Running head: Laser applications in dentistry 1

Laser Applications in Dentistry

Laser applications in dentistry 2

Abstract

Since the dental laser’s commercial debut in 1989, there has been continuous discussion and

research about laser technology. The Food and Drug Administration has approved laser therapy

as a treatment option for several dental conditions, including tooth restoration, dentin

hypersensitivity, and periodontal disease. With the development of medical technology, laser

therapy has been shown an advantageous addition to conventional treatments in increasing the

effectiveness of the outcomes of patient treatment procedures, including less bleeding, fast tissue

healing, bacteria reduction, minimal invasion, less pain, and better patient appointment planning.

To date, lasers have been applied in various clinical fields to ensure patient comfort and optimize

dental treatments. This paper is to evaluate the efficacy of laser applications in restorative,

periodontic, and orthodontic dentistry, including a comparison of the laser technology to

conventional treatments based on previous literature reviews and scientific studies. Even though

numerous scientific researches have proven that laser is effective and painless, it has not become

the standard treatment due to its high cost, requirement of training, and lack of interest in some

offices.

Keywords: Laser therapy, restorative, periodontic, orthodontic dentistry

Laser applications in dentistry 3

Laser Applications in Dentistry

In February 2017, The Journal of Dental Hygiene published a research article about the

prevalence of dental anxiety at private dental office settings. The research has shown that 19% of

the population had moderate to high dental anxiety (Boyd, Giblin, & White, 2017). Dental

anxiety can lead to frequent missed appointments and delayed treatments, which can

significantly affect a patient’s periodontal health. If dental professionals can incorporate a less

painful and more effective treatment technology to ensure patient comfort, perhaps it would

lower patients’ dental anxiety and lead to a higher success rate. Tooth decay is one of the most

prevalent diseases in the United States; approximately 85 percent of adults in the United States

have at least one tooth with decay (Nathe, 2017). Carious hard tissues need to be removed;

however, the heat, sound, and vibration produced by the dental handpiece can cause patient

discomfort (Ajilal, Khurshid, Najeeb, & Zafar, 2016). Periodontal disease is another prevalent

disease in the US and is usually treated by scaling and root planing (SRP). However, SRP cannot

completely remove bacterial deposits from the root surfaces within deep periodontal pockets

(Verma, Maheshwari, Singh, & Chaudhari, 2012). Orthodontic treatment was developed as a

functional and aesthetic saver for millions of people with abnormal teeth alignment. Inevitable

side effects include pain due to tooth movement, gingivitis, tooth decay, and root resorption

(Cokakoglu, Aydogan, & Aydin, 2017). Laser therapy is one of the most modern technologies

that may address the above issues. Laser applications in dentistry can be time efficient and

patient-friendly, together with significant reduction of pain, enhanced tissue healing, minimal

need for anesthesia, and minimal post-operative discomfort.

Literature review
Laser applications in dentistry 4

Laser was originally an acronym, LASER, for ‘Light Amplification by the Stimulated

Emission of Radiation.’ Lasers can be categorized by their different wavelengths and interactions

with soft and hard tissues. According to Verma et al. (2012), the Carbon Dioxide Lasers (CO2)

have high water affinity and can achieve tissue removal and hemostasis with low surface

penetration, however, the drawbacks are high cost and the large size of the laser unit;

Neodymium Yttrium Aluminum Garnet Lasers (Nd: YAG) can penetrate deeper into the tissue

than CO2 lasers and are efficient in surgical procedures for cutting and coagulating soft tissues.

Research has been conducted on the use of Nd: YAG lasers for nonsurgical sulcular debridement

to stabilize the periodontal disease. Erbium Laser is the laser of choice for removing hard tissues

such as enamel, restoration materials, and calculus due to its high affinity for hydroxyapatite;

because of its hydrophilic characteristics, Erbium Laser can also remove soft tissue effectively.

Diode Laser is mainly absorbed by tissue pigment and hemoglobin, which makes it ideal in

esthetic procedures such as frenectomy, gingival re-contouring, removal of inflamed tissue, and

photo-stimulation of the aphthous and herpetic lesions that are most commonly used by general

dentists.

Laser in Restorative Dentistry

Cavity preparation. According to Ajilal et al. (2016), cavity preparation includes

removal of carious hard tissues to allow functional placement of the restorative material; it also

includes pulpotomy, the removal of a portion of the pulp, with the intent of maintaining the

vitality of the remaining pulpal tissue. A conventional approach to caries removal is to use a

high-speed handpiece and manual excavators to achieve this mechanical alteration. However, the

drawback is the heat, sound, and vibration produced during the procedure that may cause patient

discomfort. CO2 and Er based lasers can cut tooth tissues without vibration and noise, and they
Laser applications in dentistry 5

can be as effective as the conventional rotary instruments. Additionally, a water spray attached to

the dental laser unit can minimize the high temperature (300 to 800 degrees Celsius) produced by

lasers. Another advantage of dental laser application during caries removal is that local

anesthesia is not required; thus, the treatment time can be reduced. A research study done to

compare the microleakage of Er:YAG laser and dental bur prepared cavities in 80 extracted

primary teeth had shown laser-prepared teeth demonstrated a better marginal seal on occlusal

and gingival margins when resin composite and two-step self-etching adhesive were used as

restorative materials (Baghalian, Bahramian, Hooshmand, Motahhary, & Nakhjavani, 2013).

Prevention of dentin hypersensitivity. Gehrig, Shen, and Willmann (2019) explained

that “dentin hypersensitivity is a short, sharp, painful reaction that occurs when areas of exposed

dentin are subjected to mechanical, thermal, or chemical stimuli” (p.505). For some individuals,

dentin hypersensitivity can affect their daily activities as simple as breathing cold air into the

mouth, eating cold foods, and brushing and flossing. Per the discussion of Asnaashari and

Moeini (2013), laser may reduce tooth sensitivity by the coagulation of protein without altering

the surface of dentin. While Ashley, Pashley, and Trowbridge (as cited in Asnaashari & Moeini,

2013, p.4) suggested that the reduction of tooth sensitivity is achieved by “coagulation and

protein precipitation of the plasma in the dentinal fluid or by alteration of the nerve fiber

activity.” Four types of lasers that are effective in reducing dentin hypersensitivity include CO2,

Nd: YAG, Er: YAG, and Er, Cr: YSGG lasers (Asnaashari & Moeini, 2013). A clinical trial done

on 31 participants had also reported the efficacy of low-level laser therapy on postoperative

sensitivity. Each participant had two class V cavities that served as an experimental group and a

control group. The tooth that served as an experimental group received laser for 60 seconds after

cavity preparation and before the restoration placement, while the control group did not receive
Laser applications in dentistry 6

any laser treatment at any point of time. As a result, pain scores after restoration were

significantly lower in the laser group compared to the control group. Therefore, researchers

suggested laser was a useful tool for reducing postoperative sensitivity in class V restorations

(Ahrari, Maleknejad, Moosavi, & Sharifi, 2015).

Laser in Periodontic Dentistry

Reduction of bacteria. Periodontal disease is an inflammatory disease affecting the

tissue and bone that are surrounding the teeth. It is characterized by gingival bleeding, increasing

pocket depth (PD), tissue destruction, and alveolar bone loss. Early stages of periodontal disease

can be effectively treated with nonsurgical periodontal therapy, the goal of which is to remove

supragingival and subgingival calculus with reinforcement of the patient’s daily biofilm removal.

Because conventional nonsurgical periodontal treatment alone cannot completely remove

bacterial deposits from the root surfaces within the deep periodontal pockets, laser therapy was

developed and has been served as an adjunctive therapy to traditional SRP.

Alzoman and Diab (2016) conducted a research to evaluate the effectiveness of laser

therapy as an adjunct to SRP in the treatment of chronic periodontitis. In their study, patients

treated with SRP alone were served as the control group, and patients treated with SRP in

addition to laser therapy were served as the experimental group. Both groups showed clinical

improvement in PD and clinical attachment level (CAL) at re-evaluation appointment compared

to their baseline data. Moreover, the experimental group did not present with any adverse effects

of the laser application and showed a better response to treatment, such as a reduction in PD and

BOP. In addition, the number of Porphyromonas gingivalis, which are the most relevant bacteria

associated with chronic periodontitis, decreased significantly from 80% to 20% (P < 0.05) upon

laser irradiation, and no significant changes are found in the SRP population in the presence of P.
Laser applications in dentistry 7

gingivalis. This study indicated that laser-assisted therapy to conventional SRP is effective in

reducing pathological bacteria compared to SRP alone. Petrovic et al. (2018) conducted a

research similar to Alzoman and Diab’s (2016), with one control group receiving only SRP, and

one experimental group receiving SRP and laser therapy. Clinical parameters were measured

before the intervention, after the fifth treatment, and after a month. The result revealed that the

values of the Plaque Index (PI) were significantly lower in both groups after the fifth treatment.

However, the parameters obtained after one month of treatment showed that the experimental

group presented with lower values in the PI, Bleeding Index, and CAL compared to the control

group. The experimental group also exhibited a statistically significant reduction in the levels of

P. gingivalis and some other periodontal bacterial pathogens. This clinical study showed that

laser-assisted therapy resulted in a short-term therapeutic, antimicrobial advantages in

comparison to SRP alone, which was consistent with Alzoman and Diab’s (2016) study.

Reduction of gingival inflammation. Abduljabbar, Vohra, Kellesarian, and Javed (2017)

conducted a clinical split-mouth survey to test the efficacy of SRP with and without adjunct laser

therapy. Clinical parameters were assessed and measured at baseline and three- and six-month

follow-up. The study showed that the clinical periodontal parameters, including BOP, PI, and PD

were significantly higher in the control sites that received SRP alone than the experimental sites

where both SRP and laser therapy were applied. It indicated that the laser-assisted periodontal

treatment was more effective in reducing periodontal inflammatory factors. Dental pain is a

significant dental phobia that many patients would describe. Laser therapy has a significant

effect on these patients as it can alleviate stress and anxiety and aids clinicians to deliver better

service. Studies also have shown that lasers are capable of sealing capillaries and providing
Laser applications in dentistry 8

hemostasis, thereby reducing swelling at the treated site and minimizing postoperative

discomfort leading to analgesic and anti-inflammatory effects (Verma et al., 2012).

Laser in Orthodontic Dentistry

Reduction of orthodontic pain and accelerating tooth movement. The conventional

treatment to the orthodontic related pain is through pain medications. However, side effects may

pose potential risks for patients. Laser therapy was believed to hyperpolarize the nerve cell

membranes and increases the pain threshold, which reduces pain without causing side effects like

most other drugs (Martins, Martins, Gordeiro, Santos-Pinto, Buschang, & Pretel, 2018). In the

clinical trial of Matins et al. (2018), Diode laser was applied to 62 participants who placed

separators between the molars. Data showed that laser therapy was effective in reducing pain but

just immediately after the separation of molars. The research of Sonesson, Geer, Subraian, &

Petren (2017) done on eleven out of thirteen studies from different countries also demonstrated a

significant pain reduction on the patients treated with laser.

Additionally, Soesson et al. (2017) tested the effects of laser therapy on tooth movement

in orthodontic treatment in three separate trial studies from India, Iran, and Turkey. Two of them

reported a significant increase in tooth movement ranging from 27% to 30%. In the peer review

of Cokakoglu et al. (2018), they stated that there are other several reports about the efficiency of

laser therapy on accelerating tooth movement. However, this research suggested no remarkable

data on tooth movement.

Prevention of gingivitis. Plaque retention on the bracket is one of the major factors that

leads to gingival inflammation. In 2014, Suetenkov, Petrova, & Kharitonova published a study

done on 60 of 12-13 years old children who were wearing metal bracket systems. Their research

indicated that after the laser treatment, the inflammation level was significantly reduced. They
Laser applications in dentistry 9

believe that the photodynamic reaction initiated by laser therapy not only helps to destroy

pathogenic flora but also coats a thin film of photocoagulation on the tissue surface to protect the

repeated invasion of microorganisms. They also suggested that the photoactivated disinfection

increases the capillary bloodstream along with increasing the level of oxygenation resulting in an

increased metabolism rate. In conclusion, the tissue is healed faster than it was treated by

conventional treatments (Suetenkov et al., 2014).

Prevention of tooth caries. Lasers can achieve the prevention of tooth caries in two

proposed mechanisms. One is to increase the hardness of the tooth structure and make the tooth

more resistant to decay; the other one is to deactivate Streptococcus mutans, a microbial factor

causing tooth caries. However, researchers also emphasized that laser therapy only helps to

decrease the intensity level of decay, but not eliminate it (Suetenkov et al., 2014).

Reduction of root resorption. Root resorption in orthodontic treatment has been known

as an unavoidable consequence of tooth movement. A study completed in 2015 on 20 patients

with 40 premolars eligible for assessment showed that there was no difference in patients

exposed to laser treatment and group patients who did not receive laser therapy. The difference of

0.033 mm3 indicated no significant benefits of laser to prevent root resorption. They also looked

into the details of resorption per root surface, but no noticeable difference was found (Ang Khaw,

Dalci, Foley, Petocz, Darendeliler, & Papadopoulou, 2018).

Discussion

There has been an explosion of laser application research studies over the past two

decades ever since its first application in dentistry. Laser technology has continued to develop.

Most of the current studies showed that laser therapy plays a valuable role in the reduction of

bacteria in periodontal pockets, postoperative sensitivity, and pain. It also promotes hemostasis
Laser applications in dentistry 10

for faster tissue healing and therefore ensures patient comfort. The drawbacks of laser treatments

are relatively expensive and require training of clinicians. Sometimes the slow movement of

laser can lead to tissue charring during the procedure, which can cause discomfort of the patient.

Most practices have not integrated laser technologies into patient’s treatments. The efficacy of

lasers can also be a doubt to many office owners when making their decisions based on the cost-

benefit analysis, which makes it understandable that dental practices are not ready to replace

conventional treatments with lasers.

Conclusion

Even though studies have proved a null hypothesis of its effects that meet various

patient’s needs, there are limitations in the research findings. There are inconsistency research

results of efficacy and effectiveness of laser therapy in dentistry. More clinical studies are needed

before laser treatment becomes a standard of care in application in restorative, periodontic, and

orthodontic dentistry. Further clinical studies on larger sample size and longitudinal studies are

necessary with the aim of supporting the efficacy and effectiveness of laser therapy. As more

research becomes available, lasers are expected to be a considerable application for dental

professionals and to play a more significant role in dentistry.

Laser applications in dentistry 11

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Laser applications in dentistry 12

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