Lakshmi A Shoba D Lakshmmarayanan L

152

Prevention of caries by pulsed CO, laser pre-treatment of enamel:

an in-vitro study
Lakshml A B

Shobha D b Lakshmtnarayanan L c Chennal

SAVEETHA DENTAL COLLEGE AND HOSPITAL

( The aim of the study was to assess the caries mh/b/tory

potent/a/ of carbon d/ox/de laser and explore the effect of
the number of pulses used to correlate canes rnhrbrtron
Canes free human mandibular molars were /rrad/ated wjth
carbon d/ox/de laser of wavelength 70 6pm at 5, 15, 25, 50
and 700 pulses Simulated canes lesions were allowed to
form by lmmersmg the teeth m art/f/Cal canes medium for
three weeks Thm sections of 75 microns were obtamed by
usmg hard tissue microtome These sectlons were observed
under polanzmg microscope, canes lesions were ldentlfied
and the/r depth was measured These values were subjected
to statlstlcal analysis The results showed that carbon d/ox/de
laser /rrad/abon can mh/b/t caries like /es/on upto 82 7%
and It was opt/ma/ at 25 pulses>

(J Indian Sot Pedo Prev Dent 2001; 19:4:152-156)

KEY WORDS : CO, laser, Pulses, Canes tnhlbltlon
LC

n ounce of prevention IS worth a pound of dental

cure IS a proven fact that has witnessed the tests of
ttme In providing a foundation for preventive dentistry
Dental canes IS a universal disease that ravages the
natural dentition Cartes I S perceived to be due to a
prolonged imbalance in the oral cavity such that factors
favouring demlnerallzatlon o f e n a m e l a n d d e n t i n
overwhelm factors that favour reminerallzatlon and repair
of these tissues
At the crystalline level mitlation of the canes process
may be invevitable, but progression from a microscopic
lesion to a clinically detectable lesion IS not a certalnlty,
because in Its early stages the process can be arrested
and a carious lesion may become Inactive2
There are various modalities of treatment for the
prevention of dental caries, among which the most
a

Post Graduate Student

Lecturer
I
Professor and Head Department of Conservatwe Dentistry and

Endodontics

I
I

commonly used methods Include application of fluorides,

pit and fissure sealants and more recently lasers
Laser therapy, which IS making its advances in dentistry
has been suggested and studied for more than 30 years3
The role of laser In prevention of canes has been explored
since 19724 From the 1960s to the early 198Os, dental
researchers continued to search for the type of laser
that might be more effective for limited hard tissue
procedures They were approved by the FDA (Food and
Drug Administration) in 19973 and included CO,, Nd
YAG and Argon laser The list of potential clintcal
application of laser to hard tissue include detection,
prevention and removal of canes, desensitization of dentin,
enamel etching, welding of ceramic materials to enamel,
osteoplasty and ostectomy4
Lasers have the ability to alter the surface of enamel
and increase Its resistance to acid demmerallzatlon CO,
laser showed promise in increasing the caries resistance
Several studies have demonstrated the potential of CO,
laser pretreatment of enamel in reducing caries formed
by acid induced dissolution Featherstone and Nelson
demonstrated the potential caries inhibitory effects of
pulsed CO, laser irradiation of enamel even at low pulses3
The variables involved to determine the potential optimum
laser Irradiation conditions that would be likely to inhibn
caries are wavelength energv level duration of pulse
number of pulses, beam size and repetition rate3
The aim of this study was to assess
1 The caries inhibitory potential of CO, laser
irradiation
2

The optimum number of pulses required to produce

canes inhibition

MATERIALS AND METHODS

36 extracted canes free human mandibular molars were
collected for the study The lingual surfaces of the teeth
were examined to ensure that they were free from canes

J lndlan

Sot Pedo Prev

153

Dent December 2001

I I
All the teeth were then coated with acrd resistant varmsh
except for 2 mm dtameter area on the lmgual surface.
Teeth were then drvrded mto 6 groups of 6 teeth each.
Group I served as control and the other groups were
subjected to laser rrradration.
Group
Group
Group
Group
Group
Group

I
II
III
IV
V
VI

Control
5 Pulses laser rrradiatron
15 Pulses laser irradiation
25 Pulses laser rrradratron
50 Pulses laser irradiation
100 Pulses laser rrradratron

All the parameters were kept constant for all groups

except for the number of pulses.
After laser irradiation the teeth were immersed for 3
weeks in beakers containing acid medium consisting of
artificial saliva (methyl cellulose and glycerine), 0 1 M
lactic acid The pH was adjusted to 4 5 with potasstum
hydroxide for the srmulated caries lesions to form
After this period the teeth were removed from the artificial
canes medium and washed with distilled water. The crown
portron of the teeth were sectioned from the root using
a diamond disc The crown portion of each tooth was
mounted in acrylic resin by using a special mould The
sectronmg of the crowns was done longrtudrnally in a
buccolmgual direction (parallel to the long axIs of the
tooth) to a thickness of 75 microns usmg a hard tissue
microtome These sections were mounted onto the glass
slide and examined by a polarizing microscope under
1 Ox magnification The canes lesions were rdentifred and
the depth of these lessons was measured for each section
in microns, photographs were taken simultaneously
The mean depth of the canes lesions for each group
were calculated and statistically evaluated by Mann
Whitney test and LSD test
I
1 Table shows the mean, standard deviation and
percentage inhibition of canes lesions in various
groups
2. It was found that the percentage mhrbrtron in,
i

Standard
Deviation

Groups

Mean

1150 00

II

583 33

49.2%

75 28

III

400 00

65.2%

89 44

IV

198 33

82.7%

53 07

200 00

82.6%

54 77

VI

200 00 *

82.6%

44 72

The exposed windows of teeth (2mm diameter) were

lrradrated with CO, laser of wavelength 10.6 pm, spot
size 2mm, 250mW energy per second pulse duratron
and a repetition rate of 1 Hz The total energy per pulse
was approximately 8J/Cm2 area (8 3J/cm2)

RESULTS AND DISCUSSION

Group
Group
Group
Group
Group

II
III
IV
V
VI

492%
65.2%
82 7%
826%
82 6%

% of Caries
Inhibition

339 12

/ -

I
1
I
I,

(See Fig l-6 for polarized light microscope pictures of

various groups E - enamel, D - Dentin, L - Body of the
lesion Arrows indicate the advancing front of the lesion).
Mann Whitney U test reveals there IS a highly significant
statrstrcal difference between all the groups at P<O 01
level except for groups IV and V,IV and VI, V and VI
which were not statistically srgnifrcatnt
LSD test also confirmed the results of Mann Whitney
test.
I
Enamel, dentrn and cementum are htghly substttuted
hydroxyapatite in which many calcium and phosphate
ions are replaced by impure ions such as sodrum and
carbonate, which IS better described as carbonated
apatite3 Removal and replacement of these acid
phosphate groups In the apatrte crystals restricted the
pattern of growth of the crystals, which results in formatron
of smaller crystals These smaller crystals were more
susceptible to acid solubility rendering them more
cariogen&
Changes in morphological and chemical characteristics
of the tooth structures are essential for prevention of
caries Many attempts have been made to alter the tooth
enamel to increase its resrstance to canes Of the various
preventive modalrtres available the most commonly used
methods include application of fluorides, sealants and
more recently the lasers.
A new era has begun in the use of lasers in dentistry

154

Lakshml A S h o b a 13 Lakshmmarayanan

Fig. 1 .

Group I (Control)

Fig. 2 :

Group-It (5 pulses CO, laser)

Fig. 3 .

Group-Ill (15 pulses CO, laser)

Fig. 4

Group-IV (25 pulses CO, laser)

Fig 5 .

Group-V (50 pulses CO, laser)

Fig. 6

Group-VI (100 pulses CO, laser)

155

J Indian Sot Pedo Prev Dent December 2001

especrally In regard to the hard trssues of the teeth The

use of lasers for early detection of cartes In con]unctron
with innovative methods for early canes intervention can
be dramatically exploited, thus preserving the tooth
structure and preventing further progression of dental
caries6
Several studies during the last 30 years have
demonstrated the potential of laser pre-treatment of
enamel to inhibit subsequent acid induced drssolutton
or artrfrcral canes like challenge in the laboratory. The
use of laser irradiation as a means of tnhrbrtrng dental
canes was first suggested by Stern and Sognnaes* Srmrlar
findings were later reported by Yamamoto, Ooya, and
satyr
Several mechanisms may contrrbute
caries resistance, including
a

to laser Induced

Physrcal changes achieved by melting the surface

through partial fusion and recrystallrzatron of the
enamel prisms making It less permeable for the
subsequent diffusion of ions into and from the
enamel

b Chemical alteration in the composrtron of mineral

phases with loss of carbonate, water and organic
substances from the enamel causing the formation
of microspaces
c Microspaces created in the mineral structure
provide a means for trapping calcium, phosphate
and fluoride ions released during demrneralrzatron,
causing them to act as sites for reprecrprtatron.
During demrneralrzatron dissolution of mineral
occurs with mobrlrzatron of calcium, phosphate
and fluoride ions from the affected dentin As
the mineral phases are released from deeper
layers of the dentin and cementum reprecrprtatron
in the more superficial layers occurs and the
surface remains intact If a microsieve network
IS established by laser irradiation, mineral phases
released from the deeper layers of dentin and
cementum may become trapped in this network
and impede lesion formation and progressionlo.
d Decreased permeability to acrds due to protein
denaturatron and swellrng, within enamel pores
resulting In caries rnhrbrtroniO
Dental hard trssues strongly absorb light In certain regrons
of the Infrared spectrum because of the crystal structure

In this study, the CO, laser was preferred as it produces

radiation which falls in the Infrared region and coincides
closely with the absorption bands of carbonated apatite.
Within the possible wavelenghts of CO, laser they
observed dramatic differences in the effect on the dental
enamel The wavelength 9 3 urn, and 10.3um produced
significant surface melting and crystal fusron, whereas
wavelength 10 6um appeared to have no crystal fusion
although it may have clmlcally and structurally altered
the composition of enamel crystals which were not
drstingutshable by SEM l2 Carbon droxrde laser absorptron
was found to be more effectrve at wavelength 9 3um
and 9 6pm resulting in higher surface temperatures which
caused surface melting and fusron of the enamel crystals.
Pogrel et al in their study on the structural changes In
the dental enamel by continuous wave CO, laser, observed
under SEM that the melted and recrystallized zone was
often thinner towards the crater and thicker In the center
In addition, there appeared to be arr bubble inclusions
which led to distortion of this zone Increasing Its
susceptrbtlrty t o acrds13
In this study, pulsed laser was preferred over continuous
mode because the former produces high peak energy
densities at the surface while minimizing the cumulative
energy deposition3
For a given pulse energy, shorter pulse time means
that, the peak deposited power densrty rncreasesll Hence
a longer interaction time of one second with a decrease
in power density was chosen for this study to make it
more clinically relevant as a caries preventive measure
In this study, the specimen were exposed to drfferent
number of pulses namely 5, 15, 25, 50 and 100 to
determine the optrmum number of pulses that result in
maximum inhibition.
The acid medium used in this study IS a valuable method
for the production of canes lrke lesions as It contains
organic and rnorganrc elements that acts as a substitute
for plaque occurring in-vrvo Moreover, the rate of lesson
formation IS comparable to those occurring rn-vrvo. The
pH of the medium was adjusted to 4.5 as thus was the
pH encountered during an in-vrvo acrd challenge14
In the present study, Groups IV, V and VI showed higher
canes inhibition than Groups II and III when compared
with the Control Group, which was statrstrcally srgnrfrcant
In thus study, increase in the number of pulses showed

156

Lakshmr A Shoba D Lakshmmarayanan L

Increased canes mhlbmon upto Group IV Highest caries

lnhtbltlon of 82 7% occurred In Group IV which was
exposed to 25 pulses Further increase in the number
of pulses in Group V and VI did not show any increase
in caries Inhibition3
I

The increased inhibition observed with increased number

of pulses was explained by ZVI Kantrow&! et al by carrying
out surface temperature measurements during and after
individual pulses Such measurements taken in similar
conditions has shown that the second pulse interacts
differently with the surface than the first pulse He further
explained that each pulse changes the optical and thermal
properties of the surface until a certain balance IS achieved
and further increase of energy density at this point does
not increase canes inhibitlon3

From this study it can be concluded that

1

3 Further increase in the number of pulses does

not increase the cartes inhibition

Gorge M , Gluck Warren M Morganstetn Jongs communrty

Powell inrtral drssolutron rate studies on dental enamel after

T Oho T Monoka A possible mechanism of acquired acid

resistance of human dental enamel by laser rrradratron Canes
Res

10

1990,

86-92

Gary H Westerman M John Hicks, Catherine M Flartz

Richard J Blankenau Lynn Powell Joel H Berh Argon laser
irradiation in root surface canes In vitro study examines laser
effects J Am Dent Assoc 1994, 125 401 407
D G A Nelson, M Shanatr R Glena C P Shrelds J D B
Featherstone Effect of pulsed low energy Infrared laser
irradiation on artrfrcal canes lake lesion formation Canes Res
1986, 20 289-299. _ ,

12

M MC Cormark D Fried J D B Featherstone, R E , Glean

and W Seka Scannrng electron microscope observation of
CO, laser effects on dental enamel J Dent Res 1995, 74
1702-l 708

13

M A Pogrel, P R Muff and G W Marshall Structural changes

in dental enamel induced by high energy continuous wave
13 890 896

14

J L Fox D Yu M Otosuka, WI Hrguchr,

rnhrbrtors

1992, 26 333-339

ZVI Kantrowrz, John D B Featherstone, Dantrel Fried Canes

Dependent on the number

Leo J Mrsekendrng, Robert M Pick Laser rn dentistry 1995

I
Dr A Lakshmr
D/o Dr A Lrnga Reddy
Kalyandurg (Post)

G S Ingram The role of carbonate In dental enamel Canes

Andhra Pradesh

Res 1973, 7 217-230

Pm-51 5 761

on the drssolutron of dental enamel Canes Res

Reprint requests to

Anantapur (Dust)

J Wong G

Powell Combrned effects of laser irradiation and chemical

Edwrna A M Krdd Sally Joyston Bechal Essentrals of dental

prevention by CO, laser treatment

24

canes 1997 2nd edrtron pg 1

of pulses used J Am Dent Assoc 1998, 129 585591

4

J L Fox D Yu M Otsuka WI Ghrguchr, J Wong , G L

CO, laser irradiation J Dent Res 1972 71 1389-l 398

dental health 1999, 4th Edrtron pg 144

W Sekea CO, laser inhibition of artrfrcal canes like lesion

carbon droxrde laser Lasers in Surgery and Medicine 1993

REFERENCES

J D B Featherstone N A Barrett D Fried, Z Kantorowrtz

formatron rn dental enamel J Dent Res 1998, 77 1397-l 403

Pulsed CO, laser pre-treatment of enamel surfaces

inhibits caries by as much as 82 7% of subsequent
caries like lesion progression

2 The inhibitory effect depends on the number of

pulses used and IS optimal at 25 pulses of laser
Irradiation.
I

11

Dental Clrnrcs of North America Laser light amplrfacatron in

dentistry 2000 October, 44(4)