Considerations regarding the use of laser technology in pediatric dentistry – an overview

Introduction

Given that tooth decay and untreated dental issues may have detrimental effects on children’s overall health and well-being, dental care and treatment are critical components of pediatric healthcare⁽¹⁾. Since the majority of research indicates that bacteria populate the mouth cavity during the first year of life⁽¹⁾, an oral examination at 1 years old may help prevent or reduce the incidence of oral disorders⁽²⁾.

A child’s visit to the dentist offers a particular psychological and behavioral experience, which could present a unique difficulty for the dentist when providing care⁽³⁾. Additionally, from a professional perspective, the main goals of dental care are to support community oral and dental health and foster the development of favorable dental attitudes⁽⁴⁾. To achieve these goals, dentists and pedodontists must meet specific requirements in order to offer efficient treatment techniques. Therefore, it is imperative to be conversant with the psychological, behavioral and physical demands of infancy; that being said, the importance of new and current technology, like lasers, cannot be overstated in this context.

LASER abbreviation stands for light amplification by stimulated emission of radiation^(5,6), being an electromagnetic energy that is distinct from regular unorganized radiant energy due to its unidirectional and monochromatic characteristics⁽⁶⁾. High-energy light beams can be transmitted and focused on a specified location with the use of lasers. This intense light beam has the potential to affect the organism chemically, mechanically and thermally⁽⁷⁾.

The use of various types of lasers in medicine has expanded to the point where several medical specialties, including ophthalmology and dermatology, now use them as the standard method of treatment for a variety of regular procedures⁽⁸⁾. Like other medical specialties, dentistry is developing at a similar rate and in a similar way⁽⁹⁾. In 1965, Sognaes and Stern proposed using lasers to prevent caries⁽⁹⁾; nevertheless, lasers were not widely used in dentistry until 1990⁽¹⁰⁾. The use of lasers in pediatric dentistry is relatively recent; these tools give pediatric dentists new ways to treat patients, essentially changing some treatment methods while supplementing others^(8,11,12).

The authors of this paper outline the benefits and uses of the most popular lasers in pediatric dentistry before making recommendations on how pedodontists might utilize this laser technology in a safe manner.

Main types of dental lasers

In dentistry, diodes (810-980 nm), CO₂ (10,600 nm) and the YAG family (2100-2940 nm), which includes Er:YAG, Er,Cr:YSGG, Hol:YAG and Nd:YAG, are the three primary types of lasers. These lasers emit a particular wavelength of light that is absorbed by particular tissues only. Because of the water absorption peak of YAG lasers, tissues’ water content volatilizes before structural damage occurs⁽¹³⁾.

Laser therapy is thought to be efficient and appropriate for treating a broad range of viral and inflammatory diseases. Furthermore, laser therapy can reduce the patients’ intraoperative and postoperative pain, as well as their physical and psychological stress. Upon reaching the tissue’s surface, laser energy may undergo various effects, such as reflection, scattering, absorption, or transmission to neighboring tissues.

The degree of absorption (that is, the depth to which a laser penetrates biological tissue) determines a laser’s performance among the four interactions in biological tissue. In general, the wavelength affects it. Generally speaking, there are two categories of lasers based on wavelength. One type of lasers are Nd:YAG and diode lasers, which have deep penetration and light that distributes throughout tissue. Another type are CO₂, Er:YAG and Er,Cr:YSGG, which absorb laser light into the superficial layer without scattering or penetrating deeper⁽¹⁴⁾.

The diode laser is becoming more and more popular due to the benefits it brings: minimally invasive interventions with a short recovery period, a wide range of uses in dentistry, pain therapy, and even whitening. This tool makes all procedures more precise and with less tissue damage.

It has FDA approval for three distinct treatment types: soft tissue surgery, biostimulation/pain therapy, and whitening. It can be safely used near dental work and implants. The diode laser can contour the tissue with minimal trauma and without necrosis, providing precise control and having a hemostatic effect. All these mean high patient’s comfort, reduced bleeding and faster recovery. Given the properties of the diode laser, a much smaller amount of anesthetic is required and, additionally, the tissue reacts better following the treatment.

The diode laser can be used in:

• surgery – for gingivectomies/gingivoplasties, periodontal curettages, excisions (fibromas, papillomas etc.), frenectomies, implant discoveries, biopsies, abscess incisions and drainage, hemostasia etc.;
• oral pathology and periodontics – treatment of oral/labial canker sores and hemangiomas, endodontic and periodontal decontamination, dental desensitization;
• pain therapy;
• teeth whitening (in just 20 minutes, with no sensitivity).

The diode laser can also be used pre-procedurally, to decontaminate the area. Due to the bactericidal effect, it can be used successfully in the case of periodontal disease and in laser-assisted periodontal therapy. The bactericidal effect makes it suitable for use before ultrasound descaling procedures. The gingiva is a tissue well irrigated with blood, which is why the use of the diode laser is the optimal option in the case of gingival remodeling. The situations that require such interventions are various, from gum removal to making room for an erupting molar, to frenectomy or for patients suffering from periodontal disease.

These are just some of the ranges of procedures it can be used for, but the most important thing to remember is that, by using the diode laser, healing is faster, and the postoperative pain and bleeding are significantly reduced.

CO₂ laser. Oral surgeons employ CO₂ lasers extensively, and they are the most widely used laser treating soft tissues in medicine and dentistry^(7,11). The wavelength at which CO₂ lasers operate is 10,600 nm^(7,15,16). CO₂ lasers are utilized in juvenile dentistry for a few soft tissue treatments, including gingivectomy, frenectomy, and the treatment of oral ulcerations⁽¹⁶⁾.

When applied to the base of the lesion, it causes the surgical region to contract, reducing its size and giving the dentist a clear working field, as well as real-time visual feedback⁽¹¹⁾. Pain following surgery is typically negligible or nonexistent⁽¹⁶⁾.

There are certain drawbacks to the CO₂ laser. Since it produces a lot of heat, the tissue is quickly carbonized⁽¹¹⁾; however, some newer models of CO₂ laser machines can also determine a few days delay in wound healing by using an ultrapulse mode which reduces carbonization⁽¹⁶⁾.

Erbium laser family (Er:YAG and Er,Cr:YSGG lasers). Since erbium lasers can treat both soft and hard tissues, they can be applied to a wide range of dental procedures for pediatric patients⁽¹⁰⁾.

The erbium laser is an excellent surgical instrument for children, as it facilitates quick wound healing^(2,5,6,8,11), it causes less discomfort following surgery, and requires very little regarding analgesics⁽¹²⁾. Because of their influence on coagulation, these lasers help to properly control bleeding during soft tissue surgeries^(5,6,8,11); additionally, sutures are not required^(6,11,17). The use of these lasers has been linked to reduced postoperative pain, edema, scar formation, and shrinking^{(2,5,6,8,17,18)}. The laser’s antibacterial and anti-inflammatory characteristics⁽⁸⁾ may enhance the prognosis following surgery^(11,17).

Diodes and NdYAG lasers are helpful in periodontal tissue therapy and in coagulation, because they have a peak in absorption in pigmented tissue⁽¹⁹⁾. Both the beam’s diameter and the amount of energy given to the optical resonator are adjustable by the operator. Additionally, the continuous or pulsed mode, relaxation times, and pulse duration can be adjusted as desired. This can regulate how the target tissue is affected.

Benefits of laser use in pediatric dentistry

Evidence suggests that lasers will remain an excellent tool in the dental industry, making them the most significant minimally invasive instruments in dentistry⁽²⁰⁾. For these reasons, laser surgery is better than scalpel surgery⁽⁷⁾. Using lasers for soft tissue surgery has several benefits: minimal postoperative pain and swelling, which promotes faster healing after surgery and less formation of scars; better cutting precision compared to using a scalpel; a visible cut and faster hemostasis because the laser plugs lymphatic and blood vessels; low risk of postoperative infections because the laser beam sterilizes the tissue while it cuts; and reduced scar formation and postoperative pain^(7,18).

Higher collagen fiber synthesis in the laser-irradiated tissues is thought to produce superior connective tissue remodeling and a more suitable healing process⁽¹⁸⁾. Blood seeping occurs after surgery when using conventional gingivectomy procedures, and local anesthetics are used⁽¹⁸⁾. By doing away with the necessity for a “knife”, lasers help the surgeon achieve the right hemostasis and lessen the discomfort and anxiety associated with such procedures for the patient⁽⁷⁾.

Pain and edema significantly reduce after a laser procedure, because histamine release is significantly lower than after utilizing a drill and scalpel⁽²⁰⁾. It has been shown that youngsters are more receptive to laser-assisted soft tissue operations⁽¹⁸⁾. Furthermore, a lot of patients are afraid of local anesthetic needles⁽⁷⁾, or they are afraid of the dental hand piece whining while they are having work done. The absence of local anesthetic injections^(8,18) and related discomfort during and after surgery is the laser’s greatest advantage for pediatric patients⁽¹⁸⁾.

As a result, many people having standard dental operations wouldn’t need to wait to “get numb” or obtain local anesthetics. Another benefit is the avoidance of local anesthetic usage^(9,12) which will help the pediatric dentist in behavior control⁽⁶⁾. Using laser procedures, pulp treatments and one-visit multi-quadrant restorations can also be completed. Little children who needed intraoral surgery had to go to the operating room in the past. It has been difficult for parents and doctors to send a newborn or a very young kid under general anesthesia for an elective surgical operation⁽²⁾. This is another issue that can be resolved with lasers. Particularly those with early childhood caries or multiple carious lesions benefit from this technique^(9,21).

Laser’s uses in children’s dentistry

In pediatric dentistry, lasers can be used for minimally invasive operations such as disease detection and prevention, tissue excision, and preservation of the remaining healthy tissues^(9,15).

Additionally, laser technology can be applied to various surgical or oral pathology treatment modalities, as well as to pulpotomy and pulpectomy^{(6,8,9,12,15)}. By reducing bacteria populations and increasing canal cleansing, a laser beam is sent into the root canals⁽⁸⁾. In the root canal, the bactericidal effect is roughly 99%⁽⁹⁾. Additionally, lasers can be utilized for various pediatric soft tissue treatments like operculectomy, frenectomy, and the exposure of unerupted teeth. They can also be used for certain oral pathologic disorders such as mucocele, fibroma, hemangioma, aphthous ulcers, pyogenic granuloma, and mucocele-like illnesses^(8,9,20,22). In order to precisely insert stainless steel crowns, which are frequently used to restore severely damaged molar teeth⁽²³⁾, superfluous gingiva can also be removed with a laser⁽²¹⁾.

Caries diagnosis

Kutsch used an argon laser to illuminate both healthy and caries-affected oral tissues. He saw that the afflic­ted tissues exhibited a strong reddish-orange color that made them easily distinguishable from the unaffected structures⁽²⁴⁾. Utilizing ultrasonic lasers based on ultrarapid pulses, which produce terahertz waves, is an additional diagnostic technique. A computer then captures and interprets the images produced by quantitative laser-type fluorescence, which uses the 488-nm argon-type laser to develop a blue light that irradiates the tooth surface. However, Hibst and Gall⁽²⁵⁾ have examined red spectrum light (655 nm) in great detail, which has led to the development of the KaVo DiagnoDent. The degree of carious damage is indicated on the monitor by a value between 0 and 99, that is displayed when the light emitted by the diode is directed towards the occlusal surface of the handpiece and then received.

Preventing dental decays

Reducing the degree of demineralization of dentin and enamel surfaces is one way these devices can be utilized to boost resistance to caries. According to Westerman⁽²⁶⁾, the argon laser also promotes fluoride absorption. CO₂ and Nd:YAG lasers were also investigated; by promoting uptake, these lasers enhanced the advantages of applying fluoride varnishes.

Taking out carious tissue

Using the ruby laser, Goldman^(27,28), Stern⁽²⁹⁾, Stern and Sogannaes⁽³⁰⁾, and Gordon⁽³¹⁾ conducted the first studies on caries eradication. Extensive dentine and enamel degradation was seen as a result of the incorrect specs being used. Several researchers have drawn attention to the fact that dentine repair is promoted, and cavities are sterilized following the use of the CO₂ laser⁽³²⁾. These days, Nd:YAG, Er,Cr:YSGG and Er:YAG lasers are the most often utilized for hard tissues. They remove the afflicted tissue selectively, block dentinal tubules, and shield pulp^(33,34).

Soft tissue surgery

Almost two decades have passed since lasers were first utilized in numerous fields of medicine for surgical purposes. In dentistry, the most common uses of lasers have been documented for soft tissue incisions and the controlled elimination of certain oral infections. When a newborn has feeding difficulties, a pediatric frenectomy can be performed; in children and adolescents, it can be used to treat speech impairments or orthodontic issues brought on by the frenum’s size or placement⁽³⁵⁾. All wavelengths are suitable for this purpose, but diodes, CO₂ and Nd:YAG lasers offer a further advantage due to their enhanced hemostatic capacity which is especially helpful for individuals with coagulation disorders^(36,37).

The molar is the tooth that is most frequently impac­ted by pericoronaritis of erupting teeth. This condition can cause discomfort, edema and congestion; however, the laser can be used to expose the crown of the affec­ted tooth. Its main benefit is that, most of the time, it doesn’t require the use of local anesthetics. However, care must be taken to ensure that the tooth beneath is not touched, because this could lead to enamel damage, which can be prevented with the right settings.

This technique makes it simple to remove hypertrophy gingival tissues (which etiology may include congenital, drug-related, or inadequate hygiene in orthodontic patients), with the major benefit being that there is no need to stitch the wound.

Clinical case

We present the case of an 18-month-old baby girl with bimaxillary gingival fibromatosis in temporary canine-molar area in a syndromic context (Ullrich syndrome), with feeding difficulties and gingival bleeding due to the hypertrophic gingival tissue (Figures 1 and 2).

 

 

Gingivectomy of hypertrophic tissue was recommen­ded in order to facilitate nutrition, hygiene and reducing inflammation, the risk of infection and the bleeding in the oral cavity. A diode laser with a 2.5 W, CW was used for the surgery, which had the benefit of excellent hemostasis on highly inflammatory tissue.

Similarly, within the oncological safety limits, lasers can be utilized to promptly and safely remove excisional samples, as well as fibrotic lesions and mucoceles. The diode laser is used to treat throat herpes and labia; some studies indicate a faster healing period^(38,39).

Tooth whitening

The primary mode of action is thermal: when laser light interacts with the bleaching gel, it is converted into heat, hastening the substance’s peroxide oxidation, which is the mechanism required to generate the whitening.

Dentine hypersensitivity treatment

The mechanism of action involves decreasing nerve transmission and causing analgesia by constricting or occluding dentinal tubules⁽⁴⁰⁾.

Analgesia

Although the exact mechanism by which the laser causes analgesia is unclear, scientists have theorized that interference from specific wavelengths to the sodium pump mechanism modifies the permeability of cell membranes, which in turn causes a transient alteration of neuronal nerve terminals by preventing the depolarization of the A and C fibers. The pulsed Nd:YAG laser was the most researched in order to achieve this.

Endodontic treatment

Lasers are now used in deep, hypersensitive cavities, as well as in pulpitis instances due to their benefits in dentinal tube closure and anesthetic action⁽⁴¹⁾. One benefit of using a laser is that it can be used to sterilize the pulp cavity and efficiently limit bleeding that appears after opening⁽⁴²⁾. Apply calcium hydroxide or MTA (mineral trioxide aggregate) after laser treatment to protect the pulp, and then use cement to create an appropriate sealing. After two years of research, Moritz et al. reported a 93% success rate in direct pulp capping using the CO₂ laser, indicating the value of this kind of laser in treatment⁽⁴³⁾.

Because of its unusual form, the laser is very helpful in treating difficult-to-reach canals, and it effectively disinfects diseased root canals. Nonvital teeth are more susceptible to fractures; still, there are current methods to strengthen their resistance with Nd:YAG or CO₂ type lasers. Apical resection failure is typically caused by microleakage; however, by sealing the exposed dentinal canals with a laser, the treatment’s success can be increased.

Photobiostimulation

An inventive technique called low-level laser treatment (LLLT) is used to promote tissue regeneration and lessen postoperative pain following specific surgical operations without having negative side effects^(44,45). The mechanism by which LLLT operates is called photobiostimulation, and it promotes the healing of soft tissues, lowers inflammation, offers nonpharmacological pain relief, strengthens the wound’s tensile strength, speeds up the healing process, and has analgesic effects due to increased endorphin release, immunostimulation, increased blood antioxidant activity, stabilizes lipid peroxidation in cell membranes, stimulates erythropoiesis, vasodilatation, and restores the acid-base balance.

But our understanding of the precise molecular pathways underlying photobiostimulation is still lacking. The synthesis, release and metabolism of various biochemical substances, such as increased production of endorphin and nitric oxide, inhibition of C-fiber afferent nerve depolarization, axonal sprouting and nerve cell regeneration, decreased levels of bradykinin, increased release of acetylcholine, or ion channel normalization, have all been proposed as mechanisms by which LLLT reduces pain^(46,47).

LLLT has been demonstrated to have the ability to lower pain, preserve the vitality of the dental pulp, promote healing, and minimize pulpal inflammation in a number of clinical and histological investigations examining its application to dental tissues. It is less invasive, it doesn’t require medication, it is affordable, and it hasn’t been associated with any negative effects^(48,49).

Discussion

The use of laser therapy in pediatric dentistry has many benefits, including: precise tissue removal because of an excellent view of the operator field; increased compliance (particularly in children) because rotative instruments do not cause vibrations; hemostatic effect by blocking blood vessels; wound sterilization due to the effect on microorganisms; reduced or absent postoperative pain because nerve endings are closed; excellent wound healing, resulting in no scarring after surgery; no need for sutures or dressings; decreased cariogenic activity of laser-prepared cavities; and shorter operating times.

The Academy of Laser Dentistry encourages the use of lasers in pediatric dentistry only when a properly trained and appropriately experienced dental professional applies them⁽⁹⁾, and it strongly advises that all providers be properly instructed and knowledgeable in their use of lasers⁽²⁾. Additionally, it is imperative that dentists take the usual safety measures for both themselves and their patients. These precautions include using high-speed oral evacuation equipment, wearing appropriate face masks and face shields, and using safety glasses, with the appropriate wavelength of laser light⁽²⁾. Dental professionals need to modify behavior management strategies in light of the emerging laser technologies⁽⁸⁾.

Moreover, the pediatric dentist should assess the efficacy, safety and effectiveness of various laser kinds, and choose the most appropriate one for each child’s dental procedure^(8,16,50).

Conclusions

Modern minimally invasive dentistry has a potential new specialty called pediatric laser dentistry, which makes it possible to provide better care for kids and teenagers in a practical “child-friendly” manner. Our patients and their parents are pleased with the technology. Additionally, using this innovative technology makes dental operations less stressful and more enjoyable. Professionals that are happy in their work are better able to assist pediatric dentistry patients in accepting the therapeutic procedure.

Taking into account everything said above, a laser could be a suitable substitute for a lot of traditional pediatric dentistry operations. Due to the laser’s minimum intrusion, children are often more cooperative during dental procedures. This improves the patients’ satisfaction and treatment quality for both parents and children.   

Corresponding author: Diana-Monica Preda E-mail: diana_monica_preda@yahoo.com

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.