| Abstract|| |
Context: Low-level laser therapy (LLLT) is an established method to accelerate wound healing through the phenomenon of biostimulation. Aims: This case study presents a novel approach for management of open apex cases associated with large peripapical lesions using 980-nm diode laser for biostimulation. Settings and Design: Case report. Materials and Methods: Two patients presenting with open apex associated with periapical lesion were selected. After access opening, canal disinfection was carried out with sodium hypochlorite and 980-nm diode laser. Calcium hydroxide was given as intracanal medicament for 1 week. When patient was asymptomatic, apical plug of 4–5 mm MTA was placed. In addition, seven sessions of LLLT were administered transcutaneously around the apices of involved teeth every alternate day for 15 days. Results: One year follow-up radiograph revealed remarkable healing of the lesion. Conclusion: The combination of increased cellular proliferation with laser biostimulation and meticulous canal disinfection with lasers has the potential of accelerating healing of the periapical lesions.
Keywords: Biostimulation, diode laser, low-level laser therapy, open apex, root canal disinfection
|How to cite this article:|
Yadav S, Nawal RR, Talwar S, Verma M. Low-level laser therapy for management of large periapical lesions associated with open apex cases. Indian J Dent Res 2020;31:334-6
|How to cite this URL:|
Yadav S, Nawal RR, Talwar S, Verma M. Low-level laser therapy for management of large periapical lesions associated with open apex cases. Indian J Dent Res [serial online] 2020 [cited 2020 May 30];31:334-6. Available from: http://www.ijdr.in/text.asp?2020/31/2/334/284573
| Introduction|| |
Low-level laser therapy (LLLT), also known as therapeutic laser treatment, is a new but well-accepted tool in regenerative medicine and dentistry. When used at an appropriate dose, LLLT has the ability to stimulate wound healing. It produces a biostimulative effect on body cells as it is readily absorbed by the cellular photoreceptors resulting in increased ATP production, mast cell activation, and fibroblast production. Because of these properties, it can reduce inflammation and promote faster resolution of periapical lesions by nonsurgical means. The following case reports highlight the nonsurgical management of symptomatic teeth with immature apices and large periapical radiolucencies using disinfection ability and biostimulative property of 980-nm diode laser to promote periapical healing.
| Subjects and Methods|| |
An 18-year-old female patient reported with a chief complaint of pus drainage and discolored maxillary right central incisor with a history of trauma at the age of 6 years. Radiographic examination showed an immature tooth with a wide open apex wrt 11 and diffuse periapical radiolucency in relation to right maxillary central and lateral incisor of approximate size 35 × 30 mm [Figure 1]a. A diagnosis of pulp necrosis with chronic apical abscess was made.
|Figure 1: (a) Preoperative radiograph, (b) immediately after obturation, and (c) 1-year follow up radiograph|
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Endodontic access opening was done after rubber dam application. Working length was assessed radiographically. Biomechanical preparation was done using hand K files (Dentsply Maillefer, Ballaigues, Switzerland) for tooth 12 in a step back fashion. After completing apical preparation till 40 no hand K file (Dentsply Maillefer), the rest of the canal was flared using progressively larger files to achieve a tapered canal shape. Root canal walls were gently cleaned for right maxillary central incisor. Copious irrigation was performed with 1% NaOCl using 30 G Max-i-Probe needle (Dentsply-Rinn, Elgin, IL, USA) during the treatment. Root canal was dried with paper points (Dentsply/Tulsa Dental, Tulsa, OK, USA). Next, the root canals were disinfected using 940-nm diode laser (Epic 10 Diode Laser; Biolase Inc., USA) applied with the wave length of 940 nm, output power of 2.5 W, continuous wave mode, 10-m s pulse duration, and 10-m s pulse interval. The laser was irradiated into the canals to a depth of 1 mm shorter than the actual root canal length, using an optical fiber with a diameter of 200 μm. Calcium hydroxide (Dento Kem, Faridabad, India) was mixed with saline to get a creamy consistency and was placed in the canal. The access cavity was sealed with a temporary restorative material, Cavit (3M, Espe, Saint Paul, MN, USA).
One week later, the calcium hydroxide dressing was removed, and irrigation was done with 1% NaOCl and 17% liquid EDTA Smear Clear (SybronEndo, CA, USA). The root canal was then dried with sterile paper points followed by placement of platelet-rich fibrin (PRF) into the periapical tissue with the help of an endodontic plugger wrt tooth no. 11. The tooth-colored ProRoot MTA (Dentsply) was prepared according to the manufacturer's instructions. MTA was applied to the apical portion of the canal using a calibrated measured plugger. MTA placement was assessed radiographically; it illustrated appropriate obturation of the apical third of the root canal. A sterile cotton pellet moistened with water was placed over the material within the root canal and the access cavity was sealed temporarily. Right maxillary lateral incisor was obturated using cold lateral condensation technique using gutta percha and AH Plus sealer (Dentsply Maillefer, Konstanz, Germany). The patient was recalled after 1 week for clinical and radiographic examination. Gutta percha backfill was performed using Obtura (Obtura/Spartan, Fenton, MO, USA) wrt tooth no. right maxillary central incisor and the access cavity was sealed using composite resin [Figure 1]b.
The patient was given seven sessions of LLLT (940 nm, 50 mW, continuous emission; Epic 10 Diode Laser, Biolase Inc.). Transcutaneous irradiation was performed around the apices of involved teeth at four points equidistant from each other around the periapical lesion for 9 s delivering a total of 16 J/cm2 in each session. Application was repeated every 48 h for 15 days. The clinical follow-up at 1 year showed the patient functioning well with no reportable clinical symptoms. The radiograph showed complete healing of the periapical radiolucency [Figure 1]c.
| Case Presentation 2|| |
A 17-year-old patient reported with a chief complaint of discolored and fractured front teeth. History of trauma was present around 10 years back. On radiographic examination, open apex was seen wrt maxillary right and left central incisor along with periapical radiolucency. A diagnosis of pulp necrosis with asymptomatic apical periodontitis was made.
Endodontic access opening was done wrt teeth no. 11 and 21 under rubber dam isolation. Working length was assessed radiographically. Root canal walls were gently cleaned for both the teeth. Copious irrigation was performed with 1% NaOCl using 30 G Max-i-Probe needle (Dentsply-Rinn) during the treatment. Next, the root canals were disinfected using 940-nm diode laser (Epic 10 Diode Laser; Biolase Inc.), and calcium hydroxide (Dento Kem) was placed in the canal for 1 week. One week later, calcium hydroxide dressing was removed, and irrigation was done with 1% NaOCl and 17% liquid EDTA Smear Clear (SybronEndo). PRF was placed into the periapical tissue with the help of an endodontic plugger wrt teeth no. 11 and 21. The tooth-colored ProRoot MTA (Dentsply) was applied to the apical portion of the canal using a calibrated measured plugger. A sterile cotton pellet moistened with water was placed over the material within the root canal and the access cavity was sealed temporarily. After 1 week, gutta percha backfill was performed using Obtura (Obtura/Spartan) and the access cavity was sealed using composite resin [Figure 2]b. Follow-up examination on 6 months showed that the patient was asymptomatic and healing of periapical lesions was evident on radiograph [Figure 2].
|Figure 2: (a) Preoperative radiograph, (b) immediately after obturation, and (c) 6-month follow up radiograph|
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| Discussion|| |
The biggest challenge while treating nonvital teeth with open apices is achieving complete elimination of the microbes from the root canal system. As aggressive mechanical instrumentation can weaken the already fragile root canal walls, disinfection of the root canal system is mainly achieved by irrigants like NaOCl and intracanal medicaments like calcium hydroxide.
In addition to NaOCl, diode laser was used for achieving thorough disinfection. A study done by Moritz et al. showed that 890-mm diode laser has a bactericidal action and could disinfect the root canal. When compared with common irrigants, diode laser has a greater depth of penetration into the dentinal tubules (up to 1000 μm). Hence, lasers used in conjugation with conservative endodontic treatment can offer new possibilities regarding the difficulties faced during cleaning of root canal system.
To accelerate periapical healing, LLLT was used in both the above cases. LLLT has been shown to accelerate the process of osseous healing by several mechanisms such as decreasing the inflammatory mediators, increasing cellular proliferation, increasing neovascularization, upregulating bone morphogenic protein, and transforming growth factor beta, and thus increasing the differentiation of mesenchymal cells into osteoblasts. All these events result in accelerated osteogenesis. LLLT protocols for bone regeneration show a large variety in literature, most of them involving daily or alternate days application for 15–21 days. Repetitive sessions were used in this study in accordance with the protocol used in previous studies on bone regeneration.,
| Conclusion and Recommendations|| |
This case report is first of its kind in which diode lasers have been successfully used at low level to induce faster healing of periapical lesion associated with open apex cases. Therefore, it is recommended that lasers should be used in future studies to evaluate and further confirm its biostimulative properties.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Sudha Yadav
Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, MAMC Complex, New Delhi, Delhi - 110 002
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]