International Journal of Oral Health Sciences

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

Evolution and advancement of lasers in dentistry - A literature review


Julie Susan Rajan1, Umbreen Noor Muhammad2,  
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

Correspondence Address:
Dr. Umbreen Noor Muhammad
Department of Lecturer of Anatomy in Basic Sciences, Riyadh Elm University, Riyadh
Kingdom of Saudi Arabia

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.



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


Full Text



 Introduction



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 years1903 – Finsen[6] – Was awarded Nobel Peace Prize and developed carbon arc lamp to treat lupus vulgaris1917 – Albert Einstein[7] – Laid foundation for predecessor “ The Maser”1957 – Charles Townes[8],[9] – Designed “Maser”1959 – Gordon Gould[10] – Introduced laser to the public1960 – 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, USA1964 –Patel[10] – Developed CO2 laser at Bell Laboratories1964 – Geusic[5] – Developed Nd: YAG laser1965 – Stern and Sognnaes[5] – Reported ruby laser could vaporize enamel and has thermal effects on dental pulp1965 – Leon Goldman[6],[14],[15] – Used laser on vital tooth and reported biomedical aspects of lasers and its effects on dental caries and other tissues1966 – Lobene et al.[14]– Used CO2 lasers in dentistry1971 – Weichman and Johnson[16] – First to use high-powered infrared (IR) CO2 laser in endodontics to seal apical foramen1974 – Yamamoto et al.[14],[17],[18],[19] – Used Nd: YAG laser for caries prevention, and for complete debridement of bacteria from apical third of root1977 – Lenz et al.[14] – First to use lasers in oral and maxillofacial surgery1985 – Shoji et al.[14] – Use of lasers for pulpotomy1985 – Pick et al.[14] – First to use lasers in periodontal surgery1986 – Zakirasen et al.[14] – Used lasers for sterilization of root canals1990 – FDA[5] – Approved use of laser therapy in intraoral gingival and mucosal tissue surgery1990 – Myers[6] – Introduced the first laser specifically for dentistry1994 – Morita[14] – Introduced Nd: YAG lasers in endodontics1998 – 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



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 English1478 articles were obtained during initial search and related articles were evaluatedRelevancies 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 studyScreened 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}

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}

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}

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}

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}

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}

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}

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:

Engineering control measures

Laser barriers and protective curtainsProtective housingMaster switch controlOptical viewing system safetyBeam stop or attenuatorInterlock requirementsLaser activation warning system.

Administration control

Appointing laser safety officerSafe working proceduresTrained and experienced personnelHazard signs using color, dimension, and location of symbol (sunburst pattern)Eye and skin examinationsTest firing.

Personal protective equipment

Eye protection using safety gogglesLaser filtration masks to prevent airborne contaminationEvacuation of laser plume using high-volume suctionProtective 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.

Periowave™: A photodynamic disinfection system that uses a photosensitizer combined with low-intensity laser to destroy bacteria and toxins after scaling and root planningPeriodontal 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 treatmentsWaterlase 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 treatmentPhoton-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 systemPiezosurgery: 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 surgeriesOsseodensification: A new method of biomechanical bone preparation for dental implant placement,[65] by protecting bone mass and shortening recovery time frame.

 Discussion



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



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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