Discuss about the LASER physics, types, applications and add a note on effect of LASERS on

Wound Healing

Þ LASER PHYSICS:
LASER: Light Amplification by Stimulated Emission of Radiation
A device that transforms light of various frequencies into a chromatic radiation in the visible, infrared
and ultraviolet regions with all the waves in phase, capable of mobilizing immense heat and power
when focused at close range. (1)

Mechanism of Action:

Laser consists of three principle parts: an energy source, an active lasing medium, and two or more
mirrors that form an optical cavity or resonator.

Figure 1: Laser- Mechanism of Action

For amplification to occur, energy is supplied to the laser system through a pumping mechanism, such
as, a flash-lamp strobe device, an electrical current, or an electrical coil. This energy is then pumped
into an active medium contained within an optical resonator, which produces a spontaneous emission
of photons. Subsequently, amplification by stimulated emission takes place as the photons are
reflected back and forth within the medium by highly reflective surfaces of the optical resonator,
before their exit from the cavity through the output coupler. (2)

In dental lasers, the laser light is delivered from the laser to the target tissue via a fibreoptic cable,
hollow waveguide, or articulated arm. Focusing lenses, a cooling system, and other controls complete
the system.

The wavelength and other properties of the laser are determined primarily by the composition of an
active medium, such as gas, crystal, or a solid-state semiconductor. (2)

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Interaction of Laser with tissues:

Interaction of
Laser with
tissues

Reflection Transmission Scattering Absorption

Figure 2: Interaction of Laser with tissues

• Reflection: Based on Refractive Index of the target tissue. Can lead to damage when directed to
an unintended target such as eyes.
• Transmission: Water is relatively transparent to the shorter wavelengths, whereas tissue fluids
readily absorb the erbium family and CO2 at the outer surface, resulting in less energy
transmission to adjacent tissues.
• Scattering: Does not possess any useful biological effect, causes heat transfer to adjacent tissue
and unwanted damaged could occur. Mostly commonly used for curing of composites.
• Absorption: It elevates the temperature and produces photochemical effects depending on the
water content of the tissues. Haemoglobin absorbs blue and green wavelengths. melanin, absorbs
short wavelengths. (4)

Biological Laser Tissue interaction

Photochemical Photothermal Photomechanical Photoelectrical

Photodynamic
Biostimulation Photoablation Photopyrolysis Photodisruption Photoaccoustic
therapy

Figure 3: Biological Laser Tissue interaction

Photochemical Interaction: The stimulatory effects of laser light on biochemical and molecular
processes that normally occur in tissues such as healing and repair. Uses low energy laser light.

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Mechanism: laser light penetrate tissue- strikes chromophore (cytochrome in mitochondria): convert
ADP to ATP – supply energy to the cell

Photodynamic Therapy: Involves the use of a photoactive dye that is activated by exposure to light
of a specific wavelength in the presence of oxygen-results in the formation of toxic oxygen species,
such as singlet oxygen and free radicals. Photodynamic antimicrobial chemotherapy (PACT) has been
efficacious in the treatment of bacterial, fungal, parasitic, and viral infections

Photothermal Interactions: Occurs at higher fluences and shorter exposure times. Radiant energy is
absorbed by tissue substances and molecules transformed into heat energy the tissue effect occurs.

- Photoablation: removal of tissue by vaporization and super heating of tissue fluid

- Photopyrolysis: burning of tissue

Photomechanical Interactions:

- Photodisruption or photomechanical: breaking apart of structures by laser light

- Photo acoustic interactions: involves the removal of tissue with shock wave generation

Photoelectric Interactions:

Photoplasmolysis: tissue is removed through the formation of electrically charged ions and particles
that exist in a semi gaseous high-energy state.

Laser Energy And Tissue Temperature :

Table 1: Effect of temperature on target tissue

When laser is absorbed, it elevates the temperature and produces photochemical effects depending
on the water content of the tissues. When a temperature of 100°C is reached, vaporization of the
water within the tissue occurs, a process called ablation. At temperatures below 100°C, but above
approximately 60°C, proteins begin to denature, without vaporization of the underlying tissue.

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Conversely, at temperatures above 200°C, the tissue is dehydrated and then burned, resulting in an
undesirable effect called carbonization.

Absorption requires an absorber of light, termed chromophores, which have a certain affinity for
specific wavelengths of light. The primary chromophores in the intraoral soft tissue are Melanin,
Haemoglobin, and Water, and in dental hard tissues, Water and Hydroxyapatite. Different laser
wavelengths have different absorption coefficients with respect to these primary tissue components,
making the laser selection procedure-dependent. (3)

Characteristics of Laser Light:

Figure 4: Characteristics of Laser Light

• Monochromatic: one specific colour and same wavelength.

• Coherence: light waves produced are same, having identical wave shapes and are in phase with
one another.
• Collimation (directional): the beam consists of specific spatial boundaries, which insures that
there is a constant size and shape of the beam emitted from the laser cavity, e.g.: dental x-ray
machine.

Laser Emission Modes

Modes Of Laser
Operation

Gate Pulsed Free Running

Continuous Wave Mode/ Pushed On Pulsed Mode/
and Off True Pulsed Mode

Figure 5: Laser Emission Modes

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Continuous Wave:

Figure 6: Continuous Wave

• Beam is emitted at only one power level

• Operator must cease the laser emission manually for thermal relaxation of tissue
• Healing may be delayed & post operative discomfort may be more (5)

Gate Pulsed Mode/ Pushed On and Off:

Figure 7: Gate Pulsed Mode/ Pushed On and Off

• Periodic alteration of laser energy

• Achieved by opening and closing of a mechanical shutter in front of a continuous wave emission.
• Targeted tissue has time to cool before the next pulse of laser is emitted (5)

Free Running Pulsed Mode/ True Pulsed Mode:

Figure 8: Free Running Pulsed Mode/ True Pulsed Mode

• Large laser energy is emitted for a short time span followed by a relatively long time in which laser
is off
• Targeted tissue has time to cool before next pulse of laser energy is emitted.
• Thin or fragile tissue must be treated in pulsed mode to prevent irreversible thermal damage to
tissues (5)

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Þ TYPES OF LASER

Figure 9: Types of Lasers

Carbon Dioxide Laser:

Figure 10: Carbon Dioxide Laser

Wavelength: 10600nm
Action: The CO2 laser wavelength has a very high affinity for water, resulting in rapid soft tissue
removal and haemostasis with a very shallow depth of penetration. Although it possesses the highest,
absorbance of any laser. (6)
Applications:
• Sealing of pit and fissures
• Welding of ceramic materials to enamel
• Prevention of caries (well absorbed by enamel)
• Treatment of dentinal hypersensitivity
Disadvantages: CO2 laser are its relative large size and high cost and hard tissue destructive
interactions. (6)

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Neodymium Yttrium Aluminium Garnet Laser:

Figure 11: Neodymium Yttrium Aluminium Garnet Laser

Wavelength: 1064 nm
Action: The Nd: YAG wavelength is highly absorbed by the pigmented tissue, making it a very effective
surgical laser for cutting and coagulating dental soft tissues, with good haemostasis. In addition to its
surgical applications, Nd: YAG laser is used for nonsurgical sulcular debridement in periodontal disease
control, and the Laser Assisted New Attachment Procedure (LANAP). (7)
Applications:
• Vaporize carious tissue
• Sterilize tooth surfaces,
• Cutting And coagulation of dental soft tissue
• Sulcular Debridement
• Dentinal hypersensitivity
• Remove Extrinsic stains
• Prepare pits and fissures for sealants

Argon Laser:

Figure 12: Argon Laser

Wavelength: 488 (blue) and 514 nm (blue-green)

Action: The argon laser wavelength is well absorbed by the pigmented tissue, making it a very effective
surgical laser for cutting and coagulating dental soft tissues, with good haemostasis

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Applications:
• Used as light activated whitening gel
• Impression materials
• Caries detection
• Composite curing
• Cutting, vaporizing and coagulating,
• Providing haemostasis (green) on gingival and oral mucosa

Erbium Laser:

Wavelength: 2940 nm (Er: YAG) and 2780 nm (Er:Cr:YSGG)

Action: The erbium lasers has two distinct wavelengths, Er, Cr: YSGG (yttrium scandium gallium
garnet) lasers and Er: YAG (yttrium aluminium garnet) lasers. The erbium wavelengths have a high
affinity for hydroxyapatite and the highest absorption of water in any dental laser wavelengths.
Consequently, it is the laser of choice for treatment of dental hard tissues. In addition to hard tissue
procedures, erbium lasers can also be used for soft tissue ablation, because the dental soft tissue also
contains a high percentage of water. (8)

Applications:

Er: YAG

• Removal healthy hard tissue and carious tooth structure

• Ablation of composites and cements
• Etching of enamel
• Osteotomy
• Cyst removal

Er:Cr:YSGG

• Restorative and etching procedures

• During cavity preparation provide rough surfaces for bonding
• Carious lesion in close proximity to the gingiva can be treated and the soft tissue recontoured with
the same instrumentation

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Diode Laser

Figure 13: Diode Laser

Wavelength: 800 nm (aluminium) and 900 nm (indium)

Action: The active medium of the diode laser is a solid state semiconductor made of aluminium,
gallium, arsenide, and occasionally indium, which produces laser wavelengths, ranging from
approximately 810 nm to 980 nm. All diode wavelengths are absorbed primarily by tissue pigment
(melanin) and haemoglobin. Conversely, they are poorly absorbed by the hydroxyapatite and water
present in the enamel. Specific procedures include aesthetic gingival re-contouring, soft tissue crown
lengthening, exposure of soft tissue impacted teeth, removal of inflamed and hypertrophic tissue,
frenectomies, and photo stimulation of the aphthous and herpetic lesions. (9)

Applications:

• Gingivoplasty
• Soft tissue curettage
• Sulcular debridement
• Coagulation on gingiva and mucosa

Excimer Laser

Wavelength: 190-400 nm

Action: Ablative photodecomposition bond breaking of molecules caused by high energy photon
application.

Applications:
• Preparation of dental hard tissues

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Þ APPLICATIONS OF LASER

Soft Tissue Hard Tissue Others

• Wound healing • Diagnostic application • Analgesic effect
• Post herpetic neuralgia & • Photochemical effects • Nerve repair and
aphthous ulcer • Laser fluorescence regeneration
• Photoactivated dye • Cavity preparation, caries, • Post-surgical pain
disinfection and restorative removal • Sinusitis
• Photodynamic therapy- • Etching
malignancies • Dentinal hypersensitivity
• Gingival re-contouring and
crown lengthening
• Exposure of
unerupted/partially
erupted teeth
• Removal of inflamed,
hypertrophic tissue
• Frenectomies
Table 2: Applications of Laser

Laser Applications in Endodontics

Pulpal Diagnosis- Laser Doppler Flowmetry

Figure 14: Laser Doppler Flowmetry

Laser doppler flowmetry: to assess the pulpal circulation
• Non-invasive, objective , painless, semi-quantitative, electro-optical technique
• Based on the changes in the RBC flux in the pulp tissue
• It refers to the apparent change in the pitch of sound that occurs if the source or the listener was
moving

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• The reflected light is detected by a photocell on the tooth surface and its output is proportional
to the number and velocity of the blood cells
• Vital Pulp Therapy

Figure 15: Direct Pulp Capping

• Direct Pulp Capping: performed by initial removal of the gross carious dentin mass using both
hand excavator and laser. Low energy is required to remove carious tissue. CO2 laser is used at 1
or 2W after irrigation followed by placement of restorative material to stimulate the formation of
reparative dentin
• Indirect Pulp Capping: caries is removed completely by application of ≤ 150 mJ -15 to 20 Hz-short
pulse duration (100-300 μs) along with air or water spray. Final decontamination should be done
carefully to avoid damage to pulp at 70-80 mJ-10 Hz-100 µ pulse duration-In focused mode with
water spray, this is followed by dentin melting which seals the deep dentinal area and reduces the
post-operative sensitivity and placement of restorative material.
• Pulpotomy: Diode lasers are well absorbed by haemoglobin and can be used for decontamination
and coagulation of the pulp. After preparing the cavity with mechanical instruments, laser is used
to decontaminate the exposed surface using a 400-μm non-activated fibre at 1W, pulsed emission.

• Photoactivated Disinfection
At different power levels, all laser wavelengths destroy the cell wall because of their photothermal
effect. Gram-negative bacteria, due to the structural characteristics of the different cell walls, are
more easily destroyed with less energy and less irradiation than gram-positive bacteria. (10)

Laser is absorbed
Osmotic alterations Direct damage to
by bacteria Cell death
in the bacterial cell the cell wall
(protoporphyrin IX)

Figure 16: Mechanism of Photoactivated Disinfection

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• Laser Activated Irrigation

Figure 17: Laser activated irrigation

Molecular level: PAD

Bulk flow level: LAI, PIPS
Photo-activated Disinfection (PAD): The laser light source of PAD has no direct effect on the target
tissue but photo-activates a specific compound that release toxic elements to the target.

Laser Activated Irrigation (LAI): The laser fibre is inserted into the canal & then activated

Fibre is withdrawn at a slow speed out of the canal or used in stationary/in-out motion over a short
distance in canal

Photon Induced Photoacoustic Streaming (PIPS): Fibre is placed outside of the canal and activated in
the pulp chamber over the canal orifices

Er lasers have specific affinity for water and are commonly used for this purpose. (10)

• Root Canal Preparation

Figure 18: Laser root canal preparation

Lasers used: Er,Cr:YSGG (2780 nm) and Er:YAG (2940 nm) as they remove both the hard & soft tissue
when in contact. While preparing the access cavity, the energy of the laser light progressively
decreases in depth (From D to P). The use of a short tip is recommended (from 4 to 6 mm), with

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diameters between 600 and 1000 μm, made of quartz to allow the use of higher energy and power.
Larger diameter – More elevated energy & power during the ablation of E; Larger irradiated surface.
(10)

• Endodontic Retreatment
Apart from rotary files and solvents, lasers have emerged as a newer modality for GP removal
Removal by laser – combination of both photothermal and photoablation effects

• Negotiating Calcified Canals

Used along with 17% EDTA. When there is presence of coronal calcification, higher energy used (30 –
40 mJ). PIPS is also helpful in locating and helping negotiate calcified canals. A pulsed dye laser emitted
at 504nm was used for the removal of a calcified attached denticle

• Endodontic Surgery
Nd:YAG or diode lasers are used for clean incision to gain access to peri radicular region. Er:YAG and
Er:Cr:YSGG can be used for apicectomy and retrograde preparation. They have the advantage of
precision, sterilisation, selective absorption, good haemostasis, reduced oedema, scarring, fastened
healing of wound and less post operative pain. (11)

Laser Application is Restorative Dentistry

• Caries Detection

Figure 19: Diagnodent

Diagnodent, a 655 nm diode laser, aids in the detection of incipient caries is called laser-induced
fluorescence. When the laser irradiates the tooth, the light is absorbed by organic and inorganic
substances present in the dental tissues, as well as by metabolites such as bacterial porphyrins. These
porphyrins showed some fluorescence after excitation by red light. Carious tissue exhibits more
fluorescence as compared to the healthy tissue which distinguish between the carious and sound

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tooth structure. The instrument’s digital display indicates the number of bacteria in this area of the
tooth and it may correspond to the extent of decay. (12)

• Caries Prevention

Laser irradiation of dental hard tissues modifies the calcium to phosphate ratio, reduces the carbonate
to phosphorous ratio and leads to the formation of more stable and less acid soluble compounds
further reducing susceptibility to acid attack and caries. (13)

• Caries Removal and Cavity Preparation

Figure 20: Laser caries removal

Er:YAG laser has an ablating spot diameter of 0.8 mm , so that irradiating dental hard tissue with laser
in focal mode allows to ablate areas no larger than 0.8 mm in diameter. The tip of the laser must be
held perpendicular to achieve maximum cutting efficiency. (14)

Typical average settings of lasers are total power of:

6 watts: enamel removal

4 watts: dentin removal

2 watts: caries removal

• Restoration removal

The Er: YAG laser is capable of removing cement, composite resin and glass ionomer

The efficiency of ablation is comparable to that of enamel and dentine. Lasers should not be used to
ablate amalgam restorations however, because of potential release of mercury vapour. The Er: YAG
laser is incapable of removing gold crowns, cast restorations and ceramic materials because of the low
absorption of these materials and reflection of the laser light.

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• Dentinal Hypersensitivity

Figure 21: Laser application for dentin hypersensitivity

A low level laser therapy (LLLT) has also been used for the treatment of dentinal hypersensitivity This
relies upon laser-induced changes to neural transmission networks within the dental pulp, rather than
alterations to the exposed dentine surface, as is the case with other treatment modalities

LLLT may elicit descending inhibition in the central nervous system, in addition to local effects on nerve
conduction. They decrease concentration of chemical agents such as histamine, acetylcholine,
serotonin, H+ and K+, all of which are pain mediators

Low-power lasers inhibit concentration of acetylcholine, a pain mediator, through increased

acetylcholine esterase activity. (15)

• Bleaching

Figure 22: Laser application for bleaching

The FDA approved standards for tooth whitening has cleared three dental laser wavelengths: argon,
CO2 and 980-nm GaAIAs diode

488-nm argon laser rapidly excites the already unstable and reactive hydrogen peroxide molecule; the
energy is then absorbed into all intermolecular and reaches eigenstate vibrations

Lasers can enhance bleaching by photo-oxidation of coloured molecules in the teeth or by interaction
with the components of the bleaching gel through photochemical reactions resulting in a visually
whitened tooth surface. (16)

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• Etching

The Er:YAG laser produces micro-explosions during hard tissue ablation that result in microscopic and
macroscopic irregularities. These micro-irregularities make the enamel surface micro retentive and
they may offer a mechanism of adhesion without acid-etching.

• Photopolymerization
The argon wavelength activates camphorquinone , a photoinitiator that causes polymerisation of the
resin composites.. The argon laser is also capable of altering the surface chemistry of both the enamel
and the root surface dentine, which reduces the probability of the recurrent caries.

Laser Application on Soft Tissues

• Aesthetic Gingival Re-Contouring and Crown Lengthening

Figure 23: Crown Lengthening using laser

Using Er;Cr:YSGG laser can be considered as valuable for aesthetic procedure such as crown
lengthening or gingival re-contouring due to its advantages like producing less pain, reasonable
bleeding, less post-operative complications and accelerated healing time. (17)

• Exposure of Unerupted And Partially Erupted Teeth

Figure 24: Exposure of partially erupted tooth using laser

The partially tooth can be exposed by removing a layer of soft tissue covering the tooth using laser
and attachment can be placed immediately.(2)

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• Removal of Inflamed or Hypertrophic Tissue

Figure 25: Laser Operculectomy

Isolated areas of transient tissue hypertrophy can be excised using the diode laser. The diode laser is
also useful for a number of isolated applications, such as, removing tissue that has overgrown mini-
screws, springs and appliances, as well as for replacing a tissue punch if needed when placing mini-
screws in the unattached gingiva.(2)

• Frenectomies

Figure 26: Laser assisted frenectomy

Laser assisted frenectomy is a simple procedure that is best performed after the diastema is closed.
Frenectomies performed with a laser permit excision of the frenum painlessly, without bleeding,
sutures, or surgical packing, and with no need for special postoperative care.(2)

Þ EFFECT OF LASERS ON WOUND HEALING

Figure 27: Mechanism of Laser therapy on wound healing

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Wound healing is a normal physiological process which takes places in four particular phases:
haemostasis, inflammation, proliferation, and remodelling. For successful healing process, all four
phases must follow in the appropriate sequence and time.
Laser therapy for wound healing is associated with reduced inflammatory infiltration intensity,
accelerate repair and healing of the wound.
Biostimulation of the Wound with lasers:
• accelerates the inflammatory phase of wound healing by altering the levels of various
prostaglandins
• increases ATP synthesis by enhancing electron transfer in the inner membrane of mitochondria
• quickens protein (collagen) synthesis by quickening DNA and RNA synthesis
• augments fibroplasia by a mechanism that is still being explored
• enhances the ability of immune cells to combat invading pathogens (20)

At low doses (e.g., 2 J/cm2), laser application stimulates proliferation, while at high doses (e.g. 16
J/cm2) it has a suppressive effect.
Low level laser therapy (LLLT) exposes tissues and cells to low levels of red and near infrared (NIR) and
IR light. This treatment is introduced to as “low level” because of usage of light at lower energy
densities in comparison to other types of laser therapy such as cutting, ablation, and thermal
coagulation of tissue. LLLT is also defined as “cold laser” therapy because of the lower power densities
used compared to those needed to produce tissue heating.

Laser application affects the fibroblast maturation and locomotion, and this in turn may contribute
to the higher tensile strengths for healed wounds.
Low-level laser treatment (LLLT) of gingival fibroblasts on culturing has shown to induce
transformation in myofibroblasts (useful in wound contraction) as early as 24 hours after laser
treatment. Jacquemier, et al (18)
Kurumada et al, observed that laser irradiation induced enhancement of calcification in wound surface
and stimulated formation of calcified tissue. These observations indicate that laser irradiation is a
useful method for the vital pulpotomy. LLLT promotes healing and dentinogenesis following
pulpotomy.

Laser therapy for wound healing reduces pain, accelerates tissue repair and healing as well as
improves nerve function and vascular activity.

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