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| case report use of Er,Cr:YSGG laser in endodontics 38 roots 4 2016 tionalradiographicimages,46 andthatanatomicvari- ations are known to significantly contribute to the occurrence of sodium hypochlorite accidents.47 Whiletryingtoachievesignificantbacterialreduc- tions, our protocol contrast with that recently re- ported by Christo et al. which used low concentra- tions of NaOCl and a Er,Cr:YSGG laser-activation technique. In fact, this protocol has been shown not to improve the antibacterial effects of NaOCl48 and, therefore, the activation of NaOCl may seem inade- quate for the management of such conditions. In accordance, it was shown that the use of Er,Cr:YSGG laser with relatively high output powers to activate irrigants such as NaOCl or EDTA may result in a high magnitude of pressure changes capable to induce ir- rigants extrusion during laser-activated irrigation.49 In order to obtain adequate microbial control cal- cium hydroxide (CH) is often recommended for the management of IRR lesions.50–52 However, the use of CH as an intra-canal medication consistently fails to present improved clinical outcomes.53–55 In the pres- entreportwemaysupportthatCHmedicationshould not be considered crucial as antimicrobial agent and neither as essential to stop the IRR progression. In fact, the decision process for not using CH as intra-canal medication during the endodontic treat- ment of IRR was also supported by the following cri- teria: (1) no irrigation technique is completely able to remove CH from simulated internal root resorption cavities14 and (2) the long-term exposure to CH can causeasignificantreductioninthemechanicalprop- erties of radicular dentine.56 Due to their biophysical properties, lasers have long been seen as a promising disinfection tool in endodontics. However, each wavelength demon- strates different biophysical interactions with the main radicular dentine components.15 The high ab- sorption coefficients in both water and hydroxyap- atitemayjustifytheselectionoftheEr,Cr:YSGGlaser (=2,780 nm)forbothsmearlayerremovalanddis- infectionpurposes.18 Conflictingevidencewhileus- ingotherwavelengthscanbefoundconsistently.57, 58 In the present report, the laser protocol consisted in two irradiations with distilled water in the main canal followed by two irradiations in dry conditions, respectively for smear layer removal and disinfec- tionpurposes.42 Therationalewasthatinwetcondi- tions the Er,Cr:YSGG laser can promote beneficial cavitation effects inside the main canal without in- creasing the extrusion of irrigants.38 Moreover, wa- ter-mediatedcavitationhasbeenshowntobehighly effectivefortheremovalofdentindebrisincompar- ison with conventional or passive ultrasonic irriga- tion.19, 38 Then, to achieve its maximum bactericidal properties,theEr,Cr:YSGGlasershouldworkonadry canal, allowing the energy to be transmitted deep into the dentinal tubules22 and to instantaneously interact with the water molecules trapped into the bacterialmembraneandwithinendodonticbiofilms.39 RFT have been shown to overcome several limita- tions attributed to bare fibres, distributing the emit- ted laser energy in a uniform ring-shaped pattern.33, 59 In similarity with any other innovative root canal treatment strategies, there are few reports demon- strating the prospective, long-term clinical out- comes associated with the use of Er,Cr:YSGG laser, namelywithRFT.However,Martinsetal.haveshown that RFT can be considered predictable as the con- comitant use of 3 % NaOCl and CH for the endodon- tictreatmentofsingle-rootedteethwithapicalperi- odontitis.42, 43 Our findings may provide further evidence that RFT can be considered safe in cases of teeth with wide apical foramina while being ade- quate to effectively reach all the contours of the re- sorption lesion. The prognosis for the conservative treatment of IRR should increase due to the report of alternative endodontic techniques along with the use of new technologies (Al-Momani & Nixon 2013, Khojaste- pour et al. 2015, Nilsson et al. 2013).2, 44, 46 Therefore, clinicians may consider this laser-assisted technique while selecting an appropriate endodontic disinfec- tion strategy for the management of IRR. Conclusion Despite their intrinsic methodological limitations, theadequatereportofsingleclinicalcasesmayeither help the understanding of unusual presentations of common diseases or assist in guiding new treatment conceptsintoclinicalpractice.45 Thiscasereportpres- entspotentialbenefitstowardstheuseofEr,Cr:YSGG laserandradialfiringtipsinendodontics.Furtherran- domised clinical trials should be conducted to clearly demonstrate its effectiveness._ Editorial note: A list of references is available from the publisher. contact Dr Miguel Rodrigues Martins,DDS,MSc,PhD Endodontic Department,Faculty of Dental Medicine, Universidade do Porto,Portugal Rua Dr.Manuel Pereira da Silva, 4200-393 Porto,Portugal Tel.:+351 914610046 miguel.ar.martins@gmail.com 42016 Tel.:+351914610046