ISSN: 2581-5989

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International Journal of Dental Science and Innovative Research (IJDSIR)

IJDSIR : Dental Publication Service
Available Online at: www.ijdsir.com
Volume – 2, Issue – 4, July – August - 2019, Page No. : 110 - 116
The Transition From Painful To Painless: Laser Pulpotomy As A Boon To Pediatric Endodontics: A Review
Gupta K1, Sharma A2 , Chauhan S 3,Gupta N4
1
Senior Lecturer, Department of Pedodontics, Himachal Institute of Dental Sciences, Paonta Sahib.
2
Government Dental Officer, Department of Pedodontics, Regional Hospital, Bilaspur.
3
Dental Surgeon, Himachal Head and Neck Hospital, Hamirpur.
4
Postgraduate Student in Department of Prosthodontics, Himachal Institute of Dental Sciences Paonta Sahib.
Correspondence Author: Kritika Gupta, Senior Lecturer, Department of Pedodontics, Himachal Institute of Dental
Sciences, Paonta Sahib, Himachal Pradesh-173025
Type of Publication: Review Article
Conflicts of Interest: Nil
Abstract problems including arch perimeter loss, supra eruption of
Vital pulpotomy can be defined as the surgical amputation opposing teeth and changes in the patient’s occlusion.
of infected and inflamed coronal pulp followed by Whenever feasible, dental treatment should attempt to
placement of a suitable medicament over the radicular maintain pulp vitality, particularly in immature permanent
pulp to preserve the vitality and function of the tooth. This teeth. Pulp vitality leads to development of a favorable
review is intended to provide an overview and scientific crown-to-root ratio, apical closure and formation of
literature on different approaches of laser pulpotomy in secondary radicular dentin. The long term survival of
primary teeth. Pulpotomy can be performed using tooth is also greater when pulp vitality is maintained.
different techniques including formocresol, calcium When irreversible pulpitis or pulp necrosis occurs,
hydroxide, enriched collagen solution, ferric sulphate, nonvital pulp therapy procedures are required to alleviate
mineral trioxide aggregate, growth factors or by non patient symptoms and maintain a functional tooth in the
pharmacological hemostatic techniques like electrosurgery dental arch. Therefore, the duty of pediatric dentist is to
or lasers. The application of lasers to dental tissues have diagnose early and give proper treatment to the child to
shown their potential to increase healing, stimulate prevent various complications. Due to the complicated
dentinogenesis and preserve vitality of the dental pulp. anatomy of the root canals in primary teeth, the proximity
Various studies led to the use of the Nd:YAG laser for of the permanent tooth germ and the difficulties in finding
pulpotomy in primary teeth as given in the following a root-canal filling material compatible with physiological
article. root resorption, pulpotomy has become a dominating pulp
Keywords: pulpotomy, laser pulpotomy, primary teeth therapy procedure2.
Introduction Pulpotomy is defined as the surgical removal of the entire
Primary teeth are very important for child’s smile, proper coronal pulp presumed to be partially or totally inflamed
1
chewing, and for developing permanent dentition . and quite possibly infected, leaving intact the vital
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Premature loss of primary teeth can cause a number of radicular pulp within the canals3. The American Academy

Corresponding Author: Kritika Gupta, ijdsir Volume-2 Issue 4, Page No. 110 - 116
Kritika Gupta, et al. International Journal of Dental Science and Innovative Research (IJDSIR)

of Pediatric Dentistry (2006-2007) defines pulpotomy as An ideal pulpotomy material to be placed on the radicular
when the coronal pulp is amputated, and the remaining pulp should be bactericidal, harmless to pulp and
vital radicular pulp tissue surface is treated with a surrounding structures, promote healing of remaining
medicament such as formocresol or ferric sulfate or with radicular pulp without interfering with the physiologic
electrocautery or laser to preserve the radicular pulp’s root resorption and not possess any toxicity 5 . In search of
4
health . Pulpotomy is recommended when the young an ideal pulpotomy medicament, various materials and
pulp already is exposed to caries and the roots are not yet techniques have been explored.
fully formed (open apices).Cooperation from child and This treatment can be performed using different
behaviour management in such children who needs techniques including formocresol, calcium hydroxide ,
extensive treatment can be difficult for the dentist, so enriched collagen solution, ferric sulphate, mineral
pulpotomy seems to be a reasonable treatment option to trioxide aggregate, growth factors or by non
meet these situations as it certainly require less time than pharmacological hemostatic techniques like electrosurgery
complete root canal treatment hence avoiding the long or Nd:YAG laser. Traditionally formocresol has been
3
chair side time . regarded as the gold standard pulpotomy medicament,
Indications for pulpotomy in primary tooth are (1) caries however its use has been questioned recently owing to
involving pulp but not causing severe irreversible pulpitis. several concerns viz. carcinogenicity, mutagenecity and
The inflammation and infection should be limited to cytotoxicity.6 However, concerns regarding the
coronal portion of pulp. (2) mechanical exposure of pulp formocresol have led investigators to search for safe and
while cavity preparation (3) traumatic exposure of pulp effective alternatives, laser being one of them. So the
after accident or fall, provided the patient is reports to the present quest is for the research of newer materials and
dentist within 24hrs and (4) intentional pulpotomy can be technologies which can provide more biocompatible
done in traumatic primary teeth where remaining crown is alternatives to formoresol 7.
very small and needs support for retention of a Lasers in Pediatric Dentistry
restoration. Contraindications to pulpotomy are abnormal Treating infants and young children is a rewarding
sensitivity to heat and cold, chronic pulpalgia, tenderness experience, especially when we guide parents and children
to percussion or palpation because of pulpal disease, down the path of prevention and interception of oral
periradicular radiographic changes resulting from disease8.
extension of pulpal disease into the periapical tissues and The American Academy of Pediatric Dentistry
marked constriction of pulp chamber or root canals. recommends that a child’s first visit to the dentist occur no
According to Ranly (1994), pulpotomy for primary teeth later than 6 months after the first teeth erupt, or around a
has been developed on three lines: devitalization child’s first birthday8 . During the initial visit, the pediatric
(mummification, cauterization), preservation (minimal dentist can assess medical history, educate parents on
devitalization, noninductive), regeneration (inductive, healthy oral practices (e.g, brushing, flossing, diet, oral
reparative). The reparative and biologic approach to habits, and fluoride) evaluate a child’s risk of developing
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pediatric pulp therapy is the devitalization approach of oral problems and, when appropriate, determine necessary
formocresol pulpotomy preventive or interceptive actions. Oral examinations by 1
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Kritika Gupta, et al. International Journal of Dental Science and Innovative Research (IJDSIR)

year of age allow for earlier recognition and treatment of similarly effective in treating soft-tissue and hard-tissue
soft-tissue pathologies and anomalies, such as tongue-ties, lesions8.
that appear at birth8 .
Guidance of the eruption and development of the primary
and permanent dentition is an integral part of treating
children and contributes to the development of a
permanent dentition that is harmonious, functional, and
esthetically acceptable. Soft-tissue procedures that once
The word laser is an acronym standing for “Light
were rejected because they necessitated general anesthesia
Amplification by Stimulated Emission of Radiation”. An
can be safely and quickly treated with lasers in the dental
amaging paradigm shift is occurring in dentistry with the
office. 8 .
technology breakthrough that gives dentists the capability
Clinical experience indicates that restorative treatment in
to perform a wide range of hard-and- soft tissue
most children can be accomplished with little or no local
procedures with improved patient outcomes, less trauma,
anesthetic agents and their associated concerns, such as lip
reduced post-op complications- and in most cases, with
or tongue biting, which often occur when the child is
no need of injections9 . As much as any wish to explore
numb8 . Postoperative problems, such as dehydration
the envelope of possible laser-tissue interaction, much of
when a child refuses adequate fluid intake after treatment,
the hype surrounding laser use in dentistry has centered on
can be avoided.
the possibility to encourage patient uptake through the
Laser technology allows the dentist to perform
avoidance of peri- and post-operative pain and discomfort.
microdentistry, removing only diseased dental tissue and
Certainly, however, today’s lasers offer an opportunity to
preserving the remaining healthy tooth structure.
deliver hard and soft tissue treatments that, make the
Lasers offer advantages like reduced chair side time,
patient experience somewhat easier10 .
elimination of high speed drill and controlled energy. It is
The first laser was developed by Theodore H. Maiman in
quick, efficient, self-limiting, has good visibility of the
1960. Using a theory originally postulated by Einstein,
operating field and shows no systemic effects at the site of
Maiman created a device where a crystal medium was
application. The use of laser also eliminates the pain of
stimulated by energy, and radiant, laser light was emitted
injections, which is considered to be a barrier to effective
from the crystal. This first laser was a Ruby laser9 .
dental treatment.
Since the introduction of lasers to dentistry, several
With the development and introduction of the erbium
studies have shown the effect of different laser devices on
family of lasers, the pediatric dentist has a safe and
dentin and pulpal tissue. Application of laser irradiation in
efficient laser to treat hard and soft tissue of the oral
vital pulp therapy has been proposed as another alternative
cavity. The erbium laser’s shallow depth of tissue
to pharmaco- therapeutic techniques3 .
penetration, high affinity for water, lack of thermal
Lasers like CO2, argon and Nd:YAG were used to
damage, and minimal reflective property make it ideal
perform pulpotomies on dogs and swine. Subsequent to
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laser for pediatric dentistry. There are two wavelengths,

Er,Cr:YSGG at 2790 nm and Er:YAG at 2940 nm, that are
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Kritika Gupta, et al. International Journal of Dental Science and Innovative Research (IJDSIR)

these animal studies, many studies were done to perform 78.3% achieved clinical and radiographic success,
11
pulpotomies in primary teeth . respectively. The success rate of Nd:YAG laser
Some studies investigating the application of lasers to pulpotomy was significantly higher than that of
dental tissues have shown their potential to increase formocresol pulpotomy.
healing, stimulate dentinogenesis and preserve vitality of Procedures For Laser Pulpotomy
the dental pulp. Various authors performed laser pulpotomy using
In 1985, Ebimara reported the effects of Nd:YAG laser different lasers at varying wavelengths, some of which are
on the wound healing of amputated pulps12 . He reported listed below.
better wound healing in pulps exposed to the laser than in Liu et al (1999)12 published a case report of 23 teeth that
controls during the first week and facilitation of dentinal received pulpotomy treatment with an Nd:YAG laser with
bridge formation in the fourth and twelfth postoperative the following settings, 2W, 20Hz, 100mJ and followed for
weeks. 12 to 24 months. Following access opening and coronal
In 1996, Wilkerson et al. evaluated the clinical, pulp extirpation, initial hemorrhage control was achieved
radiographic and histologic effects of argon laser on vital using dry, sterile cotton pellet. Complete homeostasis was
pulpotomy of swine teeth12 . The results showed that all achieved by exposure to Nd:YAG laser at 2 W, 20 Hz,
soft tissue remained normal and all teeth exhibited normal 100mJ (124J/cm2) (The SunLase 800, pulsed Nd:YAG
mobility. Reparative dentine formation was noted Dental Laser System Sunrise Technology, CA, USA) for
histologically. They concluded that use of argon laser for 15 approximately seconds. This was introduced into the
pulpotomy did not appear to be detrimental to pulp tissues. canal orifice through a standard quartz 320µm optical
These studies led to the use of the Nd:YAG laser for fiber. Then, IRM paste was placed over the pulp stumps,
pulpotomy in primary teeth. Although the first Er:YAG and the tooth was restored with either composite resin or a
laser system (Kavo Key Laser, Kaltenbachand Voigt stainless steel crown. Clinical and radiographic
GmbH & Co., Biberach/Riss, Germany) was introduced evaluations of the success of Nd:YAG laser pulpotomy
into the medical market in Germany in 1992, it was not were based on the following: absence of pain, fistula,
until 1997 that erbium dental lasers received FDA swelling and abnormal mobility; lack of internal or
clearance in the United States. However, other studies on external root resorption, periapical or furcal radiolucency.
lasers led to the use of the Nd:YAG laser for pulpotomy in In conclusion, the results of this study showed that the
primary teeth. clinical success rate of a Nd:YAG laser pulpotomy was
Jeng-fen liu in 2006 compared the effects of Nd:YAG 97%, and the radiographic success rate was 94.1%.
laser Pulpotomy to formocresol pulpotomy on Compared to a formocresol pulpotomy, the success rate of
human primary teeth. Sixty-eight teeth were treated with Nd:YAG laser treatment was significantly higher.
Nd:YAG laser and followed up for 6 to 64 months. Furthermore, Nd;YAG laser did not cause any damage to
Clinical success was achieved in 66 out of the 68 teeth (97 the permanent successors. Therefore, the Nd:YAG laser
%), and 94.1% were radiographically successful. In the pulpotomy can be considered for use as a pulpotomy
technique in clinical practice12 . Adrian reported that
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control group, 69 primary molars were treated with

formocresol and followed up for 9 to 66 months; 85.5 and irradiation of the buccal toothsurface with the
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Kritika Gupta, et al. International Journal of Dental Science and Innovative Research (IJDSIR)

neodymium: yttrium-aluminum-garnet (Nd:YAG) laser

produced less pulp damage than the ruby laser with less
histologic evidence of coagulation and focal necrosis6 .
Melcer et al. (1987) showed that the CO2 laser produced
new mineralized dentin formation without cellular
modification of pulpal tissue when tooth cavities were
irradiated in beagles and primates.
Kato et al. (1989) studied the effects of the Nd:YAG laser
on pulpotomized rat molars at low (5 watts) and high (15
watts) power settings. At 2 weeks, histologic evidence
showed osteodentin covering the amputated pulps with the Armamentarium of LLLT
low power setting and fibrous dentin formation at the One promising alternative to FC pulpotomy is low level
3
orifice wall of the root canal with the high power setting laser therapy (LLLT), which has been shown to accelerate
.McGuire et al. compared the Nd:YAG laser with wound healing process in exposed dental pulp tissue. [10]

formocresol in permanent tooth pulpotomies in dogs at 6- Therapeutic laser treatment, also referred to as LLLT, has
and 12-week post-treatment periods. No significant been used for the last 3 decades15,16 .The principle of using
differences in radiographic pathology were found between LLLT is to supply direct biostimulative light energy to the
the two groups. Histologically, the frequency of pulpal body’s cells.
inflammation was higher for the laser group (29%) at 12 Cellular photoreceptors (eg, cytochromophores and
weeks than for the formocresol group (0%). No antenna pigments) can absorb low-level laser light and
differences were found with respect to periradicular pass it on to mitochondria, which promptly produce the
inflammation and root resorption3 . cell’s fuel, ATP 16.
Jukic et al. (1987) used CO2 and Nd:YAG lasers with
energy densities of 4 J/cm2 and 6.3 J/cm2, respectively,
on exposed pulp tissue. In both experimental groups,
carbonization, necrosis, an inflammatory response, edema,
and hemorrhage were observed in the pulp tissue. In some
specimens, a dentinal bridge was formed11 .
Ebimara et al. (1988, 1992) used the Nd:YAG laser in
rats and dogs. Their results showed that lasers facilitated
pulpal healing after irradiation at 2 W for 2 s 13 .
Moritz et al. (1998) reported that the CO2 laser was a
valuable aid in direct pulp capping in human patients14.
Low Level Laser Therapy (LLLT) Low level laser therapy has potent anti-inflammatory,
analgesic and hemostatic abilities. It implicates a positive
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healing outcome thus preserving the vitality of the

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Kritika Gupta, et al. International Journal of Dental Science and Innovative Research (IJDSIR)

radicular pulp. In addition to this LLLT gives a whole new 2. Joshi PR, Baliga SM, Rathi V Nilesh, Thosar R
dimension to primary endodontics as it is non invasive and Nilima, Dharmadhikari M Priyanti and C Pratiksha .
non pharmacological entity offering therapeutic benefits A Comparative Evaluation Between Formocresol
such as lack of bleeding, faster healing, adequate analgesia And Diode Laser Assisted Pulpotomy In Primary
and reduced postoperative infections. LLLT also provides Molars– An In Vivo Study. ejpmr, 2017,4(5), 569-
many other postoperative outcomes like accelerated 575
wound healing, regeneration, relief of pain and 3. Ingle J.I., Bakland L.K., Baumgartner J.C.
enhancement of local immunity17 . The principle of using Endodontics 6. 2008; 1400-11
LLLT is to supply direct biostimulative light energy to the 4. Lawrence Kotlow. Use of an Er:YAG Laser for
body’s cells. The positive effect of LLLT on reactional Pulpotomies in Vital and Nonvital Primary Teeth J
dentinogenesis induction in human teeth was reported by Laser Dent. 2008 16(2):75-79
[18]
Ferreira et al. The application of LLLT in dentistry is 5. Niranjani K, Prasad MG, Kumar AA. Clinical
included with various clinical conditions. The general rule evaluation of success of primary teeth pulpotomy
for intra-oral treatments is to use 2 to 4 J with the intra- using mineral trioxide aggregate, laser and
oral probe and 4 to 10 J for extra-oral treatments11 . biodentine- An in vivo study. Journal of Clinical and
Various applications are Diagnostic Research 2015; 9(4): 35-37.
1. Temporomandibular disorders. 6. Lin PY, Chen HS, Wang WH, Tu YK. Primary molar
2. Hypersensitive dentin pulpotomy: a systematic review and network meta-
3. Postextraction and bone-healing therapy analysis. J Dent 2014 Sep; 42(9):1060-1077
4. Orthodontics 7. Kakarla P, Avula JS, Mallela GM, Bandi S, Anche S.
5. Herpes labialis Dental pulp response to collagen and pulpotec
6. Aphthous ulcers cements as pulpotomy agents in primary dentition: a
7. Trigeminal neuralgia etc. histological study.JConsev Dent 2013 Sep;6(5) 434-
Summary and Conclusion 438
With the rapid development of laser technology, new 8. Lawrence A. Kotlow Lasers in pediatric dentistry
lasers with a wide range of characteristics are now Dent Clin N Am 48 .2004; 889–922
available and being used in various fields of dentistry and 9. Jesse James Desai Sandip Oshita Patrick The
laser pulpotomy is one of them. Various studies have Evolution Of Lasers In Dentistry The Academy Of
proved it as 100% success both clinically and Dental Therapeutics And Stomatology
radiographically. So it becomes most important for the 10. S.Parker. Introduction, history of lasers and laser
dental practitioner to become familiar with the principles light production. British Dental Journal. 2007 jan 13;
and then choose the proper laser(s) for the intended vol 202 No.1
clinical application. 11. Bahrololoomi Z, Moeintaghavi A, Emtiazi M,
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