflammatory Periodontal conditions and highly vascularized lesions such as Hemangioma
water
y Minimal interaction and no damage to tooth surface y Both can be used for caries detection y Argon laser light illuminates the tooth, the disease
Diode
y Is a solid active medium laser y Manufactured from semiconductor crystals using y
y y y
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
y Diode WL are highly absorbed by pigmented tissue and deeply penetrating, though hemostasis is not as rapid as with Argon laser y Poorly absorbed by tooth tissues y Soft tissue surgeries can be performed near tooth y Causes a rapid increase in temperature thus, surgical site needs to be air or water cooled y Diode is an excellent soft tissue surgical laser y Small size & Portable
fluorescence from carious tooth structure, which is reflected back into a detector device in the unit
degree of caries
Neodynium:YAG (Nd:YAG)
y Has a solid state active medium, which is a garnet
y y y y
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
y Laser light is highly absorbed by melanin y Clinical applications include cutting and coagulating
soft tissues
y Energy is slightly absorbed by dental hard tissues but
there is little interaction between sound tooth structure following soft tissue surgery
y Pigmented surface carious lesions can be vaporized
Holmium:YAG
y Consists of a solid crystal of Yytrium, Aluminum
Garnet sensitized with Chromium and doped with Holmium and Thulium ions
y Delivered via Fiber optic cable y Free running pulsed mode y Wavelength is 2100 nm y Absorbed by water 1000 times more than Nd:YAG
y Using peak powers it can ablate hard calcified tissues y As a soft tissue laser instrument it does not react with
Er Cr:YSGG
y Erbium Chromium:Yytrium Scandium Gallium Garnet y Wavelength
2780 nm
y Delivered via fiber optics y Free running pulsed mode y Fiber cable diameter is much larger and requires an air
or water coolant
Er:YAG
y Erbium: Yytrium, Aluminum Garnet y Wavelength is 2940 nm y Delivered via hollow tube and fiber optic cable y Free running pulsed mode
crystal and into water that is bound to the crystalline structures of tooth
y Caries removal and tooth preparation can be easily
carried out
y The increased water content in carious lesions allows
CO2
y Gas active medium laser y Co2 pumped via electrical discharge
y Wavelength is 10,600 nm y Delivered via hollow tube or wave guide y Continuous or Gated pulsed mode
y Well absorbed by all biological hard & soft tissues y Can easily cut and coagulate soft tissue y Has a shallow depth of penetration into tissue y The laser energy is delivered by a hollow wave guide in a non contact fashion y This WL has the highest absorption in hydroxyapatite of any dental laser y Thus tooth must be protected during soft tissue application
suitable for cutting and drilling enamel & dentin as the damage to the dental pulp may occur
target tissue
y 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
y 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 ndodontic Surgery
Dental Hypersensitivity
y Characterized as short, sharp pain from exposed
dentin that occurs in response to provoking stimuli such as cold, heat or chemicals
y Not ascribed to any other dental defect or pathology y Can be attributed to non carious tooth loss (Wasting
diseases)
y Various treatment modalities y Blocking the dentinal fluid flow y Application of various agents to exposed dentinal
tubule
on 2 possible mechanisms
y 1st mechanism
implies direct effect of laser irradiation on the electric activity of nerve fibers within the dental pulp modification of the tubular structure of dentin by melting and fusing of the hard tissue or smear layer and subsequent sealing of dentinal tubules
y 2nd mechanism
anti-inflammatory effect
y Have an ability to stimulate the nerve cells y Senda et al were the first to apply He-Ne lasers y 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
y Microradiography and Electron probe analysis
irradiated dentin, recrystallization had occurred and dentin had changed to look like the original
Pulp Diagnosis
y 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)
y Helium
mW
y Wavelength is 632.8 nm y Laser beam is directed towards the tooth (to the blood
vessels)
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
y Advantages over EPT: y Can be used in traumatized teeth y Does not rely on painful sensation to determine vitality
3;48:3.)
dental material such as Calcium hydroxide or MTA is placed over a pulpal wound to encourage the formation of reparative dentin
y 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
y Moritz et al used Co2 laser for direct pulp capping y The energy level of 1 W at 0.1 second exposure time
hydroxyapatite of enamel and dentin, causing tissue ablation, melting and re-solidification
y 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
y It also has the potential to kill the microorganisms y 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
y There may be thermal damage to the periapical tissues y May be hazardous when the tooth apex is near vital
y Stabholz et al developed a new endodontic tip that can be used with Er:YAG laser
y It is delivered via a hollow tube allows lateral emission of the irradiation (side-firing), rather than direct emission through a single opening y 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
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.)
y 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
y 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)
system must be taken to protect against spreading infections when using lasers in the root canal (McKinley Ludlow 1994)
activated resins for obturation is possible using an Ar laser emitting at 477 and 488 nm (Potts Petrou 199 , 1991)
y The results indicate that an Ar laser coupled to an
material AH-26 & AH Plus (Zaman et al. 1994) and composite resin (Anic et al. 1995)
compacted resin fillings showed fewer voids than those obtained by vertical compaction (Kitamura et al, 2 5)
y 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
y A suitable wavelength has not been ascertained y Effect on the sealer per se has to be determined
Retreatment
y Rationale for using lasers in retreatment is ascribed to
y y y y
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
can be avoided
foramen of freshly extracted teeth in which the pulp had been removed
y 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
y The potential of the Er:YAG laser to cut hard dental
tissues without significant thermal or structural damage eliminates the need for mechanical drills
y 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
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
y Good hemostasis y Improved visualization of surgical site y Sterilization operative field y Reduced permeability of root surface dentin y Reduction in post operative pain y Reduced risk of contamination of surgical site by
Constraints
y Time Consuming y Increase temperature y Cause irreversible pulpal damage y Needs precise execution y Increased cost of treatment
quickly and produce less scar tissue than conventional scalpel surgery.
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
y 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
successfully to sterilize dental instruments (Adrian Gross 1979, Hooks et al. 198 , 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
y A pulsed dye laser emitted at 504 nm was used for the
aesthetic practice
y There are five lasers that are currently in the
armamentarium
Argon lasers
y The wavelength is absorbed by Hb y This attribute allows precision cutting, hemostasis &
coagulation of vascular tissue y Use of argon lasers have been used for curing composites (at low power achieving higher bond strength) y Transillumination in diagnosis of tooth fractuures
polymerization of composites y However they increase heat generation and polymerization shrinkage stresses y Studies have shown that they exhibit a narrow spectral output and do not coincide with the spectral requirements of all restorative resins y Bleaching of stained teeth
Co2 Lasers
y Used for vaporizing, cutting and coagulation of soft
tissue
y Used more for soft tissue procedures which include
Diode Lasers
y 2 different WL are used y Ga-Al-As Laser (800 nm) & In-Ga-As (980 nm) y These are used in contact mode for cavity preparation,
removal of bacterial contamination and coagulation of tissue y Also used for Diagnosis
Erbium Family
y Er lasers are absorbed by Hydroxyapatite and water y Allows to cut soft tissue, tooth structure and bone y Er:YAG (2940 nm) cuts teeth easily & quickly y Also used for removal of caries (excavation)
The Erbium laser used to remove the deca . No anesthesia was required
Definitive direct bonded restoration after preparation with the Erbium laser
Etching
y 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
y 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., 2 )
etched enamel and dentine to the presence of subsurface fissuring after laser radiation. This fissuring is not seen in conventional etched surfaces
prevalence of cohesive tooth fractures in bonding of both laser-etched enamel and dentine
Caries prevention
y Studies examined the possibility of using laser to
; Apel et al., 2
3)
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., 2 1; Arimoto et al., 2 1)
y 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 CO2 laser is employed with another peroxidebased solution to promote penetration of the bleaching agent into the tooth to provide bleaching below the surface
y 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)
associated temperature-rise studies, the use of the argon laser in place of a conventional curing light may be acceptable if the manufacturer s suggested procedures are carefully followed (FDA)
with lasers
y 3 aspects to safety: y Manufacturing process y Proper operation of the device y Personal protection
Regulatory Agencies
y American National Standard Institute (ANSI) y Food and Drug Administration (FDA) y Center for devices and Radiological Health (CDRH) y Occupational safety health administration (OSHA)
Laser Classification
Class I II Laser roperties 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 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
IIIa
IIIb
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
y Mention outside y Door Switch y Fire hazards
Eye Protection
y In 1962, the awareness to eye
protection began
injury
to the eye
Vitreous Humor as well as the lens which lead to Aqueous Flare & Cataract formation y 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 WL s Regardless of protection, NEVER look directly into the laser beam
pouches
y Oil based aerosols must not be used y The wires and protective casing / housing should be
In Conclusion
y Lasers
5)
References
y Pathways of Pulp (9th Ed.) y y y y y y y
S.Cohen Art & Science of Operative Dentistry Sturdevant Textbook of Endodontics (6th Ed.) Ingle DCNA 2000, 2005 Journal of Endodontics International Endodontic Journal Journal of American Dental Association British Dental Journal