Lasers in Medical Science (2018) 33:1621–1629

https://doi.org/10.1007/s10103-018-2588-4

REVIEW ARTICLE

Laser pulpotomy—an effective alternative to conventional

techniques—a systematic review of literature and meta-analysis
Ghassem Ansari 1 & Hanane Safi Aghdam 2 & Pardis Taheri 3 & Mitra Ghazizadeh Ahsaie 4

Received: 26 December 2017 / Accepted: 9 July 2018 / Published online: 17 July 2018
# Springer-Verlag London Ltd., part of Springer Nature 2018

Abstract
The aim of this systematic review and subsequent meta-analysis was to elaborate the efficacy of laser pulpotomy over the
formocresol pulpotomy of human primary teeth. Published materials in the MedLine were looked for through BPUBMED^ and
BPUBMED CENTRAL^. The MESH terms of BLaser^, BPulpotomy^, BPrimary teeth^, and BChildren^ were used to carry the
search from the years 1999 to 2017. Collected data were assessed by four investigators using inclusion and exclusion criteria in order
to select those studies with precise method targeted. Only clinical trials on all types of lasers were included for this systematic
reviews but only four articles were used for the meta-analysis as the rest did not meet the requirements. Statistical analysis was
conducted to see the differences. Seventeen articles completely fulfilled the inclusion criteria of this study. In general, high clinical,
radiographic, and histopathological success rates were reported in laser groups in comparison to other assessed methods. Meta-
analysis indicated that except at 36 months, in all other time intervals, Laser proved better or close results to formocresol. At
36 months, laser showed better clinical results. Laser may be considered as an adjuvant alternative for vital pulp therapy on human
primary teeth but due to the limited number of high-quality clinical research articles on laser-assisted pulpotomy, various types of
laser application methods, and different follow-up periods, reaching a net consensus is still challenging.

Keywords Laser . Pulpotomy . Primary teeth . Children

Introduction acceptance in randomized clinical trials [4–7].Pulpotomy ther-

The early primary tooth loss due to caries and infection has
strong influence on the skeletal growth and tooth develop-
ment, child’s oral function, esthetic and even phonetic; there-
fore, the preservation of natural dentition is important [1, 2].
The most common therapy for reversible pulp infection in
primary molar teeth is pulpotomy which lets the teeth remain
in the oral cavity until its exfoliation time comes [3]. This
method has attained wide clinically and radiographically
* Mitra Ghazizadeh Ahsaie
mitraghazizadeh@gmail.com
1
Department of Pediatric Dentistry, Shahid Beheshti University of
Medical Sciences, Tehran, Iran
2
Dentistry school, Shahid Beheshti University of Medical Sciences,
Tehran, Iran
3
Alborz University of Medical Sciences, Karaj, Iran
4
Department of Oral and Maxillofacial Radiology, Dental School,
Shahid Beheshti University of Medical Sciences, Tehran, Iran
apy aims at maintaining a carious tooth by removing the cor-
onal portion of the infected pulp, while preserving the unin-
fected radicular pulpal tissue. Various techniques and mate-
rials have been recommended for these purposes, such as
formocresol, glutaraldehyde, ferric sulfate, calcium hydrox-
ide, mineral trioxide aggregate (MTA), and laser therapy, but
a consensus on the ideal pulpotomy technique has not yet been
reached. During the past decades, formocresol has been the
most common pulp dressing material for pulpotomy of prima-
ry molars. This material was even considered gold standard
technique with clinical success rate of 70–97% [8]. However,
the use of formocresol became a concern due to various re-
ports on its hazardous adverse effects such as cytotoxicity,
potential carcinogenicity and mutagenicity, immune
sentisization, and wide tissue distribution beyond the apex
which may affect permanent successors [3, 8–10]. In order
not to meet these disadvantages, different materials and tech-
niques have been suggested in aims of a better pulp therapy in
primary dentition such as calcium hydroxide, bone morpho-
genic protein, glutaraldehyde, ferric sulfate, and mineral triox-
ide aggregate (MTA) [10, 11]. But due to lack of standard
1622
clinical controlled trials, their long-term biological effects are
still not fully understood as these materials remain in the tooth
until it exfoliates.
In recent years, the application of laser has been recommend-
ed in several endodontic aspects including treatment of dentinal
hyper sensitivity, pulp capping, sterilization of root canals, root
canal shaping, and obturation and pulpotomy of primary teeth
as an alternative to the conventional formocresol [12]. In con-
ventional pulpotomy procedure, the coronal pulp is amputated
either with a round bur on a low speed hand piece or with a
sharp spoon excavator. After achieving hemostasis, the pulp is
then irradiated at the canal orifices by the optimum laser power
to achieve pulp tissue coagulation while in the case of LLLT for
healing promotion (no laser coagulation) [4, 7, 13].
Studies have shown that laser overcomes histologic deficits
and can accelerate wound healing. It is also hemostatic, antimi-
crobial, and has cell-stimulating potentials [11, 13]. The laser
beam has no mechanical damage on the remaining pulp tissue
as it has no mechanical contact with it and only slightly in-
creases pulp’s thermal degree [5, 13]. Based on these character-
istics, various authors, such as Ghajari et al., Fernandes et al.,
and Saltzman et al., have claimed substantial benefits of the use
of laser over conventional techniques for pulp therapy [4, 6, 8].
Different laser types such as CO 2 , argon, Er:YAG,
Er,Cr:YSGG [14], Nd:YAG, and diode are being used in dif-
ferent settings and treating different tooth types in patients of
varying age, resulting in confusing evidence.
The aim of this systematic review and subsequent meta-
analysis was to elaborate the efficacy of laser pulpotomy over
the formocresol pulpotomy of human primary teeth.
Methods and material
Search strategy
To access relevant articles, an electronic search in MEDLINE
(via PubMed), Google scholar, Science Direct, and Cochrane
Fig. 1 Flowchart, study selection
procedure
Lasers Med Sci (2018) 33:1621–1629
library was conducted from Jan 1999 to November 2017.
English language published papers were looked for using the
f o l l o w i n g k e y w o r d s : ( ( BL a s e r s ^[ M e s h ] ) A N D
BPulpotomy^[Mesh]) AND BTooth, Deciduous^[Mesh]. All
four reviewers (Ansari, Taheri, Safiaghdam, Ghazizadeh) had
contributed to the search and evaluated the article database and
checked the reference list of relevant articles and previous re-
views on the subject (REF 2 articles). Initial paper selection was
done by two authors examining titles and abstracts of all select-
ed papers. The full texts of potentially suitable articles were
obtained for final assessment according to the exclusion and
inclusion criteria. Authors discussed the articles to reach a con-
sensus when their opinions differed. Figure 1 summarizes the
study selection process in a flowchart. The following data were
extracted from the studies and the corresponding authors of the
articles were contacted in case of missing data: study design,
sample size, mean age, tooth type, follow-up time, pulpotomy
agents and laser characteristics (wavelength, frequency, energy
density, and power), restorative material, evaluation criteria,
and clinical, radiographic, and histopathological success rate.
P values were also extracted from the articles.
Inclusion criteria
All the original in vivo studies applying laser or low level laser
on primary dentition in aims of pulp therapy were included in
this study. All animal studies and in vitro studies were exclud-
ed. Studies assessing the effect of laser in direct and in direct
pulp capping or other aims except for pulpotomy were exclud-
ed. Also, studies assessing the effect of laser pulpotomy on
permanent dentition were excluded.
Meta-analysis
The meta-analysis was performed in Meta XL 2.2 for only
four studies as the other studies did not meet the inclusion
criteria for this meta-analysis [4, 15–17]. The pooled propor-
tion of success cases in laser over formocresol, according to
Lasers Med Sci (2018) 33:1621–1629
clinical and radiographical results, in 6, 9, 12, and 36 months
were calculated and reported.
Results
Study selection
The Pubmed Search Provided 52 hits, Google Scholar search
70 hits, and Cochrane Search 11 hits. Following the initial
screening of titles and abstracts and final screening of full
texts, 17 articles completely fulfilled the inclusion criteria of
this study (Fig. 1). All original data are summarized in Table 1
and Table 2 in order to allow more convenient illustration of
the data. Table 1 demonstrates LLLT laser (no pulp tissue
coagulation with laser) and Table 2 shows all the other laser
treatments (pulp tissue coagulation).
All 17 studies used primary molars as their target teeth for
pulpotomy while no distinction was detected between first and
second molars. There was one study where the pulpotomy
process was carried out on primary canines [22].
Before laser use, in all the studies, the coronal pulp was
removed with low speed or high speed round bur and later with
sharp spoon excavator [1–17]. Total sample population varied
between different studies stand on 20 to 200 treated primary
molar teeth. Different materials had been applied such as min-
eral trioxide aggregate (MTA) [6, 18, 23], calcium hydroxide
(CH) [4, 5, 7, 19, 20], formocresol (FC) [3–7, 10, 15–17, 19],
ferric sulfate (FS) [3, 5, 7, 13, 24], zinc oxide eugenol (ZOE) [6,
19, 21, 24], and biodentin [23] with their success rate being
compared to lasers. Various types of lasers were reported being
used such as: diode [3, 6, 13, 24], Er:YAG [5, 7, 20], Nd:YAG
[15–17, 20, 22], He-Ne [17], CO2 (25), and low level laser
(LLLT) [4, 10, 18, 19] within these studies. In addition, two
studies assessed electrosurgery in comparison to laser [13, 24].
Assessment tests contained radiographic and clinical eval-
uations. Three studies had an additional histopathologic as-
sessment on the teeth after their exfoliation [6, 17, 19].
Follow-up intervals were every 3 months and lasted up to
1 year. One study had a follow-up of up to 66 months [15].
In general, high clinical, radiographic, and histopathologi-
cal success rate were reported in laser groups in comparison to
other assessed methods.
According to Tables 3, 4, 5, 6, and 7, meta-analysis indi-
cated that except at 36 months, in all other time intervals, laser
proved better or close results to formocresol. At 36 months,
laser showed better clinical results.
Discussion
A successful treatment of pulp is the main aim of pulp therapy
in a child patient in order to retain a tooth in a healthy condition
1623
(3). As a widely accepted medicament, formocresol is known to
be the gold standard in primary dentition pulp therapy.
However, recent reports of its tissue destruction and toxicity
put the use of this material in danger [9]. Therefore, several
other techniques such as electrosurgery and lasers have been
introduced as an alternative to formocresol [25]. Laser pulp
therapy has shown promising results as it can reduce pulpal
inflammation and improve its healing. Laser can also improve
formation of fibrous matrix and hard tissue barrier [26].
It is widely acknowledged that any pulp treatment may be
judged successful after 6- or 12-month period as most of the
inflammatory responses would not present their signs and
symptoms before a year is passed. In this line, it is recommend-
ed to make sure all pulp-treated teeth are followed for 24 months
minimum before they can be judged reliably successful.
Therefore, only clinical investigation with a 2-year follow-up
is considered standard for pulpotomy in primary molar teeth
according to CONSORT 2010. In this study, most of the studies
have at least 1 year of follow-up (Tables 1 and 2).
Child’s response to clinical evaluation tests such as pain may
not be reliable [27]. Children of young age are most learning
and under constant training. Their response to any stimuli is
influenced by various factors [28]. This is why their response
to pain perception is highly variable and therefore unreliable in
clinical situations, where teeth have been treated with substan-
tial pulpotomy process, they have received substantial amount
of stimulation which can be simply presented by pain regardless
of its existence. Dentist’s experience and education can signif-
icantly help for better diagnosis of child’s pain.
In this study, 16 randomized clinical trials and 1 case report
were assessed. Studies varied in their type of laser, laser char-
acteristics, follow-up periods, and results. The results were
heterogeneous; in five studies, laser pulpotomy was signifi-
cantly more successful than conventional methods (Tables 1
and 2); on the contrary, seven studies showed no significant
clinical or radiographic success rate difference between laser
and other groups (Tables 1 and 2). One study compared the
success rate of electrosurgery (ES) to laser [18]. In the study of
Marques et al., clinical, radiographic, and histopathological
results showed that laser is significantly more successful
[19] whereas in the study of Odabas et al., the results of his-
topathology were only significant but the teeth showed no
significant differences clinically or radiographically [17].
Two studies did not indicate any p value or significant param-
eter [16, 22]. Uloopi et al. (2016) compared the effectiveness
of LLLT (WL: 810 nm, E: 2 J/cm2) and MTA in pulpotomy of
primary molars. Radiographic and clinical findings indicated
no significant differences on the success rate between the two
groups after 1-year follow-up (LLLT: 80%, MTA: 94.7%, P =
0.169) [18]. Fernandez et al. (2015) compared the clinical and
radiographic effectiveness of LLLT (WL: 660 nm, E: 2.5 J/
cm2), diluted FC and CH on primary molar pulpotomy. A
100% success rate was reported for all groups after 18 months
Table 1 Overview of the pulpotomy studies using low level laser therapy (no pulp tissue coagulation with laser)
1624

NO Author and year Type of Tooth Sample Material for Laser characteristics Assessment tests Follow-up Results P value
study size pulpotomy
WL E P F
(nm) (J/cm2) (mW-W) (Hz)

1 Uloopi et al., In vivo Primary 40 • LLLT (Diode) 810 2 1.Radiography 3, 6, 12 M Success rate 3 M: (p = 0.976)
2016 [18] molar • MTA 2.Clinical 3 M: 6 M: (p = 0.316)
LLLT: 95% 12 M:(p = 0.169)
MTA: 94.7%
6 M:
LLLT: 85%
MTA: 94.7%
12 M:
LLLT: 80%
MTA: 94.7%
2 Fernandes et al., In vivo Primary 60 • Diluted FC 660 2.5 10 mW 1.Radiography 6, 12, 18 M Clinical success rate: P < 0.05
2015 [4] molar • CH 2.Clinical All groups: 100%
• LLLT Radiographic success rate:
• LLLT + CH 6 M:
FC: 100%, LLLT +CH: 85.7%,
LLLT: 80%,
CH:60%
12 M:
FC: 100%, LLLT: 80%, LLLT + CH:
78.6%, CH: 50%
18 M:
FC: 100%, LLLT + CH: 75%, LLLT:
73.3%CH: 66.7%
Internal resorption was seen in LLLT,
CH, LLLT+ CH groups.
3 Marques et al., In vivo Primary 20 • Buckley’s FC 660 2.5 10mw 50–60 1.Radiography 3- monthly Clinical and radiographic P < 0.05
2014 [19] molar (diluted at 1:5) 2.Clinical intervals success rate in all groups were seen.
• CH 3.Histopathological Histopathological success rate:
• LLLT+ ZOE statistically significant differences
• LLLT+ CH among groups
LLLT + CH:
lowest degree of pulpal inflammation
CH:
highest rate of hard tissue barrier,
odontoblastic layer, and dense
collagen fibers.
FC:
Highest incidence of
internal resorption.
4 Golpayegani et al., In vivo Primary 46 • LLLT 632 4 1.Radiography 6M Success rate: P > 0.05
2018 [10] molar • FC 2.Clinical LLLT:100%
FC:100%

CH calcium hydroxide, D day, E energy, Ed energy density, ES electrosurgery, FC formocresol, FS ferric sulfate, LLLT low level laser therapy, M month, MTA mineral trioxide aggregate, P power, S second,
W watt, ZOE zinc oxide eugenol
Lasers Med Sci (2018) 33:1621–1629
Table 2 Overview of the pulpotomy studies using Er:YAG, Nd:YAG, Diode, CO2 lasers (pulp tissue coagulation with laser)

NO Author Type of Tooth Sample size Material for Laser characteristics Assessment tests Follow-up Results P value
and year study pulpotomy
WL E P F
(nm) (J/cm2) (mW-W) (Hz)

5 Huth et al., In vivo Primary 200 • Er:YAG laser, 2940 180 mJ 2 1.Radiography 12, 18, 24 36 M Total and P > 0.05
2012 [7] molar • CH 2.Clinical clinical (placed compared to
• FS parenthetically) formocresol,
• diluted FC success rates for the only calcium
Lasers Med Sci (2018) 33:1621–1629

different methods hydroxide

(%) performed
12 M: significantly
FC: 96 (100), laser: worse
93 (98), CH: 86 (95), (p = 0.001)
FS: 86 (100).
24 M:
FC: 85 (96), laser:
78 (93),
CH: 53 (87), FS:
86 (100).
36 M:
FC: 72 (92), laser 73 (89),
CH: 46 (75),
FS: 76 (97).
6 Odabas et al., In vivo Primary 42 • Nd:YAG laser 1064 100 mJ 2W 20 1.Radiography 1, 3, 6, 9, Clinical success rate: P > 0.05
2006 [17] molar He-Ne laser 2.clinical 12 M Laser:
• 1:5 dilution of FC 3.Histopathological 1& 3 M: 100%
6 M: 90.47%
9&12 M: 85.71%
FC:
1 & 3 M: 100%
6,9,12 M: 90.47%
Radiographic
success rate:
Laser:
1 M: 100%
3 M: 90.47%
6 M: 80.75%
9, 12 M: 71.42%
FC:
1, 3 M: 100%
6, 9, 12 M: 90.47%
Histopathological
success rate:
statistically significant
difference between
7- and 60-day laser
groups with regard to
inflammatory cell
response criteria
(p < 0.05).
1625
Table 2 (continued)
1626

NO Author Type of Tooth Sample size Material for Laser characteristics Assessment tests Follow-up Results P value
and year study pulpotomy
WL E P F
(nm) (J/cm2) (mW-W) (Hz)

Statistically significant
differences between
both 7-day laser and
FC groups and 7- and
60-day FC groups with
regard to tissue
disorganization (p < 0.05)
7 Liu et al., In vivo Primary 137 • Nd:YAG laser 1064 124 2W 20 1.Radiography 6 to 64 M Clinical success rate: P < 0.05
2006 [15] molar • FC 2. clinical 9 to 66 M Laser: 97%
FC: 85.5%
Radiographic success
rate:
Laser: 94.1%
FC: 78.3%
8 Furze et al., Case report Primary 65 • Er:YAG laser 2940 400 2W 10–15 1.Radiography 3,6,9,12,24,36,48 M Success rate:
2006 [20] molar Nd:YAG laser 1064 20 2.Clinical 95.38%
With cappings
- Ca(OH)2
- Ca(OH)2 +
iodoform
- glass ionomer
cement
9 Saltzman et al., In vivo Primary 52 • DL-MTA 980 3W 1.Radiography 2·3, 5·2, 9·5, 15·7 M Clinical success rate: P > 0.05
2005 [6] molar • FC-ZOE 2. Clinical All teeth were assessed
3.Histopathologically as clinically
sound at each
Follow-up visit.
Radiographic
success rate:
Laser- MTA: 70.84%
FC- ZOE: 87.5%
10 Huth et al., In vivo Primary 200 • Er:YAG laser, 2940 180 mJ 2 Clinical 6, 12, 18, 24 M Total and clinical (placed P > 0.05
2005 [5] molar • CH parenthetically) success Compared to
• FS rates for the different FC only CH
• dilute FC methods (%): performed
12 M: significantly
FC: 96 (100), laser: 93 worse
(98), CH: 86 (95); (p = 0.001)
and FS: 86 (100).
24 M:
FC: 85 (96), laser: 78
(93),CH: 53 (87);
and FS: 86 (100).
11 Liu et al., In vivo Primary 75 • Nd:YAG laser 1064 100 mJ 2W 20 1.Radiography 6–48 M Clinical success rate: –
2003 [16] molar • FC 2. Clinical Laser: 96.9%
FC: 88.2%
Lasers Med Sci (2018) 33:1621–1629
Lasers Med Sci (2018) 33:1621–1629 1627

CH calcium hydroxide, HCo2 carbon dioxide, D day, DL diode laser, E energy, Ed energy density, FC formocresol, FS ferric sulfate, LLLT low level laser therapy, M month, MTA mineral trioxide
Table 3 Six-month laser vs FC radiographic success
P value Study RR 95%CI Weight

Fernandes 2015 0.806 0.613–1.060 45.3

–
Odabas 2006 0.895 0.697–1.148 54.6
pooled 0.854 0.710–1.026 100

Clinical success rate:

High clinical and

radiographical
success rate:

success rate:

success rate.
RR relative risk, CI confidence interval
Radiographic

Radiographic
Laser: 90.6%
FC: 82.3%
Results

98.1%

91.8%
of follow-up. Radiographic findings suggested 100% success
rate for FC, 75% in LLLT+ CH, 73.3% in LLLT alone, and
66.7% for CH groups. Internal resorption was a reported find-
Follow-up

12 to27 M

ing in LLLT, CH, and LLLT+ CH groups [4]. Niranjani et al.,

reported no significant differences between the clinical and
18 M

radiographic outcomes of MTA, diode laser (WL: 810 nm,

P: 1.5 W), and biodentine pulpotomy in primary molar teeth
Assessment tests

at 3- and 6-month follow-up (p > 0.05) [23]. Gupta et al.

1. Radiography
1. radiography

(2015) compared the clinical and radiographic success rates

2. Clinical

2.Clinical

of ferric sulfate, electrosurgery, and diode laser (WL: 980 nm,

P: 3 W) in pulpotomy and reported 100% success rate for
diode laser after 12 months with significant difference when
(J/cm2) (mW-W) (Hz)

compared to that of the other two groups (ES: 80%, FS: 80%,
20
F

P < 0.05) [13].

Marques et al. (2014) compared pulpotomy of primary
3W

2W
Laser characteristics

teeth with diluted FC, CH, LLLT+ ZOE, and LLLT+CH

P

through their clinical, radiographic, and histopathologic suc-

100 mJ

cess rates. Six- and twelve month-follow-up revealed that clin-

E

ical and radiographic success rate of all four groups to be high

(nm)

and acceptable. Histopathologic results indicated that signifi-

1060
WL

800

cant differences among the groups (p < 0.05) with LLLT+ CH

showed the lowest degree of pulpal inflammation (p = 0.029)
• CO2 Laser-ZOE

• Nd:YAG laser

while CH group showed highest rate of hard tissue barrier

Sample size Material for
pulpotomy

(p = 0.0033), odontoblastic layer (p = 0.0033), and dense col-

aggregate, P power, S second, W watt, w week, ZOE zinc oxide eugenol

lagen fibers (p = 0.0095). In the other hand, FC group showed

highest incident of internal resorption (p = 0.0142) [19].
Comparing the clinical and radiographic success rate of FS,
primary

canine)
molars
and 2

ES, and diode laser (810 nm, 7 W) in another investigation

primary
23 (21
212

Table 4 Nine-month laser vs FC clinical and radiographical success

canine
molar

molar
Primary

Primary

Primary
Tooth

Study RR 95%CI Weight

Case report

Clinical success Odabas 2006 0.947 0.758–1.184 2.097

Type of

In vivo

Liu 2006 1.000 0.960–1.041 62.7

study

Liu 2003 1.019 0.965–1.077 35.1

Pooled 1.005 0.974–1.039 100
Table 2 (continued)

Radiographic success Odabas 2006 0.789 0.583–1.070 2.082

Pescheck et al.,
2002 [21]

1999 [22]

Liu 2006 1.030 0.972–1.092 57.0

and year

Liu et al.,
NO Author

Liu 2003 1.020 0.952–1.092 40.8

Pooled 1.020 0.976–1.066 100
12

13

RR relative risk, CI confidence interval

1628 Lasers Med Sci (2018) 33:1621–1629

Table 5 Twelve-month laser VS FC radiographic success, random model Table 7 Thirty-six-month laser VS FC clinical and radiographical success

Study RR 95% CI Weight Study RR 95%CI weight

Fernandes 2015 0.806 0.613 1.060 4.561 Clinical success Liu 2003 1.259 1.006–1.575 69.5
Liu 2003 1.001 0.942 1.065 91.5 Liu 2006 1.203 0.857–1.688 30.4
Odabas 2005 0.789 0.583 1.070 3.772 Pooled 1.242 1.030–1.497 100
Pooled 0.983 0.790 1.221 100 Radiographic success Liu 2003 1.000 0.690–1.448 17.3
Liu 2006 1.099 0.927–1.302 82.6
RR relative risk, CI confidence interval
Pooled 1.081 0.926–1.262 100

RR relative risk, CI confidence interval

was reported as 80% in all three groups. Clinical success rate

of FS was 86.6%, while this rate was 100% for both ES and
diode laser (p = 0.99) [24].
Diode laser (WL: 810 nm, E: 50 mJ, F = 30 Hz) pulpotomy
was reported as an acceptable alternative to FC and FS
pulpotomy. Twelve-month follow-up indicated 97% clinical
success rates for FC while this figure was at 95% for FS and
100% for diode laser. However, radiographic success rates were
at 87, 79, and 75% for FC, FS, and diode laser, respectively [3].
Huth et al. (2012) compared relative effectiveness of Er.YAG
laser (WL: 2.94 μm, E: 180 mJ, F = 2 Hz), CH, FS, and diluted
FC in primary molar pulpotomy. After 36 months of follow-up,
the total success rate was 72, 73, 46, and 76% for FC, laser, CH,
and FS, respectively (p > 0.05) [7]. Golpayegani et al. (2018)
compared the effectiveness of LLLT (WL: 632 nm, E: 4 J/cm2)
and conventional FC in pulpotomy of primary molars. Six- and
12-month follow-up was reported with 100% success rate on
both groups with no significant difference [10]. Odabas et al.
(2006) compared the clinical, radiographic, and histopathologic
effects of Nd:YAG laser (P: 2 W, F = 20 Hz, E: 100 mJ)
pulpotomy to FC pulpotomy on primary molars. Clinical and
radiographic findings indicated no statistical significant differ-
ence between the two groups after 12-month follow-up (laser
success; radiographic: 71.42%, FC success; radiographic:
90.47%, laser success; clinical: 85.71%, FC success; clinical:
90.47%). Histopathological evidence suggests that difference
between success rate 7- and 60-day laser groups was statistical-
ly significant based on the inflammatory cell response (p <
0.05). Statistically significant differences were also found be-
tween 7-day outcome of laser and FC groups. This difference
was significant between the outcome of the FC groups at 7 and
60 days based on the tissue disorganization (p < 0.05) [17].
Table 6 Eighteen-month laser VS FC radiographic success, random model
Study RR 95%CI Weight
Fernandes 2015 0.742 0.539–1.021 7..886
Liu 2006 1.048 0.954–1.150 92.1
Pooled 1.019 0.687–1.514 100
RR relative risk, CI confidence interval
Comparing the effects of Nd:YAG laser (WL: 1064 nm, F =
20 Hz, E: 100 mJ), pulpotomy to FC pulpotomy with 66-month
follow-up showed 97% clinical success rate for laser to 85.5%
FC success rate (p = 0.042). Radiographic success rate was
94.1% for laser compared to 78.3% in FC group (p = 0.035)
[15]. Saltzman et al. (2005) investigated diode laser pulpotomy
(WL: 980 nm, P: 3 W) with MTA seal as an acceptable alter-
native to the conventional FC pulpotomy with ZOE. Clinical
results showed that all teeth were symptomless at all follow-up
visits. Radiographic success rate was 70.84% in laser-MTA and
87.5% in FC-ZOE groups (P > 0·05) [6].
Huth et al. (2005) compared the relative effectiveness of
the Er:YAG laser (WL: 2.94 μm, F = Hz frequency, E:
180 mJ), CH, and FS techniques with that of dilute FC on
primary molars that remain symptomless. After 24 months,
total success rates of FC, laser, CH, and FS were: 85, 78, 53,
and 86%, respectively. Only CH performed significantly
worse than others (p = 0.001) [5]. Liu et al. (2003) evaluated
the effects of Nd:YAG laser (P:2 W, F = 20 Hz) pulpotomy on
human primary teeth at 48 months with the clinical success
rate of 96.9% for laser and 88.2% for FC. Radiographic suc-
cess rate of laser was 90.6 and 82.3% for FC groups [16].
Pescheck et al. (2002) assessed the clinical and radiographic
success rate of CO2 laser +ZOE (1060 nm, 3 W) on 212
primary molars and concluded that laser could illustrate more
than 90% success rate after 18 months [21]. Liu et al. (1999)
had reported a case on the effect of Nd.YAG laser (WL:
800 nm, P: 2 W, F = 20 Hz frequency) pulpotomy of primary
canines. High clinical and radiographical success rates were
reported after 27-month follow-up [22].
Based on the nature and wavelength of LLLT, it is expected
to only affect pulpal tissue at its biological capacity with no
physical evidence of any change at the surface tissue [18],
while the latter is seen with most of the other laser application
[15]. While LLLT acts at the cellular level making a change in
biologic behavior in favor of healing, different other types of
lasers have a variety of applications including surface treat-
ment, hemostasis, and coagulation in order to allow proper
expected effect to be seen on the subject [13, 21, 29]. Also,
radiographies should be standard and read carefully. In some
Lasers Med Sci (2018) 33:1621–1629
studies, laser is being used with different pulp dressing such as
MTA [6], calcium hydroxide (4), or zincoxide eugenol [19];
therefore, the results should clarify which part of the interven-
tion is having the main effect on treatment outcomes [11].
Conclusion
Laser may be considered as an adjuvant alternative for vital
pulp therapy on human primary teeth, but due to the limited
number of high-quality clinical research articles on laser-
assisted pulpotomy, various types of laser application methods
and different follow-up periods, reaching a net consensus is
still challenging. More randomized clinical trials with same
method are required in order to achieve a better conclusion.
Acknowledgements The authors would like to express their sincere grat-
itude for help and support of Dr. Mahshid Namdari for valuable statistical
advices.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval No ethical approval was needed in this study.
Informed consent No informed consent was needed in this review
article.
References
1. Fuks A (2008) Vital pulp therapy with new materials for primary
teeth: new directions and treatment perspectives. J Endod. 34(7
Suppl):S18–S24
2. Oliveira T, Moretti A, Sakai V, Lourenço NN, Santos C, Machado
M, et al. Clinical, radiographic and histologic analysis of the effects
of pulp capping materials used in pulpotomies of human primary
teeth. Eur Arch Paediatr Dent2013;14(2):65–71
3. Durmus B, Tanboga I (2014) In vivo evaluation of the treatment out-
come of Pulpotomy in primary molars using diode laser, Formocresol,
and ferric Sulphate. Photomed Laser Surg 32(5):289–295
4. Fernandes A, Lourenço NN, Teixeira MN, Silveira MA, Sakai V,
Cruvinel ST, et al. Clinical and radiographic outcomes of the use of
low-level laser therapy in vital pulp of primary teeth. Int J Paediatr
Dent 2015;25(2):144–150
5. Huth K, Paschos E, Hajek-Al-Khatar N, Hollweck R, Crispin A,
Hickel R, et al. Effectiveness of 4 pulpotomy techniques–
randomized controlled trial. J Dent Res 2005;84(12):1144–1148
6. Saltzman B, Sigal M, Clokie C, Rukavina J, Titley K, Kulkarni G
(2005) Assessment of a novel alternative to conventional
formocresol-zinc oxide eugenol pulpotomy for the treatment of
pulpally involved human primary teeth: diode laser-mineral trioxide
aggregate pulpotomy. Int J Paediatr Dent 15(6):437–447
7. Huth K, Hajek-Al-Khatar N, Wolf P, Ilie N, Hickel R, Paschos E
(2012) Long-term effectiveness of four pulpotomy techniques: 3-year
randomised controlled trial. Clin Oral Investig 16(4):1243–1250
1629
8. Ghajari MF, Mirkarimi M, Vatanpour M, Fard MJK (2008)
Comparison of pulpotomy with formocresol and MTA in primary
molars: a systematic review and meta-analysis. Iranian Endod J
3(3):45–49
9. Elliott R, Roberts M, Burkes J, Phillips C. Evaluation of the carbon
dioxide laser on vital human primary pulp tissue. Pediatr Dent.
1999;21(6):327–331
10. Golpayegani MV, Ansari G, Tadayon N (2018) Clinical and radio-
graphic success of low level laser therapy (LLLT) on primary mo-
lars pulpotomyIranian. Endod J 13(1):7–12
11. De Coster P, Rajasekharan S, Martens L (2013) Laser-assisted
pulpotomy in primary teeth: a systematic review. Int J Paediatr
Dent 23(6):389–399
12. Kimura Y, Wilder-Smith P, Matsumoto K (2000) Lasers in end-
odontics: a review. Int Endod J 33(3):173–185
13. Gupta G, Rana V, Srivastava N, Chandna P (2015) Laser
Pulpotomy–an effective alternative to conventional techniques: a
12 months Clinicoradiographic study. Int J Clin Pediatr Dent 8(1):
18–21
14. Kimura Y, Yonaga K, Yokoyama K, Watanabe H, Wang X,
Matsumoto K (2003) Histopathological changes in dental pulp ir-
radiated by Er: YAG laser: a preliminary report on laser pulpotomy.
J Clin Laser Med Surg 21(6):345–350
15. Liu J (2006) Effects of Nd: YAG laser pulpotomy on human pri-
mary molars. J Endod 32(5):404–407
16. Liu J (ed) (2003) Nd: YAG laser pulpotomy of human primary
teeth. International Congress Series, Elsevier
17. Odabaş M, Bodur H, Bariş E, Demir C (2007) Clinical, radiograph-
ic, and histopathologic evaluation of Nd: YAG laser pulpotomy on
human primary teeth. J Endod. 33(4):415–421
18. Uloopi K, Vinay C, Ratnaditya A, Gopal AS, Mrudula K, Rao RC
(2016) Clinical Evaluation of Low Level Diode Laser Application
For Primary Teeth Pulpotomy. J Clin Diagn Res 10(1):ZC67–ZC70
19. Marques N, Neto N, Rodini CO, Fernandes A, Sakai V, Machado
M, et al. Low-level laser therapy as an alternative for pulpotomy in
human primary teeth. Lasers Med Sci 2015;30(7):1815–1822
20. Furze HA, Furze ME (2006) Pulpotomy with laser in primary and
young permanent teeth. J Oral Laser Appl 6(1):389–399
21. Pescheck A, Pescheck B, Moritz A (2002) Pulpotomy of primary
molars with the use of a carbon dioxide laser: results of a long-term
in vivo study. J Oral Laser Applications. 2(3):61–67
22. Liu J, Chen L, Chao S (1999) Laser pulpotomy of primary teeth.
Pediatr Dent 21(2):128–129
23. Niranjani K, Prasad M, Vasa A, Divya G, Thakur M, Saujanya K
(2015) Clinical evaluation of success of primary teeth Pulpotomy
using mineral trioxide aggregate (®), laser and biodentine (TM)-an
in vivo study. J Clin Diagn Res: JCDR 9(4):ZC35–ZC37
24. Yadav P, Indushekar K, Saraf B, Sheoran N, Sardana D (2014)
Comparative evaluation of ferric sulfate, electrosurgical and diode
laser on human primary molars pulpotomy: an Bin-vivo^ study.
Laser Ther 23(1):41–47
25. Jukić S, Anić I, Koba K, Najzar-Fleger D, Matsumoto K (1997) The
effect of pulpotomy using CO2 and Nd: YAG lasers on dental pulp
tissue. Int Endod J 30(3):175–180
26. AlGhamdi K, Kumar A, Moussa N (2012) Low-level laser therapy:
a useful technique for enhancing the proliferation of various cul-
tured cells. Lasers Med Sci 27(1):237–249
27. Huguet A, Stinson JN, McGrath PJ (2010) Measurement of self-
reported pain intensity in children and adolescents. J Psychosom
Res 68(4):329–336
28. von Baeyer CL (2009) Children’s self-report of pain intensity: what
we know, where we are headed. Pain Res Manag 14(1):39–45
29. Fernandes K, Ribeiro D, Rodrigues N, Tim C, Santos A, Parizotto
N, et al. Effects of low-level laser therapy on the expression of
osteogenic genes related in the initial stages of bone defects in rats.
J Biomed Opt 2013;18(3):038002