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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 6-14

Evolution and advancement of lasers in dentistry - A literature review


1 Department of Basic Sciences, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia
2 Department of Lecturer of Anatomy in Basic Sciences, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia

Date of Submission07-Feb-2021
Date of Decision27-May-2021
Date of Acceptance20-Apr-2021
Date of Web Publication9-Aug-2021

Correspondence Address:
Dr. Umbreen Noor Muhammad
Department of Lecturer of Anatomy in Basic Sciences, Riyadh Elm University, Riyadh
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_2_21

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  Abstract 


Technological revolution has maximized access to information and increased popularity in Light Amplification by Stimulated Emission of Radiation (LASER) use that raised patient expectations for painless and noninvasive procedures. Currently, lasers have created a potentially profitable arena in patient care and well-being, in the field of dentistry and medicine. Introducing lasers into dentistry helped the practitioners to overcome the constraint of conventional procedures. Recently, the foothold of lasers in modern dentistry provided ease, efficiency, specificity, and comfort both to clinicians and patients. This article summarizes evidence-based published studies on several aspects of laser applications, pros and cons, safety measures, and current advancements in dentistry to convey significant information to aid dental practitioners. To acquire related information, database search strategy was implemented using keywords such as “lasers.” A few decades ago, lasers were handled only by specialists or researchers; however, over the years, laser advancements have revealed a paradigm shift in dentistry, promising a concrete future in all aspects of dentistry and postsurgical care.

Keywords: Carbon dioxide laser, diode laser, erbium laser, low-level laser therapy


How to cite this article:
Rajan JS, Muhammad UN. Evolution and advancement of lasers in dentistry - A literature review. Int J Oral Health Sci 2021;11:6-14

How to cite this URL:
Rajan JS, Muhammad UN. Evolution and advancement of lasers in dentistry - A literature review. Int J Oral Health Sci [serial online] 2021 [cited 2021 Dec 1];11:6-14. Available from: https://www.ijohsjournal.org/text.asp?2021/11/1/6/323527




  Introduction Top


The word “LASER” denotes “Light Amplification by Stimulated Emission of Radiation,”[1],[2] which generates electromagnetic radiation of uniform wavelength, phase, and polarization that is stimulated by an external field, thereby producing monochromatic, coherent, intense, and collimated light. Understanding the concept of laser wavelength with oral tissue interaction can improve patient management. In dentistry,[3],[4] unlike other fields of medicine and surgery, laser is considered an adjunctive to deliver precise tissue management to achieve hard and soft tissue procedures.

History of lasers

  • Theoretically, laser light production was developed some 90 years ago and first used on extracted tooth about 47 years ago. In 1900, first pulsed Nd: YAG laser was released[5] as to have better interaction with dental hard tissues. By 1970s, researchers found medical carbon dioxide (CO2) and discovered that Nd: YAG lasers can be used in clinical oral soft tissues. Commercially available dental lasers have become more eminent only for the last 3–4 years
  • 1903 – Finsen[6] – Was awarded Nobel Peace Prize and developed carbon arc lamp to treat lupus vulgaris
  • 1917 – Albert Einstein[7] – Laid foundation for predecessor “ The Maser”
  • 1957 – Charles Townes[8],[9] – Designed “Maser”
  • 1959 – Gordon Gould[10] – Introduced laser to the public
  • 1960 – Theodore Maiman[11],[12],[13] – First to demonstrate lasers from a ruby crystal; built the first functioning laser with a mixture of helium and neon at Hughes Research Laboratories, Malibu, CA, USA
  • 1964 –Patel[10] Developed CO2 laser at Bell Laboratories
  • 1964 – Geusic[5] – Developed Nd: YAG laser
  • 1965 – Stern and Sognnaes[5] – Reported ruby laser could vaporize enamel and has thermal effects on dental pulp
  • 1965 – Leon Goldman[6],[14],[15] – Used laser on vital tooth and reported biomedical aspects of lasers and its effects on dental caries and other tissues
  • 1966 – Lobene et al.[14]– Used CO2 lasers in dentistry
  • 1971 – Weichman and Johnson[16] – First to use high-powered infrared (IR) CO2 laser in endodontics to seal apical foramen
  • 1974 – Yamamoto et al.[14],[17],[18],[19] – Used Nd: YAG laser for caries prevention, and for complete debridement of bacteria from apical third of root
  • 1977 – Lenz et al.[14] – First to use lasers in oral and maxillofacial surgery
  • 1985 – Shoji et al.[14] – Use of lasers for pulpotomy
  • 1985 – Pick et al.[14] – First to use lasers in periodontal surgery
  • 1986 – Zakirasen et al.[14] – Used lasers for sterilization of root canals
  • 1990 – FDA[5] – Approved use of laser therapy in intraoral gingival and mucosal tissue surgery
  • 1990 – Myers[6] – Introduced the first laser specifically for dentistry
  • 1994 – Morita[14] – Introduced Nd: YAG lasers in endodontics
  • 1998 – Mazeki et al.[14] – Did root canal shaping with Er: YAG laser.


Thus, over the last decades, advancements over laser applications led researchers to explore the benefits of laser use in medical and dental fields. Currently, erbium lasers (Er: YAG, Er, Cr: YSGG), Nd: YAG, diode, and CO2 are the most commonly used lasers in dentistry. Clinicians have considered use of erbium lasers as wavelength is said to be safe, effective, and convenient in dentistry when compared with conventional methods. The purpose of this review is to summarize the evolution, uses, applications, and pros and cons of lasers; as well as its evolution and advancements in dental care to aid dental practitioners.


  Materials and Methods Top


This literature review was accomplished by maintaining a criteria using electronic database search strategy. Articles were referred and reviewed according to the inclusion and exclusion criteria to be specific.

Search strategy

To obtain relevant information, database search was undertaken using PubMed data, Medline, J Dent, ScienceDirect, Google Scholar, ResearchGate, and Medical Subject Headings related with dental lasers. The key items used in the search were “lasers,” laser photodynamic therapy, diode lasers, erbium, chromium: yttrium-scandium-gallium-garnet lasers, and dental lasers.

Study selection

Study type

  • Referred articles were in English
  • 1478 articles were obtained during initial search and related articles were evaluated
  • Relevancies of the obtained articles were assessed by reading titles and abstracts, out of which 1268 articles screened and 105 were rejected as it was not related to the study
  • Screened articles were evaluated for eligibility according to their theoretical level.


Participant type

  • Ninety-four eligible articles were subjected to inclusion–exclusion criteria [Table 1], out of which 17 were irrelevant with indistinct information and not related to the study.
  • Reference lists of the articles were also evaluated.
Table 1: Inclusion-exclusion criteria

Click here to view


Outcome measures

Seventy-seven articles from 2000 to 2020 were selected, and relevant articles before 2000 were also included for historical references and if any needed.

Data extraction

Relevant data retrieved from each study were included in the review.

Study

Publication year: Relevant articles from the year 2000 to 2020 was included in the study.

Design: Study was subjected to PRISMA guidelines.

Data analysis

Obtained data were subjected to preferred reporting items for systematic literature review [Figure 1].
Figure 1: Preferred reporting items for literature review used in this study

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Principle of lasers

Dental lasers use the energy generated by atomic electron shifts,[20],[21] producing coherent monochromatic electromagnetic radiation between the ultraviolet and the far IR section of the electromagnetic spectrum, producing both visible and invisible lights with particular wavelength and color,[4],[8] which act on the particular tissue site to attain the desired effect. The basic principle involved in laser action is quantum nature of light and stimulated emission. Lasers produces heat[22] that converts electromagnetic energy into thermal energy. Emitted laser has three characteristic features: monochromatic, coherent, and collimated.

Laser has the following components,[14],[23] as depicted in [Figure 2].
Figure 2: Diagrammatic representation of the mechanism of action in a laser using resonator, excitation source, and amplification

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Optical cavity

It consists of lasing medium and parallel mirror. Light is emitted by process of optical amplification, which is monochromatic and of single wavelength with three principal parts: an energy source;[22] an active lasing medium with gaseous (argon and CO2), crystal or solid state (Nd: YAG, Er: YAG), and semiconductor wafers made of indium, gallium, aluminum, and arsenic; and two or more mirrors that form an optical cavity or resonator.

Pump energy source (excitation source)

For amplification to occur, energy is supplied by pumping mechanism using a flash lamp strobe device, an electric current or an electric coil into an active medium contained within an optical resonator. The photons are reflected back and forth through the medium by highly reflective surfaces of the optical resonator causing amplification.

Cooling system, focusing lenses, and other controls

The remaining energy is converted into heat to provide cooling in the form of water, and finally, a collimated, coherent, monochromatic laser beam of light is generated.

Dental lasers have fiberoptic cable (visible and IR lasers),[24] or hollow wave guide (middle and far IR lasers), or articulated arm (UV, visible, and IR lasers) to deliver the laser light to the target tissue, in the following manner:[1],[25] Reflection, Transmission, Scattering, Absorption. Temperature is elevated when laser is absorbed and thus produces photochemical effects depending on the water content in the tissues. The principle mechanism of action of laser energy on the yissue is photothermal.

Ablation occurs when temperature is reached to 100° C causing vaporization of water within the tissues. Tissue is dehydrated and burned at temperature above 200°C, resulting in carbonization.

The mechanism of laser–tissue interaction[23],[24],[26],[27] is depicted in [Table 2].
Table 2: Mechanism of laser-tissue interaction

Click here to view


Laser wavelength and tissue interaction

Characteristic of lasers depends on its wavelength,[22] which affects both the clinical applications and the design of lasers. Laser selection is procedure dependent[25],[28] as different laser wavelengths have different absorption coefficients with respect to primary tissue components. Understanding the fundamental principle of laser–tissue interaction[26] will enable the clinician to choose the appropriate laser for the desired treatment. Lasers are used on target tissues according to their wavelength, delivery system, and their effects,[29] on particular tissues. The wavelength, delivery, and effects of different lasers on target tissues are shown in [Table 3].
Table 3: Wavelength and delivery of dental lasers on target tissues and its effects

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Classification of lasers

Lasers have become beneficial in managing a wide range of dental complications and therapeutic treatments that aims in tissue management. They are classified into various categories,[8],[36] but mostly, its requisition is done as hard tissue, soft tissue, and nonsurgical lasers. Soft tissue lasers helps in soft tissue removal and hemostasis, for periodontal and gingival tissue management. Due to its high affinity for hydroxyapatite and high absorption of water, Erbium lasers are used for both hard and soft tissue ablations during surgeries, apicectomies and in operative dentistry. Er:YAG[1] lasers are optically and electrically pumped lasers and are classified according to type of lasing medium. Low-level laser therapy[2],[6],[37] have a biomodulating effect on oral healing. It reduces duration of inflammation and promotes tissue repair, wound healing with less scarring, relieves dental pain and TMJ problems. The mixture of noble gases such as argon (argon fluoride), krypton (krypton fluoride),[6] and xenon (xenon fluoride) with reactive gases produce a special type of gas discharge called excimer lasers, effective in disinfecting root canals. Thus, lasers were classified according to several studies done by researchers and their implications in dentistry, as shown in [Table 4].
Table 4: Classification and types of lasers

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Clinical applications of lasers

Lasers are expected to make a benchmark in dentistry with its major advancements in clinical applications. Hard and soft tissues[21] can be treated using lasers without direct contact, vibrations, and pain; thus, it can be utilized in many divisions of dentistry. Researchers have effectively used lasers in their clinical practices. It is imperative that any clinician hoping to pursue laser use in practice[8],[43] must have a solid understanding about these devices, its specific biological effects on target tissues, advantages and disadvantages, and procedures associated with them, as shown in [Table 5].
Table 5: Applications, advantages, and disadvantages of lasers in dentistry

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Laser safety measures

Nature of effect of lasers on tissue comprises wavelength, exposure time, spot size,[15],[72],[73],[74] and tissue variables of physical and chemical composition. To ensure safe and effective operation of dental lasers, precautionary measures must be considered. Lasers are not advised in patients with pacemakers, pregnant women, epileptic patients, and arrhythmic patients and avoided in glands,[8] tumors, or on lupus lesions. According to the ANSI Z136 series of laser safety standards,[39],[75] control measures are categorized as:

  1. Engineering control measures


    • Laser barriers and protective curtains
    • Protective housing
    • Master switch control
    • Optical viewing system safety
    • Beam stop or attenuator
    • Interlock requirements
    • Laser activation warning system.


  2. Administration control


    • Appointing laser safety officer
    • Safe working procedures
    • Trained and experienced personnel
    • Hazard signs using color, dimension, and location of symbol (sunburst pattern)
    • Eye and skin examinations
    • Test firing.


  3. Personal protective equipment


    • Eye protection using safety goggles
    • Laser filtration masks to prevent airborne contamination
    • Evacuation of laser plume using high-volume suction
    • Protective clothing, surgical gloves, and footwear to be worn by operator.


Medico legal considerations

Most professional liability insurance policies are designed for dental specialists,[25],[29] and a conservative soft tissue surgery with dental laser is considered a covered procedure. Prior informed consent must be considered routine, and the patients must read and acknowledge with signature before any laser dental treatment. Each clinician must take a course from a reputable provider.

Recent advancements in lasers

Currently, erbium lasers are considered suitable for dental treatment,[22] due to its dual ability to ablate hard and soft tissues with minimal damage.

  1. Periowave™: A photodynamic disinfection system that uses a photosensitizer combined with low-intensity laser to destroy bacteria and toxins after scaling and root planning
  2. Periodontal Waterlase MD: It uses Er, Cr; YSGG for minimally invasive surgical periodontal laser therapy,[76] giving efficient periodontal attachment level restoration. Target application: Restorative, multidisciplinary dental procedures, cosmetic procedures, oral surgery, root canal disinfection, implants and periodontal treatments
  3. Waterlase C 100: It is indicated in full,[22] partial, and split thickness flap, soft tissue curettage, removal of diseased, infected, inflamed, necrosed soft tissue within periodontal pocket, osteoplasty, osseous recontouring, ostectomy, and osseous crown lengthening. Target application: Restorative procedures, extraction, early periodontal treatment
  4. Photon-induced photoacoustic streaming: A recent advance in root canal therapy[77] developed by DiVito EE that creates powerful shockwaves at subablative levels to clean with disinfecting irrigants, three-dimensionally throughout the entire root canal system
  5. Piezosurgery: It is an ultrasound device using ultrasonic vibration for procedures[65] such asosteotomy and osteoplasty. It can also be used for retrograde preparation of root canal, ridge augmentation, ridge expansion, tooth extraction, and orthodontic surgeries
  6. Osseodensification: A new method of biomechanical bone preparation for dental implant placement,[65] by protecting bone mass and shortening recovery time frame.



  Discussion Top


The intension of using lasers in dental surgery is to minimize postoperative effects on soft tissues. With the entry of lasers, ease and comfort were brought into different fields of medicine and dentistry; such as target-oriented, rapid wound healing, and increased collagen production at the surgical site, painless procedures, time-saving, and minimal damage to soft tissues. According to the review of many researchers such as Sharma et al.,[45] Matsumoto et al.,[46] George,[24] it was observed that lasers gifted many advantages over constraints of conventional methods. Many researchers such as Maheshwari et al.,[1] Colaco,[2] Luke et al.,[6] Mensudar et al.,[14] Gauli et al.[30] discussed in their studies that each laser has its own features with its own specific contributions in different sections of dentistry. Thus, lasers can become stepping stones in most dental practices all around the world; hence, it is of significant importance that laser applications and its management be known to all practicing clinicians.


  Conclusion Top


Lasers have made tremendous improvements in the dental world by the 21st century. Laser-based technology holds greater promise in the coming future and thus emphasizes on a combination of diagnostic and therapeutic laser technique. It is expected that specific lasers will contribute to most dental practices all around the world mainly due to its noninvasive approach. Significant contribution of lasers in the modern dental practice has served as an adjunctive to conventional mechanical procedures. Further researches based on scientific and clinical studies are required to further evaluate the beneficial effects of lasers, since laser usage has taken a rapid leap in this advanced technological era.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

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