clinical evaluation of er,crysgg and gaalas laser therapy

8/15/2019 Clinical Evaluation of Er,CrYSGG and GaAlAs Laser Therapy

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Clinical evaluation of Er,Cr:YSGG and GaAlAs laser therapy

for treating dentine hypersensitivity: A randomized

controlled clinical trial

Hasan Guney Yilmaz a,* , Sevcan Kurtulmus-Yilmaz b, Esra Cengiz c ,Hakan Bayindir a, Yasar Aykac d

a Department of Periodontology, Faculty of Dentistry, Near East University, Mersin 10, TurkeybDepartment of Prosthodontics, Faculty of Dentistry, Near East University, Mersin 10, TurkeycDepartment of Endodontics and Restorative Dentistry, Faculty of Dentistry, Near East University, Mersin 10, TurkeydDepartment of Periodontology, Faculty of Dentistry, Ankara University, Ankara, Turkey

1. Introduction

Dentine hypersensitivity (DH) is characterized by an acute,

non-spontaneous, short or long-lasting pain originating from

exposure of the dentine to thermal, chemical, mechanical, or

osmotic stimuli, which cannot be attributed to any other

dental pathology.1,2 Although different theories have been

proposed for the mechanism of DH, Bra ¨ nnstro ¨ m’s hydrody-

namic mechanism3 is the most widely accepted one. Accord-

ing to this theory, external stimuli cause movement of fluid

j o u r n a l o f d e n t i s t r y 3 9 ( 2 0 1 1 ) 2 4 9 – 2 5 4

a r t i c l e i n f o

Article history:

Received 25 November 2010

Received in revised form

21 December 2010

Accepted 7 January 2011

Keywords:

Laser therapy

Dentine hypersensitivity

Desensitizing agents

a b s t r a c t

Objective: The advent of dental lasers has raised another possible treatment option for

dentine hypersensitivity (DH) and has become a research interest in the last decades. The

aimof this randomized,controlled, double-blind, split mouth,clinical study was to evaluate

and compare the desensitizing effects of erbium, chromium-doped:yttrium, scandium,

gallium and garnet (Er,Cr:YSGG) to galium–aluminium–arsenide (GaAlAs) laser on DH.

Methods: Fifty-one patients participated in this study for a total of 174 teeth. DH was

assessed for all groups with a visual analog scale. For each patient, the teeth were

randomized to three groups. In the diode laser group, sensitive teeth were irradiated withthe GaAlAs laser at 8.5 J/cm2 energy density. In the Er,Cr:YSGG laser group, sensitive teeth

were irradiated with Er,Cr:YSGG laserin thehard tissue mode using a none-contact probe at

an energy level of 0.25 W and repetition rate of 20 Hz, 0% water and 10% air. In the control

group no treatment was performed. Treatment time was 60 s for GaAlAs laser and 30 s for

Er,Cr:YSGG laser.

Results: When compared with the control group and baseline data, in both laser groups,

laser irradiation provided a desensitizing effect immediately after treatment and this effect

was maintained throughout the study ( p < 0.05). No significant differences between

Er,Cr:YSGG and GaAlAs laser groups were found at any follow-up examination ( p > 0.05).

Conclusion: Based on these findings, it may be concluded that both Er,Cr:YSGG and GaAlAs

lasers were effective in the treatment of DH following a single application.

# 2011 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +90 5338328433; fax: +90 3926802025.E-mail address: [email protected] (H.G. Yilmaz).

a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m

journal homepage: www.intl.elsevierhealth.com/journals/jden

0300-5712/$ – see front matter # 2011 Elsevier Ltd. All rights reserved.

doi:10.1016/j.jdent.2011.01.003

http://dx.doi.org/10.1016/j.jdent.2011.01.003mailto:[email protected]://dx.doi.org/10.1016/j.jdent.2011.01.003http://dx.doi.org/10.1016/j.jdent.2011.01.003mailto:[email protected]://dx.doi.org/10.1016/j.jdent.2011.01.003


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inside dentinal tubules inwardly or outwardly, promoting

mechanical deformation of nerve endings at the pulp/dentine

interface, which is transmitted as a painful sensation. Under

normalconditions,dentine is covered by enamelor cementum

and is not sensitive to direct stimulation. DH occurs only with

the exposure of the peripheral terminations of dentinal

tubules.4 There are various treatment methods for DH and

the effectiveness of these methods is directly associated withtheir capacity to support the sealing of dentinal tubules to

prevent dentinal fluid flow or blocking nerve activity.5,6 The

agents most frequently used for DH treatment can be

classified as follows: protein precipitants, tubule-occluding

agents or tubule sealants.5

The use of lasers opens a new dimension in the treatment

of DH. Several different theories have been suggested to

explain the effect of laser irradiation on dentine, that involve

sealing of dentinal tubules by melting and re-crystallization

of dentine, evaporation of the dentinal fluid, analgesic effect

related to depressed nerve transmission or obliterating the

dentinal tubules with tertiary dentine production.7–9 Many

lasers, including helium–neon (He–Ne), neodymium-dope-d:yttrium, aluminium and garnet (Nd:YAG), erbium-dope-

d:YAG (Er:YAG) and carbon dioxide (CO2), have desensitizing

effects.6–8,10 Recently, the results of galium–aluminium–

arsenide (GaAlAs) diode laser irradiation in DH treatment

were successful in clinical trials.6,9,11 Erbium, chromium-

doped:yttrium, scandium, gallium and garnet (Er,Cr:YSGG)

laser is expected to show efficiency in dental applications.12–14 However, to the best of our knowledge, there are no

published data available concerning the clinical outcome of a

desensitizing treatment with an Er,Cr:YSGG laser. Therefore,

the aim of this in vivo study was to evaluate and compare the

desensitizing effects of Er,Cr:YSGG laser and GaAlAs diode

laser at 3-month follow-up. The study tested the nullhypotheses that laser treatment of dentine had no effect

on the level of DH of patients, and that the effect of a

Er,Cr:YSSG laser was notdifferent from that of a GaAlAsdiode

laser.

2. Materials and methods

2.1. Patient selection

Fifty-one patients (22 males and 29 females) with 174 teeth

affected by DH between the ages of 18 and 60 (mean age:

44 9.7 years) volunteered for this study. For inclusion inthe study the subjects had to have 3 or more hypersensitive

teeth in different quadrants. Exclusion criteria included

carious lesions on the selected or neighbouring teeth,

defective restorations, any professional desensitizing ther-

apy on the selected teeth during the last 6 months, use of

desensitizing toothpaste in the last 3 months; being under

analgesics/anti-inflammatory drugs at the time of the study,

pregnancy or smoking. After having received oral and

written information about the intention and the design of

the study, and having signed the informed consent form,

the subjects were included in the study. Study protocol and

related consent forms were approved by our Institutional

Review Board.

2.2. Evaluation of dentine hypersensitivity

The vitality of all experimental teeth was controlled at the

beginning and end of the trial by means of an electric pulp

tester (Digitest, Parkel, NY, USA). For 4 weeks before

treatment, all patients were enrolled in an oral hygiene

programme and received oral hygiene instructions on two

appointments as well as professional tooth cleaning accord-ing to individual needs. Prior to the application of lasers in all

groups, DH was assessed by an evaporative stimulus.A strong

air-blast from a dental syringe was directed to the exposed

cervical area for 3 s at a distance of 1 cm and at right angle to

the buccal site of the assigned teeth, whilst adjacent teeth

were isolated with cotton rolls. Air stimulus time was

controlled by a chronometer and the distance was measured

by a UNC-15 periodontal probe (Hu-Friedy, Chicago, IL, USA).

Patients were asked to record their overall sensitivity by

marking a point on a 10 cm visual analog scale (VAS),

anchored at each end by the phrases ‘‘No pain’’ and

‘‘Unbearable pain’’. All stimuli were given by one operator

in the same dental chair with the same equipment yielding similar air pressure (55–60 psi) and air temperature (21–22 8C)

each time.

2.3. Laser treatment

In thissplit-mouth study, for each patient, selected teeth were

randomly assigned to Er,Cr:YSGG laser group, GaAlAs diode

laser group or control group by the lottery method.In the diode

laser group, sensitive teeth were irradiated with the GaAlAs

laser (LaserSmile, Biolase Technology, Irvine, CA, USA) using

810 nm continuous waveform at 8.5 J/cm2 energy density. In

the Er,Cr:YSGG laser group, sensitive teeth were irradiated at

2780 nm with Er,Cr:YSGG laser (Waterlase MD, BiolaseTechnology, Irvine, CA, USA) in the hard tissue mode with

the MZ6 sapphire tip (600 mm diameter, 6 mm length) using

non-contact mode at an energy level of 0.25 W, repetition rate

of 20 pulses/s and pulse duration of 140 ms, 0% water and 10%

air. Treatment time was 60 s for GaAlAs laser and 30 s for

Er,Cr:YSGG laser by scanning the cervical part in an over-

lapping pattern. At the control group, no treatment was

performed. The patients did not know what kind of therapy

each tooth was receiving. All laser irradiations were per-

formed by thesameexaminer. If any subjects had more than 3

sensitive teeth, all teeth on the same side received the same

treatment. The effectiveness of all treatments was assessed at

four examination periods; immediately, at 1 week, 1 and 3months after treatment by one examiner who was not aware

of the type of treatment applied. All patients used a soft

toothbrush and toothpaste without any anti-hypersensitivity

agent. These products were provided by the researchers. In

addition, subjects were asked not to use any mouthrinse and/

or fluoride products during the study.

2.4. Sample size calculation

A minimum clinically significant difference in VAS scores of

0.6 was determined from the available literature on DH.15 The

power analysis was conducted based on this minimum

clinically significant difference in VAS scores, using alpha at



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level 0.05, at 80% power and a s of 1.16. On the basis of these

data, the numberof patients required to be enrolled to conduct

this study was calculated as 40.

2.5. Statistical analysis

Mean values of the clinical parameters were calculated for all

groups. Normality of the data distribution was checked by the

Kolmogorov–Smirnov test. Nonparametric tests were chosen

because the data were not distributed normally. Intra-group

time-dependent data were analysed by Friedman’s test, andWilcoxon’s rank sum testwas usedto evaluate the differences

within groups at each time point. Values of p < 0.05 were

accepted as statistically significant.

3. Results

All 51 patients completed the 3-month study period. Their

baseline demographic characteristics are presented in Table 1.

Thirty-eight percent of teeth were maxillary or mandibular

premolars, followed by mandibular central and mandibular

lateral incisors (Table 2). No complicationssuch as adverse pulp

effects were observed throughout the study. The response of the patients to the air stimuli throughout the study, and the

effects of treatments at the different time points can be seen in

Fig.1.Whencomparedwiththecontrolgroup,intheEr,Cr:YSGG

and GaAlAs laser groups, laser irradiation provided a desensi-

tizing effect immediately after treatment that was maintained

throughout the study ( p < 0.05) (Table 3). No significant

differences between the laser groups were found at any time

points ( p > 0.05) (Table 3). Intragroup comparisons revealed

that the differences between baseline scores and immediately,1 week, 1 and 3 months after treatment were statistically

significant in Er,Cr:YSGG and GaAlAs laser groups (Table 3). In

the control group no significant differences were found at the

intragroup comparisons (Table 3).

4. Discussion

Traditional DH treatment is based on the application of

desensitizing agents, which obliterates the dentinal tubules

exposed to the oral environment.12–14 Since the use of tubule

occlusive agents has some disadvantages such as need for

repeated applications, longer treatment time and patientcompliance, the need for use of alternative treatment

Table 1 – Demographic characteristics of patients.

Characteristics Data

Age (year)

Range 18–60

Mean 44

Standard deviation 9.7

Gender

Male 22Female 29

Table 2 – Distribution of teeth included the study.

Teeth Number of teethincluded in study

Maxillary central incisors 8

Maxillary lateral incisors 12

Maxillary canine 14

Maxillary premolars 34

Maxillary molars 10Mandibular central incisors 18

Mandibular lateral incisors 18

Mandibular canine 20

Mandibular premolars 32

Mandibular molars 8

[

Fig. 1 – Reduction of dentine hypersensitivity in all groups at 3-month follow-up.

j o u r n a l o f d e n t i s t r y 3 9 ( 2 0 1 1 ) 2 4 9 – 2 5 4 251


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modalities has arisen.14 With the development of laser

technology, a new treatment option for DH has occurred in

the last decade. Most experimental and clinical studies

regarding the effectiveness of low level laser therapy (LLLT)

on DH were performed using semiconductor diode lasers with

wavelengths in the range of 635–830 nm, and dosages in the

range of 2–10 J/cm2,6,11,16 GaAlAs laser irradiation at maximum

power of 60 mW does not affect the enamel or dentine surface

morphologically. However, a small fraction of the laser energy

at 830 nm wavelength is transmitted through dental hardtissues to reach the pulp. These lasers’ treatments have an

immediate analgesic effect by depressing nerve transmission.

According to physiological experiments, this immediate effect

of GaAlAs laser is caused by blocking the depolarization of C-

fibre afferents.6

In this clinical trial an Er,Cr:YSGG laser was also used for

the treatment of DH. The Er,Cr:YSGG laser is a relatively new

device which can ablate enamel and dentine due to its high

absorption in water and its strong absorption by hydroxyl

radicals existing in the hydroxyapatite structure.17–19 Earlier

studies showed that the Er,Cr:YSGG laser could create precise

hard tissue removal by the interaction of laser energy with

atomized water droplets at the tissue interface with theablation of hard tissue.17,18 Er,Cr:YSGG laser uses not only

existing water in tissue but also exogenic water for ablation.20

Since it has been reported that, the exogenous water has a

greater affect than endogenous water on the dentine abla-

tion,21 in the present study Er,Cr:YSGG laser was used without

water. The results of a previous study22 showed that

carbonization occurred even at 0.5 W when Er,Cr:YSGG laser

was used without water. Therefore, the energy settings of the

present study were lower than the threshold for carboniza-

tion, melting and surface roughness. The high absorption of

the Er,Cr:YSGG laser emission wavelength (2.78 mm) in water

may result in the deposition of insoluble salts from the

exposed tubules by evaporation of the dentinal fluid. Thus, itcould be suggested that this deposition is responsible for

obturation of the dentinal tubules and reducing DH. Er:YAG

laser has similar effects with Er,Cr:YSGG laser since its

wavelength (2.94 mm) is very close to that of the Er,Cr:YSGG

laser.17 Schwarz et al.8 theorized that Er:YAG shows its

immediate efficiency on DH using the above-mentioned

mechanism. Another possible mechanism of the Er,Cr:YSGG

laser on DH is its effect on the neural receptor TRPVl which is

known to be stimulated by heat. Anecdotal reports in dentistry

have suggested that the Er,Cr:YSGG laser may assist in local

anaesthesia on a short-term basis.23,24 Park et al.25 reported

that thermal-sensitive TRPs in dental sensory nerves may

serve as tooth pain sensors. Thus, Er,Cr:YSGG laser treatment

may cause dental analgesia via TRPVl inhibition. In a recent

paper, Ryu et al.26 tested the effects of a Er,Cr:YSGG laser (the

same as was used in the current study) at energies similar to

those used in the current study, on cultured trigeminal

neurons and cell cultures overexpressing TRPVl. They also

used the laser on TRPV1 knockout mice vs. control mice,

injected in the hindpaw with 0.33 mM capsaicin, the essence

of hot peppers. In normal animals, this substance elicits

intense hindpaw linking/shaking responses. When they used

the water cooled Er,Cr:YSGG laser to treat the capsaicin-treated site, the mice showed significant reductions in pain-

related behaviour. Similar laser treatment of TRPV1 knockout

mice did not show any analgesia. The authors speculated that

the laser actsdirectly on the TRPV channelfunction in sensory

neurons rather than by damaging cells. The high bactericidal

potential of Er,Cr:YSGG laser27 is also important since bacteria

have theability to lower pain thresholds in sensitive teeth as a

result of increased inflammatory mediator synthesis.28 Re-

cently Franzen et al.29 reported that, Er,Cr:YSGG laser

irradiation at 0.25 W without water spray reduced micro-

organisms on dentine surfaces without signs of carbonization

or melting. In this clinical trial, both Er,Cr:YSGG and GaAlAs

lasers produced immediate desensitizing effects after a singletreatment.

The long-term duration of desensitizing effectsis as critical

as the rapid reduction of DH. Previous studies reported that

the effects of many topical desensitizing agents, dentifrices,

and products containing ferric aluminium and potassium

oxalates are not permanent, because they do not adhere to the

dentine surface.30 However, histological studies have reported

that when the diode laser is used with correct parameters,

besides the immediate analgesic effect, pulpal hard tissue

formation is enhanced as a reaction to laser light in the dental

pulp over a long time period.31,32 Stimulation of odontoblasts,

production of reactionary irregular dentine and obliteration of

dentinal tubules provoked by diode laser may be reasons forthe prolonged suppression of pain in DH.16 Er,Cr:YSGG laser

light is more highly absorbed by OH ions than water molecules

so Er,Cr:YSGG laser can cause a rise in surface temperature

and thuschange the mineral content of enamel and dentine.33

Recently, de Freitas et al.34 indicated that low power laser

irradiation with the Er,Cr:YSGG laser at 0.25 W or 0.5 W can be

an alternative to the use of fluoride for the caries preventive

treatment. They stated that, this irradiation was claimed to

make the surface more resistant to acid as a result of chemical

alterations in the enamel structure. Thus, the authors

speculate that Er,Cr:YSGG laser reduces DH in long-term

due to the caries preventive and solubility reducing effects on

dental hard tissues. The current study demonstrated that,

Table 3 – Mean degree of VAS scores and standard deviation in all groups over 3 months.

Group Baseline Immediate Week 1 Month 1 Month 3

Er.Cr:YSGG 7.2 1.4 1.5 1.4*,# 1.2 1.1*,# 1.1 1.2*,# 1 1.1*,#

GaAlAs 7.1 1.3 1.7 1.3y,# 1.6 1.3y,# 1.2 1.2y,# 1.1 1.1y,#

Control 6.9 1.4 6.6 1.6 6.5 1.5 6.6 1.4 6.4 1.4

* Post treatment VAS scores were lower than baseline VAS scores at Er,Cr:YSGG group, p < 0.05, Friedman’s test.y Post treatment VAS scores were lower than baseline VAS scores at GaAlAs group, p < 0.05, Friedman’s test.# The differences at immediate, 1 week, 1 and 3 months after treatment were statistically significant between laser groups and control group,

p < 0.05, Wilcoxon’s rank sum test.



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positive results of irradiation of both lasers were maintained

for 3-months without any side effects.

5. Conclusion

Both the Er,Cr:YSGG laser and the GaAlAs diode laser

irradiation seem to be suitable for routine clinical treatmentfor DH, due to the rapid and 3-months clinical effectiveness

without adverse reactions. Also laser treatment seems to be

more comfortable and faster than traditional DH treatment,

since the time consuming procedures such as isolation of

operation field and repeated applications were eliminated.

Further studies are necessary to evaluate the morphological

alterations of the dentine surfaces under scanning electron

microscopy after Er,Cr:YSGG laser application for DH

treatment.

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clinical evaluation of er,crysgg and gaalas laser therapy

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