Download Evidence-based dentistry on laser paediatric dentistry

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Evidence-based dentistry on laser
paediatric dentistry: review and outlook
G. OLIVI*, M.D. GENOVESE**, C. CAPRIOGLIO***
ABSTRACT. Aim The goal of paediatric dentistry is to provide preventive education to parents and patients as well
as interception and therapy of dental diseases in a minimally invasive way using a stress-free approach. Different
laser wavelengths are used for different applications following these minimally invasive concepts: argon, KTP,
diode, Nd:YAG, and CO2 lasers are used for soft tissue applications and the erbium family is used for both soft
and hard tissue procedures. This paper offers a revision and a discussion of the international literature, showing
also some clinical procedures. related to these scientific studies. Soft tissues laser applications in Pediatric
Dentistry include application in oral surgery as well as in periodontics and orthodontics. Laser applications on
hard tissues include caries prevention and detection and application for sealing of pits and fissures. Also
application for cavity preparation, carious removal and pulp therapy are discussed.
KEYWORDS: Paediatric dentistry; Laser surgery; Frenectomy; Gingivectomy; Impacted tooth; Caries prevention;
Caries diagnosis; Dental caries preparation; Dental trauma.
Introduction
The goal of paediatric dentistry is to educate both
children and parents about prevention in order to
reduce dental pathologies in early and late childhood
as well as in adolescence. The common objective is
tissue preservation (preferably by preventing disease
and intercepting its progress), this means performing
treatment with as little tissue loss as possible. With the
new techniques available (digital radiology with low
radiation emission, diagnostic laser and the dental
operative microscope) we can aim for both an early
diagnosis and a minimally invasive therapy (ozone
therapy, air abrasion, rotary instruments for micropreparation and the laser). As reported by Martens and
underlined by Gutknecht [Martens, 2003; Gutknecht
et al., 2005] «children are the first in line to receive
dental laser treatment» and based on the micro
dentistry motto filling without drilling, we agree with
the philosophy that laser-supported dental diagnosis
and treatment is crucial for treating children
successfully according to the latest research in
dentistry.
This paper will present a review of the international
*Private Practice, Rome.
Department of Biophysical, Medical, and Dental Sciences and Technologies,
University of Genoa, Italy
**Private Practice, Rome, Italy
***Private Practice, Pavia. Visiting Professor University of Parma, Italy
E-mail: [email protected]
EUROPEAN JOURNAL OF PAEDIATRIC
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literature that provides scientific evidence (EBD) on
the use of laser and its various possible applications in
paediatric dentistry, and will attempt a discussion and
a correct interpretation of the different results
reported. A selection of clinical cases will document
the clinical applications related to these scientific
studies.
Laser applications in paediatric
dentistry
Laser in paediatric dentistry is an alternative
instrument that sometimes complements, and other
times substitutes, traditional techniques: various
applications are possible on both soft and hard tissues
using different laser wavelengths (Tables 1, 2; Fig. 1).
Leaving the discussion on the physical basis of laser
therapy to other works and publications, it should
however be remembered that different wavelengths do
not have a similar interaction with the different
chromophores (haemoglobin, water, hydroxyapatite)
contained in the target tissue (mucosa, gingiva, dental
tissue) and therefore the therapy is influenced by the
different optical affinity and absorption coefficients of
the tissues for each particular wavelength.
Soft tissue applications
Laser application in oral surgery
The use of laser for the removal of oral diseases and
the therapy of lesions of the oral mucosa has specific
applications in the field of paediatric dentistry.
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OLIVI G., GENOVESE M.D. AND CAPRIOGLIO C.
Soft tissues
KTP 532
- Argon
- Diode 810,940,980
- Nd:YAG 1064
-
- CO2 10600
Hard and soft tissues
Er,Cr:YSGG 2780
Er:YAG 2940
Low level laser
Elium Neon 635
Diode 810
FIG. 1 - Laser absorption in tissues.
TABLE 1 - Laser classification.
Soft tissues
Hard tissues
Dental Traumatology
Low level laser
Oral surgery
Caries prevention/detection
Dental injuries
Biostimulation and pain control
Periodontics
Sealing of pits and fissures
Soft tissue injuries
Orthodontics
Cavity preparation, caries removal
Endodontics
TABLE 2 - Laser applications in paediatric dentistry.
All the laser wavelengths with optical affinity for
haemoglobin and water (chromophores contained in
the gingiva and mucosa) can be used for these
applications: argon, KTP, diode, Nd:YAG and CO2
lasers are useful for cutting, vaporisation and
decontamination of the soft tissue, performing a very
good coagulation and haemostasis, and are ideal for
vascular lesions [Baggett et al., 1999; Barak et al.,
1991]; Er,Cr:YSGG and Er:YAG lasers are also
effective for these applications due to the good
absorption by the water content of gingiva and
mucosa, but with less bleeding control.
The use of an air-water jet delivered through the
handpiece of the erbium laser allows a clean incision
and vaporisation of the soft tissues with limited rise in
the temperature, and the absence of peripheral
necrotic tissue allows the performance of very
accurate biopsies [Boj et al., 2007; Olivi et al., 2007].
Many authors agree with the advantages of laser
application on soft tissues: quick and easy to use, less
use of local anaesthesia, excellent control of bleeding
during incision, sutureless technique, post-operative
recovery often asymptomatic due to the
decontaminating effects, and antalgic and
biostimulant effects.
Moreover, the excellent clinical results improve the
patient acceptance of the therapy and facilitate the
operator’s intervention, which at times can be very
complicated when using traditional techniques [Boj et
al., 2005; Genovese and Olivi, 2008]. Furthermore
the need for analgesics and anti-inflammatory
medications is drastically reduced compared to
conventional procedures.
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Table 3 lists the treatable conditions as reported by
various authors.
Laser application in periodontics
and orthodontics
The decontaminating effect of different lasers in the
pockets of patients with periodontal disease has been
widely documented in adults, but there is little
documentation of laser-assisted therapy of
periodontitis in young patients. Instead there are
many clinical situations that require intervention on
soft tissue before, during and after the orthodontic
treatment, and the laser can be used in the procedures
reported in Table 4. These procedures, needed for the
orthodontic treatment or its completion, become
extremely simple, safe and rapid, and can be
perfomed by the orthodontic specialist himself.
Herpes labialis
Aphtosis
Haemangioma
Fibroma
Papilloma
Epulis
Piogenic granuloma
Mucocele
Eruption cyst
Dentigerous cyst
Foreign body
TABLE 3 - Conditions that can be treated with laser.
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Frenectomy
Gingivectomy
Gingivoplasty
Opercolectomy
Laser enamel etching
Biostimulation and pain relief during orthodontic movement
TABLE 4 - Procedures that can be performed using a laser.
Different wavelengths can be used in these
procedures, employing different techniques,
according to the different laser-tissue interaction
[Kravitz and Kusnoto, 2008]. Among the most
effective laser applications in orthodontics, and the
most widely performed and documented are
frenectomies: several authors reported less postoperative pain, discomfort and fewer functional
complications (speaking and chewing) compared to
the traditional techniques, where diode, Nd:YAG,
Er:YAG, Er,Cr:YSGG and CO2 lasers were used,
resulting in a better perception of the therapy by the
patient [Haytac and Ozcelik, 2006; Kara, 2008].
Labial upper and lower frenectomies can be
performed: the laser is extremely simple and effective
even in newborns, in cases of severe ankiloglossia or
tight maxillary frenum that make breastfeeding
difficult [Kotlow, 2004].
Gingivectomy, gingivoplasty, and opercolectomy
can be easily performed without anaesthesia with all
wavelengths, and brackets can be immediately
attached [Sarver and Yanosky, 2005; Fornaini et al.,
2007].
Other authors have reported positive results with the
application of LLLT to speed teeth’s orthodontic
movement, stimulating the modulation of the initial
inflammatory response, thus obtaining the results in a
shorter period [Cruz et al., 2004; Youssef et al., 2008;
Pretel et al., 2007], while other studies reported the
CO2 laser local effect in reducing pain associated with
orthodontic force application, without interfering
with the tooth’s movement [Fujiyama, 2008].
Clinical implication
Laser is an alternative, valuable technique for soft
tissue applications. Lesions of oral mucosa as well as
soft tissue orthodontic problems are effectively
treated with laser. The treatment of paediatric patients
requires the application of the minimal effective
power for these procedures (Fig. 2, 3, 4).
FIG. 2 - Female, 6 years old; lingual grenectomy: diode
810nm laser; parameters used: 1.0 to 1.5W c.w. topic
anaesthesia.
FIG. 3 - Female, 13 years old; impacted maxillary cuspid: Erbium:YAG laser vaporization of the mucosa, no bleeding
(parameters used: 10pps-75mJ-0.75W- water spray- no anhestesia); laser conditioning of the exposed enamel
(parameters used: 20pps-75mJ-1.5W).
FIG. 4 - Female, 14 years old; orthodontic therapy: Erbium:YAG laser gingivectomy for early bonding of the bracket,
absolutely no bleeding (parameters used: 10 to 20pps-75mJ-0.75-1.5W- water spray- no anaesthesia).
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Hard tissue applications
Laser application for caries prevention
The in vitro studies to verify the possibility of an
increase of acid resistance and of micro-hardness of
the enamel surface following laser radiation started at
the end of the 1980s.
As of today, several studies on these applications
have been done with more or less uniform results but
the clinical evidence is extremely limited.
The studies of this application fall into two broad
categories based on the use of different laser
wavelengths: Argon laser at 488-514 nm and CO2
laser at 9300, 9600, 10600 nm. Also the erbium laser
2780 and 2940 nm was investigated in modifying the
physical-chemical characteristics of the enamel
surface: the results of these studies were assessed by
testing cross-sectional micro-hardness and enamel
solubility.
In 1995 Flaitz et al. reported that Argon laser
irradiation combined with acidulated phosphate
fluoride treatment (APF) resulted in a decrease of
lesion depth by more than 50% compared with
control lesions, and by 26% to 32% when compared
with lased-only lesions.
In 1999 other authors reported a significant
reduction of white spotting or etching, using a zinc
fluoride and Argon laser combination. It seems that
this treatment stabilises the hydroxyapatite crystals
and restores its structural defects.
The possibility of providing a protective barrier
against a cariogenic attack in primary teeth using
Argon laser irradiation combined with APF was
investigated; the surface coatings associated with this
treatment may contain fluoride-rich calcium and
phosphate mineral phases that could act as reservoirs
for fluoride, calcium, and phosphate, thus providing
a certain degree of protection from caries.
Another study reported that the micro-hardness of
the enamel surface was higher when exposed to low
Argon laser irradiation only or Argon laser
irradiation combined with APF vs. no treatment
(control) [Westerman et al., 2003].
The other line of research dates 1998, when
Featherstone et al. reported 70% inhibition of caries
progression by using 9.300 nm and 9.600 nm laser
(fluence from 1 to 3 J/cm2), comparable with the
inhibition produced by the daily use of fluoride
toothpaste. The subsurface temperature increase was
minimal (<1°C at 2 mm depth), and another study
reported no thermal damage to the pulp. Also the
latest study confirmed that the CO2 laser was efficient
in reducing the subsurface enamel demineralisation
and that its association with a high-frequency
fluoride treatment may enhance this protective effect
[Steiner-Oliveira et al., 2008].
A more recent research reported that the erbium
laser wavelengths also apparently have the potential
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to increase acid resistance: subablative erbium
energies can reduce enamel solubility increasing
caries resistance without severe alterations of the
enamel, but without reaching statistical significance
[Apel et al., 2004].
Clinical implications
Subablative CO2 laser irradiation of young healthy
teeth could be an effective method for caries
prevention; long term clinical studies are needed to
validate this application. Further studies are also
needed to evaluate the erbium family’s ability to
increase the acid resistance of permanent teeth.
Laser for carious detection
This is the application most frequently and
extensively investigated in paediatric dentistry. Of
the 79 papers indexed under Laser Paediatric
Dentistry in the PubMed as of July 31, 2008, 31
studied the use of this device for carious detection.
This non-ablative laser emits fluorescence light,
visible in the red spectrum at 655 nm (LF), which
proved useful as an additional method for occlusal
caries detection.
Several studies compared different caries detection
methods: visual inspection alone, visual inspection
with magnification, bite-wing x-ray and laser
fluorescence. Lussi et al., in 2003 stated that LF
could be used as an additional tool in the detection of
occlusal caries in deciduous teeth and its good
reproducibility should enable monitoring of the
carious process over time.
Burin et al. [2005], Mendes et al. [2006], and
Barberia et al. [2008] considered the fluorescence
device better than bite-wing x-ray for occlusal caries
detection.
Other authors reported that the reliability and the
diagnostic validity (sum of sensitivity and
specificity) of LF are very high, and also higher than
bite-wing radiography for proximal caries detection
in primary teeth. Also caries detection of proximal
tooth surfaces might be influenced by the condition
of the adjacent tooth [Lussi et al., 2006]. Some
studies investigated the impact of the operator on the
results and concluded that the reliability,
predictability and the reproducibility of the results
did not depend on the operator factor [Bengtson et
al., 2005].
Other studies reported that LF methods for occlusal
caries detection are more efficient in deciduous than
in permanent teeth, but concluded that LF was not
able either to detect in vitro remineralisation of
natural incipient caries lesions of primary teeth nor to
monitor the mineral loss in caries lesions
development in primary teeth [Mendes et al., 2003].
A recent study [Braga et al., 2008] reported that the
LF performs better at the dentin threshold than at the
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enamel threshold; they therefore concluded that this
method does not perform well in detecting initial
enamel caries lesions, confirming what found in
previous studies that demonstrated a good
performance of LF in predicting the extension of the
caries lesions.
The LF presents a better correlation with the lesion
depth than with mineral loss in smooth-surface caries
lesions and the assessment of mineral loss was
unreliable. Several studies investigated particular
situations that could affect the results: the presence of
brown or dark spots on fissures tended to overscore
discolored surfaces, while the presence of plaque
worsened the performance of the LF method. Also
the presence of toothpaste residual after teeth
cleansing can modify the detection with false
readings. Caries detection under dental sealants was
unreliable and not recommended due to a high
likelihood of inaccurate readings caused by the
intrinsic fluorescence of sealant material.
Clinical implications
In daily practice, dentists can consider the LF
system a reliable complementary tool for the visual
inspection of occlusal surfaces, both in primary
molars and permanent first molars.
New device tips also enable the detection of
proximal lesions.
Laser application for sealing of pits and fissures
The use of laser for pre-treatment of pits and
fissures, before application of sealant on the occlusal
surface of young teeth, was investigated.
Several in vitro studies were performed to evaluate
the bond strength and the microleakage of pit and
fissure sealants, comparing invasive techniques and
laser irradiation, with or without acid etching. Most
of these studies reported no significant difference
between the two types of enamel preparation when
etching was performed.
In fact, preparing and treating the enamel surface
exclusively by means of Er:YAG laser resulted in the
highest degree of leakage [Youssef et al., 2006; LupiPégurier et al., 2007].
On the contary, Moshonov et al. [2005] found no
difference in microleakage between laser and acid
etching, suggesting that the technique may be
effective.
Also the pre-treatment with Er,Cr:YSGG laser had
no influence on the resistance to microleakage of
bonded fissure sealants in primary teeth [Cehreli et
al., 2006].
A study by Francescut and Lussi [2006] reported
important considerations about the energy applied for
this application: they concluded that mechanical
preparation prior to fissure sealing did not enhance
the final performance of the sealant, reporting that
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laser at 600 mJ and bur removed most of the hard
tissue.
Clinical implications
Laser irradiation did not eliminate the need for acid
etching prior to fissure sealant placement. Laser
irradiation may be considered an additional tool in
the sealant application procedure, for the overall
cleansing and disinfecting effect: care must be taken
with the energy applied so as not to over-prepare pit
and fissure surfaces.
Laser application for cavity preparation and caries
removal
Different laser wavelengths were studied for cavity
preparation: the CO2 laser was investigated first, but
the results were not good, due to the thermal damage
that affected the irradiated dental tissues; other
clinical and experimental investigations showed the
therapeutic possibility of treating early childhood
caries of the enamel with Nd:YAG laser [Birardi et
al., 2004], but the micro-morphological analysis
showed collateral damage of the dental tissues.
Today two wavelengths, the Er,Cr:YSGG at 2780
nm and Er:YAG at 2940 nm are successfully used for
treating dental hard tissues.
The initial studies on the use of the erbium laser for
cavity preparation and caries removal date back to
1989, when Hibst and Keller were the first to evaluate
the cutting ability of the Er:YAG laser on hard tissue
of human teeth.
In the first decade of research, various authors
studied the parameters and variables for using the
erbium laser, evaluating the morphological effects on
hard and pulp tissues: the effects of energy density,
pulse repetition rate, and air-water jet were reported.
Moritz et al., in 1998 studied the possibility of
etching the enamel, reporting that the results obtained
with the laser were the same as those achieved with
orthophosphoric acid.
The Authors [Olivi and Genovese, 2007] confirmed
the efficacy of the erbium laser in cavity preparation
and removal of carious tissue, researching the
optimal parameters of use.
The idea of substituting the drill with a laser
instrument which has less impact on the patient (the
laser works on hard tissue with no contact, no
vibration, no noise and less pain) has brought about
the introduction of this device in paediatric dentistry.
Various studies and clinical reports showed how the
laser, used by numerous operators as an alternative to
rotary instruments in paediatric restorative dentistry,
brings an added measure of safety even when used in
the treatment of very young children, a new
possibility for minimal interventions [Kornblit et al.,
2008], and an overall better acceptance compared to
traditional techniques [Keller at al., 1998; Liu et al.,
2006; Takamori et al., 2003].
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A study tested the laser efficacy on treating primary
teeth, comparing the performance of four different
dentin excavation methods in deciduous teeth: steel
bur, polymer bur, Er:YAG laser, and manual
excavator [Celiberti et al., 2006], evaluating different
parameters, indicating both the efficacy and the
potential for minimally invasive therapy.
The use of manual excavators seemed the most
suitable method for carious dentin removal in
deciduous teeth, combining good treatment time with
effective caries removal, while the steel bur appeared
the fastest but with the highest level of overpreparation. The laser produced intermediate results,
among the slowest but with a low level of overpreparation according to the minimally invasive
concepts (Fig. 5).
Laser and composite adhesion
The problem of the composite adhesion to lased
surfaces is still controversial..
Many authors reported how adhesion to laserablated or laser-etched dentin and enamel of
permanent teeth is lower compared to conventional
rotary preparation and acid etching. These studies
highlight the importance of energy output, avoidance
of substructural damage, the need for standards for
laser energy output in relation to the different tooth
substrates and the need of acid-etching both for
dentin and enamel even after laser conditioning
[Brulat et al., 2007; Ceballo et al., 2002; De Moor
and Delmè, 2006; Dunn et al., 2005].
Even studies on primary teeth reported how
Er:YAG laser irradiation of dentin, at 60 mJ/2Hz,
80 mJ/2Hz and 100mJ/2Hz prior to adhesive
protocol, adversely affected bond strength
[Monghini et al., 2004].
On the opposite side, other authors reported that
primary dentin treated with Er,Cr:YSGG laser at the
lower wattage of 0.5 Watt (50 mJ) did not require
etching for bonding, while as the energy level
increases, the addition of etching as part of the
conditioning provides adequate bonding [Sung et al.,
2006].
Some studies on shear bond strength to the enamel
of primary teeth reported superior results for the
Er:YAG laser group compared with the control group,
using 60 and 80 mJ, or similar results to the control
group mechanically prepared and acid-etched using
100 mJ energy [Lessa et al., 2007; Wanderley et al.,
2005].
Other studies investigated the microleakage of
cavities prepared by the laser and here again different
results were reported: some authors, using the dye
penetration method, found that the microleakage of
GIC and composite materials of laser-prepared
cavities is lower than that those prepared by burs
[Yamada et al., 2002; Quo et al., 2002].
Comparative studies on different methods of cavity
preparation, drill, air abrasion and laser, reported that
Er:YAG laser-prepared cavities at 300 mJ/4Hz and
400 mJ/4Hz showed the highest degree of infiltration
[Borsatto et al., 2006; Kohara et al., 2002], and better
composite resin marginal adaptation was obtained
when Er:YAG laser preparation was followed by a
total acid etching [Bertrand et al., 2006].
Clinical implications
Laser cavity preparation is closely related to
different variables. Fluence, power density and pulse
length, but also laser angulation, focus mode, the
FIG. 5 - Male, 7 years old; laser diagnosis and therapy: laser carious detection of the second primary molar. Laser caries
removal and tooth preparation with Er,Cr:YSGG laser (parameters used: enamel 1,5 to 4W-15 to 100pps 45%water/55%air. dentin 2,5W-20pps 35% water 40% air; laser smoothening and conditioning: 2W-50mJ-40pps 45% water/55% air; no
anhestesia; 30 sec orthophosphoric acid etching).
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amount of air-water jet are all factors that can cause
substructural damage to the dentin. A final
conditioning at low wattage both on dentin and
enamel is advisable. Acid etching on lased dentin and
enamel produces uniform results, eliminating the thin
layer of substructural damage, exposing the collagen
fibers and creating a substrate for the formation of the
hybrid layer; acid etching modifies the Silverstone
enamel class 2 and 3 into class 1, allowing better
composite adaptation.
Laser application in endodontics
The use of lasers with different wavelengths in
endodontics is well documented for adults but there
are few studies on paediatric endodontics. Lasers are
indicated for:
1. pulp capping;
2. pulpotomy;
3. root canal disinfection.
Few studies that investigate laser performance in
maintaining pulp tissue vitality are indexed in the
PubMed library. Different laser wavelengths and
parameters related to the different devices were used.
The common delineator was the low laser energy
applied (from 0.5 to 1.0 W), delivered in defocused
mode, preferably using low repetition rate or
superpulsed mode.
Santucci [1997] first reported a high success rate of
90% after 6 months, using Nd:YAG laser for
coagulation and glass ionomer cement as pulp
capping agent.
Studies from Moritz et al. in 1998 reported success
rates of 89% and 93% after 1 and 2 years compared
to 68% and 66 % of the calcium hydroxide control
group. The CO2 laser has a purely thermal effect on
the tissue; 90-95% of the energy delivered to the
tissue is absorbed by a fine tissue layer (100 µ) and
transformed into heat.
Also the erbium wavelengths are almost completely
absorbed by the water in a superficial layer and
transformed into heat; however, these lasers have less
coagulating effect. Jayawaedena et al. [2001]
demonstrated, in an animal model, good healing
capacity with the formation of a dentin bridge and
reparative dentin using 150 mJ - 10 pulses.
Olivi and Genovese in 2006 reported the
importance of the use of the Er,Cr:YSGG laser with
adjustable air-water jet as a single minimally
invasive instrument for carious removal and pulp
coagulation to avoid over-preparation and
overheating of the residual dental tissue, with tooth
survival of 80% after 4 years. The same author
compared the efficacy of two laser systems,
Er,Cr:YSGG laser and Er:YAG laser, with
conventional calcium hydroxide procedure, and
reported 80% success in the Er,Cr group, 75% in the
Er:YAG group, while the control group had 63%
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success rate at 2 years [Olivi et al., 2007].
Pulpotomy is a very common technique in primary
teeth: although pulpotomy with formocresol (1:5
dilution) is used with success, there is a tendency
today to seek alternative techniques, considering the
carcinogenic and mutagenic potential of its
formaldehyde component.
Lasers have been
proposed for pulpotomy, and a study from Pescheck
et al. [2002] compared favourably CO 2 laser
treatment to formocresol for pulpotomy in primary
teeth, with a survival rate from 91% to 98%. Other
studies reported that the superpulsed mode produced
a markedly higher success rate than the continuous
wave mode.
Elliot et al., in 1999 also found a significant inverse
correlation between the laser energy applied to the
pulp and the degree of inflammation at 28 days and a
99.4% clinical success after 4 years compared to
88.2% of the formocresol control group. Guelmann et
al., in 2002 instead reported the correlation of the
healing with the age and the apex size of the primary
teeth. The Nd:YAG laser was also used for pulpotomy
on human primary teeth, but a recent study showed a
clinical success rate of 85.71% and a radiographic
success rate 71.42% at 12 months, compared to the
formocresol group that presented a clinical and
radiographic success rate of 90.47% at 12 months
[Odabas et al., 2007].
Although there are no clinical reports on paediatric
endodontics, permanent teeth can be treated with
Nd:YAG and diode laser, for their high bactericidal
effect in root and lateral canals.
Only one study on laser used in primary teeth is
indexed in PubMed. It compared the root canal walls
cleaning and shaping effect of different procedures in
primary teeth, using Er,Cr:YSGG laser with manual
or rotary instrumentation techniques. It reported that
treatment with Er,Cr:YSGG laser provided similar
cleanliness when compared with the rotary
instrumentation technique and was superior to
manual instrumentation, while the laser technique
required less time for completion of the cleaning and
shaping procedures when compared with both rotary
or hand instrumentation [Soares et al., 2008].
Clinical implications
During this procedure, attention must be given to
the energy applied. Low energy delivered in
defocused mode and pulse or superpulsed mode
guarantees good superficial coagulation and good
decontamination to maintain the vitality of the
residual pulp in pulp capping application.
Particular care must be taken with the application
of laser energy into primary root canals for root canal
cleaning and disinfecting, due to the characteristic
anatomy of the apex and to the penetration depth of
near infrared lasers.
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Laser application in dental
traumatology
Dental traumas are frequent in children. They can
be complex events, and at times real emergencies in
which laser-assisted therapy can offer new treatment
possibilities [Caprioglio D. and Caprioglio C., 2006]
Very little attention is devoted to this topic in the
international literature and there are no well–coded
guidelines for laser applications in these specific
clinical events. The advantages correlated to laser
applications on hard and soft tissue and on the
exposed pulp make laser technology useful in this
field as already reported by the authors.
Laser application in dental traumatic injuries
Crown fracture involves the enamel and dentin and
exposes the pulp, if complicated.
As underlined in the hard tissue paragraph, only
erbium family lasers can guarantee good results in
tooth excavation, reducing post-operative discomfort
and sensitivity as well as providing minimally
invasive dentistry. These lasers can be used to
perform the entire procedure: tooth margin
preparation and finishing, coagulation of the exposed
pulp, pulpotomy or pulpectomy (if needed)
[Caprioglio et al., 2003], as well as soft tissue
procedures.
Crown fracture exposes a large number of dentinal
tubules: erbium-chromium and erbium lasers, when
used with only a little amount or no water jet, have
the capacity to produce fusion and sealing of the
dentinal tubules (depth up to 4 um), resulting in a
reduction of the tissues’s permeability to fluids, thus
reducing dentinal hypersensitivity (Fig. 6).
The other laser wavelengths (diode, Nd:YAG, CO2)
also have this beneficial therapeutic action for this
application. As reported in the previous paragraphs,
they can also be applied:
- to perform indirect or direct pulp capping;
- to decontaminate infected root canals;
- to treat soft tissue defects.
Laser application in soft tissue traumatic injuries
Indirect traumas are lesions to the supporting
structures, in particular the alveolar bone, the gum,
the ligament, the fraenum and the lips.
Lasers are currently an available option for the
treatment of dental soft tissue and, as reported in the
literature cited above, they provide good coagulation
(with extremely clean working area), effective
decontamination, photobiostimulation and pain
reduction effect for the treatment of traumatic
injuries, with no suture, good and rapid healing by
second intention and minor discomfort for the patient
(Fig. 5).
The authors have experienced and reported an
improvement in these procedures by using lasers in
the following applications:
- decontamination of the alveolus following
traumatic avulsion;
- treatment of a periodontal defect following dental
luxation or sub-luxation;
- microgingival surgery for the treatment of
traumatic dental injury;
- gingivectomy and gingivoplasty;
- surgical cutting (e.g. to remove a tooth fragment).
Clinical implications
All the exposed advantages related to laser
applications on hard and soft tissue and on exposed
pulp tissue make laser technology useful in this field.
Low level laser application
Laser application in biostimulation and pain
control (LLLT)
A non-traumatic introduction to dentistry can be
represented by low level laser therapy (LLLT) or soft
laser therapy. There is a large body of literature on
this particular topic, even if both methodologically
and in terms of doses, there is still considerable
difference of opinion [Benedicenti, 2005]. Even
FIG. 6 - Male, 8.2 years old. (A) Crown fracture of 1.1 and 2.1 and right cross-bite. The teeth fragments of 1.1 and 2.1 were
previously reattached twice by a colleague, but the treatment failed again. (B-C) Laser-assisted bevel and final appearance by
using an Er:Yag laser ( 150-100 mj, 15-10 Hz for respectively enamel and dentin). (D) One year follow up and orthodontic
correction.
36
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REVIEW ON THE USE OF LASER IN PAEDIATRIC DENTISTRY
though helium-neon lasers were initially used (632.8
nm), the ones in use today are the semiconductor
diode lasers (830 nm or 635 nm).
The LLLT has an important pain-reducing and
biostimulating effect with acceleration of the
reparative processes that have a considerable clinical
importance, especially in those patients with a
compromised immune system (young patients
affected by insulin dependent diabetes, history of
endocarditis, cardiac dysfunction or malformations
or cardiac surgical and prosthetic valves
reconstruction, oncological patients undergoing
chemotherapy or radiation). In short, LLLT
stimulates the tissue repair processes, influencing a
large number of cell systems (fibroblasts,
macrophages, lymphocytes, epithelial cells,
endothelium), and can also have a series of benefits
on inflammatory mechanism, reducing the exudative
phase and stimulating the reparative process [Mendez
et al., 2004; Pretel et al., 2007; Ribeiro et al., 2002;
Schindl et al., 2000; Whelan et al., 2001].
In LLLT the power is delivered with an irradiation
energy ranging from 30 to 50 Joules for cm2 and a
total energy from 300 to 350 J daily. After 3-5 days of
biostimulation, it is already possible to observe a
considerable reduction of swelling and an
acceleration of the epithelisation and collagen
deposition phase.
The LLLT has a number of applications in
dentistry, both at the soft tissue level (biostimulation
of lesions, aphthous stomatitis, herpetic lesions,
mucositis, pulpotomy), and the hard tissue level
(acceleration of orthodontic movement) as well as
neurally (analgesia, neural regeneration, temporomandibular pain, post-surgical pain, orthodontic
pain). According to Tuner and Hode [2004], and to
Gutknecht et al. [2005], LLLT has five main
indications in paediatric dentistry.
- The eruption of both deciduous and permanent
teeth is sometimes painful: the irradiation of the
lymph nodes in the area is advisable for pain
relief.
- A laser radiation dose of 2 J has a brief anaesthetic
effect of the mucosa, allowing painless injection
with a needle.
- Direct application of a laser radiation dose of 4 to
6 J into an exposed cavity of a deciduous tooth can
be used for pain reduction.
- Post-traumatic treatment after lip and front-tooth
trauma to reduce swelling and pain can be
achieved by applying a laser radiation dose of 3 to
4 J.
- A laser radiation dose of 1 to 2 J as an additional
treatment in pulp capping improves treatment
outcome. According to the author’s clinical
experience a daily irradiation of 1-2 J/cm2
(repeated for 3-4 days) can bring good results.
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Further clinical studies are needed to establish
suitable irradiation conditions.
Discussion
The diverse parameters of use and clinical and
experimental results reported in the international
literature may mislead the non-expert wishing to
explore this field of application of laser technology.
The studies on soft tissue are for the most part in
line, with similar protocols and reproducible results:
this is due to the fact that the lasers involved (diode,
Nd:YAG, CO2) make use of a similar technology,
allowing the same operative protocols.
The studies on hard tissue utilize the erbium family
of lasers: here there is a variety of types available, not
only with different wavelengths (2780 and 2940 nm),
but also with different overall construction. The
studies done cannot be compared for various reasons:
power density and fluence are only one aspect of the
energy delivered to the target tissue. Above all the
delivery systems are different: optical fibers (hollow
fibers) or articulated arms transmit energy in a
substantially different way so that the energy
delivered to the tissue is very different from that
selected on the display.
Air/water flow and pressure of the integrated spray,
the pulse length, the beam profile, are other
parameters that affect the results of the laser tissue
interaction.
Beyond a presentation of the literature that validates
the proposed therapies, it is important to underline
that the operator factor is fundamental, even with laser
therapy.
The resulting minimally invasive therapy is
conditioned both by the knowledge of laser
technology as well as the application of the correct
energy (the minimal effective), which also depends on
the manual ability of the operator who must learn to
act on the tissues with precision. Using an instrument
that works without contact requires learning the
correct operating technique and a period of training
with a more or less extended learning curve.
A correct psychological approach to the patient also
contributes considerably to the success of the therapy,
which is often felt by patients and their families as
very comfortable and acceptable, sometimes even
magical.
Conclusion
Laser is very effective in paediatric dentistry and
represents a good treatment option. It enables optimal
preventive, interceptive, and minimally invasive
interventions for both hard and soft tissue procedures.
It is important for the professional to understand the
physical characteristics of the different laser
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OLIVI G., GENOVESE M.D. AND CAPRIOGLIO C.
wavelengths and their interaction with the biological
tissues to ensure that they are used in a safe way, in
order to provide the benefits of this technology to
young patients. Therefore a period of education and
training is highly recommended before applying this
technology on paediatric patients.
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