Adan Stabholz,DillD

ldam Stebholz graduatedfiom the Hebrau Univerig-Hadassah

Schoolof Dental Medicine founded by the Alpha
OmegaFraternityin 1974 and in 1978
he completedthe graduateprogramin
Endodontics
at the University
of Pennsylvania.In 1988,he was appointedHead
of the Depaftmentof Endodontics
at the
Hebrew University-Hadassah
Schoolof
DentalMedicinga positionhe hasheld
eversince.In 1993,hewas electedDean
of the HebrewUniversity-Hadassah
School
of DentalMedicine,
andin 1996hewasreelectedas Deanfor a secondconsecutive
5-yearterm.In thisyear,he wasalsopromotedto the rankof full professor
in Endodontics. He was awarded honorary
degreesfiom the Universityof Bucharest
and the Universityof BuenosAiresand
theCertificate
of Medtof theAlphaOmega
InternationalDental Fraternig.He receivedfiom the lsraelDentalAssociation
the highestawardfor outstanding
contributionto the dentalprofessionin lsrcel.
Prof.Stabholzhas publishedextensively
in thedentalliterature,
istheauthorof severalchapters
in endodontictextbook and
haslecturedat manyinternational
dental
meetings.Hiscunentresearchis focused
on the applicationof lasea in dentistry.
Heis the immediatepastPresident
of the
Intemational
Federation
of EndodonticAssociations,
the Chairmanof the Scientific
Councilof the lsraelDentalAssociation.
andis a memberof the Boardof Directors
of the AlphaOmegaInternational
Dental
Fraternity.
ln 2O05,Adam Stabholzwas
electedagainasDeanof the Hebrerrv
University-Hadassah
Schoolof DentalMedicinefor a 4-yearterm.

Sharunlt Sahar-Helft,DMD

he rapid developmentof lasertechnologyand a better understanding

oI a laser'sinteractionwith biologic tissueshaswidened the spectrur
of possibleapplicationsof lasersin endodontics.The developmentol
new deliverysysteml including thin and flexible fibersand new endodontic
tips, hasmadeit posdibleto apply this technologyto variousendodonticprocedures,including pulpal diagnosis,pulp cappingand pulpotomy,cleaning
and disinfectingthe root canalsystem,obturation of the root canal system
endodonticretreatment,and apicalsurgery.
Although the interestin the clinical useo[ Iasersystemsfor endodontic proceduresis increasing,thereare
still some concernsassociatedwith
their use-mainly a lack of sufficient
well designedclinical studies that
demonstrateclearly the advantage
of lasersovercurrentlyusedconventionalmethodsand tdchniques.
Selection of the suitable wavelengthfrom the variouslasersystems
offeredto thedentalpractitioners
requires advancedtraining and good
understandingof the differentcharacteristicsof eachlasersystem.One
of the most significantapplications
o[ lasersin endodontics relatesto
the cleaningand the disinfectionof
the root canalsystem,which this article will address.
CLEANINGAND DISINFECTING
THE ROOTCANAL SYSTEM
Bacterial contamination of the
root canal systemis consideredthe
principle etiologicfactor for the developmentof pulpal and periapical
lesions.'-' Obtaining a root canal
systemfree o[ irritants is a major

goal of root canal therapy. Biomechanical instrumentation of the

root canal system has been suggestedto achievethis task.However
because of the complexity of the
root canalsystem,it hasbeenshown
that the completeelimination of debris and achievementof a sterileroot
5
canalsystemis very difficult,a and
a smearlayer,which coversthe instrumentedwalls of the root canal,
1 6-fl

ts lormed.-

The smearlayer consistsof a superficial layer on the surfaceof the

root canal wall approximately I to
2 pm thick and a deeper layer
packed into the dentinal tubules to
a depthof up to 40 pm.8lt contain
inorganic and organic substances
including microorganismsand necrotic debris.' ln addition to the
possibilitythat the smearlayer itself
may be infected,it can also protect
the bacteria already present in the
dentinal tubules by preventing the
application of successfulintracana
disinfection agenrc.lo PashleylI
consideredthat a smear layer containing bacteria or
bacterial

__-

Shennlt Srharlhlft is a clinic insEuctol in the Deparfnent of Endodontics at Hebrew UniversigHadassahSchoolof DentalMedicine
in Jerusalem(HUHSDM),lsrael.She
graduatedher dentalstr.rdies
wiilr her
DMDdegreein "CarolDavilla"University,BucharestRomania,in t 99 | . After
graduatingshewasa clinicalinstructor
in the Departmentof RestorativeDentistryat the TelAvivUniversityMaurice
and GebriellaGoldshlegger
Schoolof
DentalMedicinefrom 1992to 1997.
She then went to HUHSDM,wlrere
she completedthe postgraduate
programin the Endodontics
in 2fl)0. Dr.
SharonitSahar-Helftcurrentlyworks
in privatepractice,
limitedto endodontics.

loehua llloshonoY,DMD
lochuaMoshonovisanassociate
clinicalprofessorand actingChairmanof
the Department
of Endodontics
at the
Hebrew University-Hadassah
Faculty
of DentalMedicine,Jerusalem,
lsrael.
He is PastPresident
of the lsraelEndodonticSocietyand PastChairmanof
the ExecutiveCommitteeof the 4th
World Congressof the lnternational
Federation
of Endodontic
Associations
(IFEA).
Heis a memberof the national
boardofendodontics
ofthe stateof lsrael.Dr.Moshonovhasauthoredand
coauthoredmany scientificarticles
and is invitedto lecturesboth nationallyand internationally.
Hiscurrentresearchfocuseson the applicationof
laserin dentistryand he also maintainsa privatepracticelimitedto endodonticsin TelAviv,lsrael.

Figurel. The prototypeof the RCLaseSide-FiringSpiralTip (Lumenis,yokneam, lsrael) is shown in the root canal of an extractedmaxillarycanine in which the side
wall of the root was removedto enablevisualizationof the tip.

productsmight provide a reservoir

of irritants.Therefore,rcomplete
removal of the smearlayer would be
consistentwith the eliminationof irritantslrom the root canalsystem.l2
I
Peterset al.l clearlyshowedthat
more than 35okof the canal'ssurface
arearemainedunchangedfollowing
instrumentationof the root canalusing 4 nickel-titanium(Ni-TD preparation techniques.Becausemost
curuently used intracanal medicaments have a limited antibacterial
spectrumanda limite{abiiityto difluseinto the dentinalttrbules,it was
suggestedthat newer treatment
strategiesdesignedto eliminatemicroorganismsfrom the root canal
systemshouldbe considered.
These
must include agentsthat can penetrate the dentinal tubuies and destroy the microorganisms,located
in an areabeyond the host defense
mechanisms,where they cannot be

reachedby systematicallyadministered antibacterialagents.t*

It has also been documented in
numerous studies that COr,tt
Nd:YAG,l5-17 argon,tt't8 Er,
Cr:YSGG,leand Er:YAG'o''l lase.
irradiation has the ability to remove
debrisand smearlayerfrom the root
canalwalls following biomechanical
instrumentation.The task of cleaning and disinfectinga root canalsystem which containsmicroorganisms
gatheredin a biofilm becamevery
difficult,certainbacterialspecies
become more viruient when harbored
there and demonstrate stronger
pathogenicpotential and increased
resistanceto antimicrobial agents
becausethat stucturehas the abiiity
to prevent the entrv and action o[
I
suchagents.22
Bergmans
et al.2 tried
to define the role of iaseras a disinfection tool by using Nd:YAG laser
irradiation on some endodontic

Figure2. The RCLase

Side-Firing
SpiralTip(Lumenis).

196

Alpha Omegan o Volume I0l

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tracanal use of lasers that cannot

be overlooked.2a
The emissionof laserenergyfrom
the tip of the opticalfiber or the laser
guide is directedalong the root canal and not necessarylaterallv to
the root canal walls.2t'Therefoie.it
is almost impossiblero Lbtain uniform coverageof the canal surface
usinga Laser.2a'25
Also,becausethermal damageto the periapicaltissues
is potentially possible,the safetyof
such a procedurealwayshas to be
considered." Direct emission of
laserirradiation from the rip of the
optical fiber in the viciniry of the
apicalforamenof a tooth may result
in transmission of the irradiation
beyond the foramen.This, in rurn,
may undesirablyaffectthe supporting tissuesof the tooth and can be
hazardousin teeth with closenroximity to rhe mental loramenor l-o
the mandibular nerve.25'26
In their
revieq Matsumotoet a|.26alsoemphasizedthe possibielimitations of
the use ofiaser in the root canalsystem. They suggestedthat "removal
of smearlayer and de\ris by laser
Figure
3. Scanning
electron
microscope is possible,however.it is difficult
photographs
of a lasedwall of a root
to cleanall root canalwalls,because
canalat its (A) apical,(B) middle,and
the
laser is emitted straight ahead,
(C)cornalparts,respectively,
showvery
making
it almost impossible ro
cleansurfacesof the root canalwalls,
freeof smearlayeranddebris,
andclean irradiate the lateral canal walls."
opendentinal
tubules.(Original
magni- They strongly recommended imfication:x300)
proving the endodontictip to enable
irradiation of ail areasof the root
pathogensin vivo. They concluded canalwalls.
that Nd:YAG laser irradiation is
The Er:YAGlaser has gained innot an alternative but a possible creasing popuiarity among clinisupplement to existing protocols cians following its clearanceby the
for canal disinfections,becausethe
U.S.Foodand Drug Administration
propertiesof laser light may aliow
(FDA) for use on hard dental
a bactericidaleffect beyond I mm
tissues.2T
of dentine. Endodontic parhogens
Stabholz eL a1.25'26
recently rethat grow as biofilms are difficult to
ported the developmentof a new
eradicate,_.even
upon direct laser endodontic tip which can be used
exposure.-"
with an Er:YAG laser system.The
There are several hmitations
beam of the Er:YAG laser is delivthat may be associatedwith the ineredthrough a hollow tube, making

Alpha Omegan o Volume l0l

o Number 4

t-,

it possibleto developan endodontic

tip that allowslateralemissionof the
irradiation (side-firing) rather rhan
direct emission through a single
openingat its far end. This new endodontic side-firing spiral tip was
designed to fit the shape and the
volume of root canalspreparedby
Ni-Ti rotary instrumenrarion. It
emits the Er:YAG laser irradiation
laterallyto the walls of the root canal
through a spiral slit Iocatedall along
the tip. The tip is sealedar irs far
end, preventing the transmission
of irradiation to and through the
apicalforamenof the tooth (Figures
t and 2).
The efficacy of the endodontic
side-firing spiral tip in removing debns and smearlayer from distal and
palatal root canals of freshly extracted human molars was examined. Scanningelectronmicroscopy
of the lasedroot canalwalls revealed
cleansurfacesthat werefreeof smear
layer and debris.26
Figures 34 to 3C are scanning
electron microscopy photographs
of a root canal wall that has been
lased. Figure 3,{ is the apical portion, Figure 38 is the middle, and
Figure 3C is the coronal. Figure 4
shows the apical portion of a wall
that hasnot receivedlasertreatment.

Figure4. Scanningelectronmicroscope
photographsof a a non lased wall of
a root canal at its apical parts,demonstrate unclean surfacesof the root canalswalls with smearlayerand debris.
The dentinaltubules cannot be seen.
(Originalmagnification:
x300.)

197

Figure5. (A) An l8-year-old

femalecamewith hermotherto ourendodontic
cliniccomplaining
on a badtastein hermouthand
of a lesionin hergumsin thefrontareaof hermouth.Theclinicalexamination
Presence
revealeiasinustractopeningcloseto the
incisor.
qqel o!lhe rightlateralmaxillary
Theradiograph
showedan internalresorption
anda largeradioluceni
ur""-intheapical
thirdof the root.A diagnostic/length
measuremeniradiograph
alsodemonstrated
the presence
Jf rootperforation
in thatpartof
the root.Thepatientandhermotherwereadvised
thatthe prognosis
of thetoothis verypoorandthe optionof placinga dental
implantto replace
the lateralincisorshouldbeconsidered.
rhe motheraskedusto try savingthetoothbecause
herdauihterwas
scheduled
journeythat couldnot be postponed.
to leaveon a_several-week
(B) Th; tootliwas openedandthe rootianal was
cleanedandshaped.Ca(OH)2
wasplacedfor 3 monthsandthenieplacedwitiri freshlypreparedsamematerial.
After6 months
thesinustractdid notdisappear
andno signsof healingcouldbe obierved.(G)Themotirerandthepatientweretoldthatasa last
resortwe couldofferto treatthetoothwithournewlydeveloped
side-firing
spiralendodontic
tip whiih mayhelpin providing
better
disinfection
of the infectedrootcanalsystem.
Thepictureshowsthe RCLaletip
positioned
in thecontraangleileft)andthe radiogtaphshowsthetip insidethe rootcanal.(D)Radiograph
showsthelateralmaxillary
incisorfoltowingcompietiinof ttrerootcanal
fillingusing.ahot gutta-percha
(E)A 2-yearfollow-upradiograph
technigue.
showscomplete
healirigof the periapical
lesion.The
sinustractdisappeared
andthe patientis freeof symptoms.
The dentinal tubules in the root
run a relatively straight course between the pulp and the periphery
in contrast to the typical S-shaped

198

contours of the tubules in the tooth

crown.tt Studies have shown that
bacteriaand their byproducts, present in infected root canals, may

invade the dentinal tubules. The

presenceof bacteria in the dentinal
iubules of infected reerh ar approximatelyhalfthedistancebetweenthe

Alpha Omegan o Volume l0I

o Number 4

Figure6. (A) A 42-year-oldmale was referredfor an endodonticevaluationby his dentistwho suspecteda verticalroot fractureon
the secondmandibularright molar.Dentalhistoryrevealedthat the tooth was reconstructedI 2 yearsagofollowing poor root canal
therapyand the patienthad previouslyexperiencedpain and swellingin this area.(B) At the first appointment,the leakyrestoration
andthe screwpostwere removedand the distalroot canalwas thoroughlyinigatedusingsodium hypochlorite.The small piecesof
the old gutta perchafilling were washed out. Ca(OH)2dressingwas placedand the patient was offered to be treated with the
RCLase
Side-FiringSpiralEndodonticTip. (C and D) The endodontictreatmentwas completed6 months later (May 2005). Follow-upradiographstaken l, 2, and4 yearsaftercompletionof the endodontictreatmentshow completehealingof the periapical
lesion.

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AlphaOmegan o Volume l0l o Number 4

199

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>

<L

root. canal walls and the cementodentinal iunction was also reporred.28'zeThese findings justify
the rationaleand need for developing an effective means of removing
the smearlayer from root canalwalls
following biomechanical instrumentation.This would allow disinfectants and laser irradiation to
reach and destroy microorganisms
harboring in the dentinal tubules.
Two clinical caseexampleswill illustratehow this side-firingEr:YAG
laser irradiation can contribute to
a successfulendodonticresult.
The first caseis a maxillary lateral
incisor with a large area of intemal
resorption (Figure 5A). The canal
wasdebridedand filled with a calcium
hydroxide paste and temporized for
7 months (Figure 5B). The laser
was used along with conventional
instrumentation(Figure 5C) and the
final obturation was accomplished
(Figure 5D). Approximately 2 years
later, the resorption has ceasedand
the periapicaltissueshavehealednormally (Figure 5E).
The secondcaseshowsa mandibular secondmolar with a failing endodontic treatment (Figure 64). After
debridementof the distalroot, the laserwas used to cleanthe canalwalls,
calcium hydroxide pastewas placed,
and the tooth was temponzed
(Figure68). Sevenmonths later,the
roots were instrumented,lased,and
obturated (Figure 6C). Figure BD
shows the progressivehealing, and
nearly 3 years later, the tooth and
penodontium are healthy.
CONCLUSION
ln various laser systemsused in
dentistry the emitted energy can be
delivered into the root canal system
by a thin optical fiber (Nd:YAG,
KTP-Nd:YAG, ErCr;YSGG, argon,
and diode) or by a hollow tube

(COz and Er:YAG). Therefore,the

potential bactericidaleffectof laser
irradiation can be effectively used
for additionalcleansingand disinfecting of the root canalsystemfollowing
biomechanicalinstrumentation.This
effecthasbeenvalidatedin numerous
studies using availablqwavelengths
such as COr,to't' I.ld:YAG,32-35
KTP-Nd:YAG,36excimer,3T'38diode,3eand Er:YAG.aM2
The apparent consensusis that
dental laser irradiation has the potential to kill microorganisms,
which aidsin successfulendodontic
treatment.

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