Lasers in Endodontics

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Lasers in endodontics: A review

Article in International Endodontic Journal · June 2000Impact Factor: 2.97 · DOI: 10.1046/j.1365-2591.2000.00280.x · Source: PubMed

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3 authors , including:

Yuichi Kimura

Ohu Universit y

94 PUBLICATIONS 2,771 CITATIONS

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Petra Wilder-Smith

University of Califo rnia, Irvine

139 PUBLICATIONS 2,334 CITATIONS

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Available from: Petra Wilder-SmithRetrieved on: 26 May 2016

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© 2000 Blackwell Science Ltd International Endodontic Journal, 33 , 173–185, 2000 173

BlackwellScience,LtdREVIEW

Lasers in endodontics: a review

Y. Kimura 1, P. Wilder-Smith 2 & K. Matsumoto 11Department of Endodontics, Showa University School of Dentistry, Japan; and 2Beckman Laser Institute and Medical Clinic,University of California, Irvine, California, USA

Abstract

Kimura Y, Wilder-Smith P, Matsumoto K. Lasers inendodontics: a review. International Endodontic Journal, 33 ,173–185, 2000.

Since the development of the ruby laser by Maiman in1960 and the application of the laser for endodontics by

Weichman in 1971, a variety of papers on potentialapplications for lasers in endodontics have been pub-lished. The purpose of this paper is to summarize laserapplications in endodontics, including their use in pulpdiagnosis, dentinal hypersensitivity, pulp capping andpulpotomy, sterilization of root canals, root canal shapingand obturation and apicectomy. The effects of laser on

root canal walls and periodontal tissues are also reviewed.The essential question is whether a laser can provide equalor improved treatment over conventional care. Secondaryissues include treatment duration and cost/benet ratio.This article reviews the role of lasers in endodontics sincethe early 1970s, summarizes many research reportsfrom the last decade, and surmises what the future may

hold for lasers in endodontics. With the potential avail -ability of many new laser wavelengths and modes,much interest is developing in this promising eld.

Keywords: dentine, laser diagnosis, laser therapyuse, root canal treatment.

Received 14 January 1999; accepted 12 April 1999

Introduction

Since the ruby laser was developed by Maiman (1960) ,researchers have investigated laser applications in den-tistry. A laser is a device which transforms light of variousfrequencies into a chromatic radiation in the visible,infrared, and ultraviolet regions with all the waves inphase capable of mobilizing immense heat and powerwhen focused at close range. Stern & Sognnaes (1964)and Goldman et al . (1964) were the rst to investigatethe potential uses of the ruby laser in dentistry. Theybegan their laser studies on hard dental tissues byinvestigating the possible use of a ruby laser to reducesubsurface demineralization. Indeed, they did nd areduction in permeability, to acid demineralization, of enamel after laser irradiation.

After initial experiments with the ruby laser, cliniciansbegan using other lasers, such as argon (Ar), carbon

dioxide (CO2), neodymium: yttrium-aluminum-garnet(Nd:YAG), and erbium (Er):YAG lasers. The rst laseruse in endodontics was reported by Weichman & Johnson

(1971) who attempted to seal the apical foramen invitro by means of a high power-infrared (CO 2) laser.Although their goal was not achieved, sufcient relevantand interesting data were obtained to encourage furtherstudy. Subsequently, attempts were made to seal the apicalforamen using the Nd:YAG laser ( Weichman et al . 197 2).Although more information regarding this laser’s inter-action with dentine was obtained, the use of the laser inendodontics was not feasible at that time. Since then,many papers on laser applications in dentistry have beenpublished (Midda & Renton-Harper 1991, Pick 199 3,Wigdor et al . 1993 , 1995), with growing interest in thistopic in the last 5 years. Many papers have been publishedon endodontic applications and much information has beengathered. Nevertheless, in dentistry and in endodonticsin particular, acceptance of this technology by clinicianshas remained limited, perhaps partly due to the fact thatthis technology blurs the border between technical,biological, and dental research. The purpose of this paperwas to summarize laser applications in endodontics.

Correspondence: Dr Yuichi Kimura, Department of Endodontics, ShowaUniversity School of Dentistry, 2–1-1 Kitasenzoku, Ohta-ku , Tokyo145–8515, Japan (fax: +81 3 3787 1229; e-mail: [email protected]).

https://www.researchgate.net/publication/224884409_Stimulated_Optical_Radiation_in_Ruby_Lasers?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/17892513_Laser_use_in_endodontics_A_preliminary_investigation?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/17892513_Laser_use_in_endodontics_A_preliminary_investigation?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/18659508_Laser_use_in_endodontics_Part_II?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/18659508_Laser_use_in_endodontics_Part_II?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/18659508_Laser_use_in_endodontics_Part_II?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/14770496_The_Effect_of_Lasers_on_Dental_Hard_Tissues?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/14770496_The_Effect_of_Lasers_on_Dental_Hard_Tissues?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/14770496_The_Effect_of_Lasers_on_Dental_Hard_Tissues?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/14770496_The_Effect_of_Lasers_on_Dental_Hard_Tissues?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/14770496_The_Effect_of_Lasers_on_Dental_Hard_Tissues?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/14770496_The_Effect_of_Lasers_on_Dental_Hard_Tissues?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/224884409_Stimulated_Optical_Radiation_in_Ruby_Lasers?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/18659508_Laser_use_in_endodontics_Part_II?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/17892513_Laser_use_in_endodontics_A_preliminary_investigation?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/17892513_Laser_use_in_endodontics_A_preliminary_investigation?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2


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Laser applications for endodontics Kimura et al.

International Endodontic Journal, 33 , 173–185, 2000 © 2000 Blackwell Science Ltd174

Diagnosis of blood ow in the dental pulp

Laser Doppler owmetry (LDF) was developed to assessblood ow in microvascular systems, e.g. in the retina,gut mesentery, renal cortex and skin ( Morikawa et al .1971 , Riva et al . 197 2). This original technique utilizeda light beam from a helium–neon (He-Ne) laser emit-ting at 632.8 nm, which, when scattered by movingred cells, underwent a frequency shift according to theDoppler principle. A fraction of the light back-scatteredfrom the illuminated area was frequency shifted in thisway. This light was detected and processed to produce asignal that was a function of the red cell ux (volumeof cells illuminated × mean cell velocity). This informa-tion can be used as a measure of blood ow, the valuebeing expressed as a percentage of full scale deection(percentage FSD) at a given gain. This method wasadopted to monitor blood ow in intact teeth in animals(Edwall et al . 1987, Gazelius et al . 1987) and in man(Gazelius et al . 198 6, 198 8, Olgart et al . 1988 , Wilder-Smith 1988a, Ingolfsson et al . 1994). Other wavelengths

of semiconductor laser have also been used: 780 nm(Watson et al . 1992 , Zang et al . 1996 ) and 780– 820 nm ( Vongsavan & Matthews 1993 , 1996, Hart-mann et al . 199 6, Odor et al . 1996 a). Zang et al . (1996)demonstrated greatly improved results using forwardscattering detection, as opposed to conventional back-ward scattering detection. These results were conrmedby Sasano (199 8). Odor et al . (1996b ) reported thatthe 810 nm wavelength showed good sensitivity, butpoor specicity, and that the 633 nm wavelengthshowed good specicity, but poor sensitivity. Nonlaserlight (peak output at 576 nm) has also been used forthe detection of pulpal perfusion (Diaz-Arnold et al .1994). In general, infrared light (780–810 nm) has agreater ability to penetrate enamel and dentine thanshorter wavelength red light (632.8 nm) ( Vongsavan &Matthews 199 3). Table 1 shows the laser character-istics used in LDF. LDF techniques are united in theirvalidity for pulp vitality testing as they reect vascularrather than nervous responsiveness ( Tronstad 199 2).

Due to some of the inherent problems associated withthis technology, Sasano et al . (1997) considered it tobe limited in its usefulness for human pulp vitalitytesting. The lasers used for LDF are usually at a low-powerlevel of 1 or 2 mW, and no repor ts on pulp injury bythis method have been made. The other use of laser fordiagnostics related to endodontics was the applicationof an excimer laser system emitting at 308 nm forresidual tissue detection within the canals ( Pini et al .1989 a). Figure 1 shows the identication of differenttypes of dental lasers.

It has not been established that laser Doppler owmeters provide a reliable indication of changes in redcell ux of pulp tissue under physiological conditions

Lasers

Penetration ability(enamel and dentineat the thickness of 3 mm) Specicity Sensitivity

He–Ne(633 nm) 2.11% good poorGaAlAs(810–830 nm) 3.91% poor good

a Referred by Watanabe et al . 1991 , Watanabe 1993 , Odor et al . 1996 b).

Table 1 Laser characteristics used in LDF a

Figure 1 Identication of different types of dental lasers.

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Kimura et al. Laser applications for endodontics


due to problems such as artifacts, e.g. indication of changes in red cell ux of gingival tissue or changes inambient light intensity, and movement artifacts.

Dentinal hypersensitivity

Dentinal hypersensitivity can arise through incorrecttooth brushing, gingival recession, inappropriate diet,and because of other factors ( Schuurs et al . 1995 ). It isclaimed that 18% of all patients have some degree of sensitivity, and a range of therapies have been devised toalleviate this condition ( Midda 199 2). The sensation of pain is generally accepted to be associated with patentdentinal tubules not covered by smear layer termin-ating on the root surface. Stimulus transmissionacross dentine in hypersensitive teeth may be mediatedby a hydrodynamic mechanism (Absi et al . 1987).Grossman (1935) suggested a number of require-

ments for treatment of this condition; these still holdtrue today. Therapy should be nonirritant to the pulp;relatively painless on application; easily carried out;rapid in action; effective for a long period; withoutstaining effects; and consistently effective. To date, mostof the therapies have failed to satisfy one or more of these criteria, but some authors report that lasers maynow provide reliable and reproducible treatment,documenting success rates of up to 90%. The lasers usedfor the treatment of the dentinal hypersensitivity aredivided into two groups: low output power lasers [He-Neand gallium/aluminum/arsenide (GaAlAs) lasers], andmiddle output power lasers (Nd:YAG and CO

2 lasers).

Several authors have investigated the He–Ne laseremitting at 632.8 nm ( Senda et al . 1985 , Matsumotoet al . 1986, Gomi et al . 1986, Wilder-Smith 1988b).Parameters used for the treatment of dentinal hyper-sensitivity approximate 6 mW for 1–3 min. Effectivenesscould be up to 90%. Using the GaAlAs laser, the mostfrequently applied wavelengths were 780 nm ( Matsumoto

et al . 1985 a,b, Kawakami et al . 1989, Gerschman et al .1994) and 830 nm (Hamachi et al . 1992, Mezawa et al .1992). Parameters used for the treatment of dentinalhypersensitivity were 30 mW for 0.5–3 min. Effectivenessrated up to 80%. The Nd:YAG laser (wavelength of 1.064 µm) was rst investigated by Matsumoto et al .(1985c), then also by others ( Renton-Harper & Midda1992 , Gelskey et al. 1993, Jabbar 199 3, Lan & Liu 1996 ).Total energy output used ranged from 1.8 to 25 J. Theseinvestigations demonstrated effectiveness rates averaging72%. Moritz et al. (1996) reported the treatment of dentinalhypersensitivity using the CO 2 laser, followed by others(Moritz et al . 1998a , Zhang et al . 1998 a). Output powersused for this treatment ranged from 0.5 to 3 W, and asuccess rate of over 90% was reported. Table 2 lists thelasers used for the treatment of dentinal hypersensitivity.

The mechanism causing a reduction in hypersensitivityis mostly unknown, but it is thought that the mechanism

for each laser is different. In the case of low-power lasers(He–Ne and GaAlAs lasers), a small fraction of the laser’senergy is transmitted through enamel or dentine toreach the pulp tissue (Watanabe et al . 199 1, Watanabe199 3). It has been suggested that He–Ne laser irradiationmay affect the electric activity (action potential) and notaffect peripheral A ∂ or C-ber nociceptors ( Rochkindet al . 1987 , Jarvis et al . 1990). GaAlAs laser radiation at830 nm has a pain suppressive effect by blocking thedepolarization of C-ber afferents ( Wakabayashi et al .199 3); GaAlAs laser emissions at 904 nm have an ana-lgesic effect on the cat tongue although mechanismsremain unclear ( Mezawa et al . 198 8). Laser energyat 1064 nm (Nd:YAG laser) is transmitted throughdentine (Zennyu et al . 1996), indicating thermallymediated effects (Funato et al . 1991), and pulpal analgesia(Whitters et al . 1995). Using the CO 2 laser at moderatelaser energies, mainly sealing of dentinal tubules isachieved, as well as reduction of permeability (Boninet al . 1991). CO 2 laser irradiation may cause dentinal

Table 2 Laser list used for the treatment of dentinal hypersensitivity

Lasers Parameters Effective rate (%) References

He–Ne 6 mW for 2–3 min 84 Senda et al . 1985(632.8 nm) 6 mW for 1–3 min 90 Matsumoto et al . 1986GaAlAs 30 mW for 0.5–3 min > 85 Matsumoto et al . 1985a, b(780 nm) 30 mW for 0.5–3 min 94.6 Kawakami et al . 1989GaAlAs 30 mW for 0.5–3 min 83.9 Hamachi et al . 1992(830 nm) 30 mW for 5 min 58 Mezawa et al . 1992Nd:YAG 10 W for 0.5–2.5 s 100 Matsumoto et al . 1985c(1.064 µm) 10–100 mJ/p for 2 min 100 Renton-Harper & Midda (1992)CO 2 0.5 W for 5–30 s 98.6 Moritz et al . 1996(10.6 µm) 1 W for 5–10 s 100 Zhang et al . 1998a

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ntal_studies?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/19465723_Response_of_to_He-Ne_laser_experimental_studies?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/13365962_Effects_of_CO2_Laser_in_Treatment_of_Cervical_Dentinal_Hypersensitivity?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/15415722_A_clinical_study_of_the_pulsed_NdYAG_laser-induced_analgesia?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/14574500_Dentists'_views_on_cervical_hypersensitivity_and_their_knowledge_of_its_treatment?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2


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Laser applications for endodontics Kimura et al.

International Endodontic Journal, 33 , 173–185, 2000 © 2000 Blackwell Science Ltd176

desiccation, yielding temporary clinical relief of dentinalhypersensitivity (Fayad et al . 1996). The sealing depthachieved by Nd:YAG laser irradiation on dentinal tubulesmeasured less than 4 µm (Liu et al . 199 7).

Pulpal effects of this type of laser irradiation havebeen investigated. The GaAlAs laser at a wavelength

of 780 nm, and an output power of 30 mW for3 min caused no damage to pulp tissues in monkeys(Matsumoto et al . 1985d). After exposure to theNd:YAG laser, no histologically measurable responsewas observed using a power of 50 mJ/pulse at 10 Hz for30 s (total energy: 15 J) ( White et al . 199 5). At anoutput power of 10 W for 0.3 s in the continuous wavemode (total energy density 31 J cm –2), the pulp showedexudative inammatory changes with hyperaemia andfocal degeneration of the odontoblasts immediately afterirradiation (Nakamura 198 7). Using the CO 2 laser, nodamage was reported after pulpal exposure to 3 W of power for 2 s in the continuous wave mode usingmonkeys and dogs (Melcer et al . 1985).

In general, the efcacy of lasers is higher than othermethods, but in severe cases, it is less effective. It isnecessary to consider the severity of dentinal hyper-sensitivity before laser use.

Pulp capping and pulpotomy

In mature adult teeth, conventional pulp treatmentoptions include pulp capping or root canal treatment.The outcome of pulp capping procedure, whether director indirect, is unpredictable and success rates ranging

from 44 to 97% have been reported. Pulpal extirpationand root canal treatment are performed if pulp cappingprocedures are not indicated. In immature perman-ent teeth, devitalization and root canal treatment arenot advisable until full apex formation and closurehave occurred. Thus endodontic treatment of choicecomprises pulpotomy and subsequent dressing withcalcium hydroxide. If a laser is used for the procedures,a bloodless eld would be easier to achieve due to theability of the laser to vaporize tissue and coagulate andseal small blood vessels. Moreover, the treated woundsurface would be sterilized.

Melcer et al . (1987) rst described laser treatment of exposed pulp tissues using the CO 2 laser in dogs toachieve haemostasis; Ebihara et al . (1988, 1992) usedthe Nd:YAG laser in rats and dogs. Their results showedthat lasers facilitated pulpal healing after irradiationat 2 W for 2 s. Moritz et al . (1998b) reported that theCO2 laser was a valuable aid in direct pulp cappingin human patients.

The rst laser pulpotomy was performed using theCO2 laser in dogs by Shoji et al . (1985) and subsequentreports from Figueiredo et al . (1995), Jukic et al . (199 7),Wilder-Smith et al . (1997 a), and Dang et al . (1998).Similar work using the Nd:YAG laser was performed indogs (Ebihara 1989) and rats (Kato et al . 1989). The

Ga-As semiconductor laser was used for this purpose inmice ( Kurumada 1990 ) and the Ar laser in swines(Wilkerson et al . 199 6).

No detectable damage was observed in the radicularportions of irradiated pulps with the CO 2 laser ( Shojiet al . 198 5). Wound healing of the irradiated pulpseemed to be better than that of controls at 1 week, anddentine bridge formation in the irradiated pulp wasstimulated at 4 and 12 weeks after operation using theNd:YAG laser (Ebihara 1989). Direct effects on the pulpwere examined using Nd:YAG laser in rats (Ebihara et al .1988) and the CO 2 laser in dogs ( Wilder-Smith et al .1997a , Dang et al. 1998). In both cases, no laser damagewas found in tissues underlying the laser-ablatedtissues, with the presence of secondary dentine and aregular odontoblast layer. Wilder- Smith et al . (1997a)and Dang et al . (1998) found CO 2 laser pulpotomy to bevery successful, even in teeth with large exposure sites,subjected to bacterial contamination for several days.

For laser use in pulp capping and pulpotomy, anappropriate parameter must be selected. If the laserenergy is too strong, the treatment will be unsuccessful.

Modication of root canal walls

Endodontic instrumentation produces organic andmineral debris on the wall of the root canal. Althoughthis smear layer may be benecial, in that it providesan obstruction of tubules and decreases dentine perme-ability, it also may harbour bacteria and bacterialproducts (Fogel & Pashley 1990). For these reasons, theremoval by a laser of the smear layer and its replacementwith an uncontaminated chemical sealant, or sealingby melting the dentine surface, has become a goal.

Weichman & Johnson (1971) rst applied a laser tothe root canals by attempting to seal the apical foramenin vitro by means of a high-power CO 2 laser. Althoughthe goal was not achieved, sufcient data were obtainedto encourage further study. Other studies into the effectsof CO2 laser irradiation on dentine were performed oftenusing scanning electron microscopy (SEM) ( Silbermanet al . 1994 ) and confocal laser scanning microscopy(Kimura et al . 1998a).

After CO2 laser irradiation, dentine permeabilitywas reduced ( Pashley et al. 199 2), and a wide range of

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s://www.researchgate.net/publication/13863827_CO2_laser_treatment_of_traumatic_pulpal_exposures_in_dogs?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/13863827_CO2_laser_treatment_of_traumatic_pulpal_exposures_in_dogs?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/13863827_CO2_laser_treatment_of_traumatic_pulpal_exposures_in_dogs?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/13863827_CO2_laser_treatment_of_traumatic_pulpal_exposures_in_dogs?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/13863827_CO2_laser_treatment_of_traumatic_pulpal_exposures_in_dogs?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/17892513_Laser_use_in_endodontics_A_preliminary_investigation?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2https://www.researchgate.net/publication/21752297_Effect_of_CO2_laser_energy_on_dentin_permeability?el=1_x_8&enrichId=rgreq-31372ee8-fd77-4bb3-b4a3-2d3362721dc1&enrichSource=Y292ZXJQYWdlOzEyMDI3OTE5O0FTOjE1OTUyOTAwMjA4NjQwMEAxNDE1MDQ2MDg2Mzc2


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Kimura et al. Laser applications for endodontics


morphological changes were observed (Tanji & Matsumoto1994, Lopes et al . 1995, Anic et al . 199 6, Khan et al .199 7). Moreover, debris removal and morphologicalchanges were facilitated by the laser irradiation withdiamine silver uoride [Ag(NH 3)2F] (Eto et al . 1999).The CO2 laser emitting in the 9.3–10.49 µm region

(Featherstone & Nelson 198 7, Onal et al . 1993 , Taka-hashi et al . 1998 , Kimura et al . 2000), caused surfacefusion and inhibition of subsequent lesion progressionin dentine and improved the bonding strength of a com-posite resin to dentine depending on laser parameters.

Using the Nd:YAG laser Weichman et al . (1972) ,attempted to seal the entrance to the root canal at theapex of a tooth in vitro . The development of a thin brefor the Nd:YAG laser stimulated its application in rootcanals. Many reports on Nd:YAG laser preparation of root canals have been published (Dederich et al . 198 4,1988 , Levy 1992 , Bahcall et al . 1993, Goodis et al .1993 , Marques et al . 1995 , Miserendino et al . 1995 ,Lopes et al . 199 5, Saunders et al . 199 5). Debris andsmear layer were removed using appropriate laserparameters ( Morita 1994 , Koba 1995, Harashima et al .1997 a, Koba et al . 1998 a,b, 1999a), and dentine per-meability was reduced ( Miserendino et al . 1995 , Anicet al . 1996). Since absorption of Nd:YAG laser irradi-ation is enhanced by black ink, it potentiates laser effectson root canals ( Zhang et al . 1998 b). Argon laser irradi-ation can achieve an efcient cleaning effect on instru-mented root canal surfaces (Moshonov et al . 1995a,Matsuoka et al . 1996, Zhang et al . 1996 , Khan et al .1997 , Harashima et al . 1997b, 1998), and laser irradi-

ation in the presence of Ag(NH 3)2F solution enhancesthe effect (Zhang et al . 1996). Er:YAG laser irradiationwas more effective in removing the smear layer anddebris on root canal walls than the Ar or Nd:YAG laser(Takahashi et al . 199 6, Matsuoka et al . 1998 , Takedaet al . 1998a,b,c, 1999).

Potassium titanyl phosphate (KTP) laser (wavelengthof 532 nm) ( Tewk et al . 1993 , Machida et al . 1995 )irradiation was able to remove smear layer and debrisfrom root canals. The effects of a nanosecond-pulsed,frequency-doubled Nd:YAG laser emitted at 532 nm ondentine (Arrastia-Jitosho et al . 1998) demonstrated thatthis laser irradiation can achieve complete smear layerremoval. However, the results were inhomogeneous, andat higher energy densities thermal damage was observed.

At specic uences, the xenon chlorine (XeCl) laser(wavelength of 308 nm) can melt dentine and sealexposed dentinal tubules ( Pini et al . 1989b , Stabholzet al . 1993a, 1995, Lee et al . 1995, Dankner et al .1997). The Ar-uoride (F) excimer laser emitting at

193 nm (Stabholz et al . 1993b, Arima & Matsumoto1993 , Wilder-Smith et al . 1997b ) caused signicantremoval of peritubular dentine at relatively high uence(10~15 J/cm 2), melting and resolidication of the dentinalsmear layer being observed under the SEM.

The effects of holmium (Ho):YAG laser irradiation

emitted at 2.10 µm (Stevens et al . 1994 , Cernavin1995) demonstrated that this laser is an effective meansof ablating dentine and may be suitable for cuttingdentine. The Nd:yttrium alminum perovskite (YAP)laser emitting at 1340 nm (Blum & Abadie 1997, Fargeet al . 1998) was suggested as an effective device forroot canal preparation in endodontic retreatment.

In the research, the effects of free-electron laser (FEL)(operating in the 2–10 µm region of the infrared) ondentine were investigated at 3.0 µm (Hoke et al . 1995)and 9.4 µm (Ogino et al . 199 6). These result suggest that3.0 µm FEL irradiation affects hydroxyl apatite crystal morethan the interrod substance, a pattern not prominent withEr:YAG laser ablation; 9.4 µm FEL irradiation causedselective ablation of phosphoric acid ion and annealing.

The removal of smear layer and debris by lasers ispossible, however it is hard to clean all root canal walls,because the laser is emitted straight ahead, making italmost impossible to irradiate the lateral canal walls.

Sterilization of root canals

Numerous studies into the sterilization of root canalshave been performed using CO 2 (Zakariasen et al . 1986 )and Nd:YAG lasers ( Rooney et al . 1994 , Ebihara et al .

1994, Fegan & Steiman 199 5, Moshonov et al . 1995 b,Goodis et al . 1995 , Sekine et al . 1995, Gutknecht et al .1996a, Ramskold et al . 1997). The Nd:YAG laser ismore popular, because a thin bre-optic delivery systemfor entering narrow root canals is available with thisdevice. Many other lasers such as the XeCl laser emit-ting at 308 nm ( Stabholz et al . 1993 c), the Er:YAG laseremitted at 2.64 µm (Gomi et al . 1997), a diode laseremitting at 810 nm ( Moritz et al . 1997 a), and theNd:YAP laser emitting at 1.34 µm (Blum et al . 1997)have also been used for this purpose. All lasers have abactericidal effect at high power that is dependent oneach laser. There appears to exist a potential for spread-ing bacterial contamination from the root canal to thepatient and the dental team via the smoke producedby the laser, which can cause bacterial dissemination(Hardee et al . 1994). Thus, precautions such as a strongvacuum pump system must be taken to protect againstspreading infections when using lasers in the root canal(McKinley & Ludlow 1994 ).

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Lasers in Endodontics