LASERS IN

ENDODONTIC
S

Dr. Dax Abraham

Contents
• Introduction • Contraindications
• History • Applications in endodontics
• Principles of laser
• Interaction of laser with substrate
• Laser- tissue interaction
• Advantages
• Disadvantages
• Lasers used in dentistry
• Indications
 Introduction
• Laser is an acronym for Light Amplification by Stimulated Emission of
Radiation.

• Lasers are an important advancement in the field of Endodontics and have

changed the ways in which many procedures can be done.
 HISTORY
• Albert Einstein (1917) - Stimulated Emission
• 1954- J. Gordon and Charles H. Townes - MASER (microwave amplification by
stimulated emission of radiation)

• 1960 -Theodore Maiman’s ruby laser

• 1965- Stern and Sognaes – ruby laser could vapourize enamel

• 1971 Weichman and Johnson- introduced LASERS in Endodontics.

• 1997 - FDA clearance for first dental hard tissue laser Er - YAG.

Lasers in endodontics- IOSR-JDMS 2017

COMPONENTS OF A TYPICAL
LASER

OPTICAL
CAVITY
This is an internally
polished tube occupying
the centre of the device

D.J. Coluzzi / Dent Clin N Am 48 (2004) 751–770

Active medium
LASERS NAMED AFTER THE ACTIVE MEDIUM

Solid state
Gallium, aluminum, indium, and arsenic or solid rods of garnet crystal grown with
various combinations of yttrium, aluminum, scandium and gallium and then doped
with the elements of chromium, neodymium, or erbium

GAS - Argon, CO2

Semiconductors – Diode

D.J. Coluzzi / Dent Clin N Am 48 (2004) 751–770

EXCITATION
SOURCE
This surrounds the optical cavity and provides energy for exciting the active medium.

This may be flash light, arc light or an electromagnetic coil.

D.J. Coluzzi / Dent Clin N Am 48 (2004) 751–770

Optical resonator
This consists of two parallel mirrors placed at
each end of the optical cavity.

Laser light that is produced by the stimulated

active medium is bounced back and forth in
the optical cavity by these mirrors which
amplifies the light beam.
Cooling unit

Heat is generated as a by-product

To dissipate this heat, air or water – assisted coaxial coolants are

provided in the unit
Delivery system
The laser light delivered by a

1. Flexible hollow waveguide or tube that has an interior mirror finish. The
laser energy is reflected along this tube and exits through a handpiece at the
surgical end with the beam striking the tissue in a noncontact fashion.

2. Glass fiber optic cable. This cable can be more pliant than the waveguide, has a
corresponding decrease in weight and resistance to movement, and is usually
smaller in diameter.

D.J. Coluzzi / Dent Clin N Am 48 (2004) 751–770

Laser emission modes
1. Continuous wave - beam is emitted at only one power level
2. Gated-pulse – periodic alternations of the laser energy
3. Free-running pulsed mode/ True pulsed - large peak energies of
laser light are emitted for a short time span, usually in microseconds
followed by a relatively long time in which the laser is off.
BASIC PRINCIPLES OF LASER

• Monochromatic
• Unidirectional
• Coherent
• Collimation
LASERS TRANSFORMS LIGHT OF VARIOUS FRQUENCIES INTO
RADIATIONS IN THE :

Radiation

D.J. Coluzzi / Dent Clin N Am 48 (2004) 751–770

Interaction of laser with substrate
• Photothermal
• Photochemical effects
• Below 100 C denaturation of proteins, hemolysis, coagulation and
shrinkage
• Above 100 C water in hard and soft tissue boils, vaporization of the
water within occurs, a process also called ablation.

Sturdevant 4th edn

• Soft tissue - high percentage of water, excision of soft tissue
commences at this temperature.

• The apatite crystals and other minerals in dental hard tissue are not
ablated at this temperature, but the water component is vaporized,
and the resulting jet of steam expands and then explodes the
surrounding matter into small particles. This mixture of steam and
solids is then suctioned away. This micro-explosion of the apatite
crystal is termed ‘‘spallation.’

D.J. Coluzzi / Dent Clin N Am 48 (2004) 751–770

• At 200.C tissue is dehydrated and then burned in the presence of air.
Carbon, is formed.

D.J. Coluzzi / Dent Clin N Am 48 (2004) 751–770

Laser–tissue interaction
• Absorption of the laser light by the target tissue is the primary and
beneficial effect of laser energy. The absorbed laser energy is
particularly important because it transforms into thermal energy and
causes changes inside the tissue.
• Shorter wavelengths ( 500–1000 nm) are readily absorbed in
pigmented tissue and blood elements.
• Argon - attenuated by hemoglobin.
• Diode and Nd:YAG - high affinity for melanin and less interaction with
hemoglobin.

D.J. Coluzzi / Dent Clin N Am 48 (2004) 751–770

• Longer wavelengths - more interactive with water and hydroxyapatite.
• The largest absorption peak for water is just below 3000 nm - Er:YAG
wavelength.
• Erbium is also well absorbed by hydroxyapatite.
• CO2 at 10,600 nm is well absorbed by water and has the greatest
affinity for tooth structure.
• Transmission - no effect on the target tissue
• Dependent on the wavelength of laser light
• Water is relatively transparent to the shorter wavelengths like argon,
diode, and Nd:YAG
• Tissue fluids readily absorb the erbium and CO2 lasers at the outer
surface, so there is little energy transmitted to adjacent tissue.
• Scattering of the laser beam could cause heat transfer to the tissue
adjacent to the surgical site, and unwanted damage could occur.
Advantages and Limitations
 Advantages

• Reduced need for anesthesia

• Greater comfort during and after surgery.

• Haemostasis and reduced risk of blood borne pathogens

• High patient acceptance

• Reduced stress and fatigue for the practitioner and staff.

• Produce less collateral thermal damage than with an electrocautery.

Limitations

• All lasers require specialized training and attention to safety

precautions.

• No single laser can perform all desired dental applications

LASER WAVE LENGTHS USED IN
DENTISTRY
 CO2 LASER (10,600 nm)

• Oldest in use, Gas active medium laser

• Cannot be delivered in an optic fiber so used in a hollow tube like wave guide
in continuous gated pulse mode.

• This wavelength has the highest absorption in hydroxyapatite of any dental

laser, about 1000 times greater than erbium. Therefore, tooth structure adjacent
to a soft-tissue surgical site must be shielded from the incident laser beam

Ingle / Cohen
 Nd:YAG (1064 nm)
• Has a solid active medium, a crystal of yttrium – aluminium – garnet
impregnated with neodymium.
• Fiber optically delivered .
• Slightly absorbed by dental hard tissue, but there is little interaction with sound
tooth structure, allowing soft tissue surgery adjacent to the tooth to be safe and
precise.
• Common clinical applications are for cutting and coagulation of dental soft
tissues with good hemostatic capability
 Argon lasers

• Effective on pigmented or highly vascular tissues- excellent hemostatic

capabilities.
• Two emission wavelengths, and both are visible to the human eye 488nm (blue in
color) and 514 nm (blue – green)
• Neither wavelength is well absorbed in dental hard tissues or in water.
• The 488-nm emission is the wavelength activates camphoroquinone, the most
commonly used photoinitiator that causes polymerization of the resin in composite
restorative materials.
• The 514-nm wavelength has its peak absorption in tissues containing hemoglobin,
hemosiderin, and melanin; thus, it has excellent hemostatic capabilities

Cohen
Erbium family
• Erbium, chromium:YSGG (2780 nm) has an active medium of a solid
crystal of yttrium scandium gallium garnet that is doped with erbium
and chromium.
• Erbium:YAG (2940 nm) has an active medium of a solid crystal of
yttrium aluminum garnet that is doped with erbium.
• Er:YAG instruments are a hollow wave-guide or a fiberoptic bundle
• Er,Cr:YSGG use fiberoptics.
• These two wavelengths have the highest absorption in water of any
dental wavelength and have a high affinity for hydroxyapatite
Indications
• Teeth with lateral canal leading to periodontal ligament involvement
• Teeth with pulp necrosis and purulent pulpitis
• Teeth with gangrenous changes
• Teeth with periapical lesions upto 5 mm
• Teeth that has been treated atleast 3 months with no success

Laser in endodontics- review article IOSR 2017

Contraindications
• Advanced periodontitis
• Deep crown and root fracture
• Obliterated root canals in endodontic treated teeth

Laser in endodontics- review article IOSR 2017

Application in endodontics

• Diagnostic tool
• Analgesic effect
• Laser and Dentin hypersensitivity
• Pulpotomy and direct pulp capping
• Root canal disinfection
• Laser assisted obturation
• Retreatment
• Endodontic surgery

Lasers in endodontics. IOSR-JDMS 2017

 Diagnostic tool (Laser Doppler flowmetry)
• The technique has also been used to assess blood flow in other tissue
systems, such as the retina, skin and renal cortex.

• Beam of infrared (780 to 820 nm) or near-infrared (632.8 nm) light,

directed into the tissue by optical fibers. As light enters the tissue, it is
scattered by moving red blood cells and stationary tissue cells.
Photons that interact with moving red blood
cells are scattered, and the frequency shifts
according to the Doppler principle.

Photons that interact with stationary tissue

cells are scattered but not Doppler shifted.

A portion of the light is returned to a

photodetector, and a signal is produced.

Measurement of Doppler shifted

backscattered light from moving RBCs gives
an indication of pulpal blood flow.
• Attempts have been made to use LDF technology for pulp vitality
diagnosis in traumatized teeth because this would provide a more
accurate reading of the vitality status of the pulp.
• Laser Doppler can detect blood flow more consistently and earlier
than the standard vitality tests would be expected to render a
response.
• Presently the cost of a laser Doppler flowmetry machine limits its use
in private dental offices
Position of the probe on tooth crown had a significant effect on pulpal blood flow
estimates.

To achieve reliable and comparable readings at different times, an accurate

repositioning of the light probe each time is mandatory.

Custom-made stents have been found to ensure accurate and reproducible

positioning of the measurement probe at each session.
 Indirect Pulp capping:

A reduction in the permeability of dentin achieved by sealing the dentinal

tubules.

Nd: YAG – Pulsed. ( Energy below 1W, 10 s exposure time did not increase the
intrapulpal temperature)

9.6um CO2 laser well absorbed by hydroxyapatite of enamel and dentin causing
tissue ablation, melting and re- solidification.

Ingle 6th edn

Direct Pulp Capping
• CO2 LASER after irrigating with 8% sodium hypochlorite and 3 % H2O2
for 5 min
• Calcium hydroxide paste used to dress the pulp after laser treatment
• Pulsed Nd:YAG, Argon, Er- YAG
• Pulsed Nd: YAG causes damage to the pulp tissue and thereby showed
a low success rates so it should be used only for pulp hemostasis,
sedation, antinflammatory effects, and stimulation of remaining
pulpal cells. (IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)
Pulpotomy
• First laser pulpotomy using CO2 lasers in dogs was performed by Shoji
et al.
• No detectable damage observed in intradicular portion of irradiated
pulp with CO2 laser.
• No laser damage found in tissues underlying the laser ablated tissues,
with the presence of secondary dentin and a regular odontoblast
layer.
Dentin hypersensitivity

• Earlier studies have shown effectiveness ranging from 5% to 100% of

low-output lasers on dentin hypersensitivity.

• Low output power lasers (He-Ne 632.8 nm / GaAlAs 780nm lasers)

• Middle output power lasers (Nd:YAG and CO2 lasers)

Cohen SE Asia edn

• He-Ne lasers may affect the action potential and not affect the
peripheral A or C fibers.
• GaAlAs has a pain suppressive effect by blocking the depolarization of
C fiber afferents.
• Nd:YAG lasers cause superficial occlusion of dentinal tubules of up to
4 μm in addition to action potential blockage within the pulp in vitro
or in experimental animals.
Laser in Analgesia
• Pulsed Nd:YAG
• Interferes with sodium pump mechanism, change cell membrane
permeability, blocks the depolarization of C and A fibers of the nerves.

Laser In Endodontics-A Review Article

IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)
Disinfection of root canal system
• Smear layer –
• 1-2 um thick
• 40 um in dentinal tubules
Lasers used- CO2, Nd :YAG, Argon, Er:YAG
Bergman et al – Nd:YAG (supplement and not an alternative)
Limitations
1. Laser from tip of fiber is directed
vertically in the canal and not
laterally.
2. Damage to periapical tissues.

Stabholtz et al used Er:YAG Laser.

Delivered through hollow tube with an
endodontic tip allowing lateral
emission of irradiation.
Spiral slit located all along the tip –
emits laser laterally to the walls.

Ingle 6th edn

• Enlargement and cleaning of straight canals with an Er:YAG laser was
found to be effective and in fact faster than with step-back
preparation with K files.
• Shaping curved root canals has not been satisfactory
• Er:YAG laser was more effective in debris removal, producing a
cleaner surface with a greater number of open tubules when
compared with a Nd:YAG laser.
• Nd:YAG laser-irradiated samples presented not only with melted and
recrystallized dentin and smear layer removal but also with charring in
light microscopic images.

Ingle 6th edn

• Laser energy transferred into canal surfaces, when sufficient to melt
dentin, may overheat the periodontal ligament also.
• Bahcall et al. investigated the use of the pulsed Nd:YAG laser to clean
root canals.
• Their results showed that the Nd:YAG laser may cause harm to the
bone and periodontal tissues by overheating.

Ingle 6th edn

Laser Activated Irrigation
• LAI is based on the creation of specific cavitation phenomena and
acoustic streaming in intracanal fluids as a result of photothermal and
photomechanical effects.
• The strong absorption of the Erbium laser energy (at low settings of
50-75 mJ) in water and NaOCl causes vaporization and formation of
large elliptical vapour bubbles.
• The vapour bubbles cause a volumetric expansion of up to 1,600
times the original volume of an irrigant with high intracanal pressure
which drives the fluid out of the canal.

The Use of Lasers in Disinfection and Cleaning of Root

Canals: a Review
• The bubbles implode after 100 to 200 microseconds, creating
pressure which sucks fluid back into the canal: inducing secondary
cavitation effect.
• This technique was demonstrated to be effective in the removal of
intracanal dentin debris and smear layer.
• De Moor et al. and De Groot et al. showed a higher efficiency of LAI
with Er,Cr:YSGG and Er:YAG (75 mJ, 20 Hz, 1.5 W, 4 x 5 s) and 2.5%
NaOCl in the removal of dentin debris from the apical part of the root
canal compared to conventional irrigation.
• If the Er:YAG laser is used at low settings (20 mJ, 15 Hz) and ultra-
short laser pulses (50 µs), intracanal cavitations and shockwaves are
created as a result of photoacoustic and photomechanical effects.
This phenomenon is called photon induced photoacoustic streaming
(PIPS).
 Photoacoustic streaming of irrigants
• Laser tip is placed into the coronal
access opening of the pulp chamber
only and is kept stationary without
advancing into the orifice of the
canal.
• The use of a newly designed tapered
and stripped tip with specific
minimally ablative laser settings is
required, resulting in low energy (20
mJ), a pulse repetition rate of 15 Hz,
and a very short pulse duration (50
μs).

Cohen SE Asia edn

• Erbium lasers used in
irrigant filled root canals
generate a streaming of
fluids at high speed
through a cavitation effect.

Cohen SE Asia edn

Photoactivated disinfection
• Light activated therapy / Photodynamic therapy

• Two step procedure

• Step 1- Photosensitization of infected tissue

• Step 2- Light illumination (Synergistic effect)

Cell lysis
Ingle 6th edn
• A wide range of oral bacteria could be killed by red light after
sensitization with toluidine blue and methylene blue.
• Partial inactivation of Streptococcus intermedius biofilms in root
canals of extracted teeth using toluidine blue and light applied at the
orifice level has been recently reported. (Ingle 6th edn)
Obturation

Lasers used either as a

• Heat source for softening gp to be used as an obturating material
• For conditioning the dentinal walls before placing the obturating
material.
• The first laser-assisted root canal filling procedure - Argon 488 nm
laser.
• Used to polymerize a resin that was placed in the main root canal.
• Gutta-percha softened with Argon laser created an apical seal similar
to that obtained with lateral condensation.(Matsumoto et al)

Ingle 6th edn

• Anic and Matsumoto demonstrated that the temperature elevation
induced on the outer root surface when Argon and Nd:YAG lasers
were used ranged from 12.9 C (Argon laser) to 14.4C (Nd-YAG laser).
• Detrimental to the tissues of the attachment apparatus of the teeth.
• Kimura et al demonstrated that the use of Nd-YAG laser was useful for
the reduction of apical leakage.
• Er-YAG laser beam (200 mJ, 4 Hz) for 60 seconds enhanced the
adhesion of epoxy resin-based sealers in comparison with zinc oxide-
eugenol-based root canal sealers.
Endodontic Retreatment
In removing gutta-percha and sealer from the root canal space.
• Yu, et al found that using the Nd:YAG laser enabled the removal of
filling material in more than 70% of cases, and broken instruments in
55% of cases.
• Although none of the methods used in this study resulted in complete
removal of debris from the root canal wall, the time required for the
removal of any of the root canal obturation materials using laser
ablation was significantly shorter than that required using the
conventional method.
Apical Surgery

• First attempt in endodontic surgery – Dr Weichman

• Sealed the apical foramen – Co2 laser.
• Soft tissue lasers – Nd : YAG ; Diode or Co2 used to clean incisions for
gaining direct access to periradicular region.
• Laser usage replaces aerosol producing handpieces – reduce risk of
contamination by blood borne pathogen.
• Er:YAG / Er :YSGG used for cutting into bone, apical 3rd for apicectomy.
• Soares et al. reported a new protocol for use in apical surgery. An Er-
YAG laser was used for osteotomy and root resection, whereas the
Nd;YAG laser irradiation served to seal the dentinal tubules to reduce
possible bacterial contamination of the surgical cavity.
• Precision
• Reduced working time
• Decreased post operative pain
• Reduced scarring
• Improved Hemostasis
• Better visualization
• Sterilization of the contaminated root apex
• Reduction in permeability of root surface
Criteria for a successful treatment
• Symptom-free from the end of the treatment onwards, until the last
follow-up examination (percussion negative, occlusion without
problems).
• No need for surgical interventions (extraction or apicectomy).
• Objective reduction of the apical translucency after three to twelve
months (X-ray comparison).

Journal of the Laser and Health Academy Vol. 2008

 CONCLUSIO
N

A proper and successful use of lasers in endodontics depends on

understanding of characteristics and their limitation. Lack of
understanding leads to misuse and abuse of lasers, causing
detrimental results.
References

• Lasers in endodontics – A review IEJ 2000

• Lasers in endodontics A review IOSR Journal of Dental and Medical Sciences
(IOSR-JDMS) 2017
• Ingle 6TH Edition
• Cohen South east Asia edn
• Sturdevant
• Fundamentals of dental lasers: science and instruments. Dent Clin N Am 48
(2004) 751–770
• Lasers in Endodontics. Journal of the Laser and Health Academy
• Vol. 2008