Journal of Dental Research

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CO2 Laser Inhibition of Artificial Caries-like Lesion Progression in Dental Enamel

J.D.B. Featherstone, N.A. Barrett-Vespone, D. Fried, Z. Kantorowitz and W. Seka
J DENT RES 1998 77: 1397
DOI: 10.1177/00220345980770060401

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J Dent Res 77(6): 1397-1403, June, 1998
CO2 Laser Inhibition of Artificial Caries-like
Lesion Progression in Dental Enamel
J.D.B. Featherstonel*, N.A. Barrett-Vespone2, D. Fried', Z. Kantorowitz3, and W. Seka4
'Department of Restorative Dentistry, University of California at San Francisco, Box 0758, 707 Pamassus Avenue, San Francisco, California
94143-0758; 2Johnson and Johnson, Rochester, New York; 3University of Manitoba, Winnipeg, Canada; and 4Laboratory for Laser Energetics,
University of Rochester, Rochester, New York; * to whom correspondence should be adressed.
Abstract. Several studies during the last 30 years have
demonstrated the potential of laser pre-treatment of enamel or
tooth roots to inhibit subsequent acid-induced dissolution or
artificial caries-like challenge in the laboratory. The overall
objective of ongoing studies in our laboratories is to determine,
systematically, the optimum sets of parameters for carbon
dioxide laser irradiation that will potentially effectively inhibit
dental caries in enamel and tooth roots. The aim of the present
study was to examine the roles of wavelength and fluence in
the prevention of caries progression in vitro in enamel by
means of a pH-cycling model. The hypothesis to be tested was
that the highly absorbed 9.3- and 9.6-pLm wavelengths would
be efficiently converted to heat, creating a temperature
sufficiently high to reduce the acid-reactivity of the mineral
and inhibit caries-like lesion progression in dental enamel. One
hundred and sixty caries-free tooth crowns were cleaned and
varnished with acid-resistant varnish, leaving one exposed
window of enamel. Twelve groups of 10 enamel samples were
irradiated in their individual windows by one of the four
wavelengths (9.3, 9.6, 10.3, or 10.6 [Lm) of a tunable CO2 laser.
Energy per pulse was 25, 50, 100, 200, or 250 mJ (25 pulses).
Repetition rate was 10 Hz, and beam diameter was 1.6 mm.
Fluence conditions of 1 to 12.5 J/cm2 per pulse were produced.
All teeth, including 40 non-irradiated controls, were subjected
to pH-cycling to produce artificial caries-like lesions. Results
were assessed by cross-sectional microhardness testing.
Inhibition of caries progression of from 40% to 85% was
achieved over the range of laser conditions tested. At 9.3 and
9.6 p.m, 25 pulses at absorbed fluences of 1 to 3 J/cm2
produced inhibition on the order of 70% with minimal
subsurface temperature elevation (< 1°C at 2 mm depth),
comparable with inhibition produced in this model with daily
fluoride dentifrice treatments. Safety and efficacy studies will
be required in animals and humans before these promising
laboratory results can be applied in clinical practice.
Key words: CO2 laser, artificial caries, lasers in dentistry.
Received October 7, 1994; Last Revision September 24, 1997;
Accepted September 24,1997
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Introduction
Several studies during the last 30 years have demonstrated
the potential of laser pre-treatment of enamel or tooth roots
to inhibit subsequent acid-induced dissolution or artificial
caries-like challenge in the laboratory (Stern et al., 1966,
1972; Yamamoto and Ooya, 1974; Yamamoto and Sato, 1980;
Lenz et al., 1982; Nelson et al., 1986, 1987; Nammour et al.,
1992; Hicks et al., 1993a,b; Westerman et al., 1994). Studies
by Fox and co-workers (Wong et al., 1990; Fox et al., 1992),
using a continuous-wave carbon dioxide laser (10.6 pLm)
also showed dramatic reductions in acid reactivity in tooth
mineral as a result of laser irradiation. Almost all of these
studies utilized only one wavelength and a very limited set
of laser irradiation conditions. Further, most of the studies
used continuous-wave (cw) lasers with no consideration for
the benefits possible from the use of pulsed lasers. Nelson
and co-workers (Nelson et al., 1986, 1987; Featherstone and
Nelson, 1987) demonstrated the potential caries-inhibitory
effects of pulsed carbon dioxide laser irradiation of enamel
at low fluences. They achieved inhibition of subsequent
demineralization of enamel of up to 50% with the laser
conditions they used, and reported that these effects were
wavelength-dependent. These workers hypothesized that
the carbon dioxide laser wavelengths (9.3, 9.6, 10.3, and 10.6
p.m) were efficiently absorbed by the carbonated apatite
mineral of the tooth and that the absorbed light was rapidly
transformed to heat near the surface, causing loss of
carbonate from the mineral with a subsequent marked
decrease in acid reactivity. However, no systematic
examination of the numerous parameters involved has been
conducted to date to determine the potential optimum laser
irradiation conditions that would be likely to inhibit caries
clinically. The variables involved are wavelength, pulse
width, incident and absorbed pulse energy, beam diameter,
number of pulses, repetition rate, and irradiation intensity.
Further, until recently (Fried et al., 1996), transient
temperature measurements (with 1-ps time resolution) at
the surface of tooth enamel during irradiation by the four
principal wavelengths of the carbon dioxide laser were not
available. Yu et al. (1992) indicated temperatures of 300°C or
more with cw 10.6-p.m irradiation by calculation but were
not able to make experimental measurements. The
1397
1398 Featherstone et al.
temperature at which carbonate is driven from the
carbonated apatite is in the range of 400 to 600°C (Holcomb
and Young, 1980), and the melting point of the carbonated
apatite ranges from approximately 950 to 12000C (Ellies et
al., 1988). The resultant effects of such laser-induced
temperature changes on caries inhibition remain to be
elucidated.
The overall objective of ongoing studies in our
laboratories is to determine, systematically, the optimum
sets of parameters for carbon dioxide laser irradiation that
will potentially effectively inhibit dental caries in enamel
and tooth roots. The aim of the present study was to
examine the roles of wavelength and fluence in the
prevention of caries progression in vitro in enamel by means
of a pH-cycling model. The hypothesis to be tested was that
the highly absorbed 9.3- and 9.6-pum wavelengths would be
efficiently converted to heat, creating a temperature
sufficiently high to reduce the acid-reactivity of the mineral
and inhibit caries-like lesion progression in dental enamel.
Materials and methods
Tooth preparation
The crowns of molars or premolars collected from oral surgeons
in the Rochester, NY, area (1 ppm F in the water supply) were
utilized in the present study. The teeth therefore fall into
National Institutes of Health exempt category 4 and therefore
do not require an institutional human subjects review approval.
We have no knowledge of the subjects from whom the teeth
were derived, and the teeth were not identified by subject
source in any way. Tooth crowns which were caries-free by
visual inspection were cleaned with detergent and de-ionized
water as described previously (Featherstone et al., 1983),
removed from the roots, and coated with acid-resistant varnish,
with one window approximately 2 mm square of exposed
enamel left on a buccal or lingual surface. Sixteen groups of ten
teeth each were utilized in the experiments.
Laser conditions
Since the aim of the present study was to investigate further the
wavelength dependency we previously reported (Featherstone
and Nelson, 1987), we chose the four principal wavelengths
available from a tuned CO2 laser, namely, 9.3, 9.6, 10.3, and 10.6
,um. Our previous studies (Nelson et al., 1986) had indicated
that, with the laser available to us at that time, from 200 to 400
pulses over a period of approximately 10 min (20 mJ/pulse;
pulse duration, 100 to 200 ns; irradiation intensity, -1 MW/cm2)
were needed to produce a maximum of 50% inhibition of
subsequent subsurface demineralization of enamel.
Subsequently, the axial thermal relaxation time (Tr) of
enamel was calculated to be approximately 60 p,s for a 10-p.m
thermal gradient length and absorption coefficient of 1000 cm-
The energy deposited at pulse durations less than Tr is
"thermally confined" to a thin layer at the enamel surface. Pulse
durations << Tr result in ablation with minimal deposition of
heat into the sample. Hence, the optimum pulse duration for the
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j Dent Res 77(6) 1998
desired thermal modification is on the order of Tr.
Consequently, we selected a pulse duration of 100 p.s for the
present experiments. For the future practical utilization of laser
treatment of enamel in the mouth to inhibit caries progression,
the treatment time must be minimized to a few seconds rather
than minutes. Separate temperature measurements (Fried et al.,
1996) showed that, at 10 J/cm2 and 10 Hz, a cumulative
temperature increase (i.e., between individual pulses) occurred
at the enamel surface. This increase reached a steady state
(conduction losses = rate of energy deposition), after 10 pulses, of
about 200°C, so that, for example, at 9.6 p.m, a single-pulse peak
surface temperature of -800°C became -1000°C after about 10
pulses (Fried et al., 1996). We have shown, in a separate study, that
inhibition of subsurface caries-like lesions increases markedly up
to about 10 pulses, and the effect levels off somewhere between 10
and 25 pulses (Kantorowitz et al., 1998). For these reasons, we
chose 25 pulses and a repetition rate of 10 Hz.
To produce these laser irradiation conditions, we purchased
a tunable carbon dioxide laser from Pulse Systems, Inc. (Los
Alamos, NM) with pulse duration variable from 50 to 500 p.s,
wavelength tunable from 9 to 11 pm, maximum peak energy
output of 250 mJ per pulse, and repetition rate of 1 to 10 Hz.
Each of the enamel samples, prepared as described above, was
irradiated in the individual window at one of the four
wavelengths (9.3, 9.6, 10.3, or 10.6 pLm) under the following
conditions: energy per pulse of 25, 50, 100, 200, or 250 mJ; 25
pulses; repetition rate, 10 Hz; and a beam diameter of 1.6 mm
(to produce the desired fluence conditions of 1 to 12.5 J/cm2 per
pulse).
pH-cycling
The pH-cycling model, as we have described several times
previously (Featherstone et al., 1986, 1990; White and
Featherstone, 1987), was used to produce lesions with a
demineralization challenge and remineralization period
alternating daily. Each test group consisted of ten teeth (human
enamel crowns as described above) with one exposed window.
All teeth, with the exception of the control groups, were pre-
irradiated as described above. Four non-irradiated control
groups of ten teeth each were utilized. The test regimen in each
24-hour period proceeded as follows:
(1) Teeth underwent 6 hrs of demineralization at 37°C in a
buffer containing 2.0 mmol/L calcium, 2.0 mmol/L phosphate,
and 0.075 mol/L acetate at pH 4.3. Each tooth was immersed
individually in 40 mL of solution.
(2) The teeth were removed from solution and thoroughly
rinsed in double-deionized water.
(3) The teeth were then immersed individually for 17.5 hrs at
37°C in 20 mL of a mineralizing solution overnight to simulate
the remineralizing stage of the caries process. The mineralizing
solution was supersaturated with calcium phosphate (calcium =
1.5 mmol/L, phosphate = 0.9 mmol/L), with potassium
chloride at 150 mmol/L and cacodylate buffer to pH 7.0 (20
mmol/L). This solution approximates the degree of saturation
with respect to the apatitic minerals found in saliva and is
similar to that used by ten Cate and Duijsters (1982).
(4) When the teeth were removed from the mineralizing
solution, they were rinsed in double-deionized water, and the
pH-cycling regime was repeated for 9 days and nights of
j Dent Res 77(6) 1998 Laser Inhibition of Caries Progression 1399

Table. Inhibition of mineral loss following laser pre-treatment of enamel

Wavelengthb Incident Energy Incident Fluence AZ (SD)a Percent Statistical

(p.m) (mJ/pulse) J/cm2/pulse) (p.m x vol%) Inhibition Significancec
9.3 50 2.5 582 (437) 64a bcc
9.3 100 5 521 (289) 68 bc
9.3 200 10 600 (329) 63 bc

9.6 25 1.25 647 (416) 60 bc

9.6 50 2.5 476 (288) 70 ab
9.6 100 5 470 (370) 71 ab
9.6 200 10 842 (401) 48 cd

10.3 200 10 434 (248) 73 ab

10.6 50 2.5 894 (262) 45 d

10.6 100 5 936 (271) 42 d
10.6 200 10 690 (299) 57 cd

10.6 250 12.5 237 (172) 85 a

a Mean (SD = standard deviation) relative mineral loss, AZ(p.m x vol% mineral), for human enamel pre-treated by CO2 laser,
followed by 9 days' pH cycling (n = 10 for treatment groups, n = 40 for non-irradiated controls). AZ(SD) for the non-
irradiated controls (n = 40) was 1613 (576). Percent inhibition was calculated relative to the control group.
b ps,
Beam diameter was 1.6 mm, pulse width 100 repetition rate 10 Hz, and number of pulses 25 in each treatment group.
c Values with the same adjacent letter (a, b, c, etc.) were not significantly different (p < 0.05) by the LSD test. All laser-
irradiated groups were significantly different from the control group.

alternating demineralization and remineralization treatments, Results

as described above, with one intervening weekend in the
mineralizing solution.
Assessment of demineralization/remineralization
At the conclusion of the pH-cycling, the teeth were rinsed in
double-deionized water, sectioned longitudinally through the
center of the lesions, and embedded in epoxy resin with the cut
face exposed as previously described (Featherstone et al., 1983,
1986; White and Featherstone, 1987). After serial polishing, each
lesion was assessed by cross-sectional microhardness testing by
means of techniques routinely used in our laboratory
(Featherstone et al., 1983, 1986, 1990), except that a detailed
"Xscatter pattern" was used starting at 15 p.m from the
anatomical surface with indents at 5-pm intervals between 15
and 50 p.m from the surface, and then at 25-pm intervals from
50 to 300 p.m across the lesion and into the underlying enamel
(Meyerowitz et al., 1991). The set of data representing each
artificial caries-like lesion was curve-fitted by means of a
Simpson approximation (White and Featherstone, 1987), and the
area under the lesion tracing was calculated (in units of vol%
mineral x pm) and subtracted from the normal enamel value to
give the parameter AZ, being the relative mineral loss for each
lesion. These cross-sectional microhardness profiles are
comparable with data from quantitative microradiography
(Featherstone et al., 1983; White and Featherstone, 1987). The
individual AZ values for each lesion in each group were
combined to give a mean AZ and standard deviation for each of
the laser-treated and non-irradiated control groups.
The results of the laser-treated samples and non-irradiated
control groups are given in the Table. The data are
presented as means (standard deviation = SD) of each group
for the relative mineral loss (AZ) values. Percent inhibition is
calculated as follows:
percent inhibition = {AZ(control) - AZ(treatment)} x 100
AZ(control)
The mean vol% mineral value at each depth for each group
was calculated and plotted to give group profiles, as
illustrated in Figs. 1 and 2. The profile illustrated in Fig. 1
shows one of the 9.6-,um irradiated groups and the non-
irradiated controls. The major inhibition throughout the
lesion is obvious. Fig. 2 shows the mean profile for one of
the groups irradiated at 10.6 p.m. Inhibition throughout the
lesion is again obvious, but with less inhibition than in the
9.6-p.m irradiated group.
Discussion
All of the laser irradiation conditions tested in this study
produced statistically significant inhibition of subsequent
caries-like lesion formation with a total irradiation time of
only 2.5 s (2.5 ms of actual laser irradiation). Inhibition of
caries progression of from 40% to 85% was achieved,
whereas in our previous studies (Nelson et al., 1986, 1987),
we were able to achieve a maximum of only 50% inhibition,

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1400 Featherstone et al.
100 +
90
80
70
60
- -irradiatedirrdite
sI| || | | 11 16d13 - - .|:7
50
40
-AZ
30F
20[
1OF -I46I
0t
0 20 40 60 80 100 120
Depth, jAm
Figure 1. Mineral profiles plotted as mean vol', mineral zvs. depth from the surface for the 1987; Featherstone and Nelson, 1987;
non-irradiated control teeth and for the group irradiated at 9.6 jim, 50 mJ/pulse, incident Fried et al., 1996). Reflectance at the
fluence 2.5 J/cm2/pulse, repetition rate 11) Hz, pulse width 100 gs, 25 pulses.
with most conditions giving only 10 to 40'%. In that study,
the pulse duration was -100 ns. The thermal energy during
the laser pulse was essentially confined to the absorption
depth for that laser, which we calculate was less than 2 p.m.
The thermal diffusion length of approximately 10 p.m
during the longer 100-pLs pulses is markedly larger, and
therefore the thermal energy is not confined for the 9.3- and
9.6-p.m laser pulses, and a deeper enamel layer of ap-
proximately 10 pLm will be heated sufficiently to modify the
solubility of the mineral. In the present study, numerous sets
of conditions were able to produce inhibition in excess of
60%/. These results indicate that the calculated ranges of
conditions that we predicted would produce protection of
enamel against subsequent acid challenge were well-
founded.
In previous pH-cycling studies using fluoride-containing
dentifrices, we have reported inhibition of caries
progression by fluoride-containing dentifrices of from 70 to
80%, (White and Featherstone, 1987; Featherstone et al., 1988,
1989; Featherstone and Zero, 1992). In the present
experiments, several laser treatments produced inhibition in
the range of from 70 to 850o (Table), which were not
significantly different from each other and therefore
produced inhibition comparable with that given by a once-a-
day sodium fluoride dentifrice slurry treatment. For the
members of the population who still get caries, many of the
lesions occur in the pits and fissures, where fluoride is
apparently not as effective as it is on smooth surfaces.
Previous studies in our laboratory produced inhibition by
CO2 laser treatment in occlusal surfaces similar to that
achieved for smooth surfaces (Zhang et al., 1993). Further,
combined laser and fluoride effects in occlusal surfaces were
additive (Zhang et al., 1993). It is possible, therefore, that
laser treatment of occlusal surfaces may be an effective
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I Detnt Res 77(6) 1998
caries-preventive measure.
4
In the present study, we compared a
wide range of incident energy condi-
tions for each of the 9.6- and 10.6-pm
wavelengths. With the exception of the
group irradiated at 250 mJ/pulse, all of
the lower energy conditions (from 50 to
200 mJ/pulse) for 10.6 pLm produced
inhibition of less than 58%M in contrast to
0
i inhibition on the order of 70% achieved
by 50 to 100 mJ/pulse with 9.6 pm.
Light may be reflected, absorbed, scat-
tered, or transmitted by tissue. For the
wavelengths studied here, absorption
occurs in the outer few p.m, and there-
fore scattering and transmission are
essentially zero. The high absorption
coefficients for all four CO2 wave-
140 160 lengths (see below) indicate a very
efficient transformation of light to heat
at these wavelengths (Duplain et al.,
surface, however, must also be con-
sidered. Reflectance studies by Duplain
et al. (1987), using bovine enamel, which
we recently confirmed using human enamel (Fried et al.,
1997), indicate that at 9.6 p.m (although the absorption
coefficient is very high), approximately 5000 of the energy is
reflected, whereas at 10.6 .Lm, only about lOo is reflected.
The comparable caries-inhibitory effect of 25 mJ/pulse of
incident energy at 9.6 p.m with 200 mJ/pulse at 10.6 p.m
indicates approximately a 14-fold difference in absorbed
energy for the two wavelengths to produce similar effects.
Surprisingly, at the higher incident energy level of 200
mJ/pulse with 9.6 .Lm, significantly less inhibition of caries
progression was found. In a separate study, considerable
surface damage was observed by SEM (McCormack et al.,
1995) following irradiation at this energy level by the highly
efficiently absorbed 9.6-p.m wavelength. The damaged
surfaces apparently were detrimental and provided less
resistance to the acid challenge.
Our previous studies and conclusions (Featherstone and
Nelson, 1987) indicated that 9.3- and 9.6-p.m light was much
more efficiently absorbed than the 10.3- and 10.6-.Lm
wavelengths. This conclusion is confirmed by the absorption
coefficients calculated by Duplain et al. (1987), namely,
18,500, 30,000, 6500, and 5000 cm-1 for 9.3, 9.6, 10.3, and 10.6
p.m, respectively. The different absorption coefficients
provide an explanation as to why it is possible for
approximately one-fifth (or less) of the energy at 9.6 p.m to
produce inhibition comparable with that at 10.6 p.m. The
transformation of light to heat when it is absorbed into
enamel mineral is more effective at 9.3 and 9.6 pm than it is
at 10.6 pm (Featherstone and Nelson, 1987). We have
reported elsewhere that if sufficiently high temperatures
were achieved in the enamel mineral, carbonate was lost
from the laser-treated mineral, thus reducing its reactivity
(Featherstone and Nelson, 1987; Featherstone et al., 1997).
The highest fluence per pulse (12.5 J/cm2) that we used at
j Dent Res 77(6) 1998 Laser Inhibition of Caries Progression4 14()1

10.6 p.m produced an inhibition of

85%, but this was not statistically 100 -

significantly different from that of 90 -

70% produced at 9.6 pLm with 2.5
J/cm2. Temperature measurements 80 -
in our laboratory (Fried et al., 1996)
showed that temperatures at the *E 70
surface for a single pulse at 9.6 p.m a)
and a fluence of 5 J/cm2 exceeded .r 60
900°C, whereas those for 10.6 p.m g 00 50-
were on the order of 500"C. Recent a)
measurements (Fried et al., 1996) E 40 -
made by thermocouple at a depth
of 2 mm from the surface of enamel 0 30 -
showed a temperature rise fol-
lowing 25 pulses at 10 J/cm2, 10.6 20 -
pLm of approximately 10"C at that 10 control irradiated -
depth, indicating the likelihood of
pulp damage. The corresponding 0O I I -

rise for 9.6 p.m, 25 pulses, and a 0 20 40 60 80 100 120 140

fluence of 2.5 J/cm2 (50 mJ/pulse =
25 mJ/pulse absorbed energy) was
approximately VC. The ratio of Figure 2. Mineral profiles plotted as mean vo]O/ mineral vs. depth from the surface for the non-
these internal temperature rises irradiated control teeth and for the group irradiated at 10.6 rm, 20)0 mJ/pulse, incident fIliance 10
corresponds to the ratio of the J/cm2/pulse, repetition rate 10 Hz, pulse width 100 1Ls, 25 pulses.
absorbed total energies, whereas
the surface temperature effect is
related to the absorption coefficients (Fried et al., 1996).
Extensive studies (reported elsewhere) where scanning
electron microscopy was used for observation of the effects
on enamel surfaces utilizing the same range of irradiation
conditions as those of the present study showed that, with
9.3 and 9.6 p.m, and with the fluences as used in the present
study, surface melting and recrystallization as
polycrystalline masses occurred (McCormack et al., 1995).
Conversely, at 10.3 and 10.6 pm, the original crystal size
was still observable, with no fusion or recrystallization
apparent. The AZ values reported here, however, show that
marked inhibition of dissolution occurred in all cases. This
indicates that the temperatures achieved by 10.3 and 10.6
pLm were not sufficient to melt the surface but were
sufficient to have an effect on the chemical composition of
the individual crystals, making them less susceptible to acid
dissolution. As stated above, the absorption coefficients at
10.3 pLm and 10.6 p.m are comparable (Duplain et al., 1987).
Therefore, in this study, we examined only one energy
level-namely, 200 mJ/pulse at 10.3 p.m-and inhibition of
73% was achieved. In our previous studies (Featherstone
and Nelson, 1987), 10.3 p.m was less effective than the other
three wavelengths. Further studies will be necessary to
determine the lower threshold for 10.3 pLm where it ceases
to be as effective.
As a first attempt at the direct comparison of wavelength
effects, the results for 200 mJ/pulse (fluence 10 J/cm2) for
each of the four wavelengths can be compared from the
Table. It can be seen that at these energy levels, 10.3 p.m is
apparently the most effective. However, as stated above,
with 9.6 p.m at this relatively high fluence (10 J/cm2), surface 100 to 300 p.s were found to be optimum at these
damage occurred. Therefore, a direct comparison of efficacy
in this way is not appropriate. Rather, the comparison of
Depth, jtm
percent inhibition as the end result is more suitable, with an
attempt then at determining the energy conditions at each
wavelength which are most likely to be effective. From the
Table, it can be seen that relatively low fluences/pulse in the
order of 2.5 to 5 J/cm2 were effective at wavelengtlhs of 9.3
and 9.6 pm. These values, when reflectance is taken into
consideration, indicate that absorbed fluences between 1 and
3 J/cm2/pulse were effective at inhibiting caries-like
progression at these wavelengths. These fluences at 10 Hz
and 25 pulses produced temperature rises at a depth of 2
mm in the enamel of only approximately 1"C or less, as
described above. The optimum conditions for clinical use
will be those which achieve the highest caries inhibition
with the lowest detrimental energy deposition in the
underlying tissues.
In conclusion, it has been shown that it is possible to
utilize carbon dioxide laser irradiation at wavelengths of
9.3 and 9.6 pm to alter dental enamel to make it markedly
more resistant to subsequent acid attack without
producing elevated temperatures in the unlderlying tissue
that could lead to pulpal damage. In a separate study, we
have examined the effect of number of pulses and
confirmed that 25 is optimum, with no measurable
advantage being gained with an increased number of
pulses (Kantorowitz et al., 1998). In a further study, we
examined the hypothesis that increased pulse durationi
may permit lower surface peak temperatures but higher
temperatures at depths further into the early lesion region,
which could be even more effective for caries inhaibition
(Featherstone et al., 1996). Pulse durationis in the range of
wavelengths (Featherstone et al., 1996).
In summary, irradiation of dental enamel with laser

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1402 Featherstone et al.
light at 9.3 and 9.6 p1m, 100-Ls pulse duration, 25 pulses,
with absorbed fluences of 1 to 3 J/cm2 produced inhibition
of subsurface caries-like progression comparable with that
produced in this laboratory model with daily fluoride
dentifrice treatments, and yet produced subsurface
temperature rises of only 1°C or less, which indicates that
pulp safety should not be a problem for these irradiation
conditions. Similar inhibition at 10.6 or 10.3 ,um required in
excess of 10 J/cm2 absorbed fluence, and at this energy
output, temperature rises in the pulp chamber would be
expected to be on the order of 100C, which may indicate
that such treatment could be detrimental to the pulp.
Safety and efficacy studies will be required in animals and
humans before these promising laboratory results can be
applied in clinical practice.
Acknowledgments
This work was supported by NIH/NIDR Grant DE09958.
The major technical contributions of Joanne Lofthouse and
Richard Glena are acknowledged with thanks.
References
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refraction of dental enamel at CO2 wavelengths. Appl
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Ellies LG, Nelson DG, Featherstone JD (1988). Crystallographic
structure and surface morphology of sintered carbonated
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Featherstone JD, Nelson DG (1987). Laser effects on dental hard
tissues. Adv Dent Res 1:21-26.
Featherstone JD, Zero DT (1992). Laboratory and human studies
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Featherstone JD, ten Cate JM, Shariati M, Arends J (1983).
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