diode lasers for pediatric endodontics: state‑of‑the‑art!

7© 2017 Journal of Dental Lasers | Published by Wolters Kluwer - Medknow

Introduction: Conventional chemomechanical debridement (CMD) of deciduousroot canals can significantly reduce the intracanal bacterial load but cannotassure predictable disinfection due to the inherent anatomical complexities.Newer methods are thus being employed to enhance the efficacy of pediatricendodontic disinfection, and the use of laser technology is at the forefront ofthis endeavor. Aim: The aim is to assess the efficacy of diode laser‑assisteddisinfection in comparison to conventional sodium hypochlorite (NaOCl) basedCMD in deciduous root canals.Materials and Methods:A total of 12 patientsaged5–8yearsofbothgenderswere selected.Local anesthesiawasadministeredand rubber dam isolation achieved.Access openingwasdone and the roof of thepulp chamber was removed.A sterile paper point compatible with the anatomicdiameter of the canal was introduced and left in place for 30 s (first sample)which was then transferred into an Eppendorf tube containing reduced transportfluidmedium.CMDwasperformedup to25numberK‑filewith intermittent 3%NaOCl irrigation. Post‑CMD, sterile number 25 paper points were introducedas above (second sample). Thereafter, an 810 nm diode laser (1W, CW) with aspecific endodontic E‑200 tip was introduced into the root canals 2 mm shortof the radiographic apex and was gently withdrawn in a helical zigzag motion.Another samplewas then taken using a sterileNo. 25 paper point (third sample)and transported to themicrobiological laboratory for culture.Results: Themeanreductionincolonyformingunitspostdiodelaserapplicationwasseentobe100%whencomparedto98.46%reductionafterCMDwith3%NaOCl.Conclusion:An810nmdiodelasercanbeusedasaneffectiveadjuncttoconventionalmethodsofdeciduousrootcanaldisinfection.

Keywords: Diode laser, root canal disinfection, sodium hypochlorite

Diode Lasers for Pediatric Endodontics: State‑of‑the‑Art!Rashmi G. Naik, G. A. Raviraj, Chandrashekar Murugesh Yavagal, Praveen Mandroli

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DOI: 10.4103/jdl.jdl_1_17

investigations have showcased its shortcomings dueto restrictions posed by a deeper penetration of thebacteria into anatomical complexities, namely, accessorycanals, apical branches, isthmuses, and dentinal tubules,particularly in the apical one‑third of a deciduous rootcanal.[3]

An ideal irrigation solution should be stronglyantimicrobial but not toxic to the periradicular tissueswhen extruded through the apical foramen.[4] Sodium

Original Article

Introduction

T he main goal of endodontic therapy in primaryteeth is to maintain an intact dental arch, a

healthy periodontium, and the vitality of the dental pulpwheneverpossible.[1]Thekeydeterminantsofthesuccessofsuchan interventiondependonahostof factorssuchasaccuratediagnosis, thoroughcanalcleaning,andmoreimportantly an irrigation protocol that is predictable.Alongwithprudentirrigationmethods,anoptimumusageof intracanal medicaments should also be consideredbeforetheultimateplacementofafinalrestoration.[2]

Although chemomechanical debridement (CMD) isan indispensable part of root canal therapy, several

MMNGHInstituteofDentalSciencesandResearchCentre,RajivGandhiUniversityofHealthSciences,Belagavi,Karnataka,India

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Address for correspondence: Dr. Rashmi G. Naik, MMNGH Institute of Dental Sciences and Research Centre, Rajiv

Gandhi University of Health Sciences, Belagavi, Karnataka, India. E-mail: [email protected]

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How to cite this article: Naik RG, Raviraj GA, Yavagal CM, Mandroli P. Diode lasers for pediatric endodontics: State-of-the-art!. J Dent Lasers 2017;11:7-13.

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Naik, et al.: Diode lasers for pediatric endodontics

8 Journal of Dental Lasers ¦ Volume 11 ¦ Issue 1 ¦ January-June 2017

hypochlorite(NaOCl)happenstobethemostcommonlyused irrigating solution. It acts as a potent antimicrobialagent and also has the ability to dissolve organiccomponents of dentin such as the pulpal remnants andcollagen. In addition, it is inexpensive, has a long shelflife, and is readily available. Although it is the mostcommonly used irrigant, it has an unpleasant odor andtaste, and its extrusion into periapical tissues can causeexcruciating pain, immediate swelling, and profusebleeding. When used in pediatrics, it can also damagepermanent tooth follicles, peripheral tissues, and oralmucosawhen used at full strength.[2] So to reduce theseside effects, there is a need to use the same irrigantat a lesser concentration in children but not with acompromiseinitsdisinfectingability.Thus,aconcurrentuseofasafeadjuvantwithitistheneedofthehour.

In this regard, laser‑assisted endodontic disinfectionhas gained significant acceptance. Although differentwavelengths could be used for this purpose, thenear‑infrared range from 810 to 980 nm is consideredmostsuitableduetoitsgreaterdepthofpenetration.[3]

Theuseof laser technology isnoninvasive,nonresistant,and extremely predictable.[5] Of the available options,the diode seems to be the most practical choice and isdefinitely worth considering for the aforementionedpurpose. These portable diodes have already provedtheir efficacy and versatility in several other clinicalapplications thus becoming commonplace at manycontemporary operatories. So considering these factors,the present investigation was planned to evaluate theefficacy of the 810 nm diode laser as an adjunct forendodonticdisinfectionofdeciduousrootcanals.

Material and MethodsThe study was conducted on 12 children of bothgenders in the age group of 5–8 years, recruited fromthe outpatient clinics of the Department of PediatricDentistry, Maratha Mandal’s Nathajirao G. HalgekarInstitute of Dental Sciences and Research Centre,Belagavi,Karnataka,India.

The study was approved by the Institutional ReviewBoard and Ethical Committee. Informed consent wasobtained from the parents and assentwas obtained fromthechildrenbeforethestartofthestudy.

TheinclusioncriteriaforthecaseswereinaccordancetoPinheiroetal.[6]whicharementionedbelow:1. Advancedcariouslesionsofdeciduousteethaffecting

the pulp evidenced by an intraoral periapicalradiograph

2. Deciduousteethwithatleast2/3ofrootlength3. Absence of internal or external pathological root

resorption

4. Absenceofinternaland/orexternalperforationinthefurcalarea

5. Children not having undergone any medicaltreatment/not having received antibiotics within90daysprecedingthestudy.

Theexclusioncriteriawereasfollows:1. Necroticpulps in teethwitharadiolucentarea in the

furcationrecommendedforexodontics2. Deciduous teeth with radicular resorption of more

thanhalfofthetotalrootlength3. Obliteratedrootcanals.

Clinical procedureLocal anesthesia was administered [Figure 1] withlignocaine (Lidayn, Health Biotech Ltd, Solan, India)and rubber dam (Hygenic, Coltene/Whaledent) wasplaced for isolation. Access opening was achieved,and the roof of the pulp chamber was removed witha spherical rotary round bur no. 2 [Figure 2]. Theroot length was measured with the help of digitalradiovisiography (X‑ray vision, SATELAC). A sterilepaper point compatible with the anatomic diameter ofthe root canal was introduced into each canal and leftin place for 30 s [Figure 3]. This was the first sample(Group 1) which was immediately transferred into anEppendorf tube containing reduced transportfluid (RTF)medium.[7] A number 10 K‑file (MANI, Inc., Japan)was used to negotiate the root canals and CMD wasperformed up to 25 number K‑file with intermittent3% NaOCl (Vensons, India) irrigation [Figure 4].Sterile number 25 paper points (MANI, Inc., Japan)were introduced into the debrided canals [Figure 5]and transferred into an Eppendorf tube containingRTF medium (second sample – Group 2).Thereafter, 810 nm diode laser (Elexxion, Germany)[Figures6and7]witha specificendodonticE‑series tipof200μmdiameter[Figure8]operatingat1W/CWwasintroduced into the rootcanals [Figure9]2mmshortof

Figure 1:Localanesthesiaadministration



9Journal of Dental Lasers ¦ Volume 11 ¦ Issue 1 ¦ January-June 2017

the radiographic apex.[8] While the laser was irradiated,the tip was gently withdrawn from the root canal in ahelical zigzag motion over 15 s, repeated for threecycles with intermittent 3% NaOCl irrigation. A third

sample was then taken using a sterile No. 25 paperpoint (Group3) [Figure10].All the samples transportedtomicrobiological laboratory [Figure 11] for the cultureofaerobicandanaerobicmicroorganisms.

Figure 2:Rubberdamplacementandaccessopening Figure 3:Collectionoffirstsample

Figure 6:LaserKit

Figure 4:Irrigationwith3%sodiumhypochlorite

Figure 7:“Elexxion”810nmDiodeLaser

Figure 5:Collectionofsecondsample




Microbiological sampling and cultureAll the samples were cultivated to detect the totalnumber of viable bacteria. Homogenization wasperformed for 3 min in a tube agitator [Figure 12].Sowing was performed using three aliquots seeded

with a micropipette onto the surface of blood agarplates (Himedia, India) [Figure 13]. The plates wereincubated in anaerobic jars (Oxoid Inc.) for 5 days at37°C in 85% nitrogen, 10% carbon dioxide, and 5%

Figure 9:IntroductionofDiodeLaserintotherootcanal

Figure 10:Collectionofthirdsample Figure 11:Eppendorftubescontainingsamples

Figure 12:Vortexingofsample Figure 13:Seedingonbloodagarplate

Figure 8:EndodonticE‑seriestip200μm




hydrogenatmosphere [Figure14].After5days, the totalnumbers of viable bacteria unit‑forming colonies (ufc)were determined for each sample [Figures 15 and 16]usingcolonycounterbyablindedassessor.[6]

Statistical analysisIBMStatisticalPackagefor theSocialSciencesstatisticsversion17.0wasusedandthedatawereanalyzedusingthe Friedman’s test followed by theWilcoxon test withthelevelofsignificancesetat P <0.05.

ResultsThe ufc/ml before CMD, after CMD using 3% NaOClandpostlasertreatmentareshowninTables1and2.Themean ufc/ml before CMD, post‑CMD with 3% NaOCland postlaser treatment are depicted inGraphs 1‑4.Themeanreductionintheufcpost‑CMDwith3%NaOClwasfound to be 98.46%,whereas themean reduction in theufc postlaser treatment was observed to be 100%. Thisdifferencewashighlystatisticallysignificant(P=0.028).

DiscussionThe elementary goal of any endodontic intervention isto prevent or cure periapical pathology by a maximalreduction in the number of causative pathogens. Thesuccess of endodontic therapy thus depends on theability to obtain a sterile root canal before obturationof the root canal space.This is achieved by appropriate

Figure 14:IncubationinanaerobicjarFigure 15: Colonies on mannitol salt agar plates before,postchemomechanicaldebridementandpostlaser,respectively

Figure 16:Culturedoneonmannitolsaltagar,bloodagar,Rogosaagarplates

Graph 1: Comparison of themean unit forming colonies before,postchemomechanicaldebridementwith3%sodiumhypochloriteandpostlasertreatmentusingdifferentculturemedia

Graph 2:Mean unit forming colonies before chemomechanicaldebridement

Graph 3:Meanunitformingcoloniespostchemomechanicaldebridementusing3%sodiumhypochlorite




chemo‑mechanical debridement of the root canalfollowedbyoptimalirrigationprotocol.[9]

Different irrigating solutions, namely, NaOCl,chlorhexidine, ethylenediaminetetraacetic acid, MTADetc., are used which result in a reduction of the totalmicrobial count with a modest drop in Enterococcus faecalis levels.[10] However, no irrigant till date hasmanaged tocompletelyeliminateall themicroorganismsfrominfectedrootcanals.[11]

Long‑term treatment failures and resistance toendodontic therapy are often observed when there is ahindrance to the complete depth of irrigant penetration.Moreover, microorganisms in the deeper layers ofdentin are not affected due to the insufficient depth ofpenetration of the irrigant.[12] Of all the technologicaladvances that have been tried to address the aboveshortcomings of conventional CMD, laser‑assisted

endodontic disinfection has gainedmaximal acceptance.It has been established that laser energy can eliminatemicroorganismsexistinginthecomplexanatomicalareassuchasaccessorycanals,apicalbranches,isthmuses,andlateral canals.[13] The present study thus focused on theevaluationoftheefficacyofan810nmdiodelaserwhenused as an adjunct to conventional CMD in deciduousroot canal disinfection. The choice of the wavelengthwas dictated by the superior disinfection rates reportedbysimilarstudieswhichhadusedthenearinfraredrangeoftheelectromagneticspectrum.[14]

Inthisstudy,98.46%ofdisinfectionwasachievedby3%NaOCl.Thiscouldbe justifiedbythefindingsofBeruttiwho had demonstrated that chemical disinfectants likeNaOClpenetratenomorethan130–300μmofdentin.[15]

Gutknecht et al. used diode laser for disinfection ofroot canals contaminated by E. faecalis to differingdentin thicknesses of up to 500 μ depth. The resultsdemonstrated that diode laser with 980 nm wavelengthcan eliminate bacteriawhich have penetrated to a depthof500μindentin.[16]

In another study conducted by Kreisler et al., GalliumAluminum Arsenide (diode 809 nm) laser was usedalone and in combination with NaOCl and oxygenatedwater.Laserparameterssetwerecontinuousmode(CW)at 1/5, 3 and 4/5Wpowerwith 20μ diameter fiber for

Table 1: Total viable microbiological count (ufc/ml) before chemomechanical debridement, postchemomechanical debridement and postlaser

Patient Before CMD (a) After CMD (b) Difference (a‑b) Percentage reduction Postlaser (c) Difference (a‑c) Percentage reduction1 250 2 248 99.2 0 250 100.02 92 3 89 96.7 0 92 100.03 135 2 133 98.5 0 135 100.04 258 2 256 99.2 0 258 100.05 97 1 96 98.9 0 97 100.06 60 1 59 98.3 0 60 100.07 248 2 246 99.1 0 248 100.08 94 1 93 98.9 0 94 100.09 58 2 56 96.5 0 58 100.010 137 2 135 98.5 0 137 100.011 155 1 154 99.3 0 155 100.012 200 3 197 98.5 0 200 100.0CMD=Chemomechanicaldebridement

Table 2: Mean viable microbiological counts (ufc/ml) before chemomechanical debridement, postchemomechanical debridement and postlaser

Before CMD (a) After CMD (b) Difference (a‑b) Percentage reduction Postlaser (c) Difference (a‑c) Percentage differenceMean 148.67 1.83 146.83 98.46 0 148.67 100SD 85.03 2.23 73.65 0.93 0 85.03 0Z ‑ ‑ 2.201 ‑ ‑ 2.201 ‑P ‑ ‑ 0.028 ‑ ‑ 0.028 ‑CMD=Chemomechanicaldebridement,SD=Standarddeviation

Graph 4:Meanunitformingcoloniespostlasertreatment




60 s and results showed that bacterial reduction wasmore remarkable in the group combining laser with anirrigating solution.[17] Hence, we used a similar protocolinconjunctionwith3%NaOCl.

The resultant 100% bacterial kill achieved in thepresent study further validate the outcomes of previousinterventions by Mehrvarzfar et al. who had suggestedthat a combination therapy of chemical irrigation andlaser irradiation could totally eliminate all root canalpathogens including the dreaded E. faecalis.[18] In asimilar study, the previous authors had also concludedthat laser irradiation following chemomechanicalirrigationwasmoreeffectivethanNaOClirrigationaloneforeliminatingE. faecalis.[19]

Conclusion/Limitations/Futuristic PerspectivesTheadjunctiveuseoflasershavetremendouslyinfluencedthe outcomes of conventional endodontic interventions.Accessibility to the formerly unreachable parts of theroot canal has now become commonplace with lasers.In this study, 100% canal disinfection was achieved byan 810 nmdiode laser, but further long‑term follow‑upsare needed. Furthermore, we need more research andmulticentric inputs before we could reach a consensustostandardizetheprotocolaswellasthesettingsneededto make this art and science of laser‑assisted pediatricendodontics,apredictableone!

Financial support and sponsorshipNil.

Conflicts of interestTherearenoconflictsofinterest.

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diode lasers for pediatric endodontics: state‑of‑the‑art!

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