Trends Biomater. Artif. Organs, 25(3), 119-123 (2011) http://www.sbaoi.

org

Lasers in Dentistry - An Overview

Seema Guptaa, Sandeep Kumarb
Department of Orthodontics, bDepartment of Prosthodontics, Surendera Dental College and Research Institute,
a

Sriganganagar, Rajasthan.
Corresponding author: Dr. Seema Gupta, mdsseema31@yahoo.com

Received 4 August 2010; Accepted 27 April 2011; Available online 29 May 2011

Laser dental care is possible in all of the disciplines of dentistry. The public has an expectation that their dentist should be up to date
and wants the most modern, advanced care possible. The future of lasers in dentistry is promising, and new applications and
procedures are being developed. The public is made aware of this by various media, and the word “laser“ has power because
patients want and trust the doctors who offer advanced technology. Dentists and their staffs can successfully integrate the use of
lasers into the everyday practice of dentistry. The clinician must be familiar with the fundamentals of laser physics and tissue
interaction so that the proper laser device is used to obtain the treatment objective safely and effectively. Education, training, and
marketing laser dentistry takes planning and time. The questions of fees, insurance involvement, and how offices will recoup the
investment of lasers should be thoroughly planned and discussed. The pride and excitement of being on the cutting edge of dentistry
and financial incentives make it more possible than ever to implement the use of lasers. “Clinical competence in any area of dentistry
appears to require a combination of education and clinical experience“. This article features topics of laser science, tissue interaction,
types & uses of lasers in dentistry that provide the foundation for the many applications of the use of lasers in dentistry.

Introduction

In 1960, Theodore Maiman, a scientist with the Hughes
Aircraft Corporation, developed the first working laser
device, which emitted a deep red-colored beam from a
ruby crystal. During the next few years, dental
researchers studied possible applications of this visible
laser energy. Studies in the 1970s and 1980s turned to
other devices, such as CO 2 and neodymium YAG
(Nd:YAG), which were thought to have better interaction
with dental hard tissues. The medical community in the
mid to late 1970s had begun to incorporate lasers for
soft-tissue procedures, and oral surgeons added the
technology in the early 1980s. Since that time, numerous
instruments have been made available for use in dental
practice, and more are being developed.
The clinician should consider a number of factors when
deciding whether to incorporate laser systems into their
practices. First, they should realize that several types of
lasers exist, with certain lasers approved for certain uses
in dentistry and some lasers specific to soft- or hard-tissue
applications. In addition, laser systems add significant
cost to the delivery of care, requiring a sizeable
investment in capital and the need to learn how to use
the equipment. Dentists and patients also should realize
that laser-induced tissue trauma to the surgical site can
add several more days to the healing process. This article
features topics of laser science, tissue interaction, uses
of lasers in dentistry that enjoy the best scientific support,
that provide the foundation for the many applications of
their use in dentistry.
Laser-tissue interaction
The most desired interaction 1-3 is the absorption of the
laser energy by the intended tissue. The amount of energy
that is absorbed by the tissue depends on the tissue
characteristics, such as pigmentation and water content,
and on the laser wavelength and emission mode. In
general, the shorter wavelengths (from about 500-
1000nm) are readily absorbed in pigmented tissue and
blood elements. Argon is highly attenuated by
hemoglobin. Diode and Nd:YAG have a high affinity for
melanin and less interaction with hemoglobin. The longer
wavelengths are more interactive with water and
hydroxyapatite. The largest absorption peak for water is
just below 3000 nm, which is at the Er:YAG wavelength.
Erbium is also well absorbed by hydroxyapatite. CO2 at
10,600 nm is well absorbed by water and has the greatest
affinity for tooth structure (Figure 1).
The wavelength of the light is the primary determinant of
the degree to which the light is absorbed in the target
material. Depending on the tissue, some lasers penetrate
deeper than others. By contrast, other laser wavelengths
are limited to a shallow penetration and have a surface
effect on tissue. The deeper the laser energy penetrates,
the more it is scattered and distributed throughout the
120 S. Gupta, S. Kumar
Figure 1: Approximate absorption curves of different dental
compounds by various wavelengths of dental lasers
tissue. For example, the CO2 laser penetrates only about
0.03 to 0.1 millimeters into tissue. This provides just
enough depth to seal blood vessels, lymph vessels and
nerve endings measuring up to 0.5 mm in diameter. The
clinical result of this penetration is good hemostasis and
minimal postoperative morbidity. By comparison, the
Nd:YAG laser penetrates 2 to 5 mm into tissue, it has
caused concern about the risk of collateral damage in oral
sites where bone and other hard tissue are within the range
of energy.
Once the light from dental lasers is absorbed, it is
converted to heat. The thermal effects 4 of this heat
depend, in large part, on tissue composition (that is, the
amount of water and organic and inorganic components
in the tissue) and the length of time the beam is focused
on the target tissue. The duration of exposure results in
temperature increases that may cause the tissue to
change in structure and composition. These changes may
range from denaturation to vaporization and carbonization,
and even melting followed by recrystallization in the case
Figure 2: A portion of the electromagnetic spectrum showing dental laser wavelengths being used for treatment
of hard tissue. Dentists should also be aware that heat
can be generated from the laser unit itself.
Laser wavelengths used in dentistry (Figure 2)
Argon lasers: Argon5-7 is laser with an active medium of
argon gas that is energized by a high-current electrical
discharge. It is fiberoptically delivered in continuous wave
and gated pulsed modes and is the only available surgical
laser device whose light is radiated in the visible spectrum.
There are two emission wavelengths used in dentistry:
488 nm, which is blue in color, and 514 nm, which is blue
green. Acute inflammatory periodontal disease and highly
vascularized lesions, such as a hemangioma, are ideally
suited for treatment by the argon laser. The poor
absorption into enamel and dentin is advantageous when
using this laser for cutting and sculpting gingival tissues
because there is minimal interaction and thus no damage
to the tooth surface during those procedures. Dentists
should be aware that, when used for resin curing, argon
lasers do not necessarily produce a resin with physical
properties superior to those of resins cured with traditional
halogen curing lights8,9.
Diode lasers: Diode10-12 is a solid active medium laser,
manufactured from semiconductor crystals using some
combination of aluminum or indium, gallium, and arsenic.
The available wavelengths for dental use range from about
800 nm for the active medium containing aluminium to
980 nm for the active medium composed of indium. All of
the diode wavelengths are highly absorbed by pigmented
tissue and are deeply penetrating, although hemostasis
is not as rapid as with the argon laser. These lasers are
relatively poorly absorbed by tooth structure so that soft
tissue surgery can be safely performed in close proximity
to enamel dentin and cementum. Also, similar to an argon
instrument, the continuous wave emission mode of the
diode laser can cause a rapid temperature rise in the target
tissue. The clinician should use air and sometimes water
to cool the surgical site and to continue to move the fiber
around the treatment area. The diode is an excellent soft
 Lasers in Dentistry - An Overview
tissue surgical laser and is indicated for cutting and
coagulating gingiva and mucosa and for sulcular
debridement. Finally, within certain low-energy ranges,
the diode laser can stimulate the proliferation of
fibroblasts13.
Nd-YAG lasers: It can be used to perform a number of
soft-tissue applications 14-17, including the following:
gingival troughing; esthetic contouring of gingiva;
treatment of oral ulcers. In addition, the Nd:YAG laser
can be used to remove incipient enamel caries, although
not as efficiently as can the Er:YAG, or Er,Cr:YSGG,
lasers18. The Nd:YAG laser also offers good hemostasis
during soft-tissue procedures, which facilitates a clear
operating field. The Nd:YAG laser has a number of
disadvantages, however. It has the greatest depth of
penetration of all the available dental surgical laser
systems, which means that tissues under the surface are
exposed to laser energy. This is cause for concern
because of the risk of unwanted collateral damage,
especially in the underlying bone or the dental pulp 19,20,
as well as the associated postoperative morbidity. In
addition, the diminished localization of the energy on the
tissue’s surface makes vaporization of soft tissue with
an Nd:YAG laser slower than with the better-absorbed
laser wavelengths, such as those produced by the CO2
laser. Pulpal damage (such as denaturation and disruption
of the vascular and neuronal tissue) from this laser can
occur, and is associated with a decrease in pulpal function
(that is, sensitivity).
The erbium family: There are two distinct wavelengths
that use erbium: Erbium, chromium:YSGG (2780 nm) has
an active medium of a solid crystal of yttrium scandium
gallium garnet that is doped with erbium and chromium
and Erbium:YAG (2940 nm) has an active medium of a
solid crystal of yttrium aluminum garnet that is doped with
erbium. Caries removal and tooth preparation are easily
accomplished by both the lasers. The Er:YAG laser 21-32 -
It has a number of advantages. It produces clean, sharp
margins in enamel and dentin. In addition, pulpal safety
is not a significant concern, because the depth of energy
penetration is negligible. When the Er:YAG laser is used
for caries removal, the patient usually does not require
local anesthesia. The laser is antimicrobial when used
within root canals and on root surfaces, and it removes
endotoxins from root surfaces. Finally, vibration from the
Er:YAG laser is less severe than that from the conventional
high-speed drill, and it is less likely to provoke discomfort
or pain. The laser has shown potential for removing
calculus during root débridement. On the downside, the
Er:YAG laser does not selectively remove calculus on root
surfaces.
The Er,Cr:YSGG laser 33-37 - It also has a number of
advantages. The laser produces a rough surface in enamel
and dentin without significant cracking. In dentin, no smear
layer remains, which suggests good results with bonding.
It is safe for the pulp. The disadvantages of the
Er,Cr:YSGG laser involve the etching results. With this
laser, enamel etching produces bonds with a wide range
of strengths, which can be unreliable. To minimize leakage
in resins, clinicians may need to acid-etch enamel after
preparing cavities with the Er,Cr:YSGG laser.
121
CO2 laser: It is a gas active medium laser that incorporates
a sealed tube containing a gaseous mixture with CO2
molecules pumped via electrical discharge current. The
light energy, whose wavelength is 10,600 nm. This
wavelength is well absorbed by water, second only to the
erbium family. It can easily cut and coagulate soft tissue 38,39
providing the dentist a clear operating field and it has a
shallow depth of penetration into tissue, which is important
when treating mucosal lesions. Postoperative pain usually
is minimal to none. CO2 laser also has some
disadvantages. For example, wound healing can be
delayed for a few days. Dentists should be aware that
CO2-treated tissue will have a black/brown appearance,
which is caused by a carbon residue that will easily rinse
off within the first few days after the procedure. The
exposed area can go through color changes for 10 to 14
days, eventually resulting in natural and healthy-looking
gums40
Use of lasers on hard tissues
Lasers for caries detection41-45- While laser fluorescence
has demonstrated good sensitivity and excellent
reproducibility for detecting caries, it is not able to quantify
the extent of decay. Laser fluorescence also has
performed well in the detection of residual caries. While
safety is not a concern with this low-power laser
application, more data is required to aid in the clinical
interpretation of the results and to develop a clinically
useful sense of the limits of this technology.
Lasers for removal of carious lesions and cavity
preparation- Laser systems can be used for effective
caries removal and cavity preparation without significant
thermal effects, collateral damage to tooth structure, or
patient discomfort. Er-based laser system can achieve
effective ablation at temperatures well below the melting
and vapourization temperatures of enamel 23,24,29. To date,
alternative laser systems, including super-pulsed CO2,
Ho:YAG, Ho:YSGG, Nd:YAG, Nd:NLF, diode lasers and
excimers, have not proven feasible for use for cavity
preparation in general practice settings. Other than caries
removal, this is a range of other well established laser
hard tissue procedures include desensitization of cervical
dentine (using Nd:YAG, Er:YAG, Er,Cr:YSGG CO 2, KTP,
and diode lasers), laser analgesia (using Nd:YAG,
Er:YAG, and Er,Cr:YSGG lasers), laser-enhanced fluoride
uptake (using Er:YAG, Er,Cr:YSGG, CO2, argon, and KTP
lasers).
Laser Bleaching- In October 1998, the ADA Council 46
concluded that because of concerns regarding pulpal
safety and a lack of controlled clinical studies, the CO 2
laser could not be recommended for tooth-whitening
applications. The council indicated, however, that the
argon laser might be an acceptable replacement for the
conventional curing light if the manufacturer’s suggested
procedures are followed carefully.
Use of lasers on soft tissues
Laser curettage- Both the Nd:YAG and gallium-arsenide
(or diode) lasers are promoted for curettage. A critical
review of the best available evidence, however, strongly
indicates that there is no added benefit to the patient when
this procedure is performed after traditional mechanical
122 S. Gupta, S. Kumar
scaling and root planing47,48. Proponents of laser curettage its status as an adjunct or alternative to convectional
point to the ability of these lasers to kill microorganisms. periodontal therapy.
Although the data indicate that this effect is possible albeit
inconsistent, it has not been correlated with an Summary and conclusion
improvement in periodontal attachment level. With no
demonstrable benefit and with a significant risk of collateral There is a leaning curve in the use of lasers in dentistry.
damage to the periodontium, laser curettage appears to As long as the clinician has completed a training course
be neither scientifically nor ethically justified. & proceeds through the learning curve at a comfortable
pace, the rewards will quickly be noticed by the patient
Er:YAG laser posses suitable characteristics for various and the dental team. Lasers can prove to be a blessing in
surgical and non-surgical procedures but randomized disguise if used safely and properly.
controlled clinical trials have to be encouraged to confirm
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