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‫حاتم‬‫ا‬‫لبيطار‬
Role of laser in periapical lesion
ABSTRACT
The apicoplasty is one used surgical technique so that
periapicals
pathologies can be cured, when is practically impossible to
be decided for the
conventional endodontic treatment (21)
2
(xray for periapical lesions)
1
the only treatment for these cases is to
remove the source of pathosis
in the past it is done by making flap
3
(Diagram of flap)
(the surgical approaches)
2
One problem in cases of healing-resistant
periapical lesions is to eradicate the
contamination at the periapical area. This
contamination is due to the microbiological
biofilm formed by microorganisms and their
subproducts lodged in apical third of the root,
on both cementum and dentin surface.
Paraendodontic surgery consists of the
mechanical removal of harmful agents to
promote healing and periapical health.
4
(after suturing and postopertive x ray)
The purpose: of this study was to assess the
results of Er:YAG laser irradiation on the
apical root third of newly extracted teeth to
eliminate microbial contamination on root
apex surface. Apical irradiation was
performed with an
Er:YAG laser device using an experimental
contact tip, at 100 mJ, 10 Hz, 1 W, 39 J/cm²,
3 times on the target area. SEM analysis
showed the elimination of part of the
irradiated cementum and the formation of
small roughened without exposing the
5
subjacent dentin. Vaporization of the
remaining periodontal tissue and removal of
microbiological apical biofilm (MAB) were
also observed on theirradiated areas. Under
the tested conditions and based on the
findings of this study, Er:YAG laser may be
considered effective for removal of
microbiological apical biofilm.
4
Introduction
A periapical infection results from
microorganisms colonizing and settling at the
periapex. Endodontic therapy is the first step
to treat periapical lesions. However, in some
cases periapical lesions persist even after
proper treatment and retreatment of root
canals (1). Tronstad et al. (2) reported the
presence of periapical bacterial biofilm on
resistant periapical lesions (3). (4) suggested
that successful treatment is only possible
6
with total removal of the irritating agents.
Periapical surgery is indicated for cases with
no sign of healing after retreatment (5).
When the microbiological flora is not
eradicated with apicoectomy (6), apical
curettage can be used to remove infected
tissue around the apex. However, the
removal of infected cementum and
surrounding tissue is not easy, which may
explain the persistence of a small number of
lesions that do not heal even after apical
surgery (7). A report on the effect of ruby
lasers on dental hard tissue (8) led to several
studies on laser applications in
5
dentistry. Erbium yttrium aluminum garnet
(Er:YAG) laser of 2.94 µm wavelength is
strongly absorbed by water (9). It has been
used for various clinical dental treatments
with applications on hard tissues such as
apicoectomy (10), superficial calculus
removal (11,12) apical cementum removal
(13) and bactericidal action. This study
7
evaluated Er:YAG laser efficacy on
microbiological apical biofilm (MAB) and
infected cementum removal.
6
Material and Methods
Ten human teeth with periapical lesions
extracted were involved gauze soaked in
saline and stored in a sterile flask until use.
The teeth were fixed, submerged in flask with
water and irradiated with the laser using an
experimental chisel-shaped contact tip of
0.256 mm² (Morita Co., Kyoto, Japan).
This tip presents a specific energy
distribution pattern that allows wide and
highly diffused irradiation and was designed
to provide
8
uniform ablation of the target surface during
irradiation and to avoid energy concentration
The irradiation with this tip is about 80% of
energy concentration at the center of the
contact surface in comparison to the
conventional contact tip. An Erwin (Hoya and
Morita Co., Kyoto, Japan)
7
Er:YAG laser device of 2.94 µm wavelength
was used in this study. The specimens were
irradiated with 3.5 W peak power, 1 W
average
power, 100 mJ, 10 Hz, 39 J/cm² 3 times on
the apical 3 mm of the root at an agle of 60°
during approximately 3 s.
The lased specimens were dehydrated in
99.5% ethanol, critical-point dried (Hitachi-
9
HPC, Hitachi, Tokyo, Japan), suppter-coated
with gold using an ion coater (Eiko-IB-3, Eiko
Engineering, Ibaraki, Japan) and examined
under scanning electron microscopy at 25 kV.
8
Results
The results were based on a morphological
analysis of SEM micrographs. shows an
Er:YAG laser irradiated area on the apical root
third and irradiated and non-irradiated areas
with periodontal tissue . Morphological
changes can be observed on the apical
surface with slightly uneven superficial
formations . The irradiated area at high
magnification (3000X) shows vaporization of
microbio logical apical biofilm, periodontal
11
tissue and part of the cementum surface
without dentin exposure (D). At the same
magnification (3000X), shows a non-lased
area with biofilm firmly attached to root apex
surface. surface. and show the presence of
cocci and rods on the root surface in this
biofilm layer.
9
Discussion
The treatment of postendodontic therapy
failures is very difficult because periapical
lesions usually do not respond well to
mechanical, chemo-pharmacological and
irrigating
procedures. Therefore, several methods using
conventional intracanal therapy have been
evaluated to provide a successful healing.
Microorganisms have been found in
inflammatory periapical lesions (14,15) and
11
failure in endodontically retreated teeth with
periradicular lesions are due to resistant
microorganisms present in necrotic tissue
adjacent to the apical foramen and root
surface (2,16,17). Various reports quote
periapical bacteria plaque or bacterial biofilm.
Others consider bacteria a group of
microorganisms comprising fungi, yeasts and
bacteria. Treatment successful is achieved
only with removal of the irritating agents
(16). Surgical procedures, apicoectomy or
apical curettage have been suggested due to
inadequate eradication of
10
microorganisms even after proper root canal
treatment or retreatment. The goal of apical
curettage is to eliminate infected tissues
around the apex, but it is hard to know when
the infected tissues have been completely
removed with this technique. Failures
following apicoectomy are associated with
leakage and inadequately sealed retrograde
fillings (18), and microorganisms remain
near the resected area (6). The complete
therapeutic procedure aims to eliminate
apical periodontal infections with only access
to the main root canal and the canal system.
In addition to intracanal procedures, laser
irradiation has been presented as a promising
12
method for providing morphological changes
on dentin and cementum surfaces, as well as
for biofilm removal. Different types of dental
lasers have been used to obtain successful
results in the treatment of periapical lesion
(3,8,19). The Er:YAG laser has been recently
introduced to dentistry and has potential for
different clinical applications with excellent
results.
11
Studies have shown that dental
hard substances can be removed by pulsed
Er:YAG laser irradiation. The Er:YAG laser has
attracted attention due to its capacity for
ablating hard tissue with extremely small
thermal effects (16,20). The 2.94 µm
wavelength is highly
absorbed by water and thus causes little
damage on hard tissues. This laser causes
minimal or no pain and induces little
temperature rise, leading to safe clinical use.
The findings of this study showed that laser
irradiation of contaminated apical areas
allowed superficial vaporization of the
attached microorganisms .like in other
13
clinically tested situations. Another favorable
aspect was that the laser acted only on the
contaminated cementum surface not reaching
the underlying dentin.
In the irradiation, it is necessary to mention
that both microbiological apical biofilm and
infected cementum were vaporized creating a
morphologically
12
modified surface free of exposed dentin
tubules.
The findings: of the present study showed
that the Er:YAG laser may be considered an
effective tool for removal of apical biofilm.
However, further research must be
undertaken to evaluate its clinical use. The
following conclusions may be drawn: 1)
Removal of microbial apical biofilm from
irradiated areas of root surface confirmed the
potential of Erwin laser (Morita Co.'s Er:YAG
laser device) for microorganism control; 2)
Morphological changes with small roughened
areas on cementum surface without dentin
tubule exposure suggested that the
contaminated or infected cementum had been
vaporized; 3) Periodontal tissue on the apical
14
surface of irradiated areas also seemed to
have been vaporized.
13
References
1. Sundqvist G, Figdor D, Persson S, Sjögren
U. Microbiologic analysis of teeth with failed
endodontic treatment and outcome of
conservative re-treatment. Oral Surg.Oral
Med Oral Pathol Oral Radiol Endod
1998;85:86-93.
2. Tronstad L, Barnet F, Cervone F. Periapical
bacterial plaque in teeth refractory to
endodotic treatment. Endod Dent Traumatol
1990;6:73-77
3. Noguchi N, Nori Y, Narimatsu M, Ebisu S.
Identification and localization of
extraradicular biofilm-forming bacteria
associated with refractory endodontic
pathogens. Appl Environ Microbiol
2005;71:8738-8743
15
4. Lin LM, Gaengler P, Langeland K.
Periradicular curettage. Int Endod J
1996;29:220-227.
5. Cheung GS. Endodontic failures - changing
the approach. Int Dent J 1996;46:131-138
14
6. Samaranayake LP, Stassen LF, Still DM. A
microbiological study of pre- and
postoperative apicoectomy sites. Clin Oral
Investig 1997;1:77-80
7. Allen RK, Newton CW, Brown Jr CE. A
statistical analysis of surgical and
nonsurgical endodontic retreatment cases. J
Endod 1989;15:261-266.
8. Stern RH, Sognnaes RF. Laser beam effect
on dental hard tissue. J Dent Res
1964;43:873 (Abstract).
9. Hibst R, Keller U. Experimental studies of
the application of the Er:YAG laser on the
dental hard substances: I. Measurement of
the ablation rate. Lasers Surg Med
1989;9:338-344.
16
10. Komori T, Yokoyama K, Takato T,
Matsumoto K. Clinical application of the
Erbium YAG laser for apicoectomy. J Endod
1997;23:748-750
11. Leonardo MR, Rossi MA, Silva LA, Ito IY,
Bonifácio KC. EM evaluation of bacterial
biofilm and microorganisms on apical
external root surface on human teeth. J
Endod 2002;28:815-818
15
12. Theodoro LH, Haypek P, Bachmann L,
Garcia VG, Sampaio JE, Zezell DM
Eduardo CP. Effect of Er:YAG and diode laser
irradiation on the root surface: morphological
and thermal analysis. J Periodontol
2003;74:838-843
13. Watanabe H, Aoki A, Shikawa I. Clinical
evaluation for scaling with newly developed
Er:YAG laser. J Periodontol 1997;24:864.
14. Araki AT, Ibaraki Y, Lage-Marques JL,
Kawakami T, Matsuda K, Kataoka K. Study on
morphological changes of periapical
cementum irradiated by Er:YAG laser. In: 6th
International Congress on Laser in Dentistry.
Maui, Hawaii, USA; 1998. Abstract #95:48.
17
15. Tronstad L, Barnet F, Riso K, Slots J.
Extraradicular endodontic infections. Endod
Dent Traumatol 1987;3:86-90.
16. Lin LM, Pascon EA, Skribner J, Gaengler P,
Langeland K. Clinical, radiographic and
histopathological study of endodontic
treatment failures. Oral Surgery Oral Med
Oral Pathol 1991;71:603-611
16
17. Loncali G, Sem BH, Cankaya H. Scanning
electron microscopic observations of apical
root surfaces of teeth with apical
periodontitis. Endod Dent Traumatol
1996;12:70-76
18. Stabholz A, Khayat A, Weeks DA, Neev J,
Torabinejad M. Scanning Electron microscopic
study of the apical dentine surface lased with
Nd:YAG laser following apicoectomy and
retrofill. Int Endod Traumatol 1992;25:288-
291.
19. Aun CE, Lage-Marques JL, Gavini G,
Clasen NF, Matsumoto K. Morphological
analisis of retrofilled apical dentin surface
irradiated with CO2 laser. The International
18
Society of Optical Engineering (SPIE)
Proceedings; 1998;3248:223-229.
20. Paghdiwala AF. Root resection of
endodontically treated by erbium:YAG laser
radiation. J Endod 1993;19:91-94
21- APICOPLASTY Buco maxillofacial Surgeon formed in
the Specialization Course of Regional APCD of Bauru,
SP,Brazil.Titular professor of Anatomy of the USP of Bauru
and Professor of theSpecialization Course of the Regional
APCD of Bauru, SP, Brazil
17

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د حاتم البيطار استشاري وجراح الفم والاسنان 01005684344 اتصل للحجز بالعيادة Dr.Hatem EL-Bitar

  • 1. 1 ‫بحث‬‫دكتور‬ ‫حاتم‬‫ا‬‫لبيطار‬ Role of laser in periapical lesion ABSTRACT The apicoplasty is one used surgical technique so that periapicals pathologies can be cured, when is practically impossible to be decided for the conventional endodontic treatment (21)
  • 2. 2 (xray for periapical lesions) 1 the only treatment for these cases is to remove the source of pathosis in the past it is done by making flap
  • 3. 3 (Diagram of flap) (the surgical approaches) 2 One problem in cases of healing-resistant periapical lesions is to eradicate the contamination at the periapical area. This contamination is due to the microbiological biofilm formed by microorganisms and their subproducts lodged in apical third of the root, on both cementum and dentin surface. Paraendodontic surgery consists of the mechanical removal of harmful agents to promote healing and periapical health.
  • 4. 4 (after suturing and postopertive x ray) The purpose: of this study was to assess the results of Er:YAG laser irradiation on the apical root third of newly extracted teeth to eliminate microbial contamination on root apex surface. Apical irradiation was performed with an Er:YAG laser device using an experimental contact tip, at 100 mJ, 10 Hz, 1 W, 39 J/cm², 3 times on the target area. SEM analysis showed the elimination of part of the irradiated cementum and the formation of small roughened without exposing the
  • 5. 5 subjacent dentin. Vaporization of the remaining periodontal tissue and removal of microbiological apical biofilm (MAB) were also observed on theirradiated areas. Under the tested conditions and based on the findings of this study, Er:YAG laser may be considered effective for removal of microbiological apical biofilm. 4 Introduction A periapical infection results from microorganisms colonizing and settling at the periapex. Endodontic therapy is the first step to treat periapical lesions. However, in some cases periapical lesions persist even after proper treatment and retreatment of root canals (1). Tronstad et al. (2) reported the presence of periapical bacterial biofilm on resistant periapical lesions (3). (4) suggested that successful treatment is only possible
  • 6. 6 with total removal of the irritating agents. Periapical surgery is indicated for cases with no sign of healing after retreatment (5). When the microbiological flora is not eradicated with apicoectomy (6), apical curettage can be used to remove infected tissue around the apex. However, the removal of infected cementum and surrounding tissue is not easy, which may explain the persistence of a small number of lesions that do not heal even after apical surgery (7). A report on the effect of ruby lasers on dental hard tissue (8) led to several studies on laser applications in 5 dentistry. Erbium yttrium aluminum garnet (Er:YAG) laser of 2.94 µm wavelength is strongly absorbed by water (9). It has been used for various clinical dental treatments with applications on hard tissues such as apicoectomy (10), superficial calculus removal (11,12) apical cementum removal (13) and bactericidal action. This study
  • 7. 7 evaluated Er:YAG laser efficacy on microbiological apical biofilm (MAB) and infected cementum removal. 6 Material and Methods Ten human teeth with periapical lesions extracted were involved gauze soaked in saline and stored in a sterile flask until use. The teeth were fixed, submerged in flask with water and irradiated with the laser using an experimental chisel-shaped contact tip of 0.256 mm² (Morita Co., Kyoto, Japan). This tip presents a specific energy distribution pattern that allows wide and highly diffused irradiation and was designed to provide
  • 8. 8 uniform ablation of the target surface during irradiation and to avoid energy concentration The irradiation with this tip is about 80% of energy concentration at the center of the contact surface in comparison to the conventional contact tip. An Erwin (Hoya and Morita Co., Kyoto, Japan) 7 Er:YAG laser device of 2.94 µm wavelength was used in this study. The specimens were irradiated with 3.5 W peak power, 1 W average power, 100 mJ, 10 Hz, 39 J/cm² 3 times on the apical 3 mm of the root at an agle of 60° during approximately 3 s. The lased specimens were dehydrated in 99.5% ethanol, critical-point dried (Hitachi-
  • 9. 9 HPC, Hitachi, Tokyo, Japan), suppter-coated with gold using an ion coater (Eiko-IB-3, Eiko Engineering, Ibaraki, Japan) and examined under scanning electron microscopy at 25 kV. 8 Results The results were based on a morphological analysis of SEM micrographs. shows an Er:YAG laser irradiated area on the apical root third and irradiated and non-irradiated areas with periodontal tissue . Morphological changes can be observed on the apical surface with slightly uneven superficial formations . The irradiated area at high magnification (3000X) shows vaporization of microbio logical apical biofilm, periodontal
  • 10. 11 tissue and part of the cementum surface without dentin exposure (D). At the same magnification (3000X), shows a non-lased area with biofilm firmly attached to root apex surface. surface. and show the presence of cocci and rods on the root surface in this biofilm layer. 9 Discussion The treatment of postendodontic therapy failures is very difficult because periapical lesions usually do not respond well to mechanical, chemo-pharmacological and irrigating procedures. Therefore, several methods using conventional intracanal therapy have been evaluated to provide a successful healing. Microorganisms have been found in inflammatory periapical lesions (14,15) and
  • 11. 11 failure in endodontically retreated teeth with periradicular lesions are due to resistant microorganisms present in necrotic tissue adjacent to the apical foramen and root surface (2,16,17). Various reports quote periapical bacteria plaque or bacterial biofilm. Others consider bacteria a group of microorganisms comprising fungi, yeasts and bacteria. Treatment successful is achieved only with removal of the irritating agents (16). Surgical procedures, apicoectomy or apical curettage have been suggested due to inadequate eradication of 10 microorganisms even after proper root canal treatment or retreatment. The goal of apical curettage is to eliminate infected tissues around the apex, but it is hard to know when the infected tissues have been completely removed with this technique. Failures following apicoectomy are associated with leakage and inadequately sealed retrograde fillings (18), and microorganisms remain near the resected area (6). The complete therapeutic procedure aims to eliminate apical periodontal infections with only access to the main root canal and the canal system. In addition to intracanal procedures, laser irradiation has been presented as a promising
  • 12. 12 method for providing morphological changes on dentin and cementum surfaces, as well as for biofilm removal. Different types of dental lasers have been used to obtain successful results in the treatment of periapical lesion (3,8,19). The Er:YAG laser has been recently introduced to dentistry and has potential for different clinical applications with excellent results. 11 Studies have shown that dental hard substances can be removed by pulsed Er:YAG laser irradiation. The Er:YAG laser has attracted attention due to its capacity for ablating hard tissue with extremely small thermal effects (16,20). The 2.94 µm wavelength is highly absorbed by water and thus causes little damage on hard tissues. This laser causes minimal or no pain and induces little temperature rise, leading to safe clinical use. The findings of this study showed that laser irradiation of contaminated apical areas allowed superficial vaporization of the attached microorganisms .like in other
  • 13. 13 clinically tested situations. Another favorable aspect was that the laser acted only on the contaminated cementum surface not reaching the underlying dentin. In the irradiation, it is necessary to mention that both microbiological apical biofilm and infected cementum were vaporized creating a morphologically 12 modified surface free of exposed dentin tubules. The findings: of the present study showed that the Er:YAG laser may be considered an effective tool for removal of apical biofilm. However, further research must be undertaken to evaluate its clinical use. The following conclusions may be drawn: 1) Removal of microbial apical biofilm from irradiated areas of root surface confirmed the potential of Erwin laser (Morita Co.'s Er:YAG laser device) for microorganism control; 2) Morphological changes with small roughened areas on cementum surface without dentin tubule exposure suggested that the contaminated or infected cementum had been vaporized; 3) Periodontal tissue on the apical
  • 14. 14 surface of irradiated areas also seemed to have been vaporized. 13 References 1. Sundqvist G, Figdor D, Persson S, Sjögren U. Microbiologic analysis of teeth with failed endodontic treatment and outcome of conservative re-treatment. Oral Surg.Oral Med Oral Pathol Oral Radiol Endod 1998;85:86-93. 2. Tronstad L, Barnet F, Cervone F. Periapical bacterial plaque in teeth refractory to endodotic treatment. Endod Dent Traumatol 1990;6:73-77 3. Noguchi N, Nori Y, Narimatsu M, Ebisu S. Identification and localization of extraradicular biofilm-forming bacteria associated with refractory endodontic pathogens. Appl Environ Microbiol 2005;71:8738-8743
  • 15. 15 4. Lin LM, Gaengler P, Langeland K. Periradicular curettage. Int Endod J 1996;29:220-227. 5. Cheung GS. Endodontic failures - changing the approach. Int Dent J 1996;46:131-138 14 6. Samaranayake LP, Stassen LF, Still DM. A microbiological study of pre- and postoperative apicoectomy sites. Clin Oral Investig 1997;1:77-80 7. Allen RK, Newton CW, Brown Jr CE. A statistical analysis of surgical and nonsurgical endodontic retreatment cases. J Endod 1989;15:261-266. 8. Stern RH, Sognnaes RF. Laser beam effect on dental hard tissue. J Dent Res 1964;43:873 (Abstract). 9. Hibst R, Keller U. Experimental studies of the application of the Er:YAG laser on the dental hard substances: I. Measurement of the ablation rate. Lasers Surg Med 1989;9:338-344.
  • 16. 16 10. Komori T, Yokoyama K, Takato T, Matsumoto K. Clinical application of the Erbium YAG laser for apicoectomy. J Endod 1997;23:748-750 11. Leonardo MR, Rossi MA, Silva LA, Ito IY, Bonifácio KC. EM evaluation of bacterial biofilm and microorganisms on apical external root surface on human teeth. J Endod 2002;28:815-818 15 12. Theodoro LH, Haypek P, Bachmann L, Garcia VG, Sampaio JE, Zezell DM Eduardo CP. Effect of Er:YAG and diode laser irradiation on the root surface: morphological and thermal analysis. J Periodontol 2003;74:838-843 13. Watanabe H, Aoki A, Shikawa I. Clinical evaluation for scaling with newly developed Er:YAG laser. J Periodontol 1997;24:864. 14. Araki AT, Ibaraki Y, Lage-Marques JL, Kawakami T, Matsuda K, Kataoka K. Study on morphological changes of periapical cementum irradiated by Er:YAG laser. In: 6th International Congress on Laser in Dentistry. Maui, Hawaii, USA; 1998. Abstract #95:48.
  • 17. 17 15. Tronstad L, Barnet F, Riso K, Slots J. Extraradicular endodontic infections. Endod Dent Traumatol 1987;3:86-90. 16. Lin LM, Pascon EA, Skribner J, Gaengler P, Langeland K. Clinical, radiographic and histopathological study of endodontic treatment failures. Oral Surgery Oral Med Oral Pathol 1991;71:603-611 16 17. Loncali G, Sem BH, Cankaya H. Scanning electron microscopic observations of apical root surfaces of teeth with apical periodontitis. Endod Dent Traumatol 1996;12:70-76 18. Stabholz A, Khayat A, Weeks DA, Neev J, Torabinejad M. Scanning Electron microscopic study of the apical dentine surface lased with Nd:YAG laser following apicoectomy and retrofill. Int Endod Traumatol 1992;25:288- 291. 19. Aun CE, Lage-Marques JL, Gavini G, Clasen NF, Matsumoto K. Morphological analisis of retrofilled apical dentin surface irradiated with CO2 laser. The International
  • 18. 18 Society of Optical Engineering (SPIE) Proceedings; 1998;3248:223-229. 20. Paghdiwala AF. Root resection of endodontically treated by erbium:YAG laser radiation. J Endod 1993;19:91-94 21- APICOPLASTY Buco maxillofacial Surgeon formed in the Specialization Course of Regional APCD of Bauru, SP,Brazil.Titular professor of Anatomy of the USP of Bauru and Professor of theSpecialization Course of the Regional APCD of Bauru, SP, Brazil 17