IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 16, Issue 4 Ver. VII (April. 2017), PP 18-24
www.iosrjournals.org

Laser In Endodontics-A Review Article

Dr.Pradnya V. Bansode1,Dr.Seema D.Pathak2,Dr.Madhuri Wavdhane3,
Dr.Shirish Khedgikar4,Dr.Shraddha Gite5
1
(Professor And Head Of Department, Department Of Conservative Dentistry And Endodontics, Gdc &
Hospital, Aurangabad/ Muhs,India)
2
(Associate Professor , Department Of Conservative Dentistry And Endodontics, Gdc & Hospital, Aurangabad/
Muhs,India)
3
(Associate Professor, Department Of Conservative Dentistry And Endodontics, Gdc & Hospital, Aurangabad/
Muhs,India)
4(
Lecturer, Department Of Conservative Dentistry And Endodontics, Gdc & Hospital, Aurangabad/ Muhs,India)
5 rd
(3 Year Postgraduate Student,Department Dentistry And Endodontics, Gdc & Hospital, Aurangabad/
Muhs,India)

Abstract: Lasers were introduced into the field of clinical dentistry with the hope of overcoming some of the
drawbacks posed by the conventional methods of dental procedures. Since its first experiment for dental
application in the 1960s, the use of laser has increased rapidly in the last couple of decades. At present, wide
varieties of procedures are carried out using laser.The purpose of this paper is to summarize laser applications
in endodontics, including their use in pulp diagnosis, dentinal hypersensitivity, pulp capping and pulpotomy,
sterilization of root canals, root canal shaping and obturation and Apicoectomy.The essential question is
whether a laser can provide equal or improved treatment over conventional care. Secondary issues include
treatment duration and cost/benefit ratio. This article reviews the role of lasers in endodontics and conservative
dentistry since the early 1970s, summarizes many research reports from the last decade, and surmises what the
future may hold for lasers in endodontics. With the potential availability of many new laser wavelengths and
modes, much interest is developing in this promising field.
Keywords: Dentine; laser diagnosis; laser therapy use; root canal treatment

I. Introduction
The word ―LASER‖ is widely used in dentistry. It stands for Light amplification by stimulated
emission of radiation. With the rapid development of laser technology, newlasers with a wide range of
characteristics are now available and being used in various fields of dentistry. Studies continue to be conducted
in order to make maximum use of properties of the existing lasers in the field of endodontics.History Of Lasers
In 1917, Einstein laid the foundation for the laser when he introduced the concept of stimulated emission; where
a photon interacts with an excited molecule or atom and causes the emission of a second photon having the
same frequency, phase, polarization and direction.

The Maser
A predecessor of the laser, called the MASER,for "Microwave Amplification by Stimulated Emission
of Radiation", was independently developed in 1954 at Columbia University by Charles Townes and Jim
Gordon and in Russia by Nicolay Basov and Alexandra Prokhorov.

1.1History Of Lasers In Dentistry

The most recent development in endodontic treatment is the use of lasers. Since the development of the
ruby laser by Maiman in 1960. Dental researchers began investigating lasers potential and Stern and Sognnaes
reported in 1965 that a ruby laser could vaporize enamel.[1] The first laser use in endodontics was reported by
Weichman& Johnson (1971) who attempted to seal the apical foramen invitro by means of a high power-
infrared (CO2) laser. Subsequently, attempts were made to seal the apical foramen using the Nd:YAG
laser.Practitioners and researchers began to find clinical oral soft tissue uses of medical CO2and Nd: YAG
lasers until in 1990 when the first pulsed Nd: YAG laser designed specifically for the dental market was
released. The year 1997 saw the FDA clearance of the first true dental hard tissue Er: YAG laser and the Er, Cr:
YSGG a year later. Semiconductor based diode lasers emerged in the late 1990s as well

1.2 Mechanism Of Action Of Lasers

The word laser is an acronym standing for ―Light Amplification of Radiation‖. A laser beam is created
from a substance known as an active medium, which when stimulated by light or electricity produces photons of

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 Laser in Endodontics-A Review Article

a specific wavelength. Lasers are characteristically monochromatic, unidirectional, coherent, and emitted from a
stimulated active medium. Monochromacity means that a laser beam is made of a single wavelength of light,
and all dental lasers are found in the visible or infrared portion of the electromagnetic spectrum. Once a laser
beam is produced it will travel in one direction (unidirectional), though the divergence of the beam varies by
type of laser and the associated transmission hardware. Coherence is the property that not only is a laser a single
wavelength but all the peaks and valleys of each wave travel in unison.
The active media in dentistry can be solid state, gas, or semiconductor. Solid state lasers are a crystal
matrix host doped with the light emitting, excitable atoms; such as erbium laced yttrium, aluminium, and garnet
(Er: YAG). CO2is a popular laser where the active medium is sealed in an air tight chamber. Diode lasers have a
semiconductor that when stimulated with electricity, laser light is emitted [2] Stimulated emission is a
phenomenon that occurs within the active medium. For example, in solid state Er: YAG lasers the erbium is
stimulated by light from a flash lamp with a process known as optical pumping. As an erbium atom absorbs a
photon, its electrons are elevated to higher energy level. When the electrons return to a lower energy state, two
identical photons are emitted and these photons can further stimulate more atoms in a chain reaction, resulting in
amplification of the light produced. Mirrors surrounding the active medium called a resonator further increase
this light energy. One of the mirrors called the output coupler is less than one hundred percent reflective. Light
leaks from the output coupler and these are the photons that form the laser beam. Once the beam is created it is
carried to the target tissue by various types of beam transfer hardware. Mirrors in articulated arms and optical
fibers are common examples of this hardware[3]
Different lasers considered for endodontic applications are the near infrared laser—diode (810, 940,
980 and 1,064 nm) and Nd:YAG(1,064 nm)— and the medium infrared lasers—Erbium,Chromium:
YSGG (Er,Cr:YSGG; 2,780 nm) and Erbium:YAG (2,940 nm).
Near infrared lasers such as Nd:YAG (from 803 nm to 1,340 nm) were the first to be used for root
optical fibre. The near infrared lasers are not absorbed by hard dentinal tissues and have no ablative effect on
dentinal surfaces. The thermal effect of the radiation penetrates up to 1mm into the dentinal walls, allowing for a
decontaminating effect on deeper dentine layers.
The medium infrared lasers, such as the Erbium (2,780 nm and 2,940 nm) laser family, with
flexible,fine tips have also been used. The medium infrared lasers are well absorbed by the water content of the
dentinal walls and consequently have a superficial ablative and decontaminating effect on the root canal surface.
The far infrared laser CO2 (10,600 nm) was the first to be used in endodontics for decontamination
and apical dentine melting in retrograde surgery. It is no longer used in this field with the exception of vitalpulp
therapy (pulpotomy and pulp coagulation).

II. Applications Of Lasers In Endodontics

1. Lasers as a Diagnostic Tool for Endodontics
2. Analgesic Effects of Laser
3. Laser & Dentin Hypersensitivity
4. Treatment of vital pulpal tissue-Pulpotomy andDirect pulp capping and pulp amputation
5. Root canal disinfection and irrigation-
 Access cavity preparation and root canal orifice enlargement.
 Root canal wall preparation.
 Sweeping of Root canal and irrigation.
 Sterilization or disinfection of infected canals.
 Obturation with gutta percha or resin.
 Removal of temporary cavity sealing materials, root canal sealing materials, and fractured instruments in
root canals
6. Vertical root fracture diagnosis and treatment
7. Laser Assisted Obturation and removal of gutta percha obturation material.
8. Endodontic surgery-
 Flap preparation – incision of soft tissue to prepare a flap and expose the bone.
 Cutting bone to prepare a window access to the apex (apices) of the roots
 Apicoectomy – amputation of the root end
 Root end preparation for retro fill amalgam or composite
 Removal of pathological tissues (i.e., cysts, neoplasm or abscess) and hyperplastic tissues (i.e., granulation
tissue) from around the apex.

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 Laser in Endodontics-A Review Article

Laser & Dentin Hypersensitivity

The use of lasers in endodontics has been studied since the early 1970s, and lasers have been
morewidely used since the 1990s. A successful endodontic therapy is when there is complete and
effectivecleaning of root canal.[4]Tradi-tional endodontic techniques use mechanical instru-ments, as well
asultrasound and chemical irrigation to shape, clean and completely decontaminate the endodonticsystem. There
is limitation of endodontic therapy such as lateral canals with various morphologies and dimensions.[5] The
usefulness of the debridement, cleaning and refining of the intra-radicular space is limited, because of
anatomical complexity and the difficulty of common irrigants to penetrate into the lateral canals and the apical
ramifications. Hence, there is need for new materials, tech- niques and technologies that can improve the
cleaning and decontamination of these anatomical areas.[6]
Different wavelengths have been shown to be effective in significantly reducing bacteria in infected
canals and studies have confirmed these results in vitro. Further studies have demonstrated the efficiency of
lasers in combination with commonly used irrigants, such as 17% EDTA, 10% citric acid and 5.25% sodium
hypochlorite.[7]The action of the chelating substances facilitates the penetration of laser light, which can
penetrate into the dentinal walls up to 1mm in depth and have a stronger decontaminating effect than chemical
agents. Laser-activated irrigation, has been shown to be statistically more effective in removing debris and the
smear layer in root canals compared with traditional techniques and ultrasound.[8]A recent study by DiVito et
al. demonstrated that the use of the Erbium laser at sub-ablative energy density using a radial and stripped tip in
combination with EDTA irrigation results in effective debris and smear layer removal without any thermal
damage to the organic dentinal structure. In endodontics, lasers use the photo- thermal and photomechanical
effects resulting from the interaction of different wavelengths and different parameters on the target tissues.
These are dentine, the smear layer, debris, residual pulp and bacteria in all their various aggregate forms.
Laser Wavelength Consideration[9]-The primary use of lasers in endodontics is focused on eradicating
micro-organisms in the root channel, especially in the lateral dentinal tubuli. This requires a wavelength that
shows high transmission through hydroxyapatite and water. Absorption curves show that Nd:YAG lasers, and
in particular pulsed Nd:YAG lasers, are first-choice for this application. Nd:YAG lasers show the best results in
transmission and microorganism reduction measurements.

Thermal Consideration
Behrens and Gutknecht, 1993,[10]conducted in- vitro experiments on dentine slices with laser power
settings that take into account even the most extreme situations, in order to determine that no thermal damage
occurs in pulsed Nd: YAG laser or diode laser treatments. When measuring the root surface, a temperature of
38° C was obtained after a 45-second treatment duration at 15Hz/1.5W. This value lies within the
physiological area. It must be considered that in an in-vivo situation the dental tissue is more efficiently cooled
by the blood flow that surrounds the root surface.

Morphological Changes
The smear layer is completely removed and the dental tubuli are, for the most part closed through
inorganic melting if the Nd:YAG laser is applied with 15Hz/1.5W settings.[11] Similar results can be expected
if the 810 nm laser diode is used. If the Er:YAG laser is applied, the smear layer will be completely removed
and the dental tubuli remain open.

Disinfection Effect
GUTKNECHT et al[12] achieved an average of 99.92% bacterial reduction in the root canal using the
Nd:YAG laser. In 1994, Rooney et aLand Hardee et al described reductions of 99 % when using a Nd: YAG
laser in different experimental designs and bacterial combinations. Further studies examined the depth effect of
the laser in the root canal dentine. In 1997, Klinke et al were able to prove a bactericidal effect of the Nd:YAG
laser at a depth of 1,000 μm. In comparison, a rinsing solution, such as NaOCl, only achieves effective bacterial
reduction up to a depth of 100 μm.
Indications and contra-indications for laser supported endodontic treatments
[13]

Laser-supported treatments should be favored when treating patients that show one or several of the
following symptoms:
1. Teeth with a purulent pulpitis or pulp necrosis
2. Teeth, of which the crown and root pulp show gangrenous changes
3. Teeth with peri-apical lesions (peri-apical gap from 1 mm, up to granulomas with a diameter of 5 mm and
more
4. Teeth with a peri-apical abscess

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 Laser in Endodontics-A Review Article

5. Teeth with lateral canals that lead to periodontal involvement

6. Absorption of the apex caused by inflammation or trauma
7. Teeth that have been treated for at least threemonths without success (with alternating rinsing and medicinal
inlay

2.1 Laser as a Diagnostic tool in endodontics-Determination of pulp vitality-

Laser doppler flowmetry is a device used to determine pulp vitality based on red blood cell flux in the pulp
tissue. It is particularly useful for the detection of pulp vitality in traumatized and/or immature teeth (Singh et
al., 2013)

Mechanism of Action-
Light beams from the optical fibre enters the tissue, is absorbed to some extent by the blood cells and
another fibre tip collects the scattered light and provides information about pulp vitality
Its advantages are non-invasive, painless diagnosis of the tooth , reproducible, gold standard for pulpal blood
flow determination .
Limitations are- takes longer than other vitality determination techniques, requires a special device.
Therefore, it is not conducted as a routine procedure in clinical practice

2.2.Lasers in Pulp Capping[14]- for Indirect Pulpcapping-

Pulsed Nd:YAG laser is used and black ink applied on the tooth surface. Air spray cooling is needed to
prevent pulp damage resulting from the laser energy. CO 2 laser can also be used. In some cases, it is
recommended that this laser be used with 38% silver ammonium solution. These treatments should be
performed under local anesthesia.

2.3.Direct pulp capping by laser[14]

CO2 laser irradiation is performed at 1 or 2W after irrigating with 8% sodium hypoclorite and 3%
hydrogen peroxide for more than 5 minutes. Calcium hydroxide paste must be used to dress the exposed pulp
after laser treatment, after which the cavity should be tightly sealed with cement such as polycarboxylate
cement. Pulsed Nd: YAG, argon, semiconductor diode, and Er:YAG can also be used.
Laser Ablation and Accessory Treatment for Vital Pulp Amputation[14]-The lasers used are CO2, pulsed
Nd:YAG, He-Ne and low power semiconductor diode lasers and middle power semiconductor diode lasers.
CO2 laser usage is time consuming and pulp tissue may be damaged due to several exposures. 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.

2.4.Laser & Dentin Hypersensitivity

The mechanism of laser for treatment of dentin hypersensitivity is not well explained, However
Pashley suggests that it may occur through coagulation and protein precipitation of plasma in dentinal fluid or
by alteration of nerve fiber activity. 8 Laser therapy has been recommended by Kimura etal. to treat dentin
hypersensitivity with effectiveness between 5.2% and 100%, depending on the type of laser and parameters
used. According to authors, lasers are more effective than other treatments,although effect diminishes in severe
dentin hypersensitivity. Mckarthy et al indicates that thereduction in dentin hypersensitivity could be the result
of alteration of root dentin surface, physically occluding the dentinal tubules.

2.5.Laser in Analgesia
The pulsed â Nd:YAG laser is widely used as a analgesia 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.

2.6.Root canal disinfection and irrigation-The various uses of laser in root canal treatments
are as follow
1. Access cavity preparation and root canal orifice enlargement.
2. Root canal wall preparation.
3. Sweeping of Root canal and irrigation.
4. Removal of pulp remnants and debris at the apical foramen.
5. Sterilization or disinfection of infected canals.
6. Obturation with gutta percha or resin.
7. Removal of temporary cavity sealing materials, root canal sealing materials, and fractured instruments in root
canals.

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 Laser in Endodontics-A Review Article

 Access cavity preparation- Er,Cr:YSGG (2780nm) and Er:YAG (2940nm) can be used for access cavity
preparation, root canalshaping and cleaning.
 Root canal wall preparation-Lasers such as Er:YSGG (2780nm), Er:YAG(2940nm) and Nd:YAG(1064nm)
are use 3d for root canal wall preperation15. When the laser fiber is unable to be inserted into thecanals,
reamers and files are to be used, followed by lasers. Smear layer is completely removed and dentinal tubuli
are for the most part closed if pulsed Nd:YAG laser is applied at 15 Hz / 1.5 W settings.
 Sweeping of Root canal and irrigation are done in Straight, slightly curved and wide canals with
lasers.Along with lasers, 5.25% Sodium hypochlorite or14% EDTA must be used along laser
irradiation.Nd:YAG are widely used for removal of pulp remnants and debris at the apical foramen.
Removal of pulp remnants, control of hemorrhage, and stimulation of cells surrounding the root apex as
well as debridement on the surface.
 Sterilization or disinfection of infected canals are done with Pulsed Nd:YAG, argon,
semiconductordiode,CO2, Er:YAG lasers. Because of laser energy and wavelength characteristic, they are
useful in killing microorganism.
 In endodontics, lasers use the photo-thermal and photomechanical effects resulting from the
interaction of different wavelengths and different parameters on the target tissues.

With vertical condensation method, obturation of canals can be done with Lasers. Anic and Matsumoto
attempted to investigate whether it is possible to perform the root canal filling using sectioned gutta-percha
segments and a pulsed Nd:YAG laser. With the lasers, Removal of temporary cavity sealing materials, root
canal sealing materials, and fractured instruments in root canals became possible.15 In fine and strongly curved
canals, however, there were many cases in which laser tips perforated the canal wall.

2.7.Laser in Apicoectomy, Retrograde and Endodontic Apical Cavity Preparation, and

Periapical Curettage -The advantages of laser application in endodontic surgery are identical to those
that have been reported for other oral surgical procedures. Soft tissue lasers like the Nd:YAG; Diode or CO2 can
be used for providing clean incisions for gaining direct access to the periradicular region. In addition, the use of
lasers to replace aerosol-producing handpieces in periapical surgery can reduce the risk of contamination of the
surgical environment by blood borne pathogens. The Er:YAG or the Er,Cr:YSGG lasers can be used for cutting
into bone as well as sectioning the apical 3rd for apicoectomy & have also been researched for retro-preparation.
The unique properties of laser light as they pertain to endodontic surgery are listed as follows: precision;
coagulation; decreased postoperative pain, edema and reduced scarring; sterilization; selective absorption.

2.8 Vertical root fracture diagnosis and treatment-

There are very few studies examining the use of lasers in diagnosing vertical root fracture cases.
Although Kimura et al. (2009) used diagnodent for vertical root fracture detection in vivo, this technique appears
to be impractical for clinical use. Vertical fractures can be treated using a surgical approach on the fracture side,
which involves cleaning of the fracture line and filling with composite resin or bioactive materials. Thereafter,
lasers can be used to accelerate soft tissue repair, and this has been performed previously using low power laser
therapy (Nogueira et al., 2012)

2.9.Laser Assisted Obturation:

Due to their thermal effects clinicians have also tried using lasers like the Nd:YAG for thermosoftening
gutta-percha; however there isn't much of an advantage seen over the thermoplasticised gutta-percha obturations
systems commercially available today. Nd:YAG laser has also been used for sectioning excess gutta percha left
after lateralcompaction techniques.

III.Indication And Contraindication Of Lasers In Endodontics

Indications.
a. Teeth with lateral canal leading to periodontal involvment.
b. Teeth with pulp necrosis and purulent pulpitis.
c. Teeth with gangarenous changes.
d. Teeth with periapical lesions upto 5mm or more.
e. Teeth that has been treated atleast 3 months with no success.

Contraindications
a.In advanced periodontitis cases.
b. A deep crown and root fracture.
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 Laser in Endodontics-A Review Article

c. Obliterated root canals in endodontic treated teeth.

IV. Conclusion
It is concluded that with the advent of Lasers in dentistry, the complex procedures have become
easier and time saving. Thus the patient care has improved.

Acknowledgements
It’s my immense pleasure to express my deep sense of gratitude and sincere thanks to my Dean Dr. S.
P. Dange , Government Dental College & Hospital Aurangabad

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 Laser in Endodontics-A Review Article

References
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Examples follow:
Journal Papers:
[1]. M Ozaki, Y. Adachi, Y. Iwahori, and N. Ishii, Application of fuzzy theory to writer recognition of Chinese characters, International
Journal of Modelling and Simulation, 18(2), 1998, 112-116. (8)
[2]. Note that the journal title, volume number and issue number are set in italics.
Books:
[3]. R.E. Moore, Interval analysis (Englewood Cliffs, NJ: Prentice-Hall, 1966). (8)
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[5]. P.O. Bishop, Neurophysiology of binocular vision, in J.Houseman (Ed.), Handbook of physiology, 4 (New York: Springer-Verlag,
1970) 342-366. (8)
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[7]. D.S. Chan, Theory and implementation of multidimensional discrete systems for signal processing, doctoral diss., Massachusetts
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Proceedings Papers:
[9]. W.J. Book, Modelling design and control of flexible manipulator arms: A tutorial review, Proc. 29th IEEE Conf. on Decision and
Control, San Francisco, CA, 1990, 500-506 (8)

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