Lasers in Surgery and Medicine 44:339–345 (2012)

Near-UV Laser Treatment of Extrinsic Dental

Enamel Stains
J.E. Schoenly, PhD,1 W. Seka, PhD,2,3 J.D.B. Featherstone, PhD,4 and P. Rechmann, DDS, PhD4
1
Department of Physics, University of Toronto, Toronto, Ontario, Canada, M5S 1A7
2
Laboratory for Laser Energetics, University of Rochester, Rochester, New York 14623-1299
3
The Institute of Optics, University of Rochester, Rochester, New York 14627
4
Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California at
San Francisco, San Francisco, California 94143

Background and Objectives: The selective ablation of located within the tooth structure and occur during tooth
extrinsic dental enamel stains using a 400-nm laser is development as a result of metabolic disorders (e.g., alka-
evaluated at several fluences for completely removing ptonuria and congenital erythropoietic porphyria) and
stains with minimal damage to the underlying enamel. systemic factors (e.g., tetracycline administration and
Study Design/Materials and Methods: A frequency- enamel hypoplasia) [2]. Extrinsic enamel stains are su-
doubled Ti:sapphire laser (400-nm wavelength, 60- perficial tooth discolorations adsorbed within the acquired
nanosecond pulse duration, 10-Hz repetition rate) was pellicle or dental plaque and may also be retained on the
used to treat 10 extracted human teeth with extrinsic tooth surface via ion exchange [2–4]. The chromogens
enamel staining. Each tooth was irradiated perpendicular within extrinsic stains are either non-metallic or metallic
to the surface in a back-and-forth motion over a 1-mm and typically originate from black tea, coffee, red wine,
length using an 300-mm-diam 10th-order super- mouth rinse, metallic salts, and nicotine from tobacco
Gaussian beam with fluences ranging from 0.8 to 6.4 J/ [2,3,5,6]. An extrinsic stain is mature when it becomes
cm2. Laser triangulation determined stain depth and calcified similar to dental calculus [7]. Extrinsic stains
volume removed by measuring 3D surface images before that penetrate within the superficial enamel due to enam-
and after irradiation. Scanning electron microscopy eval- el defects (e.g., tooth wear, gingival recession, and dental
uated the surface roughness of enamel following stain caries) [2,8] are internalized extrinsic stains.1
removal. Fluorescence spectroscopy measured spectra of Extrinsic stains are often removed with abrasive and/or
unbleached and photobleached stains in the spectral surface-active materials [9]. Whitening dentifrices
range of 600–800 nm. containing fine abrasives (e.g., amorphous silicas, precipi-
Results: Extrinsic enamel stains are removed with laser tated chalks, and calcium phosphates) with low concen-
fluences between 0.8 and 6.4 J/cm2. Stains removed on trations of peroxide prevent and remove extrinsic stains
sound enamel leave behind a smooth enamel surface. [10,11]. However, these abrasives are soft compared to
Stain removal in areas with signs of earlier cariogenic enamel [11] and do not effectively remove mature and in-
acid attacks resulted in isolated and randomly located la- ternalized extrinsic stains. Microabrasion is commonly
ser-induced, 50-mm-diam enamel pits. These pits contain used to erode and abrade these stains with a mixture of
0.5-mm diam, smooth craters indicative of heat transfer low-concentration acid (e.g., hydrochloric and phosphoric
from the stain to the enamel and subsequent melting and acids) and abrasive [12,13] followed by polishing [14].
water droplet ejection. Ablation stalling of enamel stains
is typically observed at low fluences (<3 J/cm2) and is ac-
Conflits of interest: None.
companied by a drastic reduction in porphyrin fluores- Contract grant sponsor: U.S. Department of Energy Office
cence from the Soret band. of Inertial Confinement Fusion Under Cooperative Agreement;
Conclusion: Laser ablation of extrinsic enamel stains at Contract grant number: DE-FC52-08NA28302; Contract grant
sponsor: University of Rochester; Contract grant sponsor: New
400 nm is observed to be most efficient above 3 J/cm2 with York State Energy Research and Development Authority; Con-
minimal damage to the underlying enamel. Unsound un- tract grant sponsor: American Society for Laser Medicine and
Surgery (ASLMS).
derlying enamel is also observed to be selectively removed *Corresponding to: Dr. J.E. Schoenly, Department of Physics,
after irradiation. Lasers Surg. Med. 44:339–345, 2012. University of Toronto, 60 St. George Street, Toronto, ON,
ß 2012 Wiley Periodicals, Inc. Canada, M5S 1A7. E-mail: [email protected]
Accepted 15 February 2012
Published online 13 March 2012 in Wiley Online Library
Key words: laser ablation; scanning electron microscopy; (wileyonlinelibrary.com).
fluorescence; enamel melting; photobleaching DOI 10.1002/lsm.22017

INTRODUCTION 1
Internalized extrinsic stains have also been referred to as intrin-
sic stains in the literature. Here, we make a distinction between
Enamel stains are either intrinsic or extrinsic dark dis- these two stain types based on the standard terminology and
colorations of the enamel [1]. Intrinsic enamel stains are definitions.

ß 2012 Wiley Periodicals, Inc.

340 SCHOENLY ET AL.

Peroxide bleaching is also commonly used to oxidize inter- California, San Francisco. They were sterilized with gam-
nalized extrinsic enamel stains [6]. Infrared lasers ma radiation and stored in a 0.1% thymol solution.
(l ¼ 800–10,600 nm) can be used to raise the tempera- During laser irradiation, the teeth were sprayed with a
ture of applied hydrogen peroxide and accelerate the rate water/air mixture at 3 ml/min and moved in a back-and-
of redox reactions in bleaching [15,16]. forth motion on a motor-driven stage at 0.2 mm/second
Near-ultraviolet (NUV; l ¼ 300–400 nm) lasers can over a 1-mm span. The effects of this water spray on the
selectively remove dental caries and calculus with little to intensity distribution at the tooth surface have been
no damage to the underlying, healthy hard tissue (i.e., reported in Ref. 28. Given the irradiation parameters, the
enamel, dentin, and cementum) [17–20]. Calculus abla- center of each irradiation path received approximately 15
tion likely relies on the preferential absorption of some pulses per pass. The circular beam does not completely
porphyrin-containing oral bacteria, a component of dental overlap at the edges as it is swept along the path so the
calculus [21–23], in the NUV where enamel and dentin edges receive fewer pulses at a lower cumulative fluence.2
are poorly absorbed [24,25]. In comparison, sound enamel
and dentin readily absorb at the non-calculus-selective Laser Profilometry
Er:YAG laser wavelength [26,27]. Selective calculus abla- A triangulation laser (l ¼ 543 nm) was focused to a
tion is preferred over non-selective dental lasers to pre- line onto the tooth surface using an F ¼ 10 cm cylindrical
vent collateral damage to the underlying dental hard lens. The depth and volume of each stain removed was
tissue. measured by scanning the line across the ablated region.
This study discusses the feasibility of selective removal For these measurements we used a 3 magnified image
of extrinsic and internalized extrinsic enamel stains using on a charge-coupled device (CCD) camera (TM-1020A-
a 400-nm laser at several fluences. Laser triangulation 15CL, JAI, San Jose, CA) oriented at 458, resulting in an
measures the stain removal, and scanning electron mi- axial resolution of 6 mm. The transverse resolution was
croscopy (SEM) assists in locating possible damage to the 60 mm  40 mm. The difference between 3D surface
underlying enamel. In the absence of reliable absorption images taken before and after irradiation results in
measurements for stains and the complexity of obtaining depth-removal maps (as described in Ref. 20).
useful samples for such measurements, we have opted to
Blue-Light Microscopy
use fluorescence spectroscopy, which can clearly distin-
guish irradiated from non-irradiated stains. This informa- Images before and after laser irradiation of the tooth
tion is used to determine a range of fluences where were taken with illumination from a flashing blue light-
extrinsic enamel staining is removed with little to no emitting diode (LED, l  450–490 nm) using the same
damage to the underlying enamel. We do not consider camera used in laser triangulation. Identical images were
treatment of intrinsic stains since laser ablation mechani- obtained when illuminating with a 400-nm light source.
cally removes the stains and would not be appropriate for Blue-light illumination provides high contrast between
intrinsic stain treatment. healthy hard tissue, dental calculus, and stains, and
serves to qualitatively distinguish unbleached from photo-
MATERIALS AND METHODS bleached calculus and stain. Photobleached calculus and
extrinsic stains appear brighter under blue-light micros-
Laser Irradiation Conditions copy as a result of increased scattering and decreased
A frequency-doubled Ti:sapphire ring laser (400-nm absorption.
wavelength, 60-nanosecond pulse duration, 10-Hz repeti-
Fluorescence Spectroscopy
tion rate, and 25-mJ pulse energy) developed at the Labo-
ratory for Laser Energetics for selective calculus ablation Fluorescence spectroscopy, comparing unbleached and
was used for extrinsic stain removal. The technical details photobleached enamel stains, was performed using the
of this NUV laser are described elsewhere [28]. The NUV experimental setup shown in Figure 1. Excess water was
laser radiation was coupled into a 600-mm core-diam gently blown off the tooth samples using an air spray be-
optical fiber with a 1.8-mm-diam tapered input fore each fluorescence measurement. The fluorescence
(FVPE600660710/2M, Polymicro Technologies, Phoenix, was excited with low pulse energy (200 mJ at 400 nm)
AZ) using a Du ¼ 0.58 engineered diffuser (RPC Photonics, over a 50-mm beam spot. The dichroic mirror (NT66-251;
Rochester, NY) and an F ¼ 7.5 cm lens. The output beam Edmund Industrial Optics, Barrington, NJ) separated the
from the fiber was demagnified to half of the fiber diame- 400-nm excitation beam from the fluorescence between
ter using an F ¼ 2 cm lens objective to create a 300-mm 600 and 800 nm and directed the fluorescence signal into
diam, 10th-order super-Gaussian irradiation beam. The a 600-mm-diam optical fiber. The transmission of the di-
peak fluence of each pulse was varied between 0.8 and chroic mirror was measured in this spectral range and is
6.4 J/cm2 by varying the laser pulse energy as annotated accounted for the final fluorescence spectra presented in
in each Figure.
Ten extracted human teeth with extrinsic enamel stain-
2
ing were treated with this laser. The teeth were obtained The cumulative fluence is the autocorrelation of the incident
beam which, for a top-hat, circular beam, is center-peaked and
from the Department of Preventive and Restorative triangular with cumulative fluence decreasing away from the
Dental Sciences, School of Dentistry at the University of path’s center.
 TREATMENT OF EXTRINSIC DENTAL ENAMEL STAINS 341

Fig. 1. Optical setup for measuring extrinsic stain fluores-

cence from a 400-nm excitation wavelength. A dichroic mir-
ror directs the 400-nm beam through an achromatic doublet
focusing onto the tooth. Fluorescence is measured through
the same optical path where the dichroic mirror preferential-
ly transmits between 600 and 800 nm. The fluorescence is
collected by an identical doublet and coupled into an optical
fiber. [Color figure can be seen in the online version of this Fig. 2. a: Light-microscope and (b) SEM images of a laser-
article, available at http://wileyonlinelibrary.com/journal/ treated extrinsic enamel stain at several fluences (four verti-
lsm] cal paths). From left to right the peak fluences are 1.9, 3.1,
4.8, and 6.4 J/cm2. Each line received six passes of the treat-
this study. The output of the optical fiber was directed
ment laser. The horizontal crack in (b) is due to the dry con-
into a USB spectrometer (HR2000CG-UVNI; Ocean Op-
ditions of the SEM. The white box in (b) on the far right
tics, Dunedin, FL) to measure the fluorescence spectra. At
vertical path is magnified in (c) showing a smooth enamel
each measurement, 50 spectra were averaged, collected
surface.
with a 10-second integration time and smoothed by apply-
ing an 5-nm spectral averaging filter. An OG590 filter path in Figure 2b is shown in Figure 2c detailing the
(Schott North America, Duryea, PA) was placed between smoothness of the underlying enamel within the irradia-
the optical fiber and achromatic doublet (NT49-779; tion path with few remaining stain remnants or debris.
Edmund Industrial Optics) to remove any remaining light A light-microscope image of an extrinsic enamel stain
either reflected or scattered from the tooth at 400 nm. on the facial side of an upper lateral incisor irradiated at
This spectral method is not depth dependent, so fluores- four ablative fluences is shown in Figure 3a. From right
cence from underlying hard tissue may have contributed to left, the fluences range from 1.6 to 6.1 J/cm2 (Fig. 3a).
to the detected fluorescence. The irradiation paths become wider as the fluence
increases, mirroring the fluence distribution (i.e., the en-
Scanning Electron Microscopy ergy efficiency for selective ablation increases) [28]. Under
The laser-treated areas were examined using SEM SEM (Fig. 3b), calcified remnants are visible in the lower
(Zeiss-Auriga CrossBeam FIB-SEM, Carl Zeiss NTS, half of the irradiation path at 1.6 J/cm2 even after eight
Peabody, MA) at The Institute of Optics, University of passes, whereas above 3 J/cm2, the irradiation paths are
Rochester. The tooth surface topology was examined generally clear except for some small photobleached rem-
using an SE2 detector and 10-keV electron beam with a nants. Small 50-mm diam, laser-induced pits in the enam-
30-mm aperture and 15 mm working distance. The teeth el are more frequently seen at the highest fluences in
were dried in a desiccator for at least 24 hours before Figure 3b. We do not observe a central, continuous crater
sputtering an 5-nm gold layer onto the tooth surface. along the length of the irradiation path, which would be
Teeth were adhered to the sample stage using conductive indicative of pristine enamel ablation. The triangulation
tape. images in Figure 3c show that 15–50 mm of the stain is
removed.
RESULTS The magnified SEM images in Figure 4 of the left-most
Light-microscope and SEM images of the lingual sur- irradiation path in Figure 3b illustrate thermal interac-
face of a lower incisor irradiated at several fluences are tions of irradiated stains with the underlying enamel that
shown in Figure 2. The fluences of the vertical irradiation may lead to laser-induced pit formation. These pits in the
paths in the light-microscope image of Figure 2a are, from enamel are seen at 6.1 J/cm2 in Figure 4a. Small, smooth
left to right, 1.9, 3.1, 4.8, and 6.4 J/cm2. Laser triangula- craters of 0.5-mm diam appear along the edges and bot-
tion images (not shown) indicate that 15 mm of stain tom of this pit. Several small holes in the enamel appear
was removed. At fluences >3 J/cm2, the extrinsic stain outside this pit, indicative of previous cariogenic acid at-
was completely removed as seen in Figure 2a. This is fur- tack on the enamel. Another laser-induced pit under the
ther validated by an SEM image of the same area in same irradiation conditions is shown in Figure 4b. The
Figure 2b. Stain remnants are observed in the SEM image smooth, submicron craters in Figure 4a are also seen in
(Fig. 2b), the left-most path after irradiation at 1.9 J/cm2. Figure 4b with smooth areas along their edges, indicating
Magnification of the white box in the far-right irradiation enamel melting.
342 SCHOENLY ET AL.

Fig. 3. a: Light-microscope, (b) SEM, and (c) triangulation

images of an extrinsic enamel stain irradiated at several flu-
ences (shown in figure). The scale in (c) is the same for (a) Fig. 5. Light-microscope images (a) before and (b) after laser
and (b). [Color figure can be seen in the online version of this irradiation at 0.8 J/cm2 and 40 passes. c: Triangulation im-
article, available at http://wileyonlinelibrary.com/journal/ age detailing the depth of the stain removed. The scale in (a)
lsm] is the same for (b) and (c). The white box in (b) is magnified
as an SEM image in (d). The white box in (d) is magnified as
Light-microscope, laser-triangulation, and SEM images of an SEM image in (e). The white box in (e) is magnified as an
a thin (<15 mm removed) extrinsic enamel stain on the SEM image in (f), indicating the continued attachment of
facial surface of an upper canine irradiated at 0.8 J/cm2 micro-organisms. [Color figure can be seen in the online ver-
and 40 passes are shown in Figure 5. Light-microscope sion of this article, available at http://wileyonlinelibrary.com/
images before (Fig. 5a) and after (Fig. 5b) irradiation indi- journal/lsm]
cate that the irradiated area has been whitened, although
not completely. The triangulation image in Figure 5c shown in Figure 5f, revealing rod-like micro-organisms
indicates that <15 mm were removed after 40 passes of still adhering to the irradiated enamel.
the irradiation beam mostly from a dark patch (compare Light-microscope, laser-triangulation, and SEM images
Fig. 5a and Fig. 5b). Part of the irradiation path (white of the same extrinsic enamel stain found in Figure 5 irra-
box in Fig. 5b) shown in the SEM image in diated at 3.1 J/cm2 and two passes are shown in Figure 6.
Figure 5d consists of a rough surface not seen in the other Light-microscope images before (Fig. 6a) and after
tooth samples except when removing an enamel stain (Fig. 6b) irradiation demonstrate that the enamel has
near amalgam. Magnification of a central area in the irra- been significantly whitened under blue-light illumination,
diation path (white box) in Figure 5d is magnified in particularly within a dark patch (i.e., caries lesion) in the
Figure 5e revealing stain remnants still adhering to the enamel. An SEM image of the same irradiation path is
enamel. Magnification within this image (white box) is shown in Figure 6c, where the whitest portion in
Figure 6b is similarly whitened in the SEM image. The
image contrast in the SEM image is due to electric-field
enhancements from the edges of multiple enamel rods in
this region. The triangulation image in Figure 6d
indicates 10–25 mm of material removed primarily within
the whitest patches in Figure 6b and c corresponding to
the darkest patch in Figure 6a. Magnification of a portion
of this white patch in Figure 6c (white box) is shown in
Figure 6e, where the honeycomb pattern of 4- to 5-mm-
diam enamel rods is observed [22]. At lower fluences
enamel rods are not as easily seen but are still observed
Fig. 4. SEM images indicating the thermal effects incurred upon closer inspection of the enamel surface (Fig. 5d).
on the enamel beneath a mature extrinsic stain. a: Laser-in- Extrinsic stain remnants are attached to the enamel with-
duced pits are formed in the enamel at 6.1 J/cm2 and four in the irradiated area. A demagnified light-microscope
passes of the laser. Smooth craters are seen on the bottom image of all irradiation paths on this tooth is shown in
and sides of this pit. b: Magnification of these smooth craters Figure 6f. The white box in this Figure corresponds to
in another laser-induced pit at identical irradiation the irradiation path in Figure 6b. There were seven irra-
conditions. diation paths with peak fluences of (from left to right) 0.8,
 TREATMENT OF EXTRINSIC DENTAL ENAMEL STAINS 343

Fig. 6. Light-microscope images (a) before and (b) after laser

irradiation of an extrinsic enamel stain at 3.1 J/cm2 and two
passes. c: An SEM image of the treated area in (b). d: Trian-
gulation image detailing the depth of the stain removed. The
scale in (a) is the same for (b)–(d). The white box in (c) is
magnified in (e), where the enamel rods are clearly observed.
f: Light-microscope image of the crown of the irradiated
canine. The white box in (f) corresponds to the irradiated
area in (a)–(c). The white arrow and asterisk in (f) indicates a
cavitated caries lesion not treated by the laser. [Color figure
can be seen in the online version of this article, available at
http://wileyonlinelibrary.com/journal/lsm]
Fig. 7. a: Fluorescence spectra between 600 and 800 nm for
3.1, 0.8, 1.7, 2.3, 4.9, and 6.1 J/cm2. The numbers of enamel, unbleached, and photobleached (P-B) stain. b: A
passes varied for each path and were (from left to right) normalized plot of (a). [Color figure can be seen in the online
40, 2, 6, and 2 passes for the rest. While each irradiation version of this article, available at http://wileyonlinelibrary.-
path appears moderately whiter under blue-light micros- com/journal/lsm]
copy the SEM images (Figs. 5d and 6e) indicate rough
enamel surfaces and clearly show enamel rods. The region Calculus and mature extrinsic enamel stains are mineral-
on the cervical indicated by the white arrow and asterisk ized biofilms where the latter is often thinner and con-
in Figure 6f is a non-laser-treated, cavitated caries lesion tains stain chromogens [8]. Removal of extrinsic enamel
with visible enamel rods. stain (50 mm thick) at 400 nm and 6.4 J/cm2 requires
Fluorescence spectra between 600 and 800 nm of enam- 20 total pulses, which is similar to measured calculus
el, unbleached, and photobleached extrinsic stains excited removal rates under identical irradiation conditions [20].
at 400 nm are shown in Figure 7. The spectrum of the Incident fluences >3 J/cm2 typically remove calculus
photobleached stain resembles the fluorescence spectrum and extrinsic stain, while lower fluences can lead to
of enamel in shape and intensity, emitting more stalling, leaving behind photobleached remnants and
fluoresced photons than the unbleached stain (Fig. 7a). debris.
Normalizing each spectrum to the maximum of each plot The underlying enamel surface after stain removal is
(Fig. 7b) reveals details not easily seen in Figure 7a. either undamaged (Fig. 2) or contains randomly isolated,
While enamel fluorescence decreases monotonically with 50-mm-diam laser-induced pits (Figs. 3 and 4). The experi-
wavelength, unbleached, and photobleached stains have a ments indicate that these laser-induced pits are a conse-
distinct structure between 615 and 700 nm that is more quence of prior cariogenic acid attacks. Enamel samples
pronounced for the unbleached stain. without visible prior damage sites appear like pristine
enamel after ablation. We have observed that sound
DISCUSSION enamel begins to ablate measurably at 12 J/cm2,
Extrinsic stain removal at 400 nm is similar to selective twice the highest fluence in this study. We conclude,
ablation of dental calculus at the same wavelength. therefore, that damage to underlying enamel after NUV-
344 SCHOENLY ET AL.

laser stain ablation is unlikely if the underlying enamel is Fluorescence spectroscopy is used to quantify molecular
pristine. differences between photobleached and unbleached enam-
The smooth, submicron craters (100–500 nm in diam- el stain in the range of 600–800 nm when excited at
eter) along the bottom and edges of laser-induced pits 400 nm (Fig. 7). The unbleached stain fluorescence spec-
(Fig. 4) are indicative of melted hydroxyapatite between trum is similar to dental calculus that is dominated by the
1,2008C and 2,0008C [29]. The smooth craters originate Soret band of porphyrins [35–38]. In calculus and caries,
from microscopic quantities of superheated subsurface this is an endogenous porphyrin (e.g., protoporphyrin IX)
water and/or explosively expulsed gases spilling molten that is commonly found in oral bacteria (e.g.,
mineral along crater edges that rapidly cool and solidify. P. intermedia, P. nigrescens, and P. melaninogenica)
Similar topologies are observed after enamel is irradiated [39–41]. Fluorescence from these porphyrins is reduced
with a CO2 laser [30]. A previous cariogenic acid attack for photobleached stains (Fig. 7b), where its fluorescence
(Fig. 4a) typically reduces the structural integrity and spectrum is similar to that for enamel. The absorption
increases the porosity of the enamel through deminerali- coefficient within a photobleached stain is reduced, allow-
zation. These enamel defects allow stain components to ing scattering to dominate as evident under blue-light mi-
diffuse 5–10 mm from the stain/enamel interface into croscopy (i.e., a photobleached stain appears bright).
superficial enamel [3,8], resulting in an internalized Subsequent ablation stalling after stain photobleaching
extrinsic enamel stain. During NUV-laser irradiation, suggests that the presence of unbleached bacterial
imbedded stain chromophores can serve as ablation porphyrins is necessary for successful mature extrinsic
initiation sites leading to the observed damage. As a stain removal at 400 nm.
result, stain ablation can be associated with removing the Our experiments show that ablative removal of extrin-
unsound enamel and transferring excess heat to the sic enamel stains using a 400-nm laser has real potential
surrounding enamel environment. to be both expedient and selective compared to conven-
Alternatively, these laser-induced enamel pits could be tional stain removal methods. Conventional alternatives
caused by large chromophore concentrations within the like brushing with a whitening dentifrice requiring
stain that could then transfer excess heat to the bulk of frequent and consistent long-term application are ineffec-
the underlying enamel and ablate it. This case is mecha- tive for well-established stains. Microabrasion is a more
nistically analogous to dye-assisted enamel ablation using expedient but non-selective method requiring subsequent
near-infrared (NIR) lasers [e.g., Nd:YAG (1,064 nm) and polishing [14] to avoid plaque accumulation. Bleaching
alexandrite (800 nm) lasers], which do not normally ab- with hydrogen peroxide penetrates into the enamel and
late enamel [31]. We rule out this effect since ablation of oxidizes the stain with negligible enamel removal [42].
underlying enamel was observed only in isolated locations However, overbleaching can lead to demineralization of
and on certain teeth with obvious signs of a prior cario- the enamel [43]. Accelerated bleaching as a result of
genic acid attack elsewhere. simultaneous laser irradiation can also potentially raise
Light surface melting and concomitant microscopic drop- the intrapulpal temperature to unacceptable levels [16].
let ejection in the vicinity of observed laser-induced pits, In contrast, the 400-nm laser is solely absorbed by the
particularly apparent in Figure 4b, may indicate decreased stain, where generated heat is thermally confined to the
vulnerability to subsequent demineralization and carious ablated volume that is mostly carried away with the ejec-
acid attack. This conjecture is based on enamel ablation ta. Stain removal within the 300-mm-diam irradiation
with a pulsed CO2 laser (l ¼ 9.6 mm), which results in a beam takes 20 pulses (i.e., 2 seconds at 10 Hz) of the
similar melted surface topology that was found to be less 400-nm laser at >3 J/cm2 with little to no damage to the
soluble and more resistant to subsequent acid attack [32]. underlying enamel.
The reduction in solubility of enamel is attributed to remov- In conclusion, selective 400-nm laser ablation of extrin-
ing carbonate constituents 4008C [26,33,34]. sic enamel stains is most efficient above 3 J/cm2. Ablation
The ablation of stained, carious enamel (Figs. 5 and 6) is incomplete at lower fluences, where stalling is more
is mechanistically analogous to the already described la- likely to occur as a result of photobleaching of porphyrins.
ser-induced pit formation initiated by imbedded bacterial Underlying pristine enamel is not removed below 12 J/
absorbers and stain chromogens. The stained, carious cm2. Cariogenic acid-attacked enamel is likely to be
enamel is an internalized extrinsic stain as is obvious by removed since stain chromogens diffused into more
the smooth enamel surface before 400-nm irradiation and porous, superficial enamel act as absorbing sites for the
exposed enamel rods after ablation. Internalized stain re- laser. The appearance of isolated, laser-induced, 50-mm-
moval demonstrates the ability of 400-nm ablation to re- diam pits containing smooth, submicron-diameter craters
move both extrinsic stains superficial to the tooth surface on this enamel surface indicates a thermal mechanism
and those stains within superficial enamel that have been consisting of surface melting and microscopic water
internalized from defects. However, the resulting rough droplet ejection.
enamel surface, with exposed enamel rods, may indicate
increased permeability and caries susceptibility. Further ACKNOWLEDGMENTS
experiments are required to assess the desirability of This work was supported by the U.S. Department of
this stain-removal modality and compare it to existing Energy Office of Inertial Confinement Fusion under
alternatives. Cooperative Agreement No. DE-FC52-08NA28302, the
 TREATMENT OF EXTRINSIC DENTAL ENAMEL STAINS 345

University of Rochester, and the New York State Energy 22. Hennig T, Rechmann P, Pecnik T, Heinz H-P, Hadding U.
Influence of second harmonic alexandrite-laser radiation on
Research and Development Authority. The support of bacterial growth. In: Wigdor HA, Featherstone JD, White
DOE does not constitute an endorsement by DOE of the JM, Neev J, editors. Lasers in dentistry II. Bellingham, WA:
views expressed in this article. This work was also SPIE, 1996;2672:40–50.
23. Lennon AM, Buchalla W, Switalski L, Stookey GK. Residual
partially financially supported through a 2010 student
caries detection using visible fluorescence. Caries Res
grant from the American Society for Laser Medicine and 2002;36(5):315–319.
Surgery (ASLMS). 24. Fried D, Glena RE, Featherstone JDB, Seka W. Nature of
light scattering in dental enamel and dentin at visible and
near-infrared wavelengths. Appl Opt 1995;34(7):1278–1285.
25. Spitzer D, ten Bosch JJ. Absorption and scattering of light in
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