Art-3-Marcelino
CARIOLOGY www.stomaeduj.com
THE USE OF ER:YAG LASER FOR DENTAL CARIES REMOVAL
Review Articles
1a 1b 2c 2d*
Geise dos Santos Marcelino , José Humberto Ribeiro Lopes , Juliana Jendiroba Faraoni , Pâmella Coelho Dias
1School of Dentistry, Faculdade Morgana Potrich (FAMP), Mineiros, Goiás, Brazil
2Restorative Dentistry Department, School of Dentistry, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
a
DDS, General Dentist; email: hisy74@gmail.com; ORCID-iD: https://orcid.org/0000-0003-0056-1580
b
DDS, General Dentist; email: zehumberto96@gmail.com; ORCID-iD: https://orcid.org/0000-0001-5028-4425
c
DDS, PhD, Researcher; email: jujfaraoni@yahoo.com.br; ORCID-iD: https://orcid.org/0000-0003-0945-4028
d
DDS, MSc, PhD student; email: pamellacdias@hotmail.com; ORCID-iD: https://orcid.org/0000-0003-4886-3940
ABSTRACT https://doi.org/10.25241/stomaeduj.2021.8(3).art.3
Background Carious tissue removal in enamel and dentin requires the use of sharp and resistant instruments.
New tools have appeared to optimize/facilitate dental treatment, among them the laser. Regarding laser
application for dental caries removal, the use of erbium laser doped with yttrium, aluminum, and garnet
(Er:YAG) stands out. The Er:YAG laser is excellent for hard tissues ablation since its wavelength of 2.940nm is
highly absorbed by water and hydroxyapatite.
Objective To review the application of the Er:YAG laser in dental caries removal, to present its advantages and
limitations in clinical practice, as well as to describe its action mechanism, and to compare its effectiveness
with different methods used to remove caries.
Data sources The search for articles to compose this literature review was carried out in the PubMed and
Embase databases.
Study selection Articles in English published between 2006 and 2021. The manual search included additional
articles and books; a total of 39 references were selected.
Data extraction Information from studies that evaluated the use of the Er:YAG laser to remove caries or
related this type of laser to other methods. Articles that evaluated characteristics of the dental structure, or
the influence of restorative materials after caries removal with the Er:YAG laser, were also considered.
Study selection Based on studies results, the Er:YAG laser presents itself as an alternative for caries removal
since it can remove demineralized tissue (selective ablation) without causing damage to the dental element.
KEYWORDS
Cariology; Dental Caries; Dental Caries Removal; Dentin; Lasers.
1. INTRODUCTION Lasers can be classified, according to their
application, in low and high-power lasers [4]. Low-
Contemporary dentistry is based on early diagnosis, power lasers can aid analgesia, reduce inflammation
adequacy of the oral environment, and prevention and stimulate tissue repair [3,5], while high-powered
of oral diseases. In recent years, new tools have ones are used in surgery, ablation of decayed tissue,
emerged to optimize/facilitate dental treatment, and orthodontics [2,4,5]. There are also lasers used
including laser. Studies carried out over the years for photodynamic therapy and tissue fluorescence
have proven the effectiveness of laser therapy for diagnosis [4].
hard and soft tissues manipulation [1-3]. Regarding the application of laser for dental
The word LASER comes from the English acronym caries removal, the use of erbium-doped yttrium,
Light Amplification by Stimulated Emission of aluminum, and garnet laser (Er:YAG laser) stands
Radiation. Its mechanism of action is based on out. This laser operates in a pulsed mode, and the
the emission of a collimated light beam of high handpiece includes a spray of water to prevent
energy intensity and can be stimulated by solid, tissue dryness and heat build-up, allowing energy to
liquid, or gaseous active medium. Lasers have be absorbed efficiently [6].
different wavelengths, and this implies the variable Several types of research have evaluated the use of
phenomena that they can present: absorption, lasers in dentistry, highlighting the erbium laser in
penetration, transmission, and diffusion. In dentistry, hard tissues [1,2,7,8]. This study aimed to perform a
the most desirable phenomenon is absorption, as it literature review about the application of the Er:YAG
will interact with living tissue, effectively exercising laser in dental caries removal and to present its
its different functions [4]. advantages and limitations in clinical practice.
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Marcelino GDS, Lopes JHR, Faraoni JJ, Dias PC. The use of Er:YAG laser for dental caries removal. Stoma Edu J. 2021;8(3):173-183.
Received: August 17, 2021; Revised: September 11, 2021; Accepted: September 27, 2021; Published: September 28, 2021
*Corresponding author: Pâmella Coelho Dias, DDS, MSc, PhD student; Department of Restorative Dentistry, School of Dentistry, University of São
Paulo, Avenida do Café, s/n, 14040-904, Ribeirão Preto, SP, Brazil; Tel./Fax: +55 16 3315-4016; e-mail: pamellacdias@hotmail.com
Copyright: © 2021 the Editorial Council for the Stomatology Edu Journal.
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2. METHODOLOGY have shown that chemical-mechanical methods
Review Articles like Carisolv® and Papacarie® are also effective in
The article search for this literature review utilized removing caries [11,12].
the PubMed and Embase databases, and the The laser is another alternative that has been used in
selection included articles published between the dental field as an effective method for removing
2006 and 2021. The terms used were “Er:YAG laser” decayed tissue, being considered a conservative
AND “dental caries removal”. The inclusion criteria method since such removal is selective. Besides,
included articles in English published between 2006 laser treatment promotes greater comfort during
and 2021 that evaluated the use of the Er:YAG laser the surgical procedure and without causing pulpal
to remove caries or related this type of laser to other damage [13-15]. The type of laser most used for this
methods. Articles that evaluated characteristics of purpose is the yttrium-aluminum-garnet erbium
the dental structure, or the influence of restorative laser (Er:YAG).
materials after removal of caries with Er:YAG laser, The Er:YAG laser is excellent for the ablation of hard
were also considered. The search excluded: literature tissues, as it has a wavelength of 2.940nm, which
reviews, monographs, case reports, studies with is highly absorbed in water and hydroxyapatite.
bovine teeth, and studies with artificial or induced The erbium laser creates microexplosions in the
demineralization. The manual search included ten hydroxyapatite by vaporizing the water molecules
studies: three books, four original articles, and three present in the hard tissues, which leads to the
reviews as they contained viable information to breakdown of this tissue during the ablation
structure this literature review. Figure 1 shows the process. This laser operates in a pulsed mode, and
flowchart detailing the selection of articles. In total, the handpiece includes a spray of water to prevent
this review included 39 references. tissue dryness and heat accumulation, allowing
the energy to be absorbed efficiently. Thus, its
action occurs without tissue carbonization and
with minimal generation of heat [6]. Its use was
approved for these purposes by the Food and Drug
Administration (FDA) in May 1997 [14].
Research that used scanning electron microscopy
(SEM) and thermographic study to evaluate the
pulp temperature during the use of Er:YAG laser in
Figure 1. Flowchart of the article selection process. deciduous and permanent teeth showed that in the
same pulse of energy, ablation in dentin was more
3. LITERATURE REVIEW effective than in enamel and that ablation and caries
removal values were significantly higher in primary
Dental caries is described in the literature as a teeth when comparing to permanent teeth, but
multifactorial disease influenced by genetic, without exceeding the temperature of 5.5°C [7].
environmental, and behavioral characteristics, being Eberhard et al. (2008) analyzed extracted decayed
a complex disease resulting from the accumulation permanent molars in which they were sectioned
of specific acidogenic bacterial colonies present in and treated with fluorescence-feedback controlled
the dental biofilm, capable of adhering to the tooth. (FFC) Er:YAG laser or diamond tips. The use of the
These, in turn, produce acids from their metabolism FCC Er:YAG laser at a threshold of 7U (units) resulted
using fermentable carbohydrates responsible for in less dentin loss when compared to the use of
decreasing the pH on the dental surface, promoting diamond tips [16].
the reduction of hydroxyapatite crystals and the A randomized clinical trial compared the efficacy
widening of the intercrystalline spaces, leading of the fluorescence-controlled Er:YAG laser and
to an increase in porosity and, consequently, the the low-speed bur in removing decayed tissue in
emergence of the disease [9]. adults. The results showed that the use of the FCC
Clinically, the active initial caries lesion appears laser at a threshold of 7 and 8U promotes the same
on enamel as a white spot with a rough and effectiveness of the bur, presenting insignificant
opaque appearance. With the progression of numbers of remaining bacteria [17].
demineralization, this lesion forms a cavity that One research evaluated different techniques
can progress to reach the dentin, which then starts for caries removal and found no selectivity for
to show generally a yellow color, moist aspect, and demineralized tissue using the Er:YAG laser. In this
softened consistency [9]. study, the laser showed significant variability in
The removal of decayed enamel and dentin tissue the results, where several samples remained with
requires the use of strong and sharp instruments amounts of remaining caries and others had tooth
to allow the proper preparation of the cavity. There structure removed in excess [18].
are several instruments used for cavity preparation, A study evaluating the rate of ablation and selectivity
such as hand instruments (chisels, dentin scoop) and of healthy and demineralized enamel and dentin
rotary instruments (carbide burs with different types promoted by a 30W (watts) diode-pumped Er:YAG
of active tip, diamond tips) [10]. Previous studies laser operating on a pulse of 20-30µs (microseconds)
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showed that this laser has considerable potential for surface and some dentinal tubules obliterated by
Review Articles
selective removal of dental caries [19]. denatured collagen and surface contaminants;
Analysis of the removal of demineralized dentin surfaces prepared with low and high-speed burs
using the FFC Er:YAG laser showed that dentin showed a thick smear layer and no micro retentions
ablation occurred effectively at fluorescence control [22].
values between 6U and 7U when measured by An in vitro study evaluated marginal microleakage
microCT (computed microtomography). While at of cavities restored with glass ionomer, comparing
a value greater than 8U, the removal of decayed Er:YAG laser with Apacaries gel and atraumatic
dentin was unsatisfactory [20]. restorative technique (ART), and found a higher level
Kornblit et al. (2008) evaluated the effectiveness of infiltration with the use of the laser to remove
of the Er:YAG laser in removing caries in deciduous caries compared to the other methods [23].
and permanent molars and observed that ablation Studies show that different techniques for removing
in areas infected by caries promoted maximum decayed tissue influence the bond strength of
maintenance of the remaining structure. According adhesive systems [24-27]. The study of Yildiz et al.
to these authors, the laser provided decontamination (2013) concluded that the chemical-mechanical
of the affected area and improved retention of the method or use of burs at low rotation compared
composite resin to the surface prepared with laser, to the Er:YAG laser show better results in terms of
promoting better marginal enamel sealing [2]. bond strength for both self-etch and total-etch
Yonemoto et al. (2006) evaluated the DIAGNOdent® adhesives [27]. In another study, using a 2-step self-
as a guide for caries removal using the Er:YAG laser. etch adhesive system, the dentin surface prepared
Values set at 11-20 were able to remove caries by the Er:YAG laser showed lower micro-tensile bond
preserving the affected dentin in vitro [21]. strength (µTBS) values compared to healthy dentin
An in vivo study used 120 primary teeth from [24]. In the study of Sattabanasuk et al. (2006), the
children aged 5 to 9 years, divided into four groups: bond strength values of a total-etch adhesive system
air rotor, Carisolv®, Papacarie®, and Er:YAG laser. The were similar for the Er:YAG laser and steel bur [25].
results were visually and tactile observed, besides Sirin Karaarslan et al. (2012) evaluated the micro-
having the values of the DIAGNOdent® pen and the tensile bond strength of 3 types of adhesive systems
FLACC scale (Face, Legs, Activity, Cry, Consolability) - Clearfil® SE Bond (2-step self-etch), G-Bond® (single-
to measure pain during the procedure. Air rotor and step self-etch), and Adper® Single Bond 2 (2-step
laser were the most effective and efficient methods, total-etch) after caries removal using a spherical steel
and laser and chemical-mechanical methods were bur at low-speed, Carisolv® gel or the Er:YAG laser.
considered more comfortable [13]. Based on the results, the techniques used to remove
Another in vivo study evaluated the FFC Er:YAG laser decayed tissue showed significant differences in
for caries removal in pediatric patients. S. mutans and bond strength between the adhesive systems. There
or Lactobacilli were found in 33.33% of the lesions. was no significant difference in the bond strength of
In a total of 79 lesions, 14 contained S. mutans and total-etch adhesive systems comparing laser and bur
15 contained Lactobacilli. The average log of colony- groups. Using the laser, Adper® Single Bond 2 was
forming units (CFU) per sample was 0 for S. mutans superior to the other adhesive systems, indicating
and Lactobacilli. The average time to perform the that total-etch adhesives are the best option in this
procedure was 2.3±1.2min. Regarding pain, 93.8% type of caries removal method [26].
of children considered laser usage comfortable [15]. The microhardness and chemical composition of
One research biochemically analyzed decayed and dentin vary according to the applied caries removal
healthy teeth treated by the fluorescence-controlled method. The chemical-mechanical technique
Er:YAG laser, where a layer of dentin was removed (Carisolv®) showed lower microhardness of the
from the bottom of the preparation to determine remaining dentin and a considerable number of
the presence of hydroxylysylpyridinoline (HP) and samples with residual caries (20%) when compared
lysylpyridinoline (LP) collagen cross-links using to the carbide bur and the Er:YAG laser (both 5%).
high-performance liquid chromatography. 100% There was no significant difference in calcium and
HP and LP were found in decayed dentin and 0.33% phosphorus rates of the three evaluated groups [28].
HP and 0.68% LP in healthy dentin. After caries A comparative clinical study between the bur and the
removal, 0.84% HP and 1.26% LP were found at the Er:YAG laser to remove caries from primary molars
5U fluorescence-control threshold and 1.56% HP showed that the laser was less efficient than the bur
and 2.48% LP at 10U. The Er:YAG laser proved to to remove caries. Regarding effectiveness, the two
be a viable method for removing the irreversibly treatments were similar to remove caries in the pulp
denatured collagen present in decayed dentin [1]. wall, and the bur was better in the surrounding walls.
Scanning electron microscope was used to The composite resin restorations for both groups
investigate the morphological changes in the remained satisfactory after one year of treatment [8].
hard dental tissues after caries removal and cavity A double-blind clinical study, performed in
preparation using different methods: Er:YAG laser, children aged 7-10 years, evaluated composite
Carisolv® gel, high-speed diamond burs, and low- resin restorations in primary teeth performed after
speed micromotor steel burs. The dental surface selective removal of necrotic dentin using an Er:YAG
after using the laser remained highly retentive, laser and a carbide bur. Adhesive restorations did not
without smear layer residues and with the presence suffer laser interference, and the SEM analysis showed
of exposed dentinal tubules. The samples treated that laser group restorations showed a 10% gap in its
with Carisolv® gel presented a rough retentive extension, and the group treated with a bur showed
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a 20% gap in the cavosurface margin after 12 months from 45 patients. No adverse reactions and no or little
Review Articles of follow-up [29]. pain were reported in most treated teeth (89.5%).
A longitudinal clinical study with four years of Tooth preparation was successfully performed
follow-up evaluated the clinical longevity of exclusively by laser in 94.7% of the cases, and the
composite resin restorations after selective caries operative time was on average 49 seconds [36].
removal in permanent molars using the Er:YAG laser
or bur preparation with chlorhexidine as dentin 4. DISCUSSION
biomodifier. The Er:YAG laser group biomodified with
chlorhexidine presented a statistically significant The Er:YAG laser to remove caries has been widely
difference for marginal adaptation criteria compared studied in recent years, showing that it is a safe and
to the other groups; for secondary caries criteria and comfortable method for the patient, minimizing the
clinical and radiographic evaluation of pulp vitality, use of local anesthesia and maintaining pulp vitality
there was no statistically significant difference [2,7,13,17].
between the evaluated groups. The authors Studies comparing different methods of caries
concluded that the method of caries removal and removal found that the Er:YAG laser, together with
dentin biomodification did not influence the survival the chemical-mechanical method, provided greater
rate of composite resin restorations [30]. comfort and satisfaction for both the operator
Prabhakar et al. (2018) evaluated morphological and the patient as they were less traumatic [13].
changes and the presence of bacterial deposits According to a systematic review, chemomechanical
in primary decayed molars submitted to carious methods are the best option for a minimally invasive
tissue removal by Carie-Care (chemical-mechanical treatment [33]. In an in vitro study, the hand excavator
method), Er:YAG laser, and tungsten carbide was the most effective technique to remove caries in
spherical bur. The results showed that the laser deciduous teeth [37].
group was the most effective of the three, with fewer Comparing caries removal effectiveness (capacity)
bacterial deposits and no smear layer formation [31]. between laser and carbide bur at low rotation,
A meta-analysis evaluated the Er:YAG laser to the results of the two methods were similar for
remove caries and for cavity preparation in children removing caries from the pulpal wall; the bur was
compared to the traditional mechanical method. This more effective on the surrounding walls of primary
study evaluated seven randomized clinical trials and molars [8]. Both techniques showed similar results
found that the laser requires more operative time but regarding the presence of residual caries [28].
is less painful. There were no statistically significant The adjusted value in lasers with fluorescence-
differences between the two types of treatment feedback control influenced selectivity for carious
concerning retention, marginal adaptation, and tissue in the studies evaluated in this literature
marginal discoloration of restorations [32]. review. Schwass et al. (2013) showed that the Er:YAG
A recent systematic review showed that the use of laser with fluorescence control selected between 7U
burs, chemomechanical method, and the Er:YAG and 8U was effective for removing demineralized
laser are efficient for caries removal, reduction of dentin [20], as well as studies by Dommisch et al.
bacteria in the tooth cavity, and do not compromise (2008) [17] and Eberhard et al. (2008) [16], where
the clinical performance of restorations [33]. the Er:YAG laser with fluorescence control at levels
An in vitro study compared the FFC Er:YAG laser of 7U and 8U promoted caries removal similar to
with the Er:YAG laser in three different pulses (super that obtained with the conventional bur, generating
short, medium short, and short pulse) regarding greater comfort and wellness to the patient. The
the efficiency of removing cariogenic bacteria and use of a laser with fluorescence control set to 9U
carious dentin and dentin temperature during and 10U did not remove all decayed tissue [17].
ablation. The results showed that no experimental Contrasting these results, Neves et al. (2011) did not
group had bacterial contamination after treatment. find selectivity when analyzing samples prepared
In the groups with varied pulses of laser energy, the with the FFC Er:YAG laser at the threshold of 7U,
dentin temperature was significantly higher than the where some specimens were overprepared, and
FFC laser [34]. others continued with decayed tissue. In this study,
A study that evaluated and compared the Er:YAG the laser was the evaluated method that presented
laser, the tungsten bur, and the polymer bur in the least minimally invasive potential [18].
caries removal showed no difference between the Regarding the morphological changes generated on
treatment time comparing the three methods. the treated dental surface, the laser did not promote
Histological analysis showed that all groups thermal damage and also left the surface highly
effectively removed the infected dentin and the laser retentive and without the presence of a smear layer;
group showed a regular 5µm thick layer of denatured while the use of burs in both high and low rotation
collagen. The group treated by the tungsten bur promoted surfaces with a thick smear layer and
presented a smear layer, and the polymer bur group absence of microretentions; the use of polymer burs
showed an affected dentin surface layer [35]. left an affected dentin layer [22,35].
Matsumoto et al. (2007) clinically evaluated the Despite the advantages of using laser as a method
applicability of the Er:YAG laser on 95 decayed teeth of removing decayed tissue, clinical studies have
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shown variation in clinical time, with laser consuming A 12-month follow-up of a randomized clinical
Review Articles
about 3x more time than the use of burs [17] with trial with a split-mouth design showed that teeth
an average treatment duration of 2.3±1.2min [15]. with decayed tissue removed by both laser and
Other studies have also shown a longer average bur and restored with a 2-step total-etch adhesive
treatment time with the use of laser, but with a system and composite resin maintained satisfactory
minor difference: 110s [8] or 49s [36] for the Er:YAG restorative treatment [8]. In a double-blind clinical
laser and 55s [8] for the low-speed carbide bur. study, the restorations of the laser group showed a
Another disadvantage found in one of the selected
lower percentage of a gap than the group treated
studies was the presence of marginal infiltration in
by bur in the analysis performed by SEM at the same
decayed teeth ablated by laser and restored with
glass ionomer [23]. follow-up time [29].
The bond strength of adhesive systems influenced In a biochemical analysis of dentin collagen on
the method used to remove caries [26]. According decayed surfaces treated with erbium laser through
to the results, the authors suggest choosing a SEM, the percentage of dehydrated collagen and
conventional adhesive system after caries removal decayed dentin reduced after laser treatment,
by the Er:YAG laser and a self-etch adhesive system becoming similar to healthy dentin [1]. In the study
after using a chemical-mechanical method. These of Krause et al. (2008), 42.9% of the samples had
results corroborate the study by Neves et al. (2011) bacterial residues, but in only 7.1%, the bacterial
that found lower micro-tensile bond strength using a count was greater than 100 CFU (colony forming
2-step self-etch adhesive after caries removal by the units) [15].
Er:YAG laser compared to the chemical-mechanical The pulp response to the application of external
method and the use of conventional burs [24]. In heat was evaluated in an in vivo study using rhesus
another study, the use of a chemical-mechanical monkeys [39]. The results showed that a temperature
technique or usage of burs at low-speed compared
increase of 2.2°C does not cause pulp changes and
to Er:YAG laser showed better results in terms of
that increase of 5.5°C allowed pulp repair for most
bond strength for both self-etch and total-etch
adhesive systems [27]. Other studies showed that the specimens (75%). In several studies, the use of the
Er:YAG does not influence the bond strength value Er:YAG laser has proven not to generate thermal
of a total-etch adhesive system [25, 38]; however, the damage to the dental structure, not exceeding the
study of Sattabanasuk et al. (2006) showed higher temperature increase above the threshold tolerated
bond strength values for Er:YAG laser compared by the dental pulp [2,7,19,34].
to steel bur evaluating a self-etch adhesive system Table 1 summarizes the 29 studies selected by
(Clearfil Protect Bond) [25]. Pubmed and Embase.
Author (Year) Substrate Type of Evaluated Er:YAG laser Conclusion
study parameters specifications
Al-Batayneh et Sound and carious In vitro - Laser ablation in - Wavelength: 2.94µm - Laser creates greater crater
al. (2014) [7] enamel and dentin comparative sound enamel and - Pulse energy: 200mJ depths in dentin than enamel
from 40 primary e study dentin - Pulse duration: 250µs for both types of teeth
40 permanent - Comparison - Frequency: 10Hz - Laser is more efficient than
extracted teeth between the Er:YAG - Power output: 6W the rotary bur to remove
laser and the rotary caries in primary teeth
bur for carious - There was no significant
removal difference between
- Surfaces changes both methods regarding
through SEM permanent teeth
- Dental ablation did not
exceed 5.5°C
- SEM: dentin ablation with
no smear layer
Baraba et al. 60 teeth with In vitro Caries removal FCC laser: -Ablated specimens were
(2018) [34] dentin caries and comparative efficiency of the FFC -Pulse energy: 350mJ bacteria-free
12 teeth without study Er:YAG laser and (enamel) and 250mJ -All laser evaluated were
caries lesion. different pulses of (dentin) efficient for caries removal
the Er:YAG laser -Pulse duration: 400µs -FCC laser group presented
-PCR analysis -Frequency: 4Hz the lowest average
-Thermal alterations -Threshold: 7U temperature
Laser with different
pulses:
-Pulses: 50µs, 100µs,
and 300µs
-Pulse energy: 350mJ
(enamel) and 250mJ
(dentin)
-Frequency: 10Hz
-Non-contact mode
-Distance: 7mm
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Review Articles Bohari et al.
(2012) [13]
120 carious
primary teeth
In vivo
comparative
-Efficiency, efficacy,
and level of pain
- Wavelength: 2.94µm
-Pulse energy: 200mJ
-Air rotor and laser were faster
and more efficient
from children study of 4 methods of -Frequency: 20Hz -Carisolv®, Papacarie®, and
aged 5 to 9 caries removal: air -Power output: 4W laser were less painful
rotor, Carisolv®, -Contact mode
Papacarie®, and
Er:YAG laser
Cardoso et al. Carious primary Systematic -Dental caries -All methods are efficient in
(2020) [33] teeth review removal efficacy, reducing CFU count and in
treatment removing caries
time, need of -Chemomechanical methods
anesthesia, CFU showed to be the best
count, restoration option for minimally invasive
performance, treatments
and pain -Conventional methods
perception among promote faster treatment, and
conventional, Er:YAG is faster than Carisolv®
chemomechanical, and Papacarie®
and laser methods. -Chemomechanical and laser
require less anesthesia and are
also less painful
-Restorations were not
affected by any of the caries
removal methods
Cebe et al. 10 permanent In vitro - Microtensile - Wavelength: 2.94µm -The Er:YAG laser did not
(2017) [38] molars with comparative strength of a total- -Power output: 3.5W impair the bond strength of a
proximal caries study etch adhesive -Pulse duration: 300µs total-etch adhesive system
system after caries (short pulse mode)
removal by the -Frequency: 10Hz
Er:YAG laser and bur -1mm distance
-Energy density: 44J/cm2
Celiberti et al. 80 deciduous In vitro - Time and - Wavelength: 2.94µm - Carbide bur was the fastest
(2006) [37] molars with comparative caries removal - Pulse energy: 200mJ and the Er:YAG laser the
dentin caries study effectiveness - Frequency: 4Hz slowest technique
and selectivity - Non-contact mode - Polymer bur and laser
of carbide bur, - Working distance: left large amounts of
Er:YAG laser, hand 12mm underprepared areas
excavator, and - Carbide bur was the least
polymer bur conservative method
- Hand excavator was the most
effective technique to remove
caries in deciduous teeth
Dommisch et 102 teeth with Randomized - Efficiency, CFU - Wavelength: 2.94µm - FCC laser at the threshold
al. (2008) [17] active caries clinical trial count, level of pain - Pulse energy: 250mJ of 7 and 8U and carbide
from 26 adult between the FCC - Frequency: 4Hz burs showed similar results
patients Er:YAG laser and - Non-contact mode regarding S. mutans and
carbide burss - Working distance: 10- Lactobacilli CFU
20mm - FCC laser was more
- Threshold: 7, 8, 9, and comfortable but significantly
10U more time consuming
compared to carbide burs
Eberhard et 165 permanent In vitro - Cavity extension - Wavelength: 2.94µm - the FCC Er:YAG laser was
al. (2008) [16] molars with comparative after caries removal - Pulse energy: 250mJ more conservative than the
dentin caries study from 2 methods: - Pulse repetition rate: 4 bur at a threshold of 7U
bur and FCC laser pulses/s - There was no difference
in contact and non- - contact and non- between the laser in contact
contact mode contact mode and non-contact mode
- Working distance: 12-
15mm
- Threshold: 6, 7, and 8U
Jepsen et al. 210 carious and In vitro - Percentage of - Wavelength: 2.94µm - the FCC Er:YAG laser showed
(2008) [1] 60 caries-free study denatured collagen - Pulse energy: 250mJ less denatured collagen at a
teeth in dentin - Pulse repetition rate: 4 threshold of 5U
- Morphological pulses/s - SEM analysis showed no
aspects of dentin - non-contact mode smear layer and tubule
after laser ablation - Working distance: exposure at the laser group
adjusted by the pilot and presence of smear layer
laser beam and smear plug at the bur
- Threshold: 5 and 10U group
- Transmission electron
microscope (TEM) analysis
showed no bacteria in the
dentin surface after laser
ablation
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Review Articles
Juntavee Primary second In vitro - Influence of - Pulse energy: 260mJ - the Er:YAG laser promoted
et al. (2013) molars with comparative Apacaries gel, - Frequency: 30Hz significant higher microleakage
[23] occlusal caries study Er:YAG laser, and - Pulse mode than Apacaries and spoon
spoon excavator excavator in ionomer
as caries removal restorations
methods in
the marginal
microleakage of
glass ionomer
restorations
Katirci et al. Permanent molars In vitro - Effectiveness - Pulse energy: 250mJ - Carbide bur and Er:YAG
(2016) [28] with occlusal comparative of three caries - Frequency: 4Hz laser had a similar outcome
caries study removal methods by - Non-contact mode regarding caries removal
stereomicroscopic - Working distance: - Carisolv® was less effective
observations and 10mm than the carbide bur and the
microindentation Er:YAG laser and presented
hardness remaining dentin with a lower
measurement hardness compared to the
- Chemical other methods
composition of the - There were no differences in
residual dentin the calcium and phosphate
ratio among the three methods
Kornblit et 30 carious teeth Clinical trial - Possible - Wavelength: 2.94µm - Children treated with Er:YAG
al. (2008) from children aged postoperative - Pulse duration: 140µs did not show any pain or
[2] 4 to 12s complications after - Pulse energy: 120 to sensitivity 7 and 28 days after
caries removal with 200mJ the treatment
the Er:YAG laser - Frequency: 2 to 20Hz
- focus mode
- Working distance: 0.8
to 1cm
Krause et 79 carious lesions Clinical trial - Efficacy of the FCC - Wavelength: 2.94µm - Treatment duration was
al. (2008) from children aged Er:YAG laser - Pulse duration: 400µs 2.3±1.2 min
[15] 3 to 12 - CFU count after - Pulse energy: 250mJ - 93.8% of the children
laser treatment - Frequency: 4Hz considered the laser treatment
- Children - non-contact mode comfortable
perceptions during - Working distance: - After laser ablation, 42.9% of
treatment 12cm the samples showed residual
- Threshold: 7U bacteria; however, only 7.1%
presented more than 100 CFU/
sample
Li et al. Carious teeth from Meta- - Duration of - Caries removal with laser is
(2019) [32] children analysis treatment more time consuming than the
- Pain perception use of bur
- Success of - the Er:YAG laser is less painful
restorations than -the bur
- There were no statistical
differences in complete
restoration retention, marginal
discoloration, and marginal
adaptation between Er:YAG
laser and bur
Matsumoto Carious teeth from Clinical trial - Pain, discomfort, - Wavelength: 2.94µm - Laser showed: low rate of
et al. (2007) adults assessment during - Pulse energy: 700mJ pain during treatment, no
[36] cavity preparation, - Frequency: 8Hz discomfort, ample efficacy,
prognosis factor, substantial efficiency, good
and overall clinical prognosis after three months
evaluation of follow-up, and mean of
treatment duration of 49s
Medioni et Carious molars In vitro - Effectiveness of - Wavelength: 2.94µm - Procedure time was similar for
al. (2016) and premolars comparative - the Er:YAG laser, - Pulse energy: 375mJ all the three methods
[35] study carbide bur, and - Pulse duration: 50µs - Histological analysis showed
polymer bur for - Frequency: 10Hz smear layer in the specimens
caries removal - Quasi-contact mode treated with carbide bur,
denatured collagen in the laser
group, and a layer of affected
dentin in the polymer bur
group
- All methods removed the
infected dentin
Neves et al. Carious molarss In vitro - Influence of the 7 - Pulse energy: 250mJ - Remaining denting from the
(2011) [24] comparative methods for caries - Pulse repetition rate: FCC Er:YAG laser group showed
study removal in the 4 pulses/s lower µTBS values
bonding capacity - Non-contact mode - Carisolv® showed the best
of the remaining - Threshold: 7U results regarding µTBS,
dentin followed by carbide bur + caries
detector
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Marcelino GDS, et al.
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Review Articles Neves et al.
(2011) [18]
Carious molars In vitro
comparative
- Caries removal
effectiveness and
- Pulse energy: 250mJ
- Pulse repetition rate:
- Chemomechanical methods
+ metal excavators showed the
study minimally invasive 4 pulses/s best results
potential of 9 - Non-contact mode - the FCC Er:YAG laser showed
methods for caries - Threshold: 7U the most variable results:
removal by microCT specimens with over and others
with under preparation
- the FCC Er:YAG laser did not
prove to be a selective method
for caries removal
Polizeli et al. 48 primary Double- - Salivary cortisol - Medium short pulse - Salivary cortisol levels were
(2019) [29] molars with blind, levels and clinical mode similar for laser and bur
occlusal and randomized performance of - Pulse energy: 250mJ - There was no difference
proximal caries clinical trial restorations after - Frequency: 4Hz regarding marginal adaptation,
from children caries removal by - non-contact mode retention, discoloration,
aged 7 to 10 the Er:YAG laser - Working distance: and secondary caries for
compared to 7cm restorations from both groups
carbide bur after one year of follow-up
Prabhakar et Carious primary In vitro - Morphological - Wavelength: 2.94µm - the Er:YAG laser showed a
al. (2018) [31] molars comparative changes - Pulse energy: 200mJ minor quantity of bacterial
study -Bacterial deposits - Energy density: 22.5J/ deposits compared to
cm2 for 10 pulse/s Carie-Carie and carbide bur;
- Non-contact mode Carie-Carie presented greatly
bacterial deposits
- Morphological changes:
Carbide bur – thin smear layer
and few open tubules; Er:YAG
laser: irregular rugged surface,
no smear layer, opened tubules;
Carie-Carie – rough surface,
smear layer, obliterated tubules
Sattabanasuk Carious third In vitro - Influence of 3 - Pulse energy: 180mJ - The total-etch adhesive
et al. (2006) molars comparative methods for caries - Frequency: 2Hz system (OptiBond Solo Plus)
[25] study removal and two - Non-contact mode showed similar results in all
types of adhesive groups (steel bur, laser, and SiC
systems in the paper)
bonding capacity - The self-etch adhesive system
of the remaining (Clearfil Protect Bond) showed
dentin lower bond strength in dentin
treated with steel bur
-Only the laser group showed
similar bond strength for the
two tested adhesive systems
Schwass et al. Teeth with In vitro - Different - Pulse energy: 600mJ - Feedback control values
(2013) [20] proximal dentin comparative thresholds of (enamel) and 250mJ higher than 8U did not remove
caries study FCC Er:YAG in the (dentin) infected caries efficiently
selectivity of caries - Frequency: 10Hz - Threshold for conservative
removal (enamel) and 4Hz caries removal lies between 7
(dentin) and 8U
- Pulse duration: 400µs
- Threshold: 4, 5, 6, 7, 8,
9, 10, 12, 16, and 20U
- Non-contact mode
Sirin Carious molars In vitro - Influence of 3 - Wavelength: 2.94µm - The total-etch adhesive
Karaarslan et comparative methods for caries - Power output: 3.5W system: similar bond strength
al. (2012) [26] study removal and three - Pulse duration: 300µs values for steel bur and laser
adhesive systems (short pulse mode) and lower for Carisolv®
in the bonding - Frequency: 10Hz - One-step and two-step self-
capacity of the - 1mm distance etch adhesive systems: similar
remaining dentin - Energy density: 44J/ bond strength values for all
cm2 three methods
- the bur group: all adhesive
systems had the same behavior
- the laser group: total-etch
adhesive showed the higher
µTBS values
- Carisolv®: two-step self-etch
adhesive showed the best
results
180 Stoma Edu J. 2021;8(3):173-183 pISSN 2360-2406; eISSN 2502-0285
Er:YAG laser for caries removal
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Review Articles
Tsanova Carious teeth In vitro - Ultrastructural - Pulse energy: 400mJ - Er:YAG laser: irregular and
& Tomov from adults comparative changes in substrates - Frequency: 20Hz rough dentin surface with no
(2010) [22] study treated with Er:YAG - Power output: 8W smear layer, exposed tubules;
laser, Carisolv®, retentive enamel
diamond bur, steel - Carisolv®: dentin with rough
bur and granular aspect, retentive
surface
The diamond bur: thin and
smooth smear layer in most
regions and absence in a few
others, opened tubules
The steel bur: smear layer and
obliterated tubules
Valério et Carious Split-mouth - Er:YAG laser - Pulse energy: 250mJ - The carbide bur is faster and
al. (2016) primary randomized effectiveness - Frequency: 4Hz more effective to remove caries
[8] molars from clinical trial compared to carbide - Non-contact mode in the surrounding walls than
children aged bur - 7mm distance Er:YAG laser
6 to 10 - CFU count - Energy density: 39J/cm2 - CFU for S. mutans and
- Restoration Lactobacilli sp. was similar for
longevity both methods
- One-year follow-up showed
no differences in restoration
longevity for both groups
Valério et Carious Longitudinal - Influence of Er:YAG - Medium short pulse - The clinical longevity of the
al. (2020) molars from clinical trial and carbide bur mode restorations was affected
[30] children aged associated with - Pulse energy: 260mJ neither by the method for
8 to 12 chlorhexidine at the - Frequency: 4Hz caries removal nor by the
longevity of adhesive - Non-contact mode dentin biomodification with
restorations after four -12mm distance chlorhexidine at four years of
years of follow-up - Energy density: 41J/cm2 follow-up
Yan et al. Teeth with In vitro study - Potential of a diode - Pulse duration: 20-30µs - Ablation with minor thermal
(2015) [19] occlusal caries pumped solid-state - Frequency: 500Hz damage
(DPSS) Er:YAG laser for - Power output: 30W - Higher ablation rate in
caries removal demineralized surfaces
compared to the sound ones
Yildiz et al. Carious In vitro - Influence of 3 - Wavelength: 2.94µm - Laser presented lower µTBS
(2013) [27] primary molar comparative methods for caries - Power output: 3.5W values than carbide bur and
teeth study removal and two - Pulse duration: 300µs Carisolv® groups regardless of
adhesive systems in (short pulse mode) the adhesive system used
the bonding capacity - Frequency: 10Hz (one-step self-etch and two-
of the remaining - 1mm distance step total-etch)
dentin - Energy density: 44J/cm2 - Bur and Carisolv® presented
the best results for both types
of adhesive systems
Yonemoto Molars with In vitro study - Values of - Pulse energy: 150-200mJ - Laser + DIAGNOdent® values
et al. (2006) occlusal DIAGNOdent® that (enamel) and 50-150mJ ≤10: overpreparation; laser +
[21] dentin caries could be used as a (dentin) DIAGNOdent® values of 11-
guide for the removal - Pulse duration: 200µs 20: removal of the outer layer
of the outer layer of Frequency: 10, 20, 25 or dentin; laser + DIAGNOdent®
carious dentin with 30Hz values of 21-30: partial
Er:YAG laser removal of the outer layer
dentin; however, there are
some limitations for clinical
application
Table 1. Summary of the selected articles.
5. CONCLUSION Despite the advantages, its use requires more clinical
time compared to the use of burs. Furthermore, the
The Er:YAG laser is a viable alternative for the treat- cost of the equipment, despite not having been
ment of caries since it can remove demineralized addressed in the review, can also be considered
a limiting factor. In general, the Er:YAG laser is
tissue without causing damage to the dental
as effective as the conventional and chemical-
element, in addition to providing greater comfort for mechanical methods for selective caries removal.
the patient due to the absence of noise, vibrations,
and pressures during removal of decayed tissue and ACKNOWLEDGMENTS
less need for anesthetic administration in most cases. None.
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Geise dos Santos MARCELINO
DDS, General Dentist
Department of Restorative Dentistry
School of Dentistry
Faculdade Morgana Potrich (FAMP)
Mineiros, Goiás, Brazi
CV
Geise dos Santos Marcelino graduated from FAMP, Mineiros, Goiás, Brazil, and is a student of the Specialization course in
Orthodontics at the Graduate Center in Dentistry – CIOG, Goiânia, Goiás. Her academic interests include Hospital Dentistry and
Pediatric Dentistry. She works as a general dentist in a private practice in Senador Canedo, Goiás and at the PSF in Taquaral de
Goiás, Goiás, Brazil.
Questions
1. Which caries removal method is the least conservative?
qa. Mechanical removal with dentin scoop;
qb. Diamond tips and air rotor;
qc. Er:YAG laser;
qd. Use of a chemical-mechanical method.
2. Which is the Er:YAG laser wavelength?
qa. 2.940nm;
qb. 2.840nm;
qc. 2.490nm;
qd. 2.480nm.
3. Which sentence is correct?
qa. Er:YAG is a selective method for caries removal;
qb. Chemical-mechanical methods cause more pain for the patients;
qc. Er:YAG can affect pulp vitality;
qd. Carbide burs cannot be used in children.
4. In dentistry, which one is the most desirable phenomenon of the laser?
qa. Diffusion;
qb. Transmission;
qc. Absorption;
qd. Penetration.
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