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linical, Radiographic, and Histopathologic Evaluation ofd:YAG Laser Pulpotomy on Human Primary Teeth

esut Enes Odabas, PhD,* Haluk Bodur, PhD,* Emre Bar�s, Research Assistant,†

nd Cem Demir, Research Assistant†

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bstracthe purpose of this study was to compare clinical,adiographic, and histopathologic effects of Nd:YAGaser pulpotomy to formocresol pulpotomy on humanrimary teeth. Patients with at least two vital primaryolar teeth that required pulpotomy, because of pulpal

xposure to caries, were selected for this study. Afteremorrhage control, complete hemostasis into the ca-al orifice was achieved by exposure to Nd:YAG laser1064 nm) and an He-Ne laser (the aiming beam of thed:YAG laser) in noncontact mode at 2 W, 20 Hz, 100J, or was achieved by applying 1:5 dilution of formo-

resol. Forty-two teeth in two groups were to be fol-owed up clinically and radiographic at 1, 3, 6, 9, and2 months. Eighteen teeth planned for serial extrac-ions were selected for histopathologic study. The teethere extracted at 7 and 60 days. The teeth in the laserroup had a clinical success rate of 85.71% and aadiographic success rate 71.42% at 12 months. Theeeth in the formocresol group had a clinical and radio-raphic success rate of 90.47% at 12 months. Thereere no statistically significant differences between

aser and formocresol group with regard to both clinicalnd radiographic success rates. There was a statisticallyignificant difference between 7- and 60-day laserroups with regard to inflammatory cell response cri-eria. Dentin bridge was absent in all samples. Notained bacteria were observed in any of these samples.n conclusion, Nd:YAG laser may be considered as anlternative to formocresol for pulpotomies in primaryeeth. (J Endod 2007;33:415–421)

ey Wordsormocresol, laser, primary teeth, pulpotomy

From the *Departments of Pediatric Dentistry and †Oralathology, Faculty of Dentistry, University of Gazi, Ankara,urkey.

Address requests for reprints to Dr. Mesut Enes Odabas.-mail address: [email protected]/$0 - see front matter

Copyright © 2007 by the American Association ofndodontists.oi:10.1016/j.joen.2006.12.013

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OE — Volume 33, Number 4, April 2007

he pulpotomy is one of the most frequently used treatments in primary dentition. Thepulpotomy treatment can help to maintain the integrity of primary teeth having

nflammation limited to the coronal pulp (1, 2).Because various materials have been recommended for pulpotomy, formocresol

s the most commonly used pulpotomy agent in primary teeth. Formocresol pulpotomyontinues to be the technique taught throughout in most dental schools in North Amer-ca (3). On the other hand, concerns about formocresol safety have been published inental and medical literatures for almost 30 years. Despite the high clinical success ratef formocresol pulpotomy, toxic, mutagenic, and carcinogenic effects of formocresolave led the clinicians to use alternative methods and agents that are more tissueompatible than formocresol. Gluteraldehyde, calcium hydroxide, electrosurgery, cor-icosteroids, collagens, ferric sulfate, freeze-dried bone, bone morphogenetic protein,nd laser have been proposed as alternative methods and agents.

Because laser treatment has advantages with respect to control of hemorrhage,terilization, and stimulation effects on the dental pulp cells, laser use for pulp treatmentas attracted dentists’ attention. Pulpotomy is a surgical removal of the soft dental tissue,nd for this purpose an atraumatic and aseptic technique is required for success. Lasersan remove the soft tissue without mechanical contact so that the trauma to the residualissues is avoided.

Since the effects of ruby laser irradiation on the dental pulp tissue have been reported4), some reports about a pulpotomy procedure using CO2, Nd:YAG, argon, diode, andrbium:yttrium aluminum garnet (Er:YAG) lasers have been published (5–11).

In animal studies, CO2, Nd:YAG, and Er:YAG lasers have been investigated in pulp-tomy procedure. Shoji et al. (11) investigated the immediate effects of a CO2 laser onmputated dental pulps in dogs. They used focused and defocused laser beams and aide range of laser power (3, 10, 30, and 60 W) in the pulpotomy procedure. Theybserved no detectable damage in the radicular portions of pulps that were irradiated.CO2 laser was compared with the Nd:YAG laser in pulpotomy procedure by Jukic et al.

6). They investigated the effects of CO2 and Nd:YAG lasers on amputated vital dentalulps in molars and premolars of dogs at 30 and 45 days. They found no newly dentinever the exposed pulp tissue in the root-canal openings after laser irradiation. Kimurat al. (7) evaluated the histopathologic effects of Er:YAG laser on the remaining pulpissue and periodontal tissues of rat at 0 days, 2 days, and 1 week after irradiation. Theyrradiated remaining pulps using an Er:YAG laser at 2 Hz and 34, 68, and 102 mJ/pulse.hey reported that the high-energy settings caused the more damage to the remainingulp tissue and periodontal tissues than the low-energy setting caused.

On the other hand, CO2, Nd:YAG, diode, and Er:YAG lasers have also been inves-igated for pulpotomy procedure in human studies. Elliott et al. (9) evaluated theesponse of the human primary pulp to the CO2 laser and formocresol for vital pulpherapy. The treated teeth were evaluated clinically and radiographically at 28 and 90ays and histologically after extraction. They suggested that CO2 laser treatment com-ared favorably to formocresol for pulpotomy procedure in primary teeth. Huth et al.10) compared the relative effectiveness of Er:YAG laser, calcium hydroxide, and ferriculfate with that of dilute formocresol. The treated teeth were re-evaluated after 6, 12,8, and 24 months. They found that only calcium hydroxide performed significantlyorse than formocresol. A diode laser pulpotomy with mineral trioxide aggregateMTA) was investigated in human primary teeth by Saltzman et al. (8). They investigated
hether laser pulpotomy with MTA sealing was an acceptable alternative to formocre-
Nd:YAG Laser Pulpotomy 415

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ol. The treated teeth were evaluated clinically and radiographically at.3, 5.2, 9.5, and 15.7 months. They found no statistically significantifferences between both groups with regard to radiologic and clinicaluccess criteria. Liu (12) compared the clinical success rate of Nd:YAGaser with formocresol pulpotomy on human primary teeth. The treatedeeth were followed up for 9 to 66 months. Liu (12) found the successate of Nd:YAG laser pulpotomy significantly higher than that of formo-resol pulpotomy.

The purpose of this study was to compare clinical, radiographic,nd histopathologic effects of Nd:YAG laser pulpotomy to formocresolulpotomy on human primary teeth.

Methodstudy Population

The participants, including 14 males and 16 females ranging be-ween 6 and 9 years of age (mean age, 7.9 years) were selected from theatient population at University of Gazi, Department of Pediatric Den-istry. The children were healthy and cooperative. The procedure, pos-ible discomfort, or risks as well as possible benefits were explainedully to parents of the children involved. This study was approved by theniversity of Ankara, Faculty of Dentistry Ethics Committee. Theatients were selected based on the following clinical and radio-raphic criteria:

The clinical criteria were as follows:

1. Patients with at least two vital primary molar teeth that requiredpulpotomy, because of pulpal exposure to caries.

2. Teeth showed no clinical evidence of excessive mobility.3. Teeth had no tenderness to percussion, no swelling, or fistula-

tion.

igure 1. (a) Pulpal bleeding after removal of coronal pulp tissue. (b and c)adicular pulp stumps.

igure 2. (a and b) Nd:YAG laser was applied at 2-W, 20-Hz, 100-mJ lasing power in

16 Odabas et al.

4. Teeth were deemed restorable.

Radiographic criteria were as follows:

1. There was an absence of external or internal root resorption.2. There was an absence of furcal, periapical radiolucencies, or

widened periodontal ligament spaces.3. No more than one-third physiologic root resorption had

occurred.

linical ProcedureAll the treated teeth were anesthetized by using 2% lidocaine with

:100,000 epinephrine and then were isolated with a rubber dam. Afteraries removal, the pulp chamber was opened with a sterile high-speediamond bur, and the coronal pulp was removed by a sterile sharppoon excavator (Fig. 1a). After the removal of coronal pulp tissue,emorrhage was controlled by placing sterile, saline-wetted cotton pel-

ets on the radicular pulp stumps under slight pressure and waiting 5inutes for primary hemostasis (Fig. 1b and c). When bleeding recom-enced during placement of the medication or laser irradiation, the

ooth was excluded from the study.

ulpotomy TechniqueIn laser group, after hemorrhage control, complete hemostasis into

he canal orifice was achieved by exposure to Nd:YAG laser (1,064 nm) andHe-Ne laser (the aiming beam of the Nd:YAG laser) in noncontact mode atW,20Hz, and100mJ(Pulsmaster600 IQ;AmericanDentalTechnologies,outhfield, MI) ( Fig. 2a, b, and c). The diameter of the fiber optic cable was20 �m. In formocresol group, complete hemostasis was achieved by ap-lying 1:5 dilution of formocresol-wetted cotton pellet. Then, intermediate

rrhage was controlled by placing sterile, saline-wetted cotton pellets on the
Hemo
to the canal orifices. (c) Complete hemostasis after laser exposure.

JOE — Volume 33, Number 4, April 2007

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estorative material paste was placed over the pulp stump, and the teethere restored with stainless-steel crowns or amalgam.

A total of 42 primary teeth of 21 patients were followed up clini-ally and radiographic at 1, 3, 6, 9, and 12 months. The outcome inerms of success or failure was determined by the following clinical andadiographic criteria:

1. No tenderness to percussion; teeth remained asymptomatic2. Absence of a sinus tract3. Absence of furcal or periapical radiolucencies4. Absence of external or internal root resorption5. Premature tooth loss

Clinical outcome assessments were made by the primary investi-ator at each follow-up visit, whereas radiographic outcome assess-ents were made by the primary investigator and one independent

xperienced clinician who was blind to the treatment.

istopathologic StudyIn the histopathologic part of our study, 9 patients were planned

or serial extractions. After pulpotomy treatments, 18 primary teeth (6rimary canines and 12 first primary molars) were extracted at 7 and 60ays. After extractions, teeth were immediately preserved in 10% buff-red formalin. After fixation, teeth were decalcified in a 10% formic acidolution. The teeth were embedded in paraffin blocks, and serial sec-ions were cut at a setting of 5-� in a buccolingual direction. The slidesere stained with hemotoxylin and eosin, light green paste, Gomori

etikulin, and Brown & Brenn technique. One tooth of each 7-day groupas not been evaluated because of technique problems. Histopathologicvaluations were performed under conventional light microscope bywo oral pathologists. All sections were evaluated according to fourriteria; inflammatory pulpal responses, tissue disorganization, reac-ionary dentin formation, and bacteria (used by Hebling et al.) (13).

ResultsThe agreement between two examiners was good for the radio-

raphic success rates (� � 0.90) using kappa statistics.

linical ResultsThe teeth in the lasergrouphadaclinical success rateof100%at1and

months, 90.47% at 6 months, and 85.71% at 9 and 12 months. The teethn the formocresol group had a clinical success rate of 100% at 1 and 3

onths and 90.47% at 6, 9, and 12 months. The clinical success observedor each group was compared at each of the five follow-up periods. Statis-

ABLE 1. Clinical Evaluation of Laser and Formocresol Pulpotomies

1 Month 3 Months

Success Failure Success Failure

Laser group 21 0 21 0Formocresol group 21 0 21 0Total 42 0 42 0

N � 42 p � 0.05 p � 0.05

ABLE 2. Radiographic Evaluation of Laser and Formocresol Pulpotomies

1 Month 3 Months

Success Failure Success Failure

Laser group 21 0 19 2Formocresol group 21 0 21 0Total 42 0 40 2

N � 42 p � 0.05 p � 0.05


ical analysis of the data, using Fisher’s exact test, revealed no statisticallyignificant differences between the two groups (Table 1).

adiographic ResultsThe radiographic success of teeth in the laser group was 100% at

month, 90.47% at 3 months, 80.75% at 6 months, and 71.42% at 9nd 12 months. The teeth in the formocresol group had a radiographicuccess rate of 100% at 1 and 3 months and 90.47% at 6, 9, and 12onths. The success observed for each group was compared at each of

he five follow-up periods. Statistical analysis of the data, using Fisher’sxact test, revealed no statistically significant differences between thewo groups (Table 2). Radiographs of a “normal” case at the last visitre shown in Figure 3a, b, and c. The radiographic findings are shownn Table 3.

istopathologic ResultsTable 4 shows the number of teeth for each score according to

roups and periods. There was a statistically significant difference be-ween 7- and 60-day laser groups with regard to inflammatory cellesponse criteria (p � 0.05). Furthermore, there were statisticallyignificant differences between both 7-day laser and formocresolroups and 7- and 60-day formocresol groups with regard to tissueisorganization (p � 0.05). Statistical evaluations of histopathologiccores are shown in Table 5.

aser (7 Days)Moderate inflammatory cell infiltration involving the coronal pulp

ersisted in all samples (Fig. 4 a). The subjacent area near the exposureite exhibited dilatation and congestion of blood vessels in most samplesFig. 4b). Particularly, near the exposure sides, odontoblast layers de-enerated, whereas predentin had no changes (Fig. 4c). Dentin bridgeas absent in all samples. No stained bacteria were observed in any of

hese samples.

aser (60 Days)In four samples, slight inflammatory cell infiltration limited to

ubjacent area near the exposure site persisted (Fig. 5a). The otherample had moderate inflammatory cell infiltration. The number ofongestion of blood vessels was increased, particularly in the inflam-ation regions of pulps (Fig. 5b). In one sample, the connective tissue

t the base of inflammation region appeared to be vitreous (Fig. 5c and). This vitreous connective tissue had calcifications that nearly oblit-rated the exposure site, and in this region, the predentin became

6 Months 9 Months 12 Months

uccess Failure Success Failure Success Failure

19 2 18 3 18 319 2 19 2 19 238 4 37 5 37 5

p � 0.05 p � 0.05 p � 0.05

6 Months 9 Months 12 Months

uccess Failure Success Failure Success Failure

17 4 15 6 15 619 2 19 2 19 236 6 34 8 34 8

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hicker at both sides of dentin walls. The collagen fibers increased in theulp (Fig. 5e). Dentin bridge was absent in all samples. No stainedacteria were observed in any of these samples.

ormocresol (7 Days)Slight and severe inflammatory cell infiltration involving the coronal

ulp persisted in two samples. The other sample had a few scattered inflam-atory cells in the pulp area. Near the exposure sides, the odontoblast layer

ad degenerated, whereas predentin had no changes. One sample had pul-al necrosis, whereas some calcifications and congestion of blood vesselsere observed in two samples. Dentin bridge was absent in all samples. No

tained bacteria were observed in any of these samples.

ormocresol (60 Days)Moderate inflammatory cell infiltration involving the coronal pulp

ersisted in all samples. The predentin became thick, and the odonto-last layer degenerated. In addition, some calcifications were observedear the thicker predentin. The pulps had normal architectural patternsnd showed minor increases in collagen fibers. The samples exhibitedilatation and congestion of blood vessels. Dentin bridge was absent inll samples. No stained bacteria were observed in any of these samples.

DiscussionBecause the alternatives to formocresol pulpotomy have moderate

dvantages, pulpotomy techniques or agents still have a questionabledvantage in 21st-century pediatric dentistry. Laser treatment has manydvantages in pulpotomy procedure including control of hemorrhage,terilization, and stimulation effects on the dental pulp cells. The laseream has no mechanical contact with the tissue; therefore, the incisions made without inflicting mechanical damage on the remaining tissuend the operation is performed under aseptic conditions. Since theevelopment of the ruby laser in 1960, different forms of lasers haveeen evaluated in studies for their applications in dentistry. However,heir use in pulpotomies was first published in 1985 (11).

The result of our study showed that clinical success rate of Nd:YAGaser pulpotomy after 12 months was 85.71% and the radiographic successate was 71.42%, which was insignificantly lower than that of formocresolulpotomy group. Diluted formocresol as the control group in this study

igure 3. (a) Radiographic follow-up of laser pulpotomy at 3 months, (b) 6 m

ABLE 3. Radiographic Findings of Pulpotomies

Laser Formocresol

Normal 15 19Periapical radiolucency 3 2Internal resorption 5 2External resorption 4 2Widened PDL 5 2Total failure 6 2

gDL, periodontal ligament.

18 Odabas et al.

howed a total success rate (90.47%) that was comparable with those ofrevious studies reporting 84% to 85% after nearly 2 years (10, 14, 15).

However, there are few human clinical trial studies using a laserulpotomy for the purpose of outcome comparison. Elliott et al. (9)valuated the response of the human primary pulp to the CO2 laser. Thearies-free teeth were evaluated clinically and radiographic at 28 and 90ays and histologically after extraction. Similar to our study, they foundo statistically significant differences between laser and formocresolroups with regard to clinical and radiologic success criteria, but theirlinical and radiologic follow-up periods were limited to 28 and 90ays. In contrast to our study, they found no statistically significantifferences between each period of laser groups with regard to inflam-atory cell response criteria. And another difference from our studyas fixation and necrosis zone in their 7-day laser histologic examina-

ion that we did not observe any in our laser groups.Huth et al. (10) compared the relative effectiveness of Er:YAG

aser, calcium hydroxide, and ferric sulfate techniques with that of di-uted formocresol in primary molars. They found that the Er:YAG laserulpotomies had a total success rate (78%) insignificantly lower than

ormocresol (85%) after 2 years.Saltzman et al. (8) investigated whether a diode laser pulpotomy

ith mineral trioxide sealing (L-MTA) could be an acceptable alterna-ive to the conventional formocresol pulpotomy and zinc oxide eugenolealing in human primary teeth. They used MTA for base material inaser pulpotomy to provide superior sealing ability while preventing theissue-damaging effects of zinc oxide eugenol. Placement of eugenol inirect contact with vital tissue initiates a moderate to severe inflamma-

ory response with resulting chronic inflammation and necrosis (16).hey found all the teeth of each group clinically successful at each

ollow-up visit, and there were no statistically significant differencesetween both groups with regard to radiologic success criteria, whereas

he radiologic success rate of L-MTA (70.8%) was lower than that ofinc oxide eugenol sealing (87.5%). In our histopathologic observa-ions, we did not notice any fixation zone at the exposure side of laseramples. In our laser groups, the pulps might have been affected byugenol because of the absence of fixation barrier. And this may explainne of the reasons of insignificant lower total success rate in laserroup.

Liu (12) compared the clinical success rate of Nd:YAG laser andormocresol pulpotomy on human primary teeth. Although we used theame lasing energy parameters of Nd:YAG laser and almost the sameatient selection criteria of Liu’s study, Liu reported higher clinical97%) and radiologic (94.1%) success rates than our findings. Liu’study is the only in vivo study reporting the success rate of laser pulp-tomy significantly higher than the formocresol group.

The histopathologic observation in our study revealed that 7- and0-day laser groups showed statistically significant differences with re-

, and (c) 12 months.

ard to inflammatory cell response criteria (p � 0.05). There was no


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tatistically significant recovery from any histopathologic criteria be-ween 7- and 60-day observation periods in the laser group. None of theamples of laser group showed necrosis, whereas 7 days of formocresolroup showed in one sample. In most samples of laser groups, odon-oblasts appeared to be a well-aligned layer, and the subjacent area nearhe exposure site exhibited dilatation and congestion of blood vessels.

Shoji et al. (11) investigated the immediate effects of a CO2aser on amputated dental pulps in dogs. They found that thermalnjury of the pulp depended more on the length of exposure than onhe output power. Histologically, they found a thin layer of coagu-ation necrosis, coagulation, and degeneration of the odontoblasticell. Similar to our findings, they observed no detectable damage inhe radicular portions of pulps that were irradiated. Jukic et al. (6)lso investigated the effects of CO2 and Nd:YAG lasers on amputatedital dental pulps in molars and premolars of dogs. They reportedhat laser irradiation caused necrosis, carbonization, inflammatorynfiltration, edema, and hemorrhage in the pulpal tissue. In ourtudy, we did not notice any carbonization zone and coagulationecrosis in the pulpal tissue. Kimura et al. (7) evaluated the his-

opathologic effects of Er:YAG laser irradiation on the pulp tissue ofat during a pulpotomy procedure. They found no newly formedentin over the exposed pulp tissue in the root canal openings 30nd 45 days after CO2 and Nd:YAG laser irradiation. In this study, weid not observe any newly performed dentin over the exposed pulp

issue either. Kimura et al. (7) suggested that the other lasers such

igure 4. Seven-day laser group; exposure site (E). (a) Moderate inflammatoration � 200). (b) The exposure site exhibited dilation and congestion of b

ABLE 4. Number of Teeth for Each Score According to Groups and Periods

Periods:

Scores: 0

Histopathologic Event GroupsInflammatory cell response Laser 0

Formocresol 1Tissue disorganization Laser 2

Formocresol 0Bacterial presence Laser 0

Formocresol 0Dentin formation Laser 0

Formocresol 0

dontoblast layers degenerated, whereas predentin had no changes (arrows) sample


s Nd:YAG or argon lasers might be better suited for pulpotomy thanr:YAG laser because of coagulation capabilities.

Because the Nd:YAG laser has a wide energy-emission range, thelinician should take into careful consideration parameters such as thexposure time, power, whether the laser emission is continuous orulsed, the type of laser tip, and the distance between the laser tip and

he surface to be irradiated (17). For these reasons, we used 2-W,0-Hz, and 100-mJ lasing energy parameters of Nd:YAG laser that wassed in a previous in vivo study to assess laser pulpotomy with long-term

ollow-up (18).In our methodology, we excluded the teeth from the study that

ecommenced bleeding during placement of the medication or laserrradiation. On the other hand, Saltzman et al. (8) suggested that the actf pulpal ablation through successive application of laser resulted inulp stumps free of hemorrhage and, therefore, might mask a trulyyperemic pulp. Regarding their opinion, this fact might have resulted

n the inappropriate selection of hyperemic teeth for pulpotomy treat-ent in our study. And this may explain one of the other reasons of

nsignificant lower total success rate in our laser group.Failure of pulpotomy in primary molars was attributed to several

actors, one of which was erroneous diagnosis of a chronically inflamedadicular pulp as noninflamed and noninfected (19). Hobson (20)xamined, extracted, and exfoliated molars to correlate clinical signsnd symptoms with the histologic status of the pulp. She suggested thatign and symptoms of teeth had a strong correlation between irrevers-

infiltration involving the coronal pulp (hemotoxylin & eosin; original magnifi-essels (arrows) (light green paste; original magnification � 200). (c) The

7 Days 60 DaysTotal

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ble changes of dental pulp. In addition to this, she also suggested thathe absence of symptoms did not preclude the presence of irreversibleathologic pulp changes. In our study, we selected teeth according tolinical and radiographic criteria, which were used in the other pulpo-omy studies.

One of the other factors was the leakage of the final restorationf pulpotomized primary molars. Although Croll and Killian (21)ecommended stainless-steel crowns as the treatment of choice foreeth that have undergone pulpotomy, Holan et al. (22) suggestedhat pulpotomized primary molars could be successfully restoredith one surface amalgam if their natural exfoliation is expectedfter not more than 2 years. Regarding Holans’ study, three teeth of

igure 5. Sixty-day laser group; exposure site (E). (a) Slight inflammatory cell ib) The number of congestion of blood vessels was increased; exposure site (Eo be vitreous (light green paste; original magnification � 40). (d) This vitreous

ABLE 5. Statistical Evaluation of Histopathologic Scores

7 DaysLaser/Formocresol

Inflammatory cell response 0.487Tissue disorganization 0.046*

p value

p � 0.05 significant with the Mann- Whitney U test.

reen paste; original magnification � 40). (e) The collagen fibers increased (Gomo

20 Odabas et al.

ach group were restored with one surface amalgam in our study.lthough we did not evaluate the final restoration success of pulpo-

omized primary molars, it was interesting to notice that all thensuccessful teeth in both groups were restored with stainless steelrowns.

In conclusion, Nd:YAG laser may be considered as an alterna-ive to formocresol for pulpotomies in primary teeth. Within thearameters used in this study, pulpotomy by Nd:YAG laser did noteem to lead any adverse pulp reactions. However, further investi-ations should be performed in order to determine safe and optimalaser parameters, and these results should be confirmed in longerollow-ups.

tion near cut pulp surface (hemotoxylin & eosin; original magnification � 40).t green paste; original magnification � 20). (c) The region (arrow) appearedctive tissue had calcifications (c) that nearly obliterated the exposure site (light

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