Braz Dent J (2011) 22(5): 377-381 Apical dentin evaluation after laser irradiation ISSN 0103-6440

377

Nd:YAG Laser Irradiation Effect on

Apical Intracanal Dentin - A Microleakage
and SEM Evaluation
Cacio MOURA-NETTO1
Camila de A. B. GUGLIELMI2
Anna Carolina Volpi MELLO-MOURA2
Renato Miotto PALO3
Daniela Prócida RAGGIO2
Celso Luiz CALDEIRA1

1Departmentof Endodontics, Dental School, USP - University of São Paulo, São Paulo, SP, Brazil
2Department of Pediatric Dentistry, Dental School, USP - University of São Paulo, São Paulo, SP, Brazil
3Department of Endodontics, Dental School, UNESP - Univ. Estadual Paulista, São José dos Campos, SP, Brazil

The purpose of this in vitro study was to evaluate the effect of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser irradiation on
intracanal dentin surface by SEM analysis and its interference in the apical seal of filled canals. After endodontic treatment procedures,
34 maxillary human incisors were randomly assigned to 2 groups. In the negative control group (n=17), no additional treatment was
performed and teeth were filled with vertically condensed gutta-percha; in the laser-treated group (n=17), the root canals were irradiated
with Nd:YAG laser (1.5 W, 100 mJ, 15 Hz) before filling as described for the control group. Two specimens of each group were
prepared for SEM analysis to evaluate the presence and extent of morphological changes and removal of debris; the other specimens
were immersed in 0.5% methylene blue dye (pH 7.2) for 24 h for evaluation of the linear dye leakage at the apical third. SEM analysis
of the laser-treated group showed dentin fusion and resolidification without smear layer or debris. The Student’s t-test showed that the
laser-treated group had significantly less leakage in apical third than the control group. Within the limitations of this study, it may be
concluded that the morphological changes on the apical intraradicular dentin surface caused by Nd:YAG laser resulted in less linear
dye apical leakage.

Key Words: Endodontics, laser, apical leakage, intracanal irradiation.

INTRODUCTION traditional method for root canal preparation produces

a significant amount of smear layer that can adhere on
The fundamental part in endodontic therapy is the the dentinal walls, obliterating the dentinal tubules.
removal of inorganic and organic debris followed by the It thus reduces dentinal permeability and hinders
appropriate filling of the canal space in order to seal it off penetration of intracanal drugs into dentin, even when
from the surrounding oral tissues. The main purpose of chemical irrigation is used combined with mechanical
this last step is to achieve a complete seal that prevents instrumentation. It has been claimed that the incidence
bacterial leakage and a further recontamination of root of leakage is significantly reduced in the absence of
canal dentin in the entire root canal system, particularly smear layer and that smear layer removal is capable of
in the apical third. Apical leakage has been proven an enhancing seal ability and hence increasing resistance
important reason for root canal treatment failure and its to bacterial penetration (4).
occurrence is generally associated with deficient smear New techniques that may result in higher success
layer removal (1-3). rates have recently been developed and the use of lasers
A number of studies have demonstrated that the in Endodontics has appeared as an interesting adjunct to

Correspondence: Prof. Dr. Cacio Moura-Netto, Departamento de Endodontia, Faculdade de Odontologia, USP, Avenida Lineu Prestes, 2227, 05508-
000 São Paulo, SP, Brasil. Tel/Fax: +55-11-3091-7839. e-mail: caciomn@usp.br

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378 C. Moura-Netto et al.

root canal treatment, especially the neodymium-doped gutta-percha and AH Plus sealer (Dentsply, DeTrey,
yttrium aluminium garnet laser (Nd:YAG). Nd:YAG laser GmbH, Konstanz, Germany) using lateral condensation
can be absorbed by mineral structures, like phosphates technique immediately after instrumentation. The
and carbonate hydroxyapatite, and disrupts crystal endodontic sealer was mixed according to the
structures by thermochemical action. The morphological manufacturer’s instructions and placed into the canal
changes are characterized by melting and resolidification with a master gutta-percha cone. The master cone was
processes on dentin surface, which can improve sealing fitted to the working length and lateral condensation
ability and reduce dentinal permeability (5). was then carried out using accessory gutta-percha cones.
It has been verified that the use of Nd:YAG laser The excess of gutta-percha was removed with a heated
in combination with hand filing could produce clean root plugger and the remaining filling material was vertically
canals without smear layer and tissue remnants (6,7). condensed with a cold plugger.
Nd:YAG laser was capable of sealing the root canal In the laser-treated group, the root canal walls
wall dentin by deposition of glass-like materials and were irradiated with a Nd:YAG laser (Pulse Master
significantly reduced dentin permeability. More recently, 1000 IQ; American Dental Technologies, Southfield, MI,
it was also reported that high-level lasers were capable of USA), with a wavelength of 1,064 nm, at the following
improving apical seal, thus preventing microorganisms parameters: pulse duration 100 µs; energy per pulse 100
to invade the periradicular tissues (8-12). mJ; frequency 15 Hz and output power 1.5 W. The beam
The purpose of this study was to evaluate the was delivered through a 320-µm optical fiber.
effect of Nd:YAG laser irradiation on the intracanal Irradiation was executed by introducing the
dentin surface by SEM analysis and its interference in fiber-optic cable along the entire length of the root
the apical leakage of filled root canals. canal, irradiating all the dentinal walls from apical to
cervical region, with helicoidal movements at a speed
MATERIAL AND METHODS of 1 mm/s. This procedure was repeated 4 times. The
specimens were kept at room temperature for 20 s
This study was conducted after approval by the between each irradiation to prevent the temperature
Ethics Committee of FOUSP - University of São Paulo rise from exceeding the accepted allowance. After laser
(Protocol #92/2008). Thirty-four human maxillary irradiation, root canals were filled as described for the
incisors were obtained from the University’s Tooth Bank control group.
and radiographs were taken to verify the presence of any
anomaly in the pulp chamber or root canal. The teeth had SEM Analysis
their crowns sectioned at the cementoenamel junction
and root canal preparation was carried out using K-files Two roots of each group were prepared to SEM
and Endo-PTC lubricant (Fórmula e Ação, São Paulo, analysis, in order to verify the apical surface morphology
SP, Brazil) combined with 2.5% NaOCl. The working with and without Nd:YAG laser irradiation. The
length of each root canal was then established 1.0 mm teeth were split in the buccolingual direction and the
short of the apical foramen and apical preparation was sections were dehydrated by a series of graded ethanol
made with a #55 file. A final flush was done using 15 solutions, sputter-coated with gold and then examined
mL of 17% EDTA (Fórmula e Ação). with a scanning electron microscope (XL30; Philips,
After instrumentation, teeth were randomly Eindhoven, Netherlands). The dentin surface located
assigned into 2 groups: a negative control group (n=17), 3 mm short of the apex and equidistant from lateral
which received no treatment before root filling; and a walls was analyzed for the presence and extension of
laser-treated group (n=17), which was irradiated with morphological changes and removal of debris.
Nd:YAG laser before root filling. Two specimens of each
group were prepared for SEM analysis and the other Dye Penetration
15 were prepared for dye penetration test.
The remaining specimens were externally coated
Specimen Treatment with 2 layers of nail polish, except for apical 2 mm and
were immersed in 0.5% aqueous solution (pH=7.2) of
Root canals of the control group were filled with methylene blue (Fórmula e Ação) for 72 h at 37ºC and

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 Apical dentin evaluation after laser irradiation 379

100% of humidity. Thereafter, they were thoroughly issue in preventing leakage and possible reinfection of
rinsed in running water and embedded individually in root canal system. In this way, the importance of smear
stone cast blocks, which were then cut longitudinally. layer elimination to improve the success rate of filled
For analysis of dye penetration, images each teeth has already been established (1,2).
root half were taken with a digital camera attached to Several laser systems have been investigated in
a stereomicroscope (SMZ/2B; Nikon, Tokyo, Japan) Dentistry over almost 30 years and Nd:YAG laser is
under the same magnification. Linear dye penetration well established for endodontic purposes. Due to laser
was measured by a single operator, blinded regarding wavelength and to the flexible conductors, Nd:YAG
groups, using Image J 1.41 software (Wayne Rasband; laser can be used to stop bleeding after pulpectomy or
National Institutes of Health, Bethesda, MD, USA). apicoectomy, to improve disinfection of root canals
Data were subjected to statistical analysis using (13,14), and to remove smear layer and seal dentinal
Kolmogorov-Smirnov test for normality and then the tubules, thus reducing dentinal permeability (8,15).
Student’s t-test for independent variables was used at a In the present study, the laser-treated showed the
significance level of 5%. lower values of dye penetration than the control group.
The smear layer was probably fused and resolidificated
RESULTS together with root canal dentin after treatment with
Nd:YAG laser, acting as a single substrate. This
Student’s t-test showed that the laser-treated outcome is in agreement with results found in other
group presented significantly less linear dye leakage studies that investigated the occurrence of melting
(1.0 ± 0.41 mm) than control group (1.68 ± 0.45 mm) and recrystallization of smear layer using this type
(p=0.0002). of laser (5). The influence of Nd:YAG laser on apical
SEM analysis of control group showed the seal when used before root canal filling with different
surface free of smear layer and open dentinal tubules resin-based cements has also been studied. It has been
(Fig. 1A). In the laser-treated group, it was observed an found that Nd:YAG was able to reduced the marginal
irregular and non-uniform surface with dentin fusion permeability, regardless of the type of root canal filling
and resolidification without smear layer and debris (Fig. material used (12).
1B). Areas with some dentinal tubules overlapping the Goya et al. (8) demonstrated by SEM that
fused dentin areas could also be observed. Nd:YAG laser irradiation combined with black ink
increases the removal of smear layer and reduces apical
DISCUSSION leakage following filling significantly. After the laser
treatment, the smear layer was melted or had evaporated
Proper seal of the apical region is an important and leakage was observed in 20% of the specimens.

Figure 1. SEM micrographs. A = control group (CG). Dentinal surface free of smear layer and with open dentinal tubules; B =
experimental group (LG): Dentin fusion and resolidification after laser irradiation with no smear layer or debris.

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However, when black ink was used before irradiation, no removal through thermomechanical ablation (21,22).
leakage occurred. Black ink can be used in association Therefore dentinal tubule exposure, increased dentin
with Nd:YAG laser irradiation because its capable of permeability and smear layer removal are common
absorbing the laser beam in a higher proportion (16,17) outcomes associated with them.
and may enhance the laser effects. In the present study, The increase of permeability provided by Er:YAG
even though no dye was used, SEM analysis also revealed laser could be of interest for permitting a free passage of
melted surfaces with recrystallized areas in the laser- irrigant solutions through the dentinal tubules, promoting
treated group. a more effective cleanliness even though this benefit is
Park et al. (10) investigated the effect of Nd:YAG more associated with chemical-surgical preparation. On
laser irradiation on apical leakage of filled root canals the other hand, the decrease in permeability produced
using an electrochemical method. The electrical by Nd:YAG laser would be interesting at the end of
resistance between standard and experimental electrodes treatment, by promoting almost complete occlusion of
in the canals was measured over a period of 10 days. dentinal tubules before root canal filling. As different
This method could provide quantitative measurements of wavelengths cause distinct tissue interactions, the
apical leakage and the opportunity to study leakage over alterations in root canal morphology and permeability
a continuous time period. Although irradiated specimens promoted by each of them will determine its indication.
showed less leaked than the control specimens, as found Nd:YAG laser is capable of sealing dentinal tubules and
in our study, increasing apical leakage over time was this mechanism hinders the passage of fluids, promoting
observed in all groups. This results suggests that laser less leakage. It was likely the reason for the lowest rate
can prevent apical leakage in a certain degree although of apical leakage observed in the present study, which
it is difficult to complete inhibit its occurrence. corroborates with previous studies (23).
Various methods have been used to evaluate apical It should be noted that in addition to applications
seal after different root canal preparation techniques. related to the intracanal preparation, the bactericidal
Because of its sensitivity and simplicity of use, dye effect of high-level lasers is also interesting for the
penetration is commonly used as an indicator of apical success of endodontic treatment. Nevertheless, among
infiltration. The depth of dye penetration represents them, only the Nd:YAG laser can achieve a high degree
the space between the root filling and the canal walls. of decontamination, even in deeper dentin layers. In
The assessment of linear dye penetration apically or contrast to the radiation at higher wavelengths like those
coronally is the most common laboratory method for of the Er:YAG and the Er,Cr:YSGG lasers, the radiation
investigating the accommodation of a root filling to the of the Nd:YAG laser is poorly absorbed by dental hard
canal walls (18). As studies that use score systems are substances and therefore deeper penetration in the tissue
very subjective, in this study methylene blue infiltration can be expected (15).
was linearly measured to quantify apical leakage. Like Temperature elevation is an inherent characteristic
any other method, dye and tracing tests do not represent of high-level lasers and thermal damage is one of the most
or simulate the exact behavior of these surface treatments important issues to be considered in the use of laser for
on clinical conditions (18). The measurement of linear root canal treatment, so deleterious thermal effects to the
dye penetration analyses only one interface between tissues surrounding the tooth must be avoided. Although
dentin surface and filling material. However, since there temperature increase on root surfaces was not assessed
is no single universally accepted model of leakage testing in the present study, it has already been demonstrated
in Endodontics, this leakage test can be used to compare that the surrounding periodontal tissues are not damaged
the effect of laser intracanal irradiation. if the laser equipment is used within correct parameters
The less leakage observed in the laser-treated and when temperature increment on root surface does
group in the present study may be due to the significant not exceeds 10°C above body temperature for more
removal of the smear layer by Nd:YAG laser. It has than 1 min (24). Temperature elevation is a function
been reported that the removal of smear layer by lasers of output intensity and irradiation time. The setting
such as Er:YAG and Er,Cr:YSGG is greater than that parameters for the present study were based on those
promoted by Nd:YAG laser (19,20). Already established safely used for laser application in endodontic treatment
as a device for hard tissue preparation, these wavelengths for permanent teeth. In addition, to prevent excessive
are highly absorbed by water, which facilitates tissue temperature rising during irradiation, the delivery fiber

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was constantly moved over the irradiated surface and an 12. Moura-Netto C, de Freitas Carvalho C, de Moura AA, Davidowicz
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Received April 8, 2011
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Accepted August 10, 2011

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