The Journal of EVIDENCE-BASED DENTAL PRACTICE

ORIGINAL ARTICLE

ERBIUM LASER TECHNOLOGY VS

TRADITIONAL DRILLING FOR CARIES REMOVAL:
A SYSTEMATIC REVIEW WITH META-ANALYSIS

SIYING TAO, DDSa,b, LAN LI, MDSa,b, HE YUAN, DDS, PHDa,b, SIBEI TAO, MDc,
YIMING CHENG, MDc, LIBANG HE, DDS, PHDa,b, AND JIYAO LI, DDS, PHDa,b
a
State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu,
China
b
Department of Operative Dentistry and Endodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
c
Renal Division, Department of Internal Medicine, West China Hospital of Sichuan University, Chengdu, China

CORRESPONDING AUTHOR: ABSTRACT

Jiyao Li, Department of Operative
Dentistry and Endodontics, West
China Hospital of Stomatology, No. 14,
3rd section, Renmin Road South,
Chengdu 610041, Sichuan Province,
China.
E-mail: jiyaoliscu@163.com
KEYWORDS
Laser, Drilling, Caries
Conflict of Interest: The authors have no
actual or potential conflicts of interest.
Source of Funding: This work was
supported by the National Science &
Technology Pillar Program during
the 12th Five-year Plan Period of
China (grant number
20911BAZ03171); Science &
Technology People-benefit
Application Demonstration Project
of Chengdu (grant number 2014-
HM02-00041-SF).
Objective
The study aimed to assess the efficacy of erbium laser technology compared with
traditional drilling for caries removal.
Methods
A systematic search was conducted through Medline via PubMed, Embase,
Cochrane databases, CNKI till December 2016. Randomised controlled trials,
quasi-randomized controlled trials, or controlled clinical trials with data
comparing the efficacy of erbium laser technology versus traditional drilling for
caries removal were included.
Results
Fourteen studies were selected in our meta-analysis. Erbium laser technology
showed an increased time when removing caries compared with drilling (mean
difference: 3.48, 95% confidence interval: 1.90-5.06, P , .0001). However, erbium
laser technology reduced the requirement for local anesthesia (risk ratio: 0.28,
95% confidence interval: 0.13-0.62, P 5 .002). Erbium laser technology was also
not significantly different to traditional drilling with regard to restoration loss,
pulpal vitality, and postoperative sensitivity.
Conclusions
Erbium laser technology showed an increased time for cavity preparation
compared with traditional drilling. However, erbium laser technology reduced the
requirement for local anesthesia. There was no significant difference between
erbium laser technology and traditional drilling regarding restoration loss, pulpal
vitality, and postoperative sensitivity.

Received 19 March 2017; revised 9 INTRODUCTION

May 2017; accepted 9 May 2017

J Evid Base Dent Pract 2017: [324-334] C aries is an infectious bacterial disease that results in the localized dissolution
and destruction of dental hard tissues. The most common methods for
removing infected hard tissues involve the use of excavators and burs, which may
1532-3382/$36.00
remove the largest amount of sound tissue (overpreparation) or leave residue of a
ª 2017 Elsevier Inc. All
certain amount of carious tissue (underpreparation). Moreover, the process is un-
rights reserved.
doi: http://dx.doi.org/10.1016/ comfortable because the pressure and heat on pulp, the vibration, noise, and pain
j.jebdp.2017.05.004 make patients anxious; therefore, it is usually necessary to use local anesthesia,

324 Volume 17, Number 4


especially for children. Presently, the concepts of minimally
invasive treatment and preventive dentistry are gaining more
and more recognition by dentists.1 The minimally invasive
caries removal techniques include the use of air abrasion,2
new polymer prototype bur,3 chemomechanical agents,4
and lasers.5
Since the early days of laser use in dentistry by Goldman
et al.,6 there are different types of lasers used to remove
caries, such as ruby6; CO27; neodymium-doped yttrium
aluminum-garnet (Nd:YAG)8; argon fluoride (ArF) excimer9;
erbium, chromium, yttrium-scandium-gallium-garnet (Er,
Cr:YSGG)10; and erbium yttrium aluminum-garnet (Er:YAG)
lasers.11 The most popular one is the Er:YAG laser, which
was authorized for use on human teeth by the Food and
Drug Administration in 1997. The Er:YAG laser wavelength
(2940 nm) coincides with the peak of water absorption
and hydroxyl radicals of hydroxyapatite. Effective ablation
of the carious tissue occurs via microexplosions from the
evaporation of the water contained in the mineralized
tissue.12-14 The efficacy, efficiency, and patient comfort
level are the most important factors considered when
patients and dentists choose a method to remove dental
caries.
Currently, there are many published clinical trials comparing
the use of the erbium laser with the drill for caries removal.
However, the efficacy of the erbium laser is still controver-
sial. Some studies have shown a better outcome after laser
treatment,15 and some have found no significant difference
with regard to the clinical success between laser and drill.16
For the pain experienced during caries removal, some
dentists have reported that the laser was more
comfortable and reduced the use of local
anesthesia,15,17,18 whereas others have demonstrated that
the laser had contributed little in reducing patients’ pain
compared with conventional drilling.19
Therefore, we aim to undertake a systematic review and
meta-analysis of the published literature to determine
whether erbium laser, compared with traditional drilling, can
improve clinical success and reduce the use of local anes-
thesia. The treatment time of these 2 methods was esti-
mated concurrent to our other investigation. The study
protocols are shown in Supplementary Material 1.
MATERIALS AND METHODS
This meta-analysis was performed according to the
Preferred Reporting Items of Systematic Reviews and Meta-
Analyses (PRISMA) items.20 The PRISMA is a concise
checklist consisting of 27 items deemed essential for
reporting a clear and complete systematic review. The
PRISMA checklist of this meta-analysis can be seen in
Supplementary Material 2.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Literature Search
We identified relevant articles by searching MEDLINE via
PubMed, the Cochrane Library, EMBASE, and CNKI from
the earliest available data indexing to December 2016. Both
MeSH heading words and free-text words were included
during the literature search. The search equations used in
each database are elaborated in Supplementary Material 3.
Reference lists of relevant studies were examined manually
to identify additional eligible articles. The search
strategies were confirmed by experts, and all relevant
articles were scrutinized.
Selection Criteria
Types of studies
Data used in this meta-analysis were all from randomized
controlled trials (RCTs), quasi-RCTs, or controlled clinical
trials of parallel design that compared the effects of erbium
laser technology with traditional drilling/rotary instruments
for caries removal.
Types of Participants
This meta-analysis selected studies that involved individuals
with caries lesions. Individuals with symptoms/evidence of
pulpal or periapical lesions were excluded. Individuals with
systemic diseases were also excluded.
Types of Intervention
Erbium laser equipment vs traditional drilling for caries
removal was selected in our meta-analysis. Both Er:YAG and
Er, Cr:YSGG laser systems were included because they have
similar working principles. Both of their wavelengths coin-
cide with the maximum absorption by water molecules and
hydroxyl group in enamel and dentin.
Outcome Measures
Outcomes were evaluated during treatment or at follow-up
visits as follows: (1) time for cavity preparation; (2) local
anesthesia requirement; (3) subjective acceptance by pa-
tients; (4) restoration loss; (5) pulpal vitality; and (6) post-
operative sensitivity.
Data Extraction and Quality Assessment
Two authors of this article (S.T. and L.L.) conducted a liter-
ature search, selected studies, and conducted data extrac-
tion independently. On comparison of the 2 reviewers’
results, consensus was reached through discussion or by
consulting a third reviewer. Titles and abstracts of all rele-
vant studies were examined for the inclusion in our meta-
analysis, and full-text articles were also inspected, if neces-
sary. To extract data from each of the published studies
included in the review, a data extraction form was used.
Study characteristics, patient characteristics, and treatment
outcomes were extracted from each study included in our
review. The study characteristics included the first author,
December 2017 325
 The Journal of EVIDENCE-BASED DENTAL PRACTICE

publication date, countries where the studies were carried
out, sample size, follow-up period, type of intervention, and
type of control. The patient characteristics included clinical
features (location of the lesions) and demographic features
of the individuals at baseline.
The Cochrane Collaboration methodology21 was used to
assess the risk of bias of each study included in this meta-
analysis. The criteria were random sequence generation,
allocation concealment, blinding of participants, blinding of
outcome assessment, incomplete outcome data, selective
reporting, and other possible sources of bias (Table 1).
Statistical Analysis
We used inverse variance weighted random-effects analysis
with 95% confidence intervals (CIs) to estimate association
for all the studies included. The random-effects models
were used to measure the effect sizes because there was
heterogeneity in the treatment efficacy.22 Random-effects

Table 1. Ascertainment of the risk of bias in the included studies.

Random Blinding of Blinding of Other

sequence Allocation participants and outcome Incomplete Selective sources of Risk of
Study generation concealment personnel assessment outcome data reporting bias bias

Zhegova, ? ? 2 2 2 2 2 Unclear
201516

Belcheva, 2 ? ? 2 ? 2 2 Unclear
201432

Zhang, 2 ? 2 2 ? 2 2 Unclear
201317

Eren, ? ? 2 2 ? 2 2 Unclear
201326

Bohari, 2 1 ? ? 2 2 2 High
201224

Yazici, ? ? 2 2 2 2 2 Unclear
201027

Dommisch, ? ? ? 2 2 2 2 Unclear
200828

Liu, 200629 ? 2 2 2 ? 2 2 Unclear

DenBesten, ? ? ? 2 2 2 2 Unclear
200119

Hadley, ? ? 2 2 2 2 2 Unclear
200030

Evans, ? ? 2 ? 2 2 2 Unclear
200031

Keller, ? ? ? 2 2 2 2 Unclear
199833

Pelagalli, 2 2 2 2 2 2 2 Low
199725

He, 201315 2 2 2 2 2 2 2 Low

1, this item would increase the risk of bias; 2 means this item would decrease the risk of bias; ?, this item was not clearly reported in the study so that it
could not be assessed accurately.

326 Volume 17, Number 4


meta-analysis was performed to acquire estimates of out-
comes, and we presented the outcomes as mean differ-
ences (continuous outcomes, including time for cavity
preparation) or risk ratios (RRs, dichotomous outcomes,
including local anesthesia requirement, restoration loss,
pulpal vitality, and postoperative sensitivity) with 95%
CIs. We assessed heterogeneity using I2 statistical index,
and I2 . 50% represented a high heterogeneity.23 P , .05
was regarded statistically significant, apart from the
heterogeneity test where P , .1 was considered
statistically significant. All the analyses were conducted
using RevMan statistical software, version 5.3, provided by
the Cochrane Collaboration.
Sensitivity Analysis
To assess the robustness of our meta-analysis results,
sensitivity analysis was performed: (1) high-quality studies
versus vs low-quality studies and (2) studies with small
sample size vs studies with large sample size.
RESULTS
Search Results and Study Characteristics
We identified 536 studies in total, among which 83 were
duplicates. Four hundred fifty-three studies were assessed
Figure 1. Flow diagram of the literature search process. CCTs, controlled clinical trials; RCTs, randomized controlled
trials.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
for inclusion, and 14 studies were finally included in our
meta-analysis (Figure 1). Main characteristics of these 14
studies can be seen in Table 2. Table 1 shows the risk of
bias of each study included. One24 of these 14 studies
were at a high risk of bias, 215,25 studies were at a low risk
of bias, and the other 11 studies16-19,26-32 were at an
unclear risk of bias according to the Cochrane
Collaboration’s assessment.
Effectiveness of Treatment
Time for Cavity Preparation (minutes)
Six15,17,18,24,28,29 of the 14 studies reported time for cavity
preparation. All the 6 studies reported a shorter preparation
time using conventional rotary instruments than erbium
laser equipment. Heterogeneity of the 6 studies was indi-
cated to be significant (P , .01, I2 5 98%). Meta-analysis
manifested a significantly shorter time for cavity pre-
paration using conventional rotary instruments than erbium
laser equipment (mean difference: 3.48, 95% CI: 1.90-5.06,
P , .0001; Figure 2).
Local Anesthesia Requirement
Four studies15,17-19 compared patients’ requirement of local
anesthesia using 2 kinds of treatment. No evidence of
significant heterogeneity was found within these 4 studies
December 2017 327
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Volume 17, Number 4

The Journal of EVIDENCE-BASED DENTAL PRACTICE

Table 2. Main characteristics of included trials.

No. of Preparation Anesthesia Pulpal Postoperative

First author teeth Age time (min) requirement Restoration vitality sensitivity
(year, country/ (laser/ range Male Follow- Location of Intervention Control (laser/ (laser/ loss (laser/ (laser/ (laser/
area) control) (mean) (%) up lesions group group control) control) control) control) control)

Zhegova (2015, 58/58 6-16 y 42 2y cer, occ, pro Er: YAG laser bur n.r n.r 0/0 n.r 0/0
Bulgaria)16 (n.r)

Belcheva (2014, 45/45 6-12 y n.r – occ, pro Er:YAG laser bur n.r n.r n.r n.r n.r
Bulgaria)32 (7.42 y)

Zhang (2013, 60/60 3-15 y 39.60 3 mo n.r Er:YAG laser bur 6.4/3.9 1/4 2/1 n.r n.r
China)17 (8.6 y)

Eren (2013, 10/10 7-12 y 60 – occ Er,Cr:YSGG bur n.r n.r n.r n.r n.r
Turkey)26 (n.r) laser

Bohari (2012, 30/30 5-9 y n.r – occ Er:YAG laser bur 5.998/3.445 n.r n.r n.r n.r
India)24 (n.r)

Yazici (2010, 54/54 19-21 y 22.20 2y occ Er,Cr:YSGG bur n.r n.r 0/1 n.r 0/0
Turkey)27 (n.r) laser

Dommisch 102/102 22-56 y 53.80 – n.r Er:YAG laser bur 3/1.02 n.r n.r n.r n.r
(2008, (n.r)
Germany)28

Liu (2006, 40/40 3-12 y 50 – pro Er:YAG laser bur 2/1 n.r n.r n.r n.r
Taiwan)29 (6 y)

DenBesten 82/42 4-18 y 53 3 mo n.r Er:YAG laser bur n.r 4/11 1/0 1/1 1/1
(2001, USA)19 (10.4 y)

Hadley 75/75 20-84 y n.r 6 mo occ, buc, Er,Cr:YSGG bur n.r n.r 0/0 0/0 n.r
(2000, USA)30 (n.r) lin, pro laser

Evans 77/77 3.5-68 y n.r – n.r Er:YAG laser bur n.r n.r n.r n.r n.r
(2000, UK)31 (n.r)

Keller (1998, 97/97 18-72 y 47 – n.r Er:YAG laser bur 7.5/4.3 6/11 n.r 0/1 n.r
Germany)33 (32.8 y)
 The Journal of EVIDENCE-BASED DENTAL PRACTICE

(P 5 .30, I2 5 18%). A significant difference between the 2

buc, buccal; cer, cervical; Er: YAG laser, erbium: yttrium-aluminum-garnet laser, wavelength: 2.94 mm; Er, Cr: YSGG laser, erbium, chrome: yttrium-scandium-gallium-garnet laser, wavelength: 2.79 mm; lin,
kinds of treatment was noted. Fewer persons in the laser
2/2 group experienced pain during cavity preparation and
n.r

asked for the use of local anesthesia (RR: 0.28, 95% CI:
0.13-0.62, P 5 .002; Figure 3).

Subjective Acceptance by Patients

Two trials31,32 investigated subjective acceptance by pa-
1/1

0/0

tients of these 2 kinds of treatments. Belcheva et al.

demonstrated that erbium YAG laser had a better level of
subjective acceptance among patients compared with
conventional rotary instruments for caries removal. Vibra-
0/1
n.r

tion, sight, and sound, which were the most common

annoyance factors for patients during conventional cavity
preparation, were eliminated using laser technology. How-
ever, the study by Belcheva et al. reported that smell and
taste during laser preparation were increased compared
n.r

0/8

with drilling (prevalence of vibration in bur/laser group:

86.7%, 2.2%; prevalence of sight in bur/laser group: 40%,
20%; prevalence of sound in bur/laser group: 62.2%, 15.6%;
prevalence of smell in bur/laser group: 17.8%, 66.7%; and
14.7/4.7

prevalence of taste in bur/laser group: 22.2%, 42.2%). Evans

n.r

et al. also reported that laser technology showed a better

level of subjective acceptance compared with traditional
drilling among patients older than 10 years. Significantly
bur

bur

less vibration was felt during laser preparation than with

drilling, but treatment time was significantly longer in the
laser group. Smell, taste, and sound showed no significant
Er:YAG laser

Er:YAG laser

difference between the 2 groups in this study. Meta-analysis

could not be performed comparing subjective acceptance
of patients in 2 kinds of treatment because data available in
both studies were limited.
occ,buc,lin,
pro,cer

Restoration Loss
n.r

Six15-17,19,27,30 of the included 14 studies reported restoration

loss. Follow-up time in the studies of DenBesten et al.,19
Hadley et al.,30 He et al.,15 Yazici et al.,27 Zhang et al.,17
1y

1y

and Zhegova et al.16 was 3 months, 6 months, 1 year,

2 years, 3 months, and 2 years, respectively (Table 2).
34.20

lingual; n.r, not reported; occ, occlusal; pro, proximal.

Heterogeneity could not be observed among the 6 studies

37

(P 5 .73, I2 5 0%). There was no significant difference

between the 2 treatment groups considering restoration
12-60 y

18-60 y
(33.6 y)
(29 y)

loss (RR: 0.90, 95% CI: 0.21–3.84, P 5 .89; Figure 4).

Pulpal Vitality
Five trials15,19,25,30,33 assessed pulpal vitality. Follow-up time in
45/61

60/60

the studies of DenBesten et al.,19 Hadley et al.,30 He et al.,15

and Pelagall et al.25 was 3 months, 6 months, 1 year, and
1 year, respectively. Keller et al.33 tested pupal vitality
Pelagalli (1997,

immediately after the treatment (Table 2). Heterogeneity of

He (2013,

these 5 studies was not significant (P 5 .97, I2 5 0%). Meta-

China)15
USA)25

analysis did not show a statistically significant difference be-

tween the 2 kinds of treatment comparing pulpal vitality (RR:
0.46, 95% CI: 0.09-2.40, P 5 .35; Figure 5).

December 2017 329

 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Figure 2. Time for cavity preparation (minutes) in erbium laser treatment vs drilling treatment. CI, confidence interval;
SD, standard deviation.
Postoperative Sensitivity
Four studies15,16,19,27 evaluated postoperative sensitivity.
Follow-up time in the studies of DenBesten et al.,19 He
et al.,15 Yazici et al.,27 and Zhegova et al.16 was 3 months,
1 year, 2 years, and 2 years, respectively (Table 2). No
significant heterogeneity was found (P 5 .7, I2 5 0%).
Meta-analysis demonstrated no significant difference be-
tween the 2 treatment groups with regard to postoperative
sensitivity (RR: 0.80, 95% CI: 0.17-3.88, P 5 .78; Figure 6).
Sensitivity Analysis
We conducted sensitivity analysis for studies with large
sample size and low risk of bias. When eliminating trials with
small sample size or high risk of bias, all results were
consistent to the meta-analysis results using all 14 studies.
DISCUSSION
Various methods for caries removal have been used in
clinical practice in the hope of compensating for the nega-
tive aspects of traditional bur, such as pain, vibration, noise,
and risk of accidental damage to soft tissues or pulp during
Figure 3. Local anesthesia requirement in erbium laser treatment vs drilling treatment. CI, confidence interval; M-H,
MantelHaensze.
330 Volume 17, Number 4
cavity preparation. Erbium laser was first introduced in
restorative dentistry in 1989.33,34 After more than 2 decades
of research, it is now widely applied clinically. In vitro and
in vivo studies have shown mixed results and conclusions
about the effects of erbium laser on caries removal.35-40
Although there are still limited data to make a conclusion
at this moment in regard to subjective acceptance by pa-
tients, our meta-analysis concluded that erbium laser
equipment can reduce the use of local anesthesia during
caries removal. Therefore, it is more comfortable for patients
compared with dental drilling objectively speaking. How-
ever, it requires a longer cavity preparation time. The effi-
cacy from follow-up evaluations, including postoperative
sensitivity, pulpal vitality, and restoration loss, showed no
significant difference between these 2 methods. Several
other systematic reviews/meta-analyses41,42 have been
performed about laser technique in caries removal. They
supported the use of laser as an alternative option for caries
removal in pediatric dentistry, due to minimal invasion,
lower risk of pulp infection, and more cooperation from
children. Other methods to remove caries were also re-
ported. A meta-analysis43 suggested that Carisolv, a chemo-

Figure 4. Restoration loss in erbium laser treatment vs drilling treatment. CI, confidence interval; M-H,
MantelHaensze.
mechanical caries removal system, was an effective alter-
native. Ultrasonic instrumentation was found to be favorable
with regard to the reduced vibration and noise compared
with dental drilling.44 Other kinds of laser technology, such
as Nd:YAG laser, were also demonstrated to have
advantages, including minimal cellular destruction.45
Our review selected 14 studies comparing 2 methods of
caries removal applied in 1646 teeth with dental caries. This
sample size was sufficient to obtain robust conclusions.
Table 2 (main characteristics of included studies) and
Table 1 (risk of bias for each study) show the quality of
evidence in our meta-analysis. The sensitivity analysis out-
comes indicated that our meta-analysis results were of high
quality. We tried to avoid any possible source of bias by
following a rigid protocol. Two review authors screened
studies and extracted data independently, and any
disagreement was resolved either through discussion or by
consulting a third assessor. However, there are still some
Figure 5. Pulpal vitality in erbium laser treatment vs drilling treatment. CI, confidence interval; M-H, MantelHaensze.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
limitations. This review was limited by both the data quantity
and data type available till December 2016, like all other
meta-analyses. We converted time units in 2 studies24,29 to
make meta-analysis possible, which was a major risk source
that might lower the quantity of evidence. The effects of
other methods of caries removal (eg, Carisolv and air
abrasion) or other kinds of laser technology (eg, Nd:YAG
laser) were not discussed.
Cavity preparation time was longer using erbium laser
technology than using rotary instruments according to our
review. The high-speed bur ablation speed is approximately
10 times of that of the laser, and in dentin, the laser ablation
speed is approximately the same as a slow rotating bur,18
which can explain our results. Nevertheless, the outcome
of time for preparation indicated high heterogeneity.
Many factors can affect the time for caries removal, such
as patients’ age, carious site, carious area, carious stage,
and different energy settings for the laser equipment. We
December 2017 331
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Figure 6. Postoperative sensitivity in erbium laser treatment vs drilling treatment. CI, confidence interval; M-H,
MantelHaensze.
tried to conduct subgroup analyses according to different
factors, but high heterogeneity still existed, which
confirmed that there was more than 1 factor affecting
treatment time in each study included. The included
studies recruited both children and adults, but treatment
time for children is usually longer than for adults because
of their limited self-control abilities and lower tolerance of
pain. The carious site, area, and stage are also crucial pa-
rameters for caries removal time. Different energy settings
for laser equipment were suggested to cause different
treatment time.18,46 These are all possible sources of high
heterogeneity in our outcome of time for cavity preparation.
Pain when removing caries is a major complaint and a major
factor leading to fear of dental procedures, especially for
children and patients with deep caries lesions. Fewer pa-
tients required local anesthesia in the laser group compared
with the traditional drilling group according to our out-
comes, which suggested that laser technology can signifi-
cantly reduce pain during caries removal, thus increasing
patients’ subjective acceptance of treatment.31,32,47 Tradi-
tional drilling treatment removes caries through bur rota-
tion, which generates a lot of heat and vibration. These can
act on the nerve fibers of dentin to cause pain. But most of
the energy of the erbium laser is absorbed by water and
converted to kinetic energy, reducing pain. Moreover, it
possesses shallow force of penetration due to its noncontact
caries removal mode and high biocompatibility because
water is used as the energy mediator.48
There were no significant differences in our results between
the 2 methods with regard to retention rates of restoration,
suggesting that erbium laser may not negatively affect the
bonding performance of adhesives to dentin or enamel,
which was confirmed in 2 previous in vitro studies.49,50
Future long-term trials are needed to explore whether the
332 Volume 17, Number 4
bonding performance of adhesives can be improved in the
long run using erbium laser. No significant difference could
be detected between the 2 methods regarding post-
operative sensitivity and pulpal vitality in our meta-analysis,
indicating that erbium laser may not do more harm to pulpal
tissues than conventional drilling during caries removal. This
finding corresponded with conclusions of 2 previous animal
experiments.10,51 The power of the meta-analyses is limited
by the quantity of qualified studies; therefore, more future
studies are still needed.
Erbium laser technology is a safe and effective carious
removal method in clinical practice. According to our find-
ings, it can significantly reduce pain but requires a longer
treatment time. Dentists are encouraged to consider using
laser technology to remove caries, especially when treating
children, patients with deep caries, and patients with anxi-
ety. However, we still look forward to more well-designed
studies to confirm our results.
CONCLUSIONS
Erbium laser technology makes fewer patients suffer from
pain during caries removal compared with traditional dril-
ling, making it preferred by patients. However, a longer
treatment time is required for this method. There was no
significant difference between these 2 caries removal
methods considering postoperative sensitivity, pulpal vital-
ity, and restoration loss during follow-up. Further well-
designed, large-sample, long-term RCTs are needed to
strengthen our conclusions.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found at
http://dx.doi.org/10.1016/j.jebdp.2017.05.004.

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