LASERS IN

ENDODONTICS
PRESENTED BY – Dr Garima Joshi
INTRODUCTION
◦ The field of dentistry has shown biggest boon in the use of modern technology to
bring improvements in the treatment procedures. Among which is the use of
LASER (Light Amplification by Stimulated Emission of
Radiation) in the field of Endodontics.
◦ developed in 1960 by a scientist working for the Hughes Aircraft Corporation,
Theodore Maiman, who proposed its mechanism based on the emitted beam
coming from a ruby crystal.
◦ Built on the principles of quantum mechanics, this device creates a beam
of light where all of the photons are in a coherent state - usually with the
same frequency and phase. This causes the light from a laser to be tightly
focused, not diverging much, resulting in the traditional laser beam.
CLASSIFICATION OF LASERS
I: According to ANSI and OHSA:
 CLASS I: These are low powered lasers that are safe to use, e.g. Laser beam pointer.
 CLASS II A: These are low powered lasers that are hazardous only when viewed directly for l He-Ne
lasers.
 CLASS II B: Low powered visible lasers that are hazardous when viewed for more than 0.25 seconds.
 CLASS III A: Medium powered lasers that are normally hazardous if viewed for less than 0.25
seconds without magnifying optics.
 CLASS III B: Medium powered lasers that are hazardous if viewed directly.
 CLASS IV: These are high powered lasers (> 0.5 W) that produce ocular skin and fire hazards.
II: Based on the wavelength of the beam:
 Ultraviolet rays: 140-400 nm
 Visible light:400-700 nm
 Infrared: 700 to microwave spectrum

III) Based on the type of laser medium used:

 Gas laser- Helium Cadmium, Helium neon, Krypton, Carbon monoxide, Argon, Nitrogen, Carbon dioxide
 Solid laser- Ruby, Rhodamine, Erbium, Neodynium.
 Liquid laser- Liquid dye , Water vapour
 Electronic laser- Semiconductor, Diode

IV) Based on the type of delivery system:

 Flexible hollow wave guide/articulating arms.
 Glass fibre optic cable
V) Based on laser modes:
 Continuous mode
 Gated mode
 Pulsed mode

VI) Based on type of interaction with tissue:

 Contact laser
 Noncontact laser

VII) Based on type of application:

a) Soft tissue lasers-low power about 1 w - Helium Neon , Gallium neon ,Gallium arsenide, Gallium
aluminium arsenide
b) Hard tissue laser-high power about 3 w or more -Argon laser, CO2 laser, Nd; YAG laser, Er; YAG
laser
,Er; YSG laser
 COMPONENTS OF LASER

An optical cavity-
• the core and centre device.
• consists of molecules, chemical or compounds elements and is known as lasing /
active medium.
• Based on the nature of active medium, it may be gas, crystal or solid semiconductor,
the laser is named.
• Argon and CO2 are the two active gaseous medium lasers used in dentistry.
2 parallel mirror placed on either side.
• excite the photons to bounce off and then re-enters the active medium to activate the release
of more photons.
• the mirrors collimate the light that is photons exactly perpendicular and make them re-enter
the active medium, while those off axis leave the lasing proc
M1(mirror)- totally reflective, M2- partially transmissive.
Photons bounce of the mirror and re-enter the medium to stimulate the release of electrons.
the light that escapes first through the mirror becomes the laser beam.
pump energy source-
◦ provided by flash lamp or electrical coil which pumps the high energy radiation into the active
medium.
A cooling system
◦ the remaining energy is converted into heat hence it is necessary to provide some form of
cooling, which is provided by water.
 PHYSICS OF LASER

• The electrons in atoms in special glasses, crystals, or gases

absorb energy from an electrical current or another laser and
become “excited.”
• The excited electrons move from a lower-energy orbit to a
higher energy orbit around the atom’s nucleus.
• When they return to their normal or “ground” state, the
electrons emit photons (particles of light).
• atom may undergo transition between two energy states E1 and
E2 if it emits or absorbs a photon of appropriate energy.
• The life time of the atoms in the excited state is normally 10-8
seconds.
EMISSION MODES
◦ Continuous wave: It is basically defined as “operation mode of a LASER with continuous light
emission”. Continuous-wave operation of a LASER means that the LASER is continuously pumped
and continuously emits light.
◦ Gated-pulse mode: there are periodic alterations of the LASER energy being on and off, much like
a blinking light.
achieved by opening and closing of a mechanical shutter in front of the beam path of a continuous
wave emission.
◦ FREE RUNNING PULSED MODE :This is a unique mode in the fact that large peak energies of
LASER light are emitted from an extremely short time span, usually in microseconds, followed by a
relatively long time in which the LASER is off.
LASER DELIVERY SYSTEM
Depending on wavelength and the access required at the terminal target tissue. (Husein, 2006;
Convissor and Coluzzi, 2004) These include;
◦ A. Articulated arms: these have joints made of tubes that allow the arm to bend at the joints where a
mirror reflects a beam into centre of the next tube without touching the inner surface of the tube.
◦ B. Hollow waveguide: It is a flexible hollow tube that has an interior mirror that reflects the laser
energy along this tube and exits through handpiece. These are much thinner than the articulated
arms.
◦ C. Glass fiberoptic cable: It is even more flexible than a wave guide, smaller in diameter with sizes
ranging from 200 to 600 microns.
TISSUE INTERACTIONS & BIOLOGICAL
EFFECTS-
◦ As the energy reaches the biological interface one of four interaction will occur
◦ REFLECTION
◦ TRANSMISSION
◦ SCATTERING
◦ ABSORPTION

There are 5 important type of biological

effects that can occur once the laser
photons will enter the tissue
• Fluorescence
• Photothermal
• Photodisruptive
• photochemical
• photobiomodulation
When a laser heats oral tissues certain reversible or irreversible
changes occur
INDICATIONS
a. Teeth with lateral canal leading to periodontal involvement.
b. Teeth with pulp necrosis and purulent pulpitis.
c. Teeth with gangrenous changes.
d. Teeth with periapical lesions upto 5mm or more.
e. Teeth that have been treated atleast 3 months with no success
CONTRAINDICATIONS
a. In advanced periodontitis cases.
b. A deep crown and root fracture.
c. Obliterated root canals in endodontic treated teeth.
ADVANTAGES
a. Ability to selectively and precisely interact with diseased tissues
b. Allows the surgeon to reduce the amount of bacteria and other oral pathogens in the surgical field
and incase of soft-tissue procedures
c. While using YSSG laser dramatic reduction of pain in most cases reduces the need for injected
anesthesia
d. Achieve good hemostasis with reduced need for sutures
e. Osseous tissue removal and contouring proceed easily with the Erbium family of laser instruments
LIMITATIONS
a. High cost
b. It requires additional training and education for various clinical applications and types of lasers
c. Accessibility to the surgical area
d. Overheating the tissue and air embolisms that could be produced by excessive air and water used
during the procedure
e. Erbium lasers cannot remove metallic restorations
f. No single wavelength will treat all dental disease
LASERS USED IN DENTISTRY
APPLICATION OF LASER IN ENDODONTICS
1. Diagnostic Tool for Endodontics
2. Analgesia
3. Dentinal Hypersensitivity
4. Vital Pulp Therapy (Pulpotomy, Direct pulp capping, and Indirect Pulp capping)
5. Root canal treatment • Access cavity preparation • Orifice location and enlargement • Preparation
of the canal walls • Irrigation and disinfection of infected canals. • Obturation of canal • Removal of
Gutter Percha obturation material; • Retrieval of temporary cavity sealing materials, root canal sealing
materials, and fractured instruments in root canals
6. Vertical root fracture diagnosis and treatment
7. Endodontic surgery-
 DIAGNOSTIC TOOL FOR
ENDODONTICS
◦ for diagnosis of blood flow in the dental pulp.
◦ Helium-neon and diode lasers at low powers of 1- 2mW are used.
◦ laser beam is directed through the crown of the tooth
◦ it passes through the blood vessels within the pulp.
◦ The moving red blood cells cause Doppler shifts in the frequency of the laser beam and backscattering
of some of the light out of the tooth.
◦ Amount of scattered or doppler shifted rays is proportional to no. of moving red blood cells -
vitality of pulp
◦ Use of lasers for pulp sensibility testing offers the advantage of not relying on a painful sensation for
diagnosis
LASERS IN ANALGESIA
◦ The pulsed â Nd: YAG laser is widely used as an analgesic in endodontics.
◦ Its wavelengths interfere with the sodium pump mechanism

change cell membrane permeability,

alter temporarily the endings of sensory neurons,

and block depolarization of C and A fibers of the nerves, causing analgesia.

LASERS AND DENTINAL
HYPERSENSITIVITY
Middle output power laser:-
Low output power laser:-
-He-Ne and Ga-Al-As(780, 830, and
-Nd:YAG(0.3-2W, 10-20Hz) and CO2
930nm) lasers
(1-2W) laser
-Reach pulp tissue and block A or C-
-Seal the dentinal tubules and
fibers
reduce permeability
PULPOTOMY
◦ Amputation of coronal pulp
◦ CO2 , Argon, Nd:YAG laser
◦ Carbonization of the pulp tissue
◦ Carbonized tissue to be removed by 3%H2O2 and 5.25% NaOCl
ROOT CANAL TREATMENT
◦ SHAPING OF THE CANAL

◦ CO2 with Ag(NH3)2F – effectively seals dentinal tubules

◦ KTP(532nm) removes smear layer and debris
◦ Ho:YAG laser (2100nm)- ablation effect and cuts the radicular dentin
◦ Nd:YAP (1340nm)– in retreatment case and root canal preparation
DISINFECTION OF THE CANAL
◦ Can be used as a adjunct to biomechanical preparation.
◦ CO2 and Nd:YAG laser for dentinal tubule disinfection
◦ Increases the efficacy of NaOCl
◦ Laser assisted disinfection of root canal:-
- Direct laser irradiation using high power diode laser
- Photo activated disinfection (PAD)
- Laser activated irrigation using NaOCl
- Photon induced photo acoustic streaming (PIPS)
◦ LIMITATION
◦ There are several limitations that may be associated with the intracanal use of lasers that cannot be
overlooked.
◦ The emission of laser energy from the tip of the laser is directed apically along the root canal and not
towards root canal walls laterally.
◦ Therefore its impossible to obtain uniform disinfection of the canal walls unless a side firing spiral tip
is used.
◦ There are also chances of damage to the peri radicular tissue because of the heat produced.
OBTURATION
◦ Argon laser for polymerization of ah plus and resin used for obturation
◦ Argon, CO2, Nd:YAG laser used to soften gutta percha.
◦ Obturation of canals can be done with Lasers using vertical condensation.
◦ Anic and Matsumoto studied whether it is possible to perform the root canal filling using sectioned
gutta-percha segments and a pulsed Nd:YAG laser.
◦ It is very time consuming thus it is not practical to use.
PERIAPICAL SURGERY
◦ Diode laser for incision – bloodless field, sterile field
◦ Er:YAG laser- for cutting hard dental tissue
◦ Er:YAG laser resulted smooth, clean resected root (Paghdiwala et al 1993)
◦ ErCr:YSGG for the retrograde cavity preparation(irregular) – not better than ultrasonic – (Norberto et al. 2009).

◦ causes conversion of apical dentin and cementum to a uniformly glazed

area.
◦ This dosen’t allow the mircorganisms to penetrate through the dentinal tubules and
other structures at the apical area.
◦ Laser when used for endodontic surgeries have been shown to reduce post
operative pain and edema and reduce scarring.
Bleaching of root canal treated discolored
teeth
◦ After root canal treatment, tooth discoloration is a common, aesthetic problem particularly in
anterior teeth.
◦ According to Nicholls, the main causes of intrinsic tooth discoloration related to endodontic
treatment are decomposition of necrotic pulp tissue, hemorrhage into the pulp chamber, intracanal
drugs and filling materials.
◦ After obturation when Gutta-percha and different types of sealers if not removed from the pulp
chamber may cause mild to severe discoloration of the tooth.
◦ Laser-assisted bleaching technique has been shown to be an efficient method to treat resistant
discolorations in less than one hour.
STERILIZATION OF INSTRUMENTS
◦ Adrian JC and Gross A have used CO2 lasers for sterilization of files, reamers and for surgical
instruments, which has been proved in 1979.
◦ Hooks et al (1980) exposed contaminated endodontic reamers to CO2 laser beam. 100%
contaminating spores were killed by laser.
◦ Argon laser sterilized the selected dental instruments which were tested at the lowest energy level.
 PROTECTION FROM LASERS
◦ The surgical environment must have a warning sign and limited access.
◦ The operator should be well trained to use a laser device.
◦ The operator, patient and the surgical team should wear protective eyewear so that any reflected
energy does no damage.
◦ The operator should wear a special surgical LASER masks with protection filters to prevent inhalation
of infectious or toxic plume smoke.
◦ Never look directly into the laser beam.
◦ Never move the laser machine during the treatment .
◦ Never use the laser in the presence of flammable anaesthetics.
◦ Infection protocol should be followed.
◦ To evacuate the plume formed by tissue ablation , high volume suction must be used
REFERENCES
◦ Pick RM, Miserendino LJ. Lasers in dentistry. Chicago: Quintessence; 1995. p. 17-25.
◦ Convissor. R.A. and Coluzzi.D J. 2004. The biological rationale for the use of lasers in dentistry. Dental clinics of North
America, 48(4):771-794.
◦ Merchant.N. 2007. Laser in conservative dentistry and endodontics. IDRR, 25-26.
◦ Parker S. 2007. Laser regulation and safety in general dental practice. Br Dent J., 202:527-531.
◦ Roy George. 2009. Laser in dentistry-Review. Int J of Dent Clin., 1(1):13-19.
◦ Caprioglioc C, Olivi G, Genovese MD. Pediatric Laserassisted dentistry: A clinical approach. Laser 2012; 1: 8-15.
◦ V. Gopikrishna , B. Suresh Chandra. Grossman’s endodontic practice, 13 th edition
◦ Cohen’s pathways of the pulp 11 th edition