The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 13, 2019

Application of Laser Irradiation for Restorative Treatments



Amin Davoudi1, Maryam Sanei2, Hamid Badrian*, 3
1 Department of Oral and Maxillofacial Surgery, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Endodontics, School of Dentistry, Khorram Abad University of Medical Sciences, Lorestan, Iran
3 Department of Operative Dentistry, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran

Abstract

Nowadays, lasers are widely used in many fields of medicine. Also, they can be applied at many branches of dental practice such as diagnosis, preventive procedures, restorative treatments, and endodontic therapies. Procedures like caries removal, re-mineralization, and vital pulp therapy are the most noticeable effects of laser irradiation which has gained much attention among clinicians. With controlled and appropriate wavelength, they can help stimulating dentinogenesis, controlling pulpal hemorrhage, sterilization, healing of collagenic proteins, formation of a fibrous matrix, and inducing hard tissue barrier. Nevertheless, there are many controversies in literatures regarding their effects on the quality of bonded restorations. It hampered a wide application of lasers in some aspects of restorative dentistry and requirements to identify the best way to use this technology. The aim of this mini review is to explain special characteristics of laser therapy and to introduce the possible applications of laser devices for dental purposes.

Keywords: Caries, Demineralization, Laser, Restorative dentistry, Vital pulp therapy.


Article Information


Identifiers and Pagination:

Year: 2016
Volume: 10
First Page: 636
Last Page: 642
Publisher Id: TODENTJ-10-636
DOI: 10.2174/1874210601610010636

Article History:

Received Date: 12/01/2016
Revision Received Date: 08/08/2016
Acceptance Date: 02/09/2016
Electronic publication date: 16/11/2016
Collection year: 2016

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open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International Public License (CC BY-NC 4.0) (https://creativecommons.org/licenses/by-nc/4.0/legalcode), which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the Department of Operative Dentistry, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran; Tel/Fax: +959132949318; E-mail: hamid.badrian@yahoo.com





INTRODUCTION

Light amplification by stimulated emission of radiation (laser) was introduced into the dentistry for the first time in 1960 by Maiman [1Maiman TH. Stimulated optical radiation in ruby lasers. Nature 1960; 187(6): 493.
[http://dx.doi.org/10.1038/187493a0]
]. Nowadays, a number of lasers are used in dentistry such as carbon dioxide (CO2) laser, neodymium yttrium aluminum garnet laser (Nd:YAG), Erbium laser and Diode laser. Each of these lasers represent some features which make them applicable for specific dental goals [2Verma SK, Maheshwari S, Singh RK, Chaudhari PK. Laser in dentistry: An innovative tool in modern dental practice. Natl J Maxillofac Surg 2012; 3(2): 124-32.
[http://dx.doi.org/10.4103/0975-5950.111342] [PMID: 23833485]
]. They can be applied for many dental branches like diagnosis, prevention, restorative procedures, and endodontics. One classification divides them into two groups of soft lasers and hard ones [3Lalani N, Foley TF, Voth R, Banting D, Mamandras A. Polymerization with the argon laser: curing time and shear bond strength. Angle Orthod 2000; 70(1): 28-33.
[PMID: 10730673]
]. CO2 and Nd:YAG lasers were the first ones that were registered for their effect on dental hard tissues [4Adrian JC, Bernier JL, Sprague WG. Laser and the dental pulp. J Am Dent Assoc 1971; 83(1): 113-7.
[http://dx.doi.org/10.14219/jada.archive.1971.0267] [PMID: 5281161]
]. Er:YAG and CO2 lasers, with higher wavelength, had the benefits of having much higher absorption and lower penetration depth (about 0.01 mm) into the hard tooth tissues [5Fuhrmann R, Gutknecht N, Magunski A, Lampert F, Diedrich P. Conditioning of enamel with Nd:YAG and CO2 dental laser systems and with phosphoric acid. An in vitro comparison of the tensile bond strength and the morphology of the enamel surface. J Orofac Orthop 2001; 62(5): 375-86.
[http://dx.doi.org/10.1007/PL00001943] [PMID: 11590826]
]. The Er:YAG laser provides a wavelength of 2940 nm which can be administered for preparing dentine, enamel and removing carious tissues [6Hibst R, Keller U. Experimental studies of the application of the Er:YAG laser on dental hard substances: I. Measurement of the ablation rate. Lasers Surg Med 1989; 9(4): 338-44.
[http://dx.doi.org/10.1002/lsm.1900090405] [PMID: 2761329]
]. The Er,Cr:YSGG is another newly introduced laser with wavelength of 2.79 μm. It induces strong water absorption energy (7000 J/cm) and can be proposed for both hard tissue and soft tissue applications [7Subramaniam P, Pandey A. Effect of erbium, chromium: yttrium, scandium, gallium, garnet laser and casein phosphopeptide-amorphous calcium phosphate on surface micro-hardness of primary tooth enamel. Eur J Dent 2014; 8(3): 402-6.
[http://dx.doi.org/10.4103/1305-7456.137656] [PMID: 25202223]
]. The aim of this mini review is to explain special characteristics and possible applications of laser devices for dental purposes.

MATERIALS AND METHODOLOGY

A data search was performed using PubMed’s electronic database of dental reports, based on the following search terms in simple or multiple conjunctions: “Laser”, “Restorative dentistry”, “Caries”, “Demineralization”, “Vital pulp therapy”. Some of the searched studies which had more relevance with the scope of this article were chosen. Consequently, case reports, studies with missing data, repeatedly published studies, and those in other languages than English were excluded. After screening both abstracts and full texts the information was gathered for summarizing.

The Effects of Laser Irradiation on Healthy Tooth Tissues

The effect of laser irradiation on enamel is observed as follows: at temperature 650°C to 1100°C, decrease in the enamel solubility would be enhanced, which highly depends on the calcium-phosphate ratio. At 1100°C, new crystalline phases would be formed by tetra Calcium Diphosphate Monoxide (alpha tri-calcium phosphate and beta-phases), which is less soluble, with less carbonate contents, and more resistant to demineralization procedures [8Bachmann L, Craievich AF, Zezell DM. Crystalline structure of dental enamel after Ho:YLF laser irradiation. Arch Oral Biol 2004; 49(11): 923-9.
[http://dx.doi.org/10.1016/j.archoralbio.2004.05.009] [PMID: 15353249]
]. In the other aspect of view, lasers might induce surface changes in enamel like surface roughness, crazing, cracking and exfoliation [7Subramaniam P, Pandey A. Effect of erbium, chromium: yttrium, scandium, gallium, garnet laser and casein phosphopeptide-amorphous calcium phosphate on surface micro-hardness of primary tooth enamel. Eur J Dent 2014; 8(3): 402-6.
[http://dx.doi.org/10.4103/1305-7456.137656] [PMID: 25202223]
].

Laser appliances remove dental tissues selectively by causing water evaporation that is unique for mineralized tissue. The Er:YAG laser makes thermal changes in water molecules of the hard tissue, so the absorbed energy results in superheating and evaporation. The increased vapor pressure causes exfoliation and micro explosive expansion of the hard tissue [9Hadley J, Young DA, Eversole LR, Gornbein JA. A laser-powered hydrokinetic system for caries removal and cavity preparation. J Am Dent Assoc 2000; 131(6): 777-85.
[http://dx.doi.org/10.14219/jada.archive.2000.0277] [PMID: 10860330]
]. The laser irradiation influences the dental tissue by making microscopic coarse surfaces without demineralization, and provides open dentinal tubules without formation of smear layer. Also, it can sterilize the surface significantly [10Ceballos L, Osorio R, Toledano M, Marshall GW. Microleakage of composite restorations after acid or Er-YAG laser cavity treatments. Dent Mater 2001; 17(4): 340-6.
[http://dx.doi.org/10.1016/S0109-5641(00)00092-0] [PMID: 11356211]
].

The adverse effect of laser devices on the pulpal health might cause severe damages to the pulp due to thermal damage during tooth preparation, such as irreversible pulpitis and pulp necrosis [11Nair PN, Baltensperger M, Luder HU, Eyrich GK. Observations on pulpal response to carbon dioxide laser drilling of dentine in healthy human third molars. Lasers Med Sci 2005; 19(4): 240-7.
[http://dx.doi.org/10.1007/s10103-004-0317-7] [PMID: 15647971]
]. However, due to demands for ideal laser instruments, researchers identified the appropriate wavelength that made selective impact to tooth tissue by selective absorption of pulsed radiation (Photothermolysis) [12Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983; 220(4596): 524-7.
[http://dx.doi.org/10.1126/science.6836297] [PMID: 6836297]
]. Also, water cooling is recommended to reduce heat during tooth preparation [13Visuri SR, Walsh JT Jr, Wigdor HA. Erbium laser ablation of dental hard tissue: effect of water cooling. Lasers Surg Med 1996; 18(3): 294-300.
[http://dx.doi.org/10.1002/(SICI)1096-9101(1996)18:3<294::AID-LSM11>3.0.CO;2-6] [PMID: 8778525]
]. Some animal [14Takamori K. A histopathological and immunohistochemical study of dental pulp and pulpal nerve fibers in rats after the cavity preparation using Er:YAG laser. J Endod 2000; 26(2): 95-9.
[http://dx.doi.org/10.1097/00004770-200002000-00009] [PMID: 11194381]
] and human studies [15Nair PN, Baltensperger MM, Luder HU, Eyrich GK. Pulpal response to Er:YAG laser drilling of dentine in healthy human third molars. Lasers Surg Med 2003; 32(3): 203-9.
[http://dx.doi.org/10.1002/lsm.10155] [PMID: 12605427]
] showed appropriate response of the pulp to the Er:YAG laser. Niar et al. [12Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983; 220(4596): 524-7.
[http://dx.doi.org/10.1126/science.6836297] [PMID: 6836297]
] observed outstanding preservation of pulpal health by means of Er:YAG laser at 2.94 μm wavelength. In another study by Nair [11Nair PN, Baltensperger M, Luder HU, Eyrich GK. Observations on pulpal response to carbon dioxide laser drilling of dentine in healthy human third molars. Lasers Med Sci 2005; 19(4): 240-7.
[http://dx.doi.org/10.1007/s10103-004-0317-7] [PMID: 15647971]
], the CO2 laser caused minimal and mild inflammatory responses to pulpal tissue.

The Effect of Lasers on Carious Structures

Detection

Laser-induced fluorescence (LF) opened a new aspect in the early diagnosis of hidden occlusal caries. DIAGNO dent is an LF-based devise which detects mineral loss according to quantitative optical methods. A red light, produced by a diode laser at 655 nm wavelength, illuminates the tooth surface and the optical fiber transmits the fluorescence of mineralized tooth tissues for detection. So, the intensity of the detected fluorescence indicates the extent of caries [16Chu CH, Lo EC, You DS. Clinical diagnosis of fissure caries with conventional and laser-induced fluorescence techniques. Lasers Med Sci 2010; 25(3): 355-62.
[http://dx.doi.org/10.1007/s10103-009-0655-6] [PMID: 19259758]
]. The reliability of DIAGNO dent, in detecting secondary caries under composite restorations, is reported to be similar to digital radiographs [17Kositbowornchai S, Sukanya C, Tidarat T, Chanoggarn T. Caries detection under composite restorations by laser fluorescence and digital radiography. Clin Oral Investig 2013; 17(9): 2079-84.
[http://dx.doi.org/10.1007/s00784-012-0908-9] [PMID: 23242816]
], however, the Cone beam computed tomography seemed to represent the best accuracy [18Ozturk E, Sinanoglu A. Histological validation of cone-beam computed tomography versus laser fluorescence and conventional diagnostic methods for occlusal caries detection. Photomed Laser Surg 2015; 33(2): 61-8.
[http://dx.doi.org/10.1089/pho.2014.3831] [PMID: 25650901]
]. Near-infrared laser transillumination (NIR-LTI) is another new generation of caries detectors which have shown promising results compared to DIAGNOdent however the researches are not vast enough to make a determined conclusion [19Bussaneli DG, Restrepo M, Boldieri T, et al. Assessment of a new infrared laser transillumination technology (808 nm) for the detection of occlusal caries-an in vitro study. Lasers Med Sci 2015; 30(7): 1873-9.
[http://dx.doi.org/10.1007/s10103-014-1704-3] [PMID: 25549960]
].

Re-mineralization and Caries Removal

Dental caries can be installed by laser irradiation due to its effect on chemical, physical and crystalline properties of the enamel. Enamel remineralization can be induced by laser irradiation at a specific wavelength. Laser irradiation might reinforce the enamel structure by causing physical fusion of the surface and reducing enamel solubility by melting, sealing and re-crystallization [7Subramaniam P, Pandey A. Effect of erbium, chromium: yttrium, scandium, gallium, garnet laser and casein phosphopeptide-amorphous calcium phosphate on surface micro-hardness of primary tooth enamel. Eur J Dent 2014; 8(3): 402-6.
[http://dx.doi.org/10.4103/1305-7456.137656] [PMID: 25202223]
]. Ultra-structural alterations in the enamel crystals might end in reduced enamel solubility. These noticeable enamel alterations are: reduction of water and carbonate content, increased amount of hydroxyl ion contents, formation of pyrophosphates, and decomposition of proteins [20Martínez-Insua A, Da Silva Dominguez L, Rivera FG, Santana-Penín UA. Differences in bonding to acid-etched or Er:YAG-laser-treated enamel and dentin surfaces. J Prosthet Dent 2000; 84(3): 280-8.
[http://dx.doi.org/10.1067/mpr.2000.108600] [PMID: 11005900]
]. Esteves-Oliveira et al. stated that CO2 laser was capable to eliminate the enamel caries progression [21Esteves-Oliveira M, Pasaporti C, Heussen N, Eduardo CP, Lampert F, Apel C. Prevention of toothbrushing abrasion of acid-softened enamel by CO2 laser irradiation. J Dent 2011; 39(9): 604-11.
[http://dx.doi.org/10.1016/j.jdent.2011.06.007] [PMID: 21741428]
]. Also, it is reported that Pulsed CO2 laser irradiation caused enamel surface fusion and inhibition of the subsurface caries-like lesions with 50% success rate [22Mohan AG, Ebenezar AV, Ghani MF, Martina L, Narayanan A, Mony B. Surface and mineral changes of enamel with different remineralizing agents in conjunction with carbon-dioxide laser. Eur J Dent 2014; 8(1): 118-23.
[http://dx.doi.org/10.4103/1305-7456.126264] [PMID: 24966758]
]. Moreover, increased micro-hardness of enamel surface was detected by several studies after laser application [7Subramaniam P, Pandey A. Effect of erbium, chromium: yttrium, scandium, gallium, garnet laser and casein phosphopeptide-amorphous calcium phosphate on surface micro-hardness of primary tooth enamel. Eur J Dent 2014; 8(3): 402-6.
[http://dx.doi.org/10.4103/1305-7456.137656] [PMID: 25202223]
, 23Fornaini C, Brulat N, Milia G, Rockl A, Rocca JP. The use of sub-ablative Er:YAG laser irradiation in prevention of dental caries during orthodontic treatment. Laser Ther 2014; 23(3): 173-81.
[http://dx.doi.org/10.5978/islsm.14-OR-13] [PMID: 25368443]
].

Laser removes selectively the carious lesions because they contain higher amounts of water than sound dentinal tissue. Laser can produce three sets of absorption bands in dentine, however the 6 μm absorption band attributes to the dominant organic materials of carious structure. More specifically, 5.8 μm of wavelength can positively remove the carious tissue with minimal damage to healthy dentine [24Kita T, Ishii K, Yoshikawa K, Yasuo K, Yamamoto K, Awazu K. In vitro study on selective removal of bovine demineralized dentin using nanosecond pulsed laser at wavelengths around 5.8 μm for realizing less invasive treatment of dental caries. Lasers Med Sci 2015; 30(3): 961-7.
[http://dx.doi.org/10.1007/s10103-013-1517-9] [PMID: 24395343]
]. Whereas, the Er:YAG and Er,Cr:YSGG lasers operate at 2.94 and 2.79 μm [25Radatti DA, Baumgartner JC, Marshall JG. A comparison of the efficacy of Er,Cr:YSGG laser and rotary instrumention in root canal debridement. J Am Dent Assoc 2006; 137(9): 1261-6.
[http://dx.doi.org/10.14219/jada.archive.2006.0384] [PMID: 16946431]
], and pulsed CO2 laser prepares high-speed and precise ablation of dental caries at wavelengths of 9.6 and 9.3 μm [26Nguyen D, Chang K, Hedayatollahnajafi S, et al. High-speed scanning ablation of dental hard tissues with a λ = 9.3 μm CO2 laser: adhesion, mechanical strength, heat accumulation, and peripheral thermal damage. J Biomed Opt 2011; 16(7): 071410.
[http://dx.doi.org/10.1117/1.3603996] [PMID: 21806256]
]. Short pulses and high dentinal absorption reduce the over heat and thermal damage of the pulp tissue. Ishii et al. tried out a nano second pulsed laser at wavelength of 5.85 μm for selective caries removal. Their results manifested minimal damage to sound dentin and successive removal of less Ca content substrates, like carious structure [27Ishii K, Kita T, Yoshikawa K, Yasuo K, Yamamoto K, Awazu K. Selective removal of carious human dentin using a nanosecond pulsed laser operating at a wavelength of 5.85 μm. J Biomed Opt 2015; 20(5): 051023.
[http://dx.doi.org/10.1117/1.JBO.20.5.051023] [PMID: 25594772]
].

The ideal cavity preparation relies on removing the affected dentin without sacrificing some healthy or at least potentially remineralizable tissues [28Toro CV, Derceli JdosR, Faraoni-Romano JJ, Marchi P, Pécora JD, Palma-Dibb RG. The use of an Er:YAG laser to remove demineralized dentin and its influence on dentin permeability. Microsc Res Tech 2013; 76(3): 225-30.
[http://dx.doi.org/10.1002/jemt.22156] [PMID: 23174887]
]. However, literature disputes about the mentioned fact for the Er:YAG. Raucci-Neto et al. reported that Er:YAG laser remained demineralized dentine with a network of ultra-structural collagen matrix [29Raucci-Neto W, Chinelatti MA, Ito IY, Pécora JD, Palma-Dibb RG. Influence of Er:YAG laser frequency on dentin caries removal capacity. Microsc Res Tech 2011; 74(3): 281-6.
[http://dx.doi.org/10.1002/jemt.20902] [PMID: 20623778]
]. Whereas, another study [30Neves AdeA, Coutinho E, De Munck J, Van Meerbeek B. Caries-removal effectiveness and minimal-invasiveness potential of caries-excavation techniques: a micro-CT investigation. J Dent 2011; 39(2): 154-62.
[http://dx.doi.org/10.1016/j.jdent.2010.11.006] [PMID: 21111770]
] has claimed that Er:YAG laser removes carious tissues non-selectively in which high volume of residual caries is remained in some specimens, and tissues are removed excessively in some others. Different irradiation parameters, specially the frequency, have remarkable effects on the quality of caries removal. For instance, higher frequencies reduce the selectivity removal of the demineralized dentin tissues [29Raucci-Neto W, Chinelatti MA, Ito IY, Pécora JD, Palma-Dibb RG. Influence of Er:YAG laser frequency on dentin caries removal capacity. Microsc Res Tech 2011; 74(3): 281-6.
[http://dx.doi.org/10.1002/jemt.20902] [PMID: 20623778]
].

Restorative Qualities after Laser Irradiation

The Er:YAG laser tends to leave dentinal tubules open with minor smear layer production during cavity preparation. Hence, higher dentin permeability could be achieved by laser rather than the rotary device or the manual excavation [31Baraba A, Miletic I, Krmek SJ, Perhavec T, Bozic Z, Anic I. Ablative potential of the erbium-doped yttrium aluminium garnet laser and conventional handpieces: a comparative study. Photomed Laser Surg 2009; 27(6): 921-7.
[http://dx.doi.org/10.1089/pho.2008.2416] [PMID: 19731997]
, 32Chinelatti MA, Raucci-Neto W, Corona SA, Palma-Dibb RG. Effect of erbium:yttrium-aluminum-garnet laser energies on superficial and deep dentin microhardness. Lasers Med Sci 2010; 25(3): 317-24.
[http://dx.doi.org/10.1007/s10103-008-0618-3] [PMID: 18982403]
]. The Er:YAG laser makes dentinal water evaporates. Also, it causes some structural changes in composition of collagen (incorporation of an OH radical) [33Bachmann L, Diebolder R, Hibst R, Zezell DM. Changes in chemical composition and collagen structure of dentine tissue after erbium laser irradiation. Spectrochim Acta A Mol Biomol Spectrosc 2005; 61(11-12): 2634-9.
[http://dx.doi.org/10.1016/j.saa.2004.09.026] [PMID: 16043057]
, 34Ferreira LS, Apel C, Francci C, Simoes A, Eduardo CP, Gutknecht N. Influence of etching time on bond strength in dentin irradiated with erbium lasers. Lasers Med Sci 2010; 25(6): 849-54.
[http://dx.doi.org/10.1007/s10103-009-0715-y] [PMID: 19655225]
], which may in turn promote the increased dentin permeability.

Some experiments are focused on the marginal leakage and bonding strength of composite resins to prepare dentin by laser irradiation. Korkmaz Y et al. studied the marginal leakage of different adhesive systems in cavities prepared by Er:YAG laser. Their results reflected higher microleakage in cervical margins specially in cementum and dentin [35Korkmaz Y, Ozel E, Attar N, Bicer CO, Firatli E. Microleakage and scanning electron microscopy evaluation of all-in-one self-etch adhesives and their respective nanocomposites prepared by erbium:yttrium-aluminum-garnet laser and bur. Lasers Med Sci 2010; 25(4): 493-502.
[http://dx.doi.org/10.1007/s10103-009-0672-5] [PMID: 19396579]
] which might be related to the technique sensitivity of bonding systems and the quality of formed hybrid layer in that regions [10Ceballos L, Osorio R, Toledano M, Marshall GW. Microleakage of composite restorations after acid or Er-YAG laser cavity treatments. Dent Mater 2001; 17(4): 340-6.
[http://dx.doi.org/10.1016/S0109-5641(00)00092-0] [PMID: 11356211]
]. Kimyai et al., surveyed the microleakage of three different adhesive systems in class V cavities prepared by Er,Cr:YSGG laser. They found higher microleakage of gingival margins rather than occlusal margins, specifically in self-etched adhesive system rather than etch and rinse two step (total etch) [36Kimyai S, Ajami AA, Chaharom ME, Oskoee JS. Comparison of microleakage of three adhesive systems in class V composite restorations prepared with Er,Cr:YSGG laser. Photomed Laser Surg 2010; 28(4): 505-10.
[http://dx.doi.org/10.1089/pho.2009.2562] [PMID: 20001320]
]. In contrast, Baghalian et al. conducted a study to compare the microleakage of restored class V cavities prepared by Er:YAG laser and conventional burs. They claimed that preparation by Er:YAG laser demonstrated a better marginal seal on occlusal and gingival margins [37Baghalian A, Nakhjavani YB, Hooshmand T, Motahhary P, Bahramian H. Microleakage of Er:YAG laser and dental bur prepared cavities in primary teeth restored with different adhesive restorative materials. Lasers Med Sci 2013; 28(6): 1453-60.
[http://dx.doi.org/10.1007/s10103-012-1222-0] [PMID: 23135785]
]. Another study confirmed mentioned results, too [38Yaman BC, Efes BG, Dörter C, Gömeç Y, Erdilek D, Yazıcıoğlu O. Microleakage of repaired class V silorane and nano-hybrid composite restorations after preparation with erbium:yttrium-aluminum-garnet laser and diamond bur. Lasers Med Sci 2011; 26(2): 163-70.
[http://dx.doi.org/10.1007/s10103-010-0755-3] [PMID: 20162317]
]. It has been noticed that the degree of microleakage might be affected by several factors such as the type of adhesive systems, the type of self-etching adhesive, the cavity margin location, and the technique of preparation [37Baghalian A, Nakhjavani YB, Hooshmand T, Motahhary P, Bahramian H. Microleakage of Er:YAG laser and dental bur prepared cavities in primary teeth restored with different adhesive restorative materials. Lasers Med Sci 2013; 28(6): 1453-60.
[http://dx.doi.org/10.1007/s10103-012-1222-0] [PMID: 23135785]
]. Also, higher microleakage of cervical margins might be due to the lack of dentinal tubules in the first 100 nm of cervical margins and higher organic content of the dentine [39Cagidiaco MC, Ferrari M, Vichi A, Davidson CL. Mapping of tubule and intertubule surface areas available for bonding in Class V and Class II preparations. J Dent 1997; 25(5): 379-89.
[http://dx.doi.org/10.1016/S0300-5712(96)00060-7] [PMID: 9241956]
].

Bond strength of composite resin is another concerning issue in released literature [40Parhami P, Pourhashemi SJ, Ghandehari M, Mighani G, Chiniforush N. Comparative study of the shear bond strength of flowable composite in permanent teeth treated with conventional bur and contact or non-contact er:YAG laser. J Lasers Med Sci 2014; 5(3): 140-5.
[PMID: 25653813]
-44Altunsoy M, Botsali MS, Sari T, Onat H. Effect of different surface treatments on the microtensile bond strength of two self-adhesive flowable composites. Lasers Med Sci 2015; 30(6): 1667-73.
[http://dx.doi.org/10.1007/s10103-014-1640-2] [PMID: 25118664]
]. Some studies experienced “laser etching effect” by irradiating laser to prepare sufficient surface roughness and permitting mechanical interlocking with adhesive resins [22Mohan AG, Ebenezar AV, Ghani MF, Martina L, Narayanan A, Mony B. Surface and mineral changes of enamel with different remineralizing agents in conjunction with carbon-dioxide laser. Eur J Dent 2014; 8(1): 118-23.
[http://dx.doi.org/10.4103/1305-7456.126264] [PMID: 24966758]
, 45Dunn WJ, Davis JT, Bush AC. Shear bond strength and SEM evaluation of composite bonded to Er:YAG laser-prepared dentin and enamel. Dent Mater 2005; 21(7): 616-24.
[http://dx.doi.org/10.1016/j.dental.2004.11.003] [PMID: 15978270]
]. However, for two or three step etch-and-rinse adhesives, phosphoric acid etching has been suggested prior to the application of mentioned adhesive systems to enhance higher bond strength [46Trajtenberg CP, Pereira PN, Powers JM. Resin bond strength and micromorphology of human teeth prepared with an Erbium:YAG laser. Am J Dent 2004; 17(5): 331-6.
[PMID: 15575443]
].

Parhami et al. compared the effect of Er:YAG laser and high speed diamond burs on the shear bond strength of flowable composite to enamel. The final conclusion was that the Er:YAG laser preparation reduced shear bond strength of tested composite resin compared to the conventional cavity preparation [40Parhami P, Pourhashemi SJ, Ghandehari M, Mighani G, Chiniforush N. Comparative study of the shear bond strength of flowable composite in permanent teeth treated with conventional bur and contact or non-contact er:YAG laser. J Lasers Med Sci 2014; 5(3): 140-5.
[PMID: 25653813]
]. Shirani et al reported negative effects of Er:YAG laser irradiation on shear bond strength of composite resins, either [42Shirani F, Birang R, Malekipour MR, Hourmehr Z, Kazemi S. Shear bond strength of resin composite bonded with two adhesives: Influence of Er: YAG laser irradiation distance. Dent Res J (Isfahan) 2014; 11(6): 689-94.
[PMID: 25540665]
]. In contrast, Altunsoy et al. evaluated the effect of different modes Er:YAG laser on the micro tensile bond strength of two different self-etch adhesive systems and flowable composite resins to dentin. Their final results indicated that pulse mode laser irradiation increased the micro tensile bond strength of both adhesive systems and flowable composite resins [44Altunsoy M, Botsali MS, Sari T, Onat H. Effect of different surface treatments on the microtensile bond strength of two self-adhesive flowable composites. Lasers Med Sci 2015; 30(6): 1667-73.
[http://dx.doi.org/10.1007/s10103-014-1640-2] [PMID: 25118664]
]. Moreover, other researches notified the improved bond strength of composite resins after laser irradiation [47Marimoto AK, Cunha LA, Yui KC, et al. Influence of Nd:YAG laser on the bond strength of self-etching and conventional adhesive systems to dental hard tissues. Oper Dent 2013; 38(4): 447-55.
[http://dx.doi.org/10.2341/11-383-L] [PMID: 23215546]
-49Esteves-Oliveira M, Zezell DM, Apel C, et al. Bond strength of self-etching primer to bur cut, Er,Cr:YSGG, and Er:YAG lased dental surfaces. Photomed Laser Surg 2007; 25(5): 373-80.
[http://dx.doi.org/10.1089/pho.2007.2044] [PMID: 17975950]
]. Both peri- and intertubular dentine would be demineralized during acid etching and collagen exposure. This procedure needs enough surface moisture after etchant removal, otherwise hybrid layer formation would decrease because of the collapse of collagen fibers [50Shahabi S, Chiniforush N, Bahramian H, Monzavi A, Baghalian A, Kharazifard MJ. The effect of erbium family laser on tensile bond strength of composite to dentin in comparison with conventional method. Lasers Med Sci 2013; 28(1): 139-42.
[http://dx.doi.org/10.1007/s10103-012-1086-3] [PMID: 22491942]
]. On one hand, the Er:YAG laser does not demineralize dentin surface and no collagen will be exposed [10Ceballos L, Osorio R, Toledano M, Marshall GW. Microleakage of composite restorations after acid or Er-YAG laser cavity treatments. Dent Mater 2001; 17(4): 340-6.
[http://dx.doi.org/10.1016/S0109-5641(00)00092-0] [PMID: 11356211]
], in the other hand, remaining peri tubular dentin after irradiation might be helpful to obtain stronger adhesion to the dentin due to its more mineral content in comparison with inter tubular dentine [51Visuri SR, Gilbert JL, Wright DD, Wigdor HA, Walsh JT Jr. Shear strength of composite bonded to Er:YAG laser-prepared dentin. J Dent Res 1996; 75(1): 599-605.
[http://dx.doi.org/10.1177/00220345960750011401] [PMID: 8655766]
].

Vital Pulp Therapy

Application of laser instruments was studied on vital pulp therapy and pulpotomy of primary teeth. Low intensity lasers can be indicated for vital pulp therapy with the success rate up to 90% in comparison with traditional methods [52Olivi G, Genovese MD. Erbium chromium laser in pulp capping treatment. J Oral Laser Appl 2006; 6(4): 291-9.]. The advantage of laser therapy is based on its bactericidal activity, hemostatic activity, reduction in elevated pulp temperature, reducing inflammation, stimulating dentinogenesis [53Gonzalez CD, Zakariasen KL, Dederich DN, Pruhs RJ. Potential preventive and therapeutic hard-tissue applications of CO2, Nd:YAG and argon lasers in dentistry: a review. ASDC J Dent Child 1996; 63(3): 196-207.
[PMID: 8853824]
, 54Odabaş ME, Bodur H, Bariş E, Demir C. Clinical, radiographic, and histopathologic evaluation of Nd:YAG laser pulpotomy on human primary teeth. J Endod 2007; 33(4): 415-21.
[http://dx.doi.org/10.1016/j.joen.2006.12.013] [PMID: 17368330]
], healing improvement by enhancing collagenic protein, formation of a fibrous matrix, and inducing hard tissue barriers [54Odabaş ME, Bodur H, Bariş E, Demir C. Clinical, radiographic, and histopathologic evaluation of Nd:YAG laser pulpotomy on human primary teeth. J Endod 2007; 33(4): 415-21.
[http://dx.doi.org/10.1016/j.joen.2006.12.013] [PMID: 17368330]
-56AlGhamdi KM, Kumar A, Moussa NA. Low-level laser therapy: a useful technique for enhancing the proliferation of various cultured cells. Lasers Med Sci 2012; 27(1): 237-49.
[http://dx.doi.org/10.1007/s10103-011-0885-2] [PMID: 21274733]
]. In an animal study by Handa et al. [57Handa K, Koike T, Hayashi K, Saito T. Application of high-frequency radio waves to direct pulp capping. J Endod 2013; 39(9): 1147-50.
[http://dx.doi.org/10.1016/j.joen.2013.06.007] [PMID: 23953288]
], three different strategies for Direct Pulp Capping were evaluated. They concluded that there was no significant difference among utilization of Er:YAG laser + MTA, Er:YAG laser + Ca(OH)2, and MTA. However, Er:YAG + MTA had better results. Based on this study, Er:YAG laser could be useful in combination with two common Direct Pulp Capping materials.

In some animal study the effect of lasers on the pulpotomy process was evaluated. An investigation by Shoji et al. [58Shoji S, Nakamura M, Horiuchi H. Histopathological changes in dental pulps irradiated by CO2 laser: a preliminary report on laser pulpotomy. J Endod 1985; 11(9): 379-84.
[http://dx.doi.org/10.1016/S0099-2399(85)80024-8] [PMID: 3934314]
], showed that the CO2 laser led to no detectable damages to the dogs’ dental pulp. In some human studies, laser application in comparison or with incorporation of some common methods was evaluated. In a study by Elliott et al. [59Elliott RD, Roberts MW, Burkes J, Phillips C. Evaluation of the carbon dioxide laser on vital human primary pulp tissue. Pediatr Dent 1999; 21(6): 327-31.
[PMID: 10509333]
], the CO2 laser had comparable response than formocresol in human primary teeth. In another study, the clinical success rate of palpotomy was compared between the Nd:YAG laser and formocresol. The results revealed that the Nd:YAG laser had significantly higher success rate than formocresol [60Liu JF. Effects of Nd:YAG laser pulpotomy on human primary molars. J Endod 2006; 32(5): 404-7.
[http://dx.doi.org/10.1016/j.joen.2006.01.005] [PMID: 16631836]
].

CONCLUSION

Lasers can be applied for remineralization and caries removing processes. They have some favorable effects on damaged pulp with controlled heat and wavelength. However, some adverse and controversial effects on quality of bonded restorations have limited their common usage in restorative dentistry. This technology needs to find its niche in dental practice by clinical and controlled research.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

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[http://dx.doi.org/10.1089/pho.2007.2044] [PMID: 17975950]
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[http://dx.doi.org/10.1007/s10103-012-1086-3] [PMID: 22491942]
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[http://dx.doi.org/10.1177/00220345960750011401] [PMID: 8655766]
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[PMID: 8853824]
[54] Odabaş ME, Bodur H, Bariş E, Demir C. Clinical, radiographic, and histopathologic evaluation of Nd:YAG laser pulpotomy on human primary teeth. J Endod 2007; 33(4): 415-21.
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