Lasers in Endo

2000 Blackwell Science Ltd International Endodontic Journal,
33

, 173185, 2000 173

Blackwell Science, Ltd

REVI EW

Lasers in endodontics: a review

Y. Kimura

1

, P. Wilder-Smith

2

& K. Matsumoto

1

1

Department of Endodontics, Showa University School of Dentistry, Japan; and

2

Beckman Laser Institute and Medical Clinic,

University of California, Irvine, California, USA

Abstract

Kimura Y, Wilder-Smith P, Matsumoto K.

Lasers in
endodontics: a review.

International Endodontic Journal,

33

,
173185, 2000.

Since the development of the ruby laser by Maiman in
1960 and the application of the laser for endodontics by
Weichman in 1971, a variety of papers on potential
applications for lasers in endodontics have been pub-
lished. 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 apicectomy. The effects of laser on
root canal walls and periodontal tissues are also reviewed.
The essential question is whether a laser can provide equal
or improved treatment over conventional care. Secondary
issues include treatment duration and cost/benet ratio.
This article reviews the role of lasers in endodontics 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 avail

-

ability of many new laser wavelengths and modes,
much interest is developing in this promising eld.

Keywords:

dentine, laser diagnosis, laser therapy
use, 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 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. Stern & Sognnaes (1964)
and Goldman

et al

. (1964) were the rst to investigate
the potential uses of the ruby laser in dentistry. They
began their laser studies on hard dental tissues by
investigating the possible use of a ruby laser to reduce
subsurface demineralization. Indeed, they did nd a
reduction in permeability, to acid demineralization, of
enamel after laser irradiation.
After initial experiments with the ruby laser, clinicians
began using other lasers, such as argon (Ar), carbon
dioxide (CO

2

), neodymium: yttrium-aluminum-garnet
(Nd:YAG), and erbium (Er):YAG lasers. The rst laser
use in endodontics was reported by Weichman & Johnson
(1971) who attempted to seal the apical foramen

in
vitro

by means of a high power-infrared (CO

2

) laser.
Although their goal was not achieved, sufcient relevant
and interesting data were obtained to encourage further
study. Subsequently, attempts were made to seal the apical
foramen using the Nd:YAG laser (Weichman

et al

. 1972).
Although more information regarding this lasers inter-
action with dentine was obtained, the use of the laser in
endodontics was not feasible at that time. Since then,
many papers on laser applications in dentistry have been
published (Midda & Renton-Harper 1991, Pick 1993,
Wigdor

et al

. 1993, 1995), with growing interest in this
topic in the last 5 years. Many papers have been published
on endodontic applications and much information has been
gathered. Nevertheless, in dentistry and in endodontics
in particular, acceptance of this technology by clinicians
has remained limited, perhaps partly due to the fact that
this technology blurs the border between technical,
biological, and dental research. The purpose of this paper
was to summarize laser applications in endodontics.

Correspondence: Dr Yuichi Kimura, Department of Endodontics, Showa
University School of Dentistry, 21-1 Kitasenzoku, Ohta-ku, Tokyo
1458515, Japan (fax: +81 3 3787 1229; e-mail: yukimura@senzoku.
showa-u.ac.jp).

IEJ280.fm Page 173 Monday, April 17, 2000 11:08 AM

Laser applications for endodontics

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Diagnosis of blood ow in the dental pulp

Laser Doppler owmetry (LDF) was developed to assess
blood ow in microvascular systems, e.g. in the retina,
gut mesentery, renal cortex and skin (Morikawa

et al

.
1971, Riva

et al

. 1972). This original technique utilized
a light beam from a heliumneon (He-Ne) laser emit-
ting at 632.8 nm, which, when scattered by moving
red cells, underwent a frequency shift according to the
Doppler principle. A fraction of the light back-scattered
from the illuminated area was frequency shifted in this
way. This light was detected and processed to produce a
signal that was a function of the red cell ux (volume
of cells illuminated

mean cell velocity). This informa-
tion can be used as a measure of blood ow, the value
being expressed as a percentage of full scale deection
(percentage FSD) at a given gain. This method was
adopted to monitor blood ow in intact teeth in animals
(Edwall

et al

. 1987, Gazelius

et al

. 1987) and in man
(Gazelius

et al

. 1986, 1988, 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

. 1996, Odor

et al

. 1996a). Zang

et al

. (1996)
demonstrated greatly improved results using forward
scattering detection, as opposed to conventional back-
ward scattering detection. These results were conrmed
by Sasano (1998). Odor

et al

. (1996b) reported that
the 810 nm wavelength showed good sensitivity, but
poor specicity, and that the 633 nm wavelength
showed good specicity, but poor sensitivity. Nonlaser
light (peak output at 576 nm) has also been used for
the detection of pulpal perfusion (Diaz-Arnold

et al

.
1994). In general, infrared light (780810 nm) has a
greater ability to penetrate enamel and dentine than
shorter wavelength red light (632.8 nm) (Vongsavan &
Matthews 1993). Table 1 shows the laser character-
istics used in LDF. LDF techniques are united in their
validity for pulp vitality testing as they reect vascular
rather than nervous responsiveness (Tronstad 1992).
Due to some of the inherent problems associated with
this technology, Sasano

et al

. (1997) considered it to
be limited in its usefulness for human pulp vitality
testing. The lasers used for LDF are usually at a low-power
level of 1 or 2 mW, and no reports on pulp injury by
this method have been made. The other use of laser for
diagnostics related to endodontics was the application
of an excimer laser system emitting at 308 nm for
residual tissue detection within the canals (Pini

et al

.
1989a). Figure 1 shows the identication of different
types of dental lasers.
It has not been established that laser Doppler ow
meters provide a reliable indication of changes in red
cell ux of pulp tissue under physiological conditions
Lasers
Penetration ability
(enamel and dentine
at the thickness of 3 mm) Specicity Sensitivity
HeNe
(633 nm) 2.11% good poor
GaAlAs
(810830 nm) 3.91% poor good
a
Referred by Watanabe et al. 1991, Watanabe 1993, Odor et al. 1996b).
Table 1 Laser characteristics used in LDF
a
Figure 1 Identication of different types of dental lasers.


Kimura et al.


33

, 173185, 2000 175

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

Dentinal hypersensitivity

Dentinal hypersensitivity can arise through incorrect
tooth brushing, gingival recession, inappropriate diet,
and because of other factors (Schuurs

et al

. 1995). It is
claimed that 18% of all patients have some degree of
sensitivity, and a range of therapies have been devised to
alleviate this condition (Midda 1992). The sensation of
pain is generally accepted to be associated with patent
dentinal tubules not covered by smear layer termin-
ating on the root surface. Stimulus transmission
across dentine in hypersensitive teeth may be mediated
by a hydrodynamic mechanism (Absi

et al

. 1987).
Grossman (1935) suggested a number of require-
ments for treatment of this condition; these still hold
true today. Therapy should be nonirritant to the pulp;
relatively painless on application; easily carried out;
rapid in action; effective for a long period; without
staining effects; and consistently effective. To date, most
of the therapies have failed to satisfy one or more of
these criteria, but some authors report that lasers may
now provide reliable and reproducible treatment,
documenting success rates of up to 90%. The lasers used
for the treatment of the dentinal hypersensitivity are
divided into two groups: low output power lasers [He-Ne
and gallium/aluminum/arsenide (GaAlAs) lasers], and
middle output power lasers (Nd:YAG and CO

2

lasers).
Several authors have investigated the HeNe laser
emitting at 632.8 nm (Senda

et al

. 1985, Matsumoto

et al

. 1986, Gomi

et al

. 1986, Wilder-Smith 1988b).
Parameters used for the treatment of dentinal hyper-
sensitivity approximate 6 mW for 13 min. Effectiveness
could be up to 90%. Using the GaAlAs laser, the most
frequently applied wavelengths were 780 nm (Matsumoto

et al

. 1985a,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 dentinal
hypersensitivity were 30 mW for 0.53 min. Effectiveness
rated up to 80%. The Nd:YAG laser (wavelength of
1.064

m) was rst investigated by Matsumoto

et al

.
(1985c), then also by others (Renton-Harper & Midda
1992, Gelskey

et al

. 1993, Jabbar 1993, Lan & Liu 1996).
Total energy output used ranged from 1.8 to 25 J. These
investigations demonstrated effectiveness rates averaging
72%. Moritz

et al

. (1996) reported the treatment of dentinal
hypersensitivity using the CO

2

laser, followed by others
(Moritz

et al

. 1998a, Zhang

et al

. 1998a). Output powers
used for this treatment ranged from 0.5 to 3 W, and a
success rate of over 90% was reported. Table 2 lists the
lasers used for the treatment of dentinal hypersensitivity.
The mechanism causing a reduction in hypersensitivity
is mostly unknown, but it is thought that the mechanism
for each laser is different. In the case of low-power lasers
(HeNe and GaAlAs lasers), a small fraction of the lasers
energy is transmitted through enamel or dentine to
reach the pulp tissue (Watanabe

et al

. 1991, Watanabe
1993). It has been suggested that HeNe laser irradiation
may affect the electric activity (action potential) and not
affect peripheral A

or C-ber nociceptors (Rochkind

et al

. 1987, Jarvis

et al

. 1990). GaAlAs laser radiation at
830 nm has a pain suppressive effect by blocking the
depolarization of C-ber afferents (Wakabayashi

et al

.
1993); GaAlAs laser emissions at 904 nm have an ana-
lgesic effect on the cat tongue although mechanisms
remain unclear (Mezawa

et al

. 1988). Laser energy
at 1064 nm (Nd:YAG laser) is transmitted through
dentine (Zennyu

et al

. 1996), indicating thermally
mediated effects (Funato

et al

. 1991), and pulpal analgesia
(Whitters

et al

. 1995). Using the CO

2

laser at moderate
laser energies, mainly sealing of dentinal tubules is
achieved, as well as reduction of permeability (Bonin

et 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
HeNe 6 mW for 23 min 84 Senda et al. 1985
(632.8 nm) 6 mW for 13 min 90 Matsumoto et al. 1986
GaAlAs 30 mW for 0.53 min > 85 Matsumoto et al. 1985a, b
(780 nm) 30 mW for 0.53 min 94.6 Kawakami et al. 1989
GaAlAs 30 mW for 0.53 min 83.9 Hamachi et al. 1992
(830 nm) 30 mW for 5 min 58 Mezawa et al. 1992
Nd:YAG 10 W for 0.52.5 s 100 Matsumoto et al. 1985c
(1.064 m) 10100 mJ/p for 2 min 100 Renton-Harper & Midda (1992)
CO
2
0.5 W for 530 s 98.6 Moritz et al. 1996
(10.6 m) 1 W for 510 s 100 Zhang et al. 1998a



Kimura et al.


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, 173185, 2000 2000 Blackwell Science Ltd 176

desiccation, yielding temporary clinical relief of dentinal
hypersensitivity (Fayad

et al

. 1996). The sealing depth
achieved by Nd:YAG laser irradiation on dentinal tubules
measured less than 4

m (Liu

et al

. 1997).
Pulpal effects of this type of laser irradiation have
been investigated. The GaAlAs laser at a wavelength
of 780 nm, and an output power of 30 mW for
3 min caused no damage to pulp tissues in monkeys
(Matsumoto

et al

. 1985d). After exposure to the
Nd:YAG laser, no histologically measurable response
was observed using a power of 50 mJ/pulse at 10 Hz for
30 s (total energy: 15 J) (White

et al

. 1995). At an
output power of 10 W for 0.3 s in the continuous wave
mode (total energy density 31 J cm

2

), the pulp showed
exudative inammatory changes with hyperaemia and
focal degeneration of the odontoblasts immediately after
irradiation (Nakamura 1987). Using the CO

2

laser, no
damage was reported after pulpal exposure to 3 W of
power for 2 s in the continuous wave mode using
monkeys and dogs (Melcer

et al

. 1985).
In general, the efcacy of lasers is higher than other
methods, but in severe cases, it is less effective. It is
necessary to consider the severity of dentinal hyper-
sensitivity before laser use.

Pulp capping and pulpotomy

In mature adult teeth, conventional pulp treatment
options include pulp capping or root canal treatment.
The outcome of pulp capping procedure, whether direct
or indirect, is unpredictable and success rates ranging
from 44 to 97% have been reported. Pulpal extirpation
and root canal treatment are performed if pulp capping
procedures are not indicated. In immature perman-
ent teeth, devitalization and root canal treatment are
not advisable until full apex formation and closure
have occurred. Thus endodontic treatment of choice
comprises pulpotomy and subsequent dressing with
calcium hydroxide. If a laser is used for the procedures,
a bloodless eld would be easier to achieve due to the
ability of the laser to vaporize tissue and coagulate and
seal small blood vessels. Moreover, the treated wound
surface would be sterilized.
Melcer

et al

. (1987) rst described laser treatment of
exposed pulp tissues using the CO

2

laser in dogs to
achieve haemostasis; Ebihara

et al

. (1988, 1992) used
the Nd:YAG laser in rats and dogs. Their results showed
that lasers facilitated pulpal healing after irradiation
at 2 W for 2 s. Moritz

et al

. (1998b) reported that the
CO

2

laser was a valuable aid in direct pulp capping
in human patients.
The rst laser pulpotomy was performed using the
CO

2

laser in dogs by Shoji

et al

. (1985) and subsequent
reports from Figueiredo

et al

. (1995), Jukic

et al

. (1997),
Wilder-Smith

et al

. (1997a), and Dang

et al

. (1998).
Similar work using the Nd:YAG laser was performed in
dogs (Ebihara 1989) and rats (Kato

et al

. 1989). The
Ga-As semiconductor laser was used for this purpose in
mice (Kurumada 1990) and the Ar laser in swines
(Wilkerson

et al

. 1996).
No detectable damage was observed in the radicular
portions of irradiated pulps with the CO

2

laser (Shoji

et al

. 1985). Wound healing of the irradiated pulp
seemed to be better than that of controls at 1 week, and
dentine bridge formation in the irradiated pulp was
stimulated at 4 and 12 weeks after operation using the
Nd:YAG laser (Ebihara 1989). Direct effects on the pulp
were 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 damage
was found in tissues underlying the laser-ablated
tissues, with the presence of secondary dentine and a
regular odontoblast layer. Wilder-Smith

et al

. (1997a)
and Dang

et al

. (1998) found CO

2

laser pulpotomy to be
very successful, even in teeth with large exposure sites,
subjected to bacterial contamination for several days.
For laser use in pulp capping and pulpotomy, an
appropriate parameter must be selected. If the laser
energy is too strong, the treatment will be unsuccessful.

Modication of root canal walls

Endodontic instrumentation produces organic and
mineral debris on the wall of the root canal. Although
this smear layer may be benecial, in that it provides
an obstruction of tubules and decreases dentine perme-
ability, it also may harbour bacteria and bacterial
products (Fogel & Pashley 1990). For these reasons, the
removal by a laser of the smear layer and its replacement
with an uncontaminated chemical sealant, or sealing
by melting the dentine surface, has become a goal.
Weichman & Johnson (1971) rst applied a laser to
the root canals by attempting to seal the apical foramen

in vitro

by means of a high-power CO

2

laser. Although
the goal was not achieved, sufcient data were obtained
to encourage further study. Other studies into the effects
of CO

2

laser irradiation on dentine were performed often
using scanning electron microscopy (SEM) (Silberman

et al

. 1994) and confocal laser scanning microscopy
(Kimura

et al

. 1998a).
After CO

2

laser irradiation, dentine permeability
was reduced (Pashley

et al

. 1992), and a wide range of


Kimura et al.


33

, 173185, 2000 177

morphological changes were observed (Tanji & Matsumoto
1994, Lopes

et al

. 1995, Anic

et al

. 1996, Khan

et al

.
1997). Moreover, debris removal and morphological
changes were facilitated by the laser irradiation with
diamine silver uoride [Ag(NH

3

)

2

F] (Eto

et al

. 1999).
The CO

2

laser emitting in the 9.310.49

m region
(Featherstone & Nelson 1987, Onal

et al

. 1993, Taka-
hashi

et al

. 1998, Kimura

et al

. 2000), caused surface
fusion and inhibition of subsequent lesion progression
in 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 the
apex of a tooth

in vitro

. The development of a thin bre
for the Nd:YAG laser stimulated its application in root
canals. Many reports on Nd:YAG laser preparation of
root canals have been published (Dederich

et al

. 1984,
1988, Levy 1992, Bahcall

et al

. 1993, Goodis

et al

.
1993, Marques

et al

. 1995, Miserendino

et al

. 1995,
Lopes

et al

. 1995, Saunders

et al

. 1995). Debris and
smear layer were removed using appropriate laser
parameters (Morita 1994, Koba 1995, Harashima

et al

.
1997a, Koba

et al

. 1998a,b, 1999a), and dentine per-
meability was reduced (Miserendino

et al

. 1995, Anic

et al

. 1996). Since absorption of Nd:YAG laser irradi-
ation is enhanced by black ink, it potentiates laser effects
on root canals (Zhang

et al

. 1998b). 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

)

2

F solution enhances
the effect (Zhang

et al

. 1996). Er:YAG laser irradiation
was more effective in removing the smear layer and
debris on root canal walls than the Ar or Nd:YAG laser
(Takahashi

et al

. 1996, Matsuoka

et al

. 1998, Takeda

et al

. 1998a,b,c, 1999).
Potassium titanyl phosphate (KTP) laser (wavelength
of 532 nm) (Tewk

et al

. 1993, Machida

et al

. 1995)
irradiation was able to remove smear layer and debris
from root canals. The effects of a nanosecond-pulsed,
frequency-doubled Nd:YAG laser emitted at 532 nm on
dentine (Arrastia-Jitosho

et al

. 1998) demonstrated that
this laser irradiation can achieve complete smear layer
removal. However, the results were inhomogeneous, and
at higher energy densities thermal damage was observed.
At specic uences, the xenon chlorine (XeCl) laser
(wavelength of 308 nm) can melt dentine and seal
exposed dentinal tubules (Pini

et al

. 1989b, Stabholz

et 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 & Matsumoto
1993, Wilder-Smith

et al

. 1997b) caused signicant
removal of peritubular dentine at relatively high uence
(10~15 J/cm

2

), melting and resolidication of the dentinal
smear layer being observed under the SEM.
The effects of holmium (Ho):YAG laser irradiation
emitted at 2.10

m (Stevens

et al

. 1994, Cernavin
1995) demonstrated that this laser is an effective means
of ablating dentine and may be suitable for cutting
dentine. The Nd:yttrium alminum perovskite (YAP)
laser emitting at 1340 nm (Blum & Abadie 1997, Farge

et al. 1998) was suggested as an effective device for
root canal preparation in endodontic retreatment.
In the research, the effects of free-electron laser (FEL)
(operating in the 210 m region of the infrared) on
dentine were investigated at 3.0 m (Hoke et al. 1995)
and 9.4 m (Ogino et al. 1996). These result suggest that
3.0 m FEL irradiation affects hydroxyl apatite crystal more
than the interrod substance, a pattern not prominent with
Er:YAG laser ablation; 9.4 m FEL irradiation caused
selective ablation of phosphoric acid ion and annealing.
The removal of smear layer and debris by lasers is
possible, however it is hard to clean all root canal walls,
because the laser is emitted straight ahead, making it
almost impossible to irradiate the lateral canal walls.
Sterilization of root canals
Numerous studies into the sterilization of root canals
have been performed using CO
2
(Zakariasen et al. 1986)
and Nd:YAG lasers (Rooney et al. 1994, Ebihara et al.
1994, Fegan & Steiman 1995, Moshonov et al. 1995b,
Goodis et al. 1995, Sekine et al. 1995, Gutknecht et al.
1996a, Ramskold et al. 1997). The Nd:YAG laser is
more popular, because a thin bre-optic delivery system
for entering narrow root canals is available with this
device. Many other lasers such as the XeCl laser emit-
ting at 308 nm (Stabholz et al. 1993c), the Er:YAG laser
emitted at 2.64 m (Gomi et al. 1997), a diode laser
emitting at 810 nm (Moritz et al. 1997a), and the
Nd:YAP laser emitting at 1.34 m (Blum et al. 1997)
have also been used for this purpose. All lasers have a
bactericidal effect at high power that is dependent on
each laser. There appears to exist a potential for spread-
ing bacterial contamination from the root canal to the
patient and the dental team via the smoke produced
by the laser, which can cause bacterial dissemination
(Hardee et al. 1994). Thus, precautions such as a strong
vacuum pump system must be taken to protect against
spreading infections when using lasers in the root canal
(McKinley & Ludlow 1994).
Laser applications for endodontics Kimura et al.
International Endodontic Journal, 33, 173185, 2000 2000 Blackwell Science Ltd 178
Sterilization of root canals by lasers is problematical
since thermal injury to periodontal tissues is possible.
It is necessary to select an appropriate laser parameter.
Root canal shaping and obturation
Root canal shaping represents an important step in the
endodontic procedure, as it aids the removal of organic
tissues and facilitates irrigation, and canal obturation.
To achieve these goals various methods have been
advocated to render the canal walls free of irregularities.
Using an Er:YAG laser, root canal orices were prepared
(Mazeki et al. 1998). After irradiation by an Er:YAG laser,
the root canal surface appeared smooth in the light
microscope and scale-like when viewed by SEM. Since
clean and regular root canal walls can be achieved using
Nd:YAG laser irradiation, root canal shaping using this
modality has been suggested (Levy 1992).
The photopolymerization of camphorquinone-activated
resins for obturation is possible using an Ar laser emitting
at 477 and 488 nm (Potts & Petrou 1990, 1991). The
results indicate that an Ar laser coupled to an optical
bre could become a useful modality in endodontic
therapy. Similar studies have been performed using the
obturation material AH-26 (Zaman et al. 1994) and
composite resin (Anic et al. 1995). An SEM examination
revealed that laterally compacted resin llings showed
fewer voids than those obtained by vertical compaction.
Ar, CO
2
, and Nd:YAG lasers have been used to soften
gutta-percha (Anic & Matsumoto 1995a,b), and results
indicate that the Ar laser can be used for this purpose to
produce a good apical seal.
It is hard to irradiate root canal walls; after laser irradi-
ation, walls are rough and uneven. It is necessary to
improve the bre tip and the method in order to irradiate
all areas of root canal walls.
Effect on periodontal tissues
The tooth root is in contact with the alveolar bone via
the periodontal membrane and ligament. During laser
usage for intracanal applications, thermal injury to period-
ontal tissues is of concern. Several studies investigating
laser-induced thermal effects on the pulp have been
published, but few studies have dealt with the effects on
the periradicular tissues from energy introduced into the
root canal. Eriksson & Albrektsson (1983) found that
the threshold level for bone survival was 47 C for 1 min.
The rst report on the effect of the Nd:YAG laser on
periodontal tissues was performed using dogs (Bahcall
et al. 1992). The results showed that the laser-treated
teeth exhibited ankylosis, cemental lysis, and major bone
remodeling. However, the parameters used in this study
(3 W and 25 pps for 30 s) were excessive. Since that time,
many other studies on periodontal effects of lasers in
dogs and rats have been published (Morita 1994, Koba
1995, Sekine et al. 1996, Inamoto et al. 1997, Koba
et al. 1998a,b, 1999a). No adverse effects by lasers on
periodontal tissues were observed if appropriate para-
meters were selected. Laser systems operate in various
modes, such as continuous wave, pulsed, chopped-wave,
and Q-switched. To minimize the rise in tissue temperature
within the target and around areas, use of the Q-switched
nanosecond pulsed mode is benecial (Kimura et al.
1997, 1998b).
If the Ho:YAG laser was used within the root canal at
the parameter below 1 W, 5 Hz and total energy 58 J,
the root surface temperature rise remained below 2.2 C
(Cohen et al. 1996).
To make the treatment successful, the effects on peri-
odontal tissues must be considered. It is very important
to select the appropriate parameter and method.
Full root canal treatment
The Nd:YAG laser was investigated by several researchers
for clinical endodontic treatment (Morita 1994, Koba
1995, Hassan 1995, Gutknecht et al. 1996b, Koba et al.
1999b). Clinical follow-up examination of infected
teeth at 3 or 6 months after laser irradiation and root
canal lling revealed that postoperative discomfort
or pain in the laser-treated group was signicantly
reduced compared to the nonlaser-treated group (Koba
1995, Koba et al. 1999b). The effect of Nd:YAG laser
on apical postoperative exudative status was evalu-
ated, and the results showed that 60% of irradiated cases
showed no or mild inammation, whereas 70% of teeth
showed severe inammation in nonirradiated cases
(Hassan 1995). The immediate drying effect of Nd:YAG
laser may be due to the evaporating effect of irradiation
on the exudate leaving the suspended materials to pre-
cipitate inside the canals followed by haemostatic and
healing effect with subsequent inhibition of the inam-
matory condition of the periapical lesion. Gutknecht
et al. (1996b) reported a clinical success rate of 82%
on the following criteria: objective reduction of apical
translucence after 312 months; freedom from complaints
on completion of the treatment (negative percussion,
occlusal load without discomfort).
It is useful to use lasers as an adjunct during conven-
tional treatment, but it is not possible to use lasers alone
for treatment.
Kimura et al. Laser applications for endodontics
2000 Blackwell Science Ltd International Endodontic Journal, 33, 173185, 2000 179
Apicectomy
Apicectomy is a surgical procedure in which the root
apex is removed; the adjacent periapical tissues are
removed and curretted at the same time. The indica-
tions for resection are mainly when previous root canal
treatment has not been successful. If a laser is used for
the surgery, a bloodless surgical eld should be easier to
achieve due to the ability of the laser to vaporize tissue
and coagulate and seal small blood vessels. If the cut
surface is irradiated, the surface is sterilized and sealed.
Moreover, the potential of the Er:YAG laser to cut hard
dental tissues without signicant thermal or structural
damage would eliminate the need for mechanical drills.
Clinical investigations into laser use for apicectomy
began with the CO
2
laser (Miserendino 1988), which
was successfully used for the treatment of a secondary
apical abscess. The use of this laser was expected to seal
the dentinal tubules in the apical portion of the root and
to sterilize the affected area. Subsequently, CO
2
laser
suitability for this purpose was examined using
extracted teeth in vitro (Neiburger 1989, Read et al.
1995, Moritz et al. 1997b) and dogs in vivo (Friedman
et al. 1991a,b, 1992). Laser use during surgery
appeared not to affect treatment results or hinder heal-
ing. However, when this laser was applied to patients
receiving apicectomies (Bader & Lejeune 1998), it did
not improve the healing process. Next, clinical studies
were performed using the Nd:YAG laser (Sumitomo &
Furuya 1988). Using extracted teeth in vitro (Stabholz
et al. 1992a,b, Arens et al. 1993, Wong et al. 1994), the
Nd:YAG laser was found to reduce the penetration of
dye or bacteria within resected roots. In the above inves-
tigations, the laser was used after root resection. When
the laser was used for resection itself, either in extracted
human teeth in vitro or in rats in vivo (Maillet et al.
1996), tissue repairs of the low-resected root surfaces
were delayed when compared with those resected with
a bur. In vitro studies using the Er: YAG laser for root
resection itself in extracted teeth (Paghdiwala 1993,
Yokoyama et al. 1996, Ebihara et al. 1997) achieved
excellent results with the smooth, clean resected root
surfaces, devoid of charring. Clinically, the use of this
laser resulted in improved healing and diminished post-
operative discomfort (Komori et al. 1996a,b, 1997a).
Use of this laser for retrograde cavity preparation in
extracted teeth showed that the working time with the
Er:YAG laser is signicantly less than with ultrasonic
tools, but no signicant differences were reported
between the groups treated with the Er:YAG laser
and the ultrasonic tools with regard to dye penetration
(Ebihara et al. 1998). The Ho:YAG laser has also been
evaluated for apicectomy in extracted teeth (Komori
et al. 1996c, 1997b). The sealing ability of this laser was
less than that of the Er:YAG laser. There have been no
reports on clinical use of this laser for apicectomy.
The use of laser for apicectomy procedure has some
merits, but it takes more time to perform when compared
to more conventional methods.
Other applications for the endodontic treatment
A pulsed dye laser emitted at 504 nm was used for the
removal of a calcied attached denticle (Rocca et al.
1994). SEM evaluation showed a sharp surface at the
base of the pulp stone after the removal.
CO
2
and Nd:YAG lasers have been used for the
attempted treatment of root fractures (Arakawa et al.
1996). However, regardless of the reapproximation
technique, laser type, energy, and other parameters used,
fusion of the fractured root halves was not achieved.
Lasers (Ar, CO
2
, Nd:YAG lasers) have been used suc-
cessfully to sterilize dental instruments (Adrian & Gross
1979, Hooks et al. 1980, Powell & Whisenant 1991).
Results indicated all three lasers (Ar, CO
2
, Nd:YAG
lasers) are capable of sterilizing selected dental instru-
ments; however, the argon laser was able to do so con-
sistently at the lowest energy level of 1 W for 2 min. Before
application of this knowledge to the clinical situation,
appropriate irradiation systems need to be developed.
It may be possible to use lasers for other treatments,
but before they can be recommended, it is necessary to
investigate their effects.
Conclusion
With the development of thinner, more exible and
durable laser bres, laser applications in endodontics
will increase. Since laser devices are still relatively costly,
access to them is limited. Ideally, the laser in the future
will have the ability to produce a multitude of wave-
lengths and pulsewidths, each specic to a particular
application. Once our knowledge of optimal laser
parameters for each treatment modality is complete,
lasers can be developed that will provide dentists with
the ability to care for patients with improved techniques
and equipment.
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