Laser physics and a review of laser applications in dentistry for children.
Abstract: Aim: The aim of this introduction to this special laser issue is to describe some basic laser physics and to delineate the potential of laser-assisted dentistry in children. REVIEW: A brief review of the available laser literature was performed within the scope of paediatric dentistry. Attention was paid to soft tissue surgery, caries prevention and diagnosis, cavity preparation, comfort of the patient, effect on bacteria, long term pulpal vitality, endodontics in primary teeth, dental traumatology and low level laser therapy. Although there is a lack of sufficient evidence taking into account the highest standards for evidence-based dentistry, it is clear that laser application in a number of different aetiologies for soft tissue surgery in children has proven to be successful. Lasers provide a refined diagnosis of caries combined with the appropriate preventive adhesive dentistry after cavity preparation. This will further lead to a new wave of micro-dentistry based on 'filling without drilling'. CONCLUSION: It has become clear from a review of the literature that specific laser applications in paediatric dentistry have gained increasing importance. It can be concluded that children should be considered as amongst the first patients for receiving laser-assisted dentistry.

Key words: Paediatric dentistry, laser applications, children.
Article Type: Report
Subject: Lasers in dentistry (Analysis)
Lasers in medicine (Usage)
Lasers in medicine (Health aspects)
Children (Health aspects)
Author: Martens, L.C.
Pub Date: 04/01/2011
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: April, 2011 Source Volume: 12 Source Issue: 2
Product: Product Code: 3832848 Lasers for Medicine NAICS Code: 334510 Electromedical and Electrotherapeutic Apparatus Manufacturing SIC Code: 3845 Electromedical equipment
Geographic: Geographic Scope: Belgium Geographic Code: 4EUBL Belgium
Accession Number: 277106744
Full Text: Introduction

Modern concepts of dentistry today are based on minimal invasive dentistry. Despite the fact that more than 50 years ago bur-less techniques had been proposed for cavity preparation starting with a first generation of an air abrasion engine [Black, 1945], it is thanks to the current refined caries diagnosis and the appropriate adhesive dentistry, that more attention has been paid to micro-preparations [Kutch, 2000]. Laser technology became developed for dental purposes and nowadays several oral applications are available for many uses. Due to this technological evolution it is possible to focus on a cavity preparation continuum (Fig. 1). Depending on the type of carious lesions a clinician can opt for a conventional G.V. Black cavity or for a micro-preparation following 'prevention by extension principles'. In the latter case a variety of minimal invasive techniques are available such as chemo-mechanical techniques as well as kinetic (airabrasion) and hydrokinetic (laser) cavity preparation systems.

[FIGURE 1 OMITTED]

During the first meeting of the world congress of micro-dentistry (WCM) it was suggested by Martens and Simonson to place 'micro-dentistry' into a modern context and offered the following definition 'micro-dentistry is the evidence-based discipline dealing with hard and soft tissue-saving procedures whose ultimate goal is lifelong optimal oral health' which WCM then adopted [Kutch, 2000].

Many children may experience laser treatment as their first contact with dentistry, accordingly there is a possibility that a new generation of patients will grow up with a different attitude towards dental care [Parkins, 2000]. Since the latter statement was made several supporting manuscripts reviewing laser-assisted paediatric dentistry have been published [Martens, 2003; Boj, 2005; Gutknecht, 2005; Olivi et al., 2009; Olivi and Genovese 2011]. The purpose of this manuscript is to describe some basic laser physics and to delineate the potential of laser-assisted dentistry in children.

Laser physics

The name 'laser' is an elegant acronym formed out of the initials of 'light amplification by stimulated emission of radiation'. Stimulated emission can happen only if incoming radiation causes the emission of radiation with the same properties such as wavelength, direction, polarisation and phase. Laser function was first described by Einstein in 1917. Laser devices are nowadays well known for medical applications and in past decades has been an increasing development of them for oral applications. Laser development started from a knowledge of the composition of light. According to modern physics, light has a dual nature, with properties of waves or particles (photons = carrier of energy). It depends on the wavelength and on certain circumstances that determine which character will dominate. Nowadays the concept of light reaches far beyond the visible spectrum (VIS) extending from about 400 to 800nm. Ultraviolet light extends to shorter wavelengths and down to X-rays. On the other side of the VIS, there is infrared light (IR) distinguished in near (up to 3[micro]m, Mg) middle (up to 50 pm) and far infrared. The electromagnetic spectrum is illustrated in Fig. 2a.

[FIGURE 2 OMITTED]

Laser light is based on having photons in the same phase and frequency (monochromatic light) and in the same direction (e.g. parallel beam). Every laser has an active medium (e.g. atoms or molecules to produce the laser light) which can be a gas, a fluid or a solid state. Typical lasers, which emit in the visible and adjacent areas of the UV and IR wavelengths (from 158nm down to the 10[micro]m of the C[O.sub.2] laser), comprise a large group. Diode and rare-earth lasers (e.g. solid state lasers based on the rare-earth ions erbium, neodymium, holmium) as well as transition metal (e.g. chromium) solid state lasers are most common in dentistry. The wavelength of a laser is determined by it's media. Figure 2b illustrates the most common laser media and their relationships to the electromagnetic spectrum. For the entire physical basis of laser therapy readers should consult the handbook on oral laser applications [Moritz, 2006]. Some knowledge of the different wavelengths is desirable.

After a period of uncertainty concerning the use of lasers in dentistry at the end of the 1990s, three wavelengths available for clinical use in hard dental tissue management were developed. These included the erbium: yttrium-aluminum-garnet [Er:YAG ([lambda] = 2.94[micro]m)], the erbium-chromium: yttrium-scandium-gadolinium-garnet [Er,Cr:YSGG, ([lambda] = 2.78[micro]m)], and the Er:YSGG ([lambda] = 2.79[micro]m). As the absorption of water in the infrared spectrum is highest for Er:YAG laser light, the efficiency of ablation (e.g. cutting enamel/dentine) seems to be the best for this device.

Besides laser applications for hard tissues, other wavelengths were developed for specific applications. The most important are the carbon dioxide (C[O.sub.2], [lambda] = 9.6 [micro]m) for oral surgery, the neodymium:yttrium-aluminum-garnet (Nd:YAG, [lambda] = 1030 nm) for endodontic and/or periodontal purposes and the potassium-titanyl-phosphate [KTP ([lambda] = 532 nm)] for bleaching, soft tissue surgery and periodontology. Furthermore, diode lasers for diagnosis and disinfection, low level lasers (LLL) for biostimulation are available. All these lasers are needed as they do not have a similar action with different chromophores, such as haemoglobin in the mucosa, water in the gingiva and hydroxyapatite in tooth enamel. Figure 3 illustrates the different wavelengths within the electromagnetic spectrum related to their peak absorption by different chromophores.

[FIGURE 3 OMITTED]

Laser light can have four possible interactions (Fig. 4) with the target tissue depending on its optical properties: absorption, transmission, reflection or scattering. Absorption is most important for hard tissue treatment as it will determine the final ablation [Olivi and Genovese, 2011]. Transmission and reflection had no effect on the target tissue. Reflected light can be used for example in caries diagnostics. Scattering weakens the intended energy and produces no useful biological effect. Dental therapy will be influenced by different absorption coefficients of the tissues for each particular wavelength.

[FIGURE 4 OMITTED]

Lasers in paediatric dentistry

Soft tissue surgery. The following applications have been described: exposure of teeth to aid eruption, gingival removal to expose areas for restoration, abnormal fraenal attachments, abnormal gingival architecture associated with tooth movement, operculectomy, fibroma removal, gingival hyperplasia resulting from drugs, cosmetic gingival contouring, aphthous ulcers and herpes labialis lesions [Parkins, 2000]. For these applications several types of lasers have been used. Argon, carbon dioxide, diode, and Nd:YAG lasers were described as cutting well, to decontaminate, coagulate and contour tissues. All laser wavelengths with optical affinity for haemoglobin and water can be used for these applications.

Although surgery in children is rare there are some reports on the use of C[O.sub.2] laser surgery treating cyclosporin-induced gingival overgrowth or vascular tumours in the oral cavity [Barak et al., 1991; Guelman et al., 2003]. The advantages of using C[O.sub.2] laser rather than a scalpel in surgery for gingival lesions are the ability of lasers to coagulate and seal blood vessels, vapourise the tissue, accurate incision and improved healing effect due to antimicrobial properties with minimal post-operative pain and swelling. Moreover, less anaesthesia and analgesia is needed. When treating children these are most important factors. The improvement for a child's acceptance of the therapy and facilitation of the operator's intervention is well reported [Boj et al., 2005; Haytac and Ozcelik, 2006; Genovese and Olivi, 2008; Kara, 2008]. An interesting application, where the laser device is easy to use and well accepted, is severe ankyloglossia or tight fraenula [Kotlow, 2004, 2011]. Within this special issue Boj [2011a and 2011b] gives an overview of lasers and soft tissues aswell as some clinical illustrations. Further Kotlow [2011] describes the use of lasers in neonates.

Prevention of caries. Laser use for preventing caries development is based on an increase of temperature within the hard tissues which causes a melting of enamel and dentine and consequently a release of carbonate as well as an improved crystal structure. This results in a increased acid resistance [Fried et al., 2001]. The combination of lasers and fluorides seem to be very promising in caries prevention. In this respect it was found that the application of acidulated phosphate fluoride (1.23% gel for 4 mins) before or after argon laser exposure resulted in a significant reduction in lesion depth when compared with argon laser alone or other methods [Hicks et al., 1995]. Comparable results were obtained in another study showing that treatment with neutral 2% NaF after irradiation with a C[O.sub.2] laser caused a remarkable increase in acid resistance of the enamel. Samples treated with neutral 2% NaF before irradiation showed a lesser effect [Kakade et al., 1996; Vitale et al., 2011].

Caries diagnosis. European clinicians no longer consider a sharp explorer to be an appropriate means of diagnosing occlusal caries because of the possibility of extending the lesion or inoculation of additional sites with cariogenic microorganisms [Pitts, 1993]. Micro-dentistry starts with refined diagnosis to allow earlier and smaller intervention resulting in a higher degree of conservation of tooth substance. For this, several tools were developed. Within the scope of this manuscript attention will be paid to two laser-based systems.

Based on earlier findings on the fluorescence of organic components of human teeth and the difference of this between sound and carious enamel, the subsequent use of an argon laser employed blue-green light in the 488nm wavelength [Bjelkhagen et al., 1982]. The technique was named quantitative light-induced fluorescence (QLF) or dye enhanced laser fluorescence (DELF) if a fluorescing dye was used. Both techniques seem to be adequate for the quantitative determination of caries as well as for occlusal and interproximal lesions [Eggertsson et al., 1999; Ferreira-Zandona et al., 1998; Stookey et al., 2000]. Further, it was concluded from an in vitro study that this QLF method of quantification of mineral loss in early carious lesions in primary teeth was slightly more accurate than in permanent teeth [Ando et al., 2001].

Searching for other excitation frequencies it was reported that at 638 or 655 nm, fluorescence intensity of caries can exceed that of sound enamel by more than one order of magnitude [Hibst, 1998]. Using this approach, a portable diode laser-based system has been developed: DIAGNOdent. An in vivo study [Lussi et al., 2001] showed that clinical inspection and analysis of bitewing radiographs exhibited statistically significant lower sensitivities (31-63%) than did the DIAGNOdent device (sensitivity > or = 92%). It is recommended that the laser device is used in the decision making process in relation to the diagnosis of occlusal caries as a second opinion in cases of doubt after visual inspection. An in vitro evaluation of diagnostic tools for diagnosis of occlusal caries in primary teeth revealed that DIAGNOdent showed a significantly improved ability (p<0.05) to detect dentinal lesions compared with visual inspection, probing and radiography. The intra-examiner kappa scores for this laser device were very high (>0.75) showing a great reproducibility [Lussi and Francesnut, 2003]. Considering the interproximal diagnosis and practical aspects of the devices see also Olivi and Genovese [2011] in this special issue.

Hard tissue ablation. An in vitro comparison of Er,Cr:YSGG laser irradiation and conventional bur in primary teeth it became clear that laser irradiation had minimal thermal damage to the surrounding tissues, minimal thermal induced changes of dental hard tissue compositions, and favourable surface characteristics [Hossain et al., 2002a]. The same investigators showed that laser cavity surface facilitated a good adhesion with composite resins and that the acid etch step could be easily avoided [Hossain et al., 2002b]. The latter recommendation became supported by the finding that microleakage of cavities prepared with lasers after composite resin restorations were better than by conventional burs using the dye penetration method [Kohara et al., 2002].

While there are an increasing number of papers on in vitro preparation, there are few reports of its clinical application. From a 3 year observation, after restoring cavities with light-cured composite resins (without etching or primer conditioning), it was concluded that an Er:YAG laser would be a useful alternative method for cavity preparation for these restorations in children [Kato et al., 2003]. Using pit and fissure sealing, the need for etching or not, related to micro-leakage has been extensively discussed in the literature and in more detail in the article by Olivi and Genovese [2011] herein.

Comfort of patients. In order to investigate patients' perception and response to cavity preparation, a direct comparison was made between conventional mechanical preparation and Er:YAG laser preparation in dental hard tissues [Keller et al., 1998]. Half of the preparations were completed by laser alone with standardised parameters, with the other half being mechanically prepared. The sequential order of treatment was randomised, and clinical parameters such as depth and location of the cavities were carefully balanced. While the patients' responses were scored as comfortable, uncomfortable, very uncomfortable they were also asked to decide which was the most uncomfortable form of treatment and the preferred method for future caries therapy. Laser treatment was found to be more comfortable than mechanical, which was highly significant. This finding was also confirmed in a split-mouth designed study where a laser energy of 1.25W was compared with a conventional drill in a population of anxious children [Ansari et al., 2002].

The use of the laser technology seems to have an improving role on children's clinical behaviour and cooperation during treatment. Furthermore comfort during cavity preparation is mostly influenced by vibration. An in vitro study using a laser Doppler vibrometer, concluded that the high-speed drilling causes greater tooth vibration and has a frequency spectrum near the high sensitivity of hearing compared with Er:YAG laser [Takamori et al., 2003] This suggests a potential factor in provoking pain and displeasure during tooth preparation is to be avoided especially in paediatric dentistry [see also Olivi and Genovese, 2011; Tanboga et al., 2011].

Endodontics in primary teeth. Pulpotomies in primary teeth are a common technique in children. An in vivo evaluation of pulpotomies with a C[O.sub.2] laser compared to formocresol revealed that the laser was superior to formocresol [Elliott et al., 1999]. Evaluating the effect of a C[O.sub.2] laser on vital pulp tissue it was found that the overall clinical success rate was 98.1% and the radiographic success was 91.8%. In that study, after pulpotomy, the haemostatic treatment of root pulp stumps was performed with a super-pulsed C[O.sub.2] laser with a 0.8mm ceramic tip for 2-5 secs. A laser power output of 3W was used to irradiate the pulp [Pescheck et al., 2002]. The laser treatment was followed by placement of zinc-oxide/ eugenol, Harvard cement and a preformed metal crown. It has to be said that no control group was used.

Dental traumatology. This is one of the main interests within paediatric dentistry. Over 75% of all trauma happens at the age of 8/9 years and mainly affects the maxillary central incisors. Although not very widely reported in the international literature several indications for laser use are given [Olivi et al., 2009]: tooth margin preparation, indirect or direct pulp capping, decontamination of infected root canals, treatment of soft tissue defects (after luxation), micro-gingival surgery, gingivectomy and surgical cutting (to remove a tooth fragment). This approach is further discussed within this issue [Caprioglio et al., 2011; Berk et al., 2011].

Monitoring long term pulp vitality is an important part of dental traumatology. Practitioners mostly combine the results of several sensitivity test completed with radiographs in order to make their diagnosis on tooth vitality. All these tests are on the one hand subjective and on the other hand there is a greater chance of under-diagnosis and consequently under treatment. Laser Doppler flowmetry (LDF) has been shown to measure the pulpal blood flow by means of blood perfusion (flux) and blood concentration, and thus the degree of vitality [Olgart et al., 1988; Gazelius et al., 1988]. On average, the output value for necrotic pulp was found to be lower than 43% of the value for vital pulp. The use of LDF in orthognatic surgery also demonstrated that a tooth without normal innervation could have an intact blood supply despite a negative response to other pulp tests [Ramsay et al., 1991; Dodson et al., 1994; Aanderud-Larsen et al., 1995]. In addition it was shown that a two-probe laser Doppler flowmetry assessment combined with simultaneous temperature measurements had an accuracy of 95%. This may be appropriate for an early and correct differential diagnosis and consequent treatment [Roeykens et al., 1999]. The use of LDF was illustrated in cases on revascularisation and studying the prognosis of luxated teeth [Andreasen et al., 1985; Mesaros and Trope, 1997]. In a study on primary incisors it was found that measuring the vascular integrity of traumatised teeth is superior to secondary evidence of neural conduction and radiographic signs. In this respect, LDF is thought to be the only technique that is objective, non-invasive, non-painful, direct, and acceptable to young children [Fratkin et al., 1999]. Using the two-probe LDF a well conducted 4 year follow-up study documented a patient suffering from a fracture line distally along the right central incisor combined with an intrusion of the maxillary left central incisor. A pathway of hyperaemia, ischaemia and restored vitality was shown within a period of 9 weeks [Roeykens et al., 2002]. Details of LDF application illustrating this technique is given elsewhere in this issue [Roeykens and De Moor, 2011].

Low level laser therapy (LLLT). This is also known as 'soft laser therapy' and 'bio-stimulation'. LLLT has been investigated and used clinically for over 30 years and started gaining popularity in Europe, Asia, South America and Australia. The ability to non-thermally and non-destructively change cell function is the basis for the current use of lasers in a number of medical fields [Walsh, 1997; Sun and Turner, 2004]. There have been publications pointing out the potential of LLLT to promote wound healing ([lambda] = 632.8nm and 780 to 900nm); to reduce pain and inflammation ([lambda] = 630 to 650nm and 780 to 900 nm), but the scientific evidence is rather poor. The mechanism behind the laser's interactions with biological tissues is still only partly understood. LLLT has an effect on enhanced synthesis of endorphins, decreased C-fibre activity, bradykinin and altered pain threshold. It may also have significant neuropharmacologic effects on the synthesis, release and metabolism of a range of neurochemicals, including serotonin and acetylcholine at the central level and histamine and prostagladins at the peripheral level. There are also significant increases in fibroblast production and activity which accelerates collagen synthesis. Recently, several studies have demonstrated the wide range of benefit of LLLT for biological tissues with their application in dentistry [Sun and Turner, 2004; Moshkova and Mayberry, 2005; Abramoff et al., 2008; Aras, 2010]. The following benefits have been described:

* cellular activation and increase of functional activity,

* stimulation of repair processes as a result of increased cell proliferation,

* anti-inflammatory effects,

* microcirculation activation and more efficient tissue metabolism,

* analgesic effects as a result of increased endorphin release,

* immunostimulation with correction of cellular and humoral immunity,

* increased anti-oxidant activity in the blood,

* stabilising lipid peroxidation in cell membranes,

* stimulation of erythropoiesis,

* vasodilatation,

* normalisation of the acid-base balance in blood,

* reflexogenic effect on the functional activity of different organs and systems.

A further contribution to this subject is given herein by Cauwels and Martens [2011] using LLLT in children suffering from cancer, and also by Rimulo et al. [2011] using LED.

Summary

The purpose of this manuscript was to review the literature and to define future perspectives for the scope of children's dentistry. Consecutively attention was paid to soft tissue surgery caries prevention and diagnosis, pit and fissure sealing, cavity preparation, comfort of the patient, endodontics in primary teeth, dental traumatology and long term vitality and finally LLLT. Table 1 gives an overview on the applicability in paediatric dentistry of most laser devices currently available. More scientific research, especially randomised clinical trials are needed. It can be concluded that for paediatric dentistry it is recommended that the DIAGNO-dent laser devices may be used in the decision-making process in relation to the diagnosis of caries as a second opinion in cases of doubt after visual inspection. Moreover its good reproducibility should enable this device to monitor the caries process over time. The use of Er:YAG avoids pain and without discomfort during cavity preparation. More in vivo research is needed to prove its usefulness in daily practice. In addition to the well-known pulp sensitivity tests, use of a Laser Doppler device has the potential to become part of standard vitality assessment especially after dental trauma. The use of laser devices seem to be very promising for pulpotomies and even superior compared with traditional therapies. KTP, C[O.sub.2] and diode lasers are recommended for treating periodontal problems and in cases of minor surgery. Although biological mechanisms are still not completely clear LLLT seems to have a significant future.

Conclusion

It can be stated that laser application in a number of types of soft tissue surgery in children has proven to be successful. Laser-assisted refined diagnosis of caries combined with the appropriate preventive adhesive dentistry after laser-assisted cavity preparation will further lead to the new wave of micro-dentistry based on 'filling without drilling'. Children are at the front line for receiving this kind of dentistry.

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L.C. Martens

Dept. Paediatric Dentistry, PaeCaMeD research group, Dental School, Ghent University, Ghent, Belgium.

Postal address: Prof L.C. Martens. Dept Paediatric Dentistry, De Pintelaan 187 (P8) B--9000 Ghent, Belgium.

Email: luc.martens@ugent.be
Table 1. Applicability of available laser devices for use
in paediatric dentistry.

Laser Device          Caries      Caries     Pit-Fissure   Haemostasis
                    Prevention   Diagnosis   And Cavity      During
                                             Preparation    Pulpotomy
ARGON                [check]

C[O.sub.2]           [check]                                 [check]

Er:YAG Er,Cr:YSGG                              [check]

Nd:YAG                                                       [check]

KTP

Laser Diode                       [check]
DIAGNOdent

Laser Diode

LASER DOPPLER
Flowmetry

Low Level Laser

Laser Device         Tooth     Soft Tissue   Biostimulation   Bleaching
                    Vitality     Surgery      Pain control

ARGON                            [check]

C[O.sub.2]                       [check]

Er:YAG Er,Cr:YSGG                [check]        [check]

Nd:YAG                           [check]

KTP                              [check]                       [check]

Laser Diode
DIAGNOdent

Laser Diode                      [check]

LASER DOPPLER       [check]
Flowmetry

Low Level Laser                                 [check]
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