dental materi als 2 7 ( 2 0 1 1 ) 3952

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Review
State-of-the-art: Dental photocuringA review
Frederick A. Rueggeberg

Dental Materials, School of Dentistry, The Medical College of Georgia, Augusta, GA, USA
a r t i c l e i n f o
Article history:
Received 7 October 2010
Accepted 22 October 2010
Keywords:
Photocuring
Quartztungstenhalogen
Plasma arc
Argon laser
LED
Beam homogeneity
a b s t r a c t
Light curing in dentistry has truly revolutionized the practice of this art and science. With
the exception bonding to tooth structure, there is perhaps no single advancement that has
promoted the ease, efciency, productivity, and success of performing dentistry. Like most
every major advancements in this profession, the technology underlying the successful
application of light curing in dentistry did not arise from within the profession, but instead
was the result of innovative adaptations inapplying newadvances to clinical treatment. One
cannot appreciate the current status of dental photocuring without rst appreciating the
history and innovations of the science and industry underlying the advances from which
it developed. This review will place the current status of the art within the context of its
historical progression, enabling a better appreciation for the benets and remaining issues
that photocuring has brought us. Lastly, the manuscript will present thoughts for future con-
siderations in the eld, offering suggestions as to how current advances in light-generating
science might yet be adapted for dental use.
2010 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
Contents
1. Introduction to the review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2. Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.1. Abbreviated history of light curing in dentistry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.2. UV-curing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.3. Visible light curing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.4. Quartztungstenhalogen lights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.5. Vital tooth bleaching and introduction of the alternative initiators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.6. The argon-ion laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.7. Plasma arc lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
2.8. High-intensity QTH lights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
2.9. Issues resulting from application of high light levels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.10. Light emitting diodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.11. First generation leD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.12. Second generation LED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Corresponding author.
E-mail address: frueggeb@mail.mcg.edu
0109-5641/$ see front matter 2010 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2010.10.021
40 dental materi als 2 7 ( 2 0 1 1 ) 3952
2.13. Third generation LEDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.14. LED construction styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.15. Summary of history. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3. Contemporary issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.1. Adequacy of exposure durations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.2. Custom, in-ofce exposure guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.3. Photocuring training device and precision curing unit evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4. Current methods and ndings in curing unit characterization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.1. Hand held curing radiometers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.2. Conventional irradiance measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.3. Spectral irradiance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.4. Determining beam irradiance inhomogeneity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.5. Importance of beam imaging to curing light characterization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.6. Nonuniformity of wavelength distribution within the beam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
4.7. Curing tip movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5. Future developments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
6. In summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
1. Introduction to the review
There is hardly a clinical procedure performed in contem-
porary dentistry where photocuring of some material is
not required. The process seems so simple, perhaps even
trivial: just point and shoot. What could be so compli-
cated? However, there is much more to this story than
that. In order to appreciate the convenience and benets
todays state-of-the-art offers, it is rst necessary to under-
stand and value how this technology developed over time.
This manuscript will provide a short review of the history
underlying development of photocuring in dentistry, focus-
ing more on issues related to construction and operation
of the light sources themselves. The perspective for appre-
ciating current technology will be established, the issues
that we currently face will be addressed, and those we have
yet to overcome. A summary of recent key ndings is pro-
vided, and thoughts on important factors affecting the future
of development in dental photopolymerization are devel-
oped.
2. Literature
2.1. Abbreviated history of light curing in dentistry
From the late 1940, with power/liquid, self-curing direct,
acrylic-based restorative materials, to the late 1960s when
the dual-paste, self-cure composite systems were popular
[1,2], use of direct polymer-based restorative materials has
changed the way dentistry is performed and perceived. The
early pastepaste systems, although rivaling their prede-
cessors with respect to appearance and durability, still left
many clinicians wanting for a faster process of fabricat-
ing tooth-mimicking restorations, where the working time
was almost innite [3], the setting time was only seconds
and not minutes, and where colors were stable and long-
term wear allowed successful use in the posterior segment
[4,5].
2.2. UV-curing
Like many advances indentistry, the technology for using light
to polymerize resin-based materials did not originate within
the profession, but instead was an existing technology that
was adapted for dental use [69]. The rst photocuring units
were designed to emit ultraviolet light (about 365nm) through
a quartz rod from a high pressure mercury source and were
introduced in the early 1970s [10]. This development was seen
as a revolutionary step in dentistry, for it allowed a cure on
demand feature, which was previously unattainable using
the self-curing products. Typical exposure durations were 20s,
but 60s provided enhanced results [11]. Filled, photocurable
composites as well as sealant materials were available [11,12],
and were used in very innovative ways to not only restore car-
ious processes, but to also repair tooth fractures and provide
easily performed esthetic results [13,14]. The phoinitiating
systemreliedonbenzoine ether-type compounds [1,15], which
broke down into multiple radicals, without need of an inter-
mediary component [16]. The spectral distribution of light
sources of the time with the absorption spectrum of the ini-
tiator help to correlate these two parameters [17]. Although
some of the restorations placed using this early technology
have proven to be remarkably successful [18], in general the
procedure was fraught with many issues. First, because of the
limited ability of light to penetrate deep within the material,
incremental buildups were required instead of bulk place-
ment, and were limited in depth [19,20]. In addition, concerns
were voicedabout the potential for harmful effects of the short
wavelength energy being exposed to human eyes (corneal
burns and cataract formation) as well as possible changes in
the oral microora [1,21].
2.3. Visible light curing
Amazingly, only a few years following the introduction of UV
radiationfor curing dental restoratives, the ability of using vis-
ible radiation was introduced: February 24, 1976. On that day,
Dr. Mohammed Bassoiuny of the Turner School of Dentistry,
Manchester, placed the rst visible light-cured composite
dental materi als 2 7 ( 2 0 1 1 ) 3952 41
restoration on Dr. John Yearn, the then head of development
of this effort by Imperial Chemical Industries (ICI) of England
[22]. Again, development of the chemistry for doing so did not
arise from the dental eld, but instead adapted from use in
the eld of polymerizing thin resin lms for printing, metal
and plastic coatings, and paints [23,24]. The optimization of a
visible light-curing photoinitiation system composition using
camphorquinone and a tertiary amine co-initiator was key to
the success of this effort, and remains the most popular basic
formulation in use today [15,2528]. The unit consisted of a
quartztungstenhalogen (QTH) source having heat absorb-
ing glass and a bandpass lter allowing only light between
400 and 550nm to pass: the wavelengths [29,30] required to
activate the photoinitiator, camphorquinone. ICI went on to
partner with Johnson and Johnson to introduce the rst light-
cured resin composite and light: the FotoFil system [29,31].
The advantages of using visible light were that 2-mm thick
increments could typically be placed using from 40s to 60s
exposure froma QTHsource, and that the potential formation
of cataracts and oral microora alteration were minimized
[31]. However, direct retinal burning and advancement of mac-
ular degeneration were now a potential for ocular damage,
as the wavelength needed to initiate the visible-light initi-
ated systems fell directly within the frequencies known to
cause immediate, and permanent damage resulting fromreti-
nal burning [32,33]. Thus, practitioners were advised to place
a ltering lm between their eyes and the curing light to pre-
clude ocular damage, while also allowing high levels of longer
wavelengths to pass in order to adequately visualize the treat-
ment eld while curing: the so-called blue-blockers [34,35].
2.4. Quartztungstenhalogen lights
The QTH light source was not developed for this purpose, but
was, instead, advanced by engineers at General Electric for
use in aircraft lights, where small but very bright and durable
sources were needed [36]. However, the QTH light became
the mainstay of dental light curing for many years, into the
late 1990s. During that time advances included a wide range
of adaptations for convenience and efcacy. Bulb wattage
increased from 35W up to 100W for hand-held units [3], and
up to 340W for table-top models [3]. Output values ranged
from an average of 400 to 500mW/cm
2
up to an extreme of
3000mW/cm
2
from one unit: The Swiss Master Light, Elec-
tro Medical Systems, Nyon, Switzerland. The ltered spectral
emission matched the absorption prole of camphorquinone
very well [17]. Units were either hand-held (gun style) using
a light source within the gun, from which light was emitted
to the target through a bundled glass ber light guide. The
gun was connected to a base power unit using a exible cord
containing electrical wires. The adaptation of a curing gun
to accept a wide variety of sizes and styles of different light
guides tting with similar focal points lead to the customiza-
tion of specic types of light delivery to oral locations [37].
The other basic model was a table top unit, which contained
a high-Wattage source directing ltered radiation to a exible
glass bundle cord [38], or a liquid light guide. The QTHsources
in the hand-held units lasted from 30 to 50h [30], and utilized
the halogen cycle to remain clear from tungsten contamina-
tiononthe inner wall of the quartz envelope [30]. Sources were
readily available, easy to install, and relatively inexpensive.
Typical exposure duration times to provide uniform proper-
ties in a 2-mm thick composite increment ranged from 40s to
60s [39], and controls allowed selected exposure intervals [40].
Units had to be fan-cooled in order to extend the working time
of the source and allow the halogen cycle to operate correctly.
2.5. Vital tooth bleaching and introduction of the
alternative initiators
Vital tooth bleaching was becoming an overnight success in
the early 1990s. However, following this type treatment, man-
ufacturers were not able to provide direct esthetic restorative
materials that were of high enough value to match the newly
bleached teeth. This situation arose because the photoinitiat-
ing system of that time only used camphorquinone, which
is a bright canary yellow, and photobleaches only slightly
upon exposures within clinically relevant times [16,41]. Thus,
after curing, the restoration tended to have a yellow, resid-
ual tinge. In order to provide restorative materials of high
value, manufacturers resorted to utilizing other photoinitia-
tors that were used for the UV coating and printing industries,
which had a small portion of their absorption range within
the short, visible light spectrum [42]. These compounds were
a class of initiator that directly broke into multiple radicals
without need for any co-initiator, and, although they were
pale yellow in color, photobleached to clear once utilized [43].
Examples of such compounds are bis(2,3,6-trimethylbenzoyl)-
phenylphosphineoxide [15,44] (Ciba Specialty Chemicals, Inc.,
Basel, Switzerland), also known as Irgacure 819, and 2,4,6-
trimethylbenzoyl-diphenylphosphine oxide [15,45] (BASF Cor-
poration, Charlotte, NC), commonly referred to as Lucerin

TPO. Later, an yellowish oily initiator (1-phenylpropane-1,2-

dione, PPD), was introduced to help broaden the overall
absorption of initiators between 400nm and 500nm [15].
When combined with CQ, a synergistic effect was found,
allowing the concentration of CQ to be reduced, thus decreas-
ing the yellow residual color following photocuring [4648],
however, others found no reduction in yellow [48]. Also, to
reduce the time needed to obtain maximal bleaching effect,
manufacturers of bleaching agents were advocating exposure
of the solutions to bright light in order to heat the compo-
nents and hasten their breakdown into peroxy radicals. The
wavelengths required for this process were short, near the vio-
let and near ultraviolet, and as well as within the blue region.
Thus, light curing units nowserve a dual-foldfunction: to pho-
toactivate resin-based restorative materials, and provide an
energy source to hasten vital tooth bleaching.
2.6. The argon-ion laser
As is typically the case, the use of the argonlaser to photopoly-
merize acrylics did not arise within the dental community,
but was instead a product of industrial development in the
coating industry. The argon-ion laser was marketed rst to
enhance the effects of vital tooth bleaching in Europe, and
is still used for that purpose today [49]. However, when rst
introduced to the United States [50], only the clinician could
operate the unit, and not auxiliary personnel [51], so the light
became more protable to use as a dental polymerization
42 dental materi als 2 7 ( 2 0 1 1 ) 3952
source. The initial delivery of power fromthe laser to the tooth
was directly through the end of a ber optic cable. However,
due to the divergent nature of that radiation, other methods
were developedinanattempt tomake afairlycollimatedbeam
of coherent energy, whose target power was not related to
the tip-to-tooth distance [52], as was the case with conven-
tional QTH light guides. The devices proved very effective in
providing high physical properties in dental restorative mate-
rials [53], andbecause of the units tremendous radiant output,
some noted that shorter exposure times were needed to pro-
vide similar properties as a QTH source [54], while some did
not [55]. The size and footprint of the unit were very large
at rst [56], but a single source could be adapted so that one
laser could feed multiple operatories using a network of ber
optic cabling [56]. Over time, the unit became much smaller,
and could easily t into an operatory, but because of weight,
needed to be on a cart, if moved fromroom-to-room. However,
owing to the high expense (near $5000) of a typical unit, the
inability to replace the source by ofce personnel, and the ele-
vated room temperatures resulting from the device use, this
curing system became outdated in a short time. The emis-
sion prole of argon-ion lasers marketed in the Unites States
eliminated the strongest output at 514nm for some reason.
This wavelengthwas typically used to provide hemostatis [52],
and was present as a selectable feature on units marketed
in Europe. Excluding the 514nm peak, the major output from
dental argon lasers in the US occurred at 488nm, just on the
sharply declining, long wavelength leg of camphorquinone
absorption. Other minor emission peaks at 457.9nm, 468nm,
and 476.5nm do occur within high CQ absorption levels, and
are thus effective in curing, but others emissions are not:
496nm [52]. High speed pulsing of the light was found to
provide enhanced surface and depth conversion over con-
tinuous exposure [57], and some researchers advocated that
each brand and shade of composite required an individual-
ized energy delivery for optimal performance [58]. Designs
for a portable diode laser for dental light curing have been
developed, but to date, no commercial product has arisen [59].
2.7. Plasma arc lights
Because dental auxiliaries were prohibited from using the
argon laser in the US, technology was imported from Europe
(French patent #2,305,092, 1976), that had already met with a
great amount of success: the plasma-arc curing light. Devel-
oped in the mid 1960s [60], this type source was not initially
developedfor dental purposes, but insteadwas usedtoprovide
broad-banded radiation for visualization of operating elds
(endoscopy andcolonoscopy, for examples) as well as for mini-
mally invasive medical procedures. The source consists of two
tungsten electrodes separated by a small distance, encased in
a high pressure gas-lled chamber, having a synthetic sap-
phire window through which the light emission was directed
froma parabolic reective surface [30]. Ahighelectrical poten-
tial is developed between the two electrodes, which then
forms a spark, ionizing the gas, and providing a conductive
path (a plasma) between the electrodes. Once the initial spark
is established, electronics then adjust the operating current to
maintain light generation through a variety of sophisticated
feedback system [30]. The gas originally used in dental PAC
lights in Europe contained argon, and was extremely high in
output, allowing claims of sub-second exposures in adver-
tisements tobe usedtoreplace conventional 4060s exposures
using the QTH light. These units had to be highly ltered, as
they generated tremendous amounts of infrared light (result-
ing in heat generation at the target) as well as ultraviolet
(having dangerous ozone formationpotential). Indental appli-
cations, these types of light sources were pulsed and initially
developed for curing UV-polymerizable resins, although no
commercial unit could be found [19]. They were later adapted
for use in visible-light cured products [61]. Thus, the table top
unit contained the conventional heat-absorbing glass and vis-
ible bandpass lters, but the light emitted after this entered
a three-foot-long liquid light guide [62], which acted as a very
long optical lter, eliminating UV and IR radiation, and pass-
ing only visible light [30]. The typical output from these types
of lights was near 2000mW/cm
2
, and was broad banded: from
380 to 500nm, with a naturally occurring peak near 460nm,
where CQ has its optimal absorption. Originally designed in
Europe as the Argo HP, claiming the ability to cure compos-
ite using sub-second exposures, the unit was attempted to
be marketed in the US by DMDS, Inc, of Salt Lake City, UT,
as the Apollo 9500. It is conjectured that the source in this
unit contained argon, which allowed it to emit higher than
conventional xenon, but did not last as long. However, issues
with licensing led to the US version of the light introduced
in August, 1998 as the Apollo 95e [51]. This unit was quite
small, and touted provision of adequate exposure times of
3s as being equivalent to that of a 40 or 60s exposure from
a QTH light. However, the reason why this unit provided no
longer continuous exposure than 3s did not arise from its
adequacy of providing sufcient energy to optimally cure a
composite within that time, but instead was attributed to the
power supply driving the source not containing sophisticated
enough feedback to allow continuous output for any longer
time. To perform adequately clinically, multiple 3-s exposures
were typically required [63,64]. The unit offered a variety of
removable curing tips at the end of the light guide: curing tips:
430nm or 460nm for resin curing and 400500nm for bleach-
ing. It was from the confusion concerning tip selection for
curing specic restorative materials that the confusionstarted
related to the issue of what light will work with which com-
posite or bonding resin. Subsequent PACunits overcame many
of the initial shortfalls of the Apollo 95e: broad banded output
(not requiring a special bandpass tip end), longer, continuous
exposure times, and a general tendency to provide adequate
composite curing using a single 10-s exposure [30].
2.8. High-intensity QTH lights
The QTH light was then competing with PAC units for mar-
ket share. In order to respond to the new, high output device,
manufacturers of QTH lights used different mechanisms to
increase the overall output of their units, and claimed they
were equivalent to a PAC unit with respect to performance.
First, source settings were available to boost light output
over normal values. This mechanism really just drove the la-
ment at a higher voltage, exceeding accepted tolerance values
than the bulb manufacturer suggested. Settings in such out-
put modes were nolonger than10s, as longer exposures would
dental materi als 2 7 ( 2 0 1 1 ) 3952 43
severely degrade the operating lifetime of the source. Another
mechanism of increasing output was the development of the
turbo-tip. This device was a rigid glass ber bundle, but
had the individual bers drawn while hot, so that the bun-
dle diameter was smaller at the distal, emitting end than at
the proximal, receiving end of the guide. By doing so, the same
amount of power was present at bothends, but was distributed
over a much smaller area at the emitting end, resulting in
about a 1.6 times increase in irradiance [65]. This type tip is
still widely used in contemporary LED units to help increase
overall output values. However, even with both of these fea-
tures in operation, the output of the QTHdid not match that of
a typical PAC light of the day [30]. The future for the QTH light
is not bright, as many governmental agencies are banning
this tremendously inefcient incandescent light sources from
general usage soon. Thus US government has stipulated dead-
lines by which incandescent light sources will stopped being
marketed: elimination of the 100-W bulb in 2012 and ending
with removal of the 40-W source by 2014 [66].
2.9. Issues resulting from application of high light
levels
During this time of application of ever increasing irradi-
ance levels to teeth and gingiva, issues arose related to the
application of excessive heat to the target. Clinicians were
admonished to direct light output ontheir thumb nail to sense
the level of heat evolved from a light. In addition, with such
high intensity levels, the PAC lights were now noted to cause
a high degree of polymerization stress, as the resin was poly-
merized so fast that relaxation was not allowed to occur in
the polymer network before it became vitried. To overcome
this problem, researchers found that if the light intensity was
delivered in such a manner as to control the rate of curing,
stress relief would occur by allowing the resin to ow prior to
vitrication. It was hoped that in so doing the potential for
debonding between the restoration and the tooth would be
much lower [67]. In addition, less heat would generate in the
target during the restorative process [68]. However, little dif-
ference was noted in microleakage studies [6971]. Thus arose
the concept of soft-start polymerization.
When rst introduced, this exposure method was added
as a selectable feature on QTH lights, and resulted in an ini-
tial short (10-s) low-level output near 100mW/cm
2
, which was
followed by an immediate jump to full output power for the
remainder of the exposure: step curing [72]. Later changes
resulted in a time-based increase of the light initially applied,
with the remainder of exposure providing full output: ramp
curing [73]. Still another modication was provided as the
pulse-delay technique, where, for the last composite incre-
ment to be cured, a very low level, short duration exposure
was given (3s at 200mW/cm
2
), The clinician was advised
to treat another patient (for 510min) while the composite
was allowed to ow and relieve stress, after which a bolus
of higher output power was provided to complete the cure
(30s at 500mW/cm
2
) (BISCO VIP). However, the results did not
produce any remarkable differences to what was being used
conventionally [74].
An issue with use of this type exposure delivery is the ade-
quacy of energy delivery at the bottom of an increment. Thus,
the possible correlation between enhanced marginal adapta-
tion, reduced shrinkage, and lowered curing stress using this
curing protocol might have been related to an overall lower
extent of cure at the bottom surface [75,76]. As long as an ade-
quate exposure is provided during the high-output phase of
this technique, concerns about under polymerization are not
an issue [77].
Variations of a soft-start feature are still offered on many
contemporary light curing units, even LEDs. Comparison
of material conversion between conventional 40s exposure
and that when using a ramped soft-start procedure did not
indicate any signicant different difference [73], however,
contraction strain and the polymerization exotherm were
decreased [73,78]. To remain competitive, manufacturers of
PAClights also attempted to utilize a soft-start mode to reduce
the tremendously high stresses and temperature rises devel-
oped from their use. However, the operational characteristics
of the PAC light do not provide for low irradiant output, as
the spark arising from even the minimal voltage needed to
maintain its presence produces more irradiance than does a
conventional QTHlight using regular output. Thus, benets of
soft-start curing withthese types of units could not be realized
[79]. However, one manufacturer incorporated a modulated
level of output during exposure in order to maintain an overall
high irradiant output, but also to decrease target temperature
[80].
2.10. Light emitting diodes
The 50th anniversary of the invention of the light emitting
diode (LED) is fast approaching [81]. Use of this technology has
truly changed our lives, and will continue to do so, as it proves
to be an efcient, cost-effective lighting source. These solid
state devices rely on the forward-biased energy difference
(band gap) between two dissimilar semiconductor substrates
(n-type conduction band, and p-type valence band), to deter-
mine the wavelength of emitted light [30]. They are much
more efcient than previous types of dental light sources, are
light weight, and can be easily battery powered for portabil-
ity. During the middle-to-late 1990s, tremendous strides were
made in the video display, optical communications and solid-
state lighting industries withthe introductionof light emitting
diodes (LEDS). At that time, the red laser was used for pro-
viding the source of reading optically encoded video discs.
Because the wavelength of red is longer than that of blue, the
physical size of the hole through which the light had to pass
in order to create a digital signal was also large. With devel-
opment of shorter wavelength, blue LEDs, smaller sized holes
were requiredthanwithred, andliterally many more openings
could be placed into the same physical area occupied by fewer
and larger holes that transmitted red light. Thus, more digi-
tal information could be stored on smaller sized media, and
development in LEDs within this wavelength range became a
focus of interest [82].
Blue emissions were developed using indium
galliumnitride (InGaN) substrates in the early 1990s [81]. This
was also a color needed to activate phosphors to emit yellow,
enabling the rst white-appearing LED in history [81,83]. It
was thus coincidental that the output range of the newly
developed blue LEDs fell within the maximal absorption of
44 dental materi als 2 7 ( 2 0 1 1 ) 3952
CQ, enabling the possibility of using blue LEDs as a dental
light-curing source. As has been mentioned previously, it did
not take long before the blue LED made its way into a dental
curing light [30,84].
2.11. First generation leD
These lights were rst introduced to the commercial mar-
ket at the end of 2000 [85], with the introduction of the
LUX
o
MAX light (Akeda Dental A/S, Lystrup, Denmark), how-
ever the concept was developed much earlier: 1995 [86,87]. A
typical design of rst generation LED curing lights used an
assemblage of multiple, individual LED, single-emitting 5mm
lamp LED elements (each chip providing 3060mW) into a
focused, axial [88,89] or planar array [87], arranged such that
the combined output of the luminaire was sufcient enough
to provide sufcient energy to activate CQ. Arrays of from
seven (Freelight, 3M/ESPE, St. Paul, MN) to 64 (GC-e-light, GC
America, Alsip, IL) were available, but even with those num-
bers, the extent of radiation was not sufcient to warrant
competition with respect to providing decreased exposure
time over that of the standard QTH light. In addition, bat-
tery technology relied upon use of NiCad cells, which were
plagued with poor performance and memory effects. How-
ever, because some photo-curable restorative products used
only the short wavelength, alternative initiators, the new blue
LED lights would not polymerize them, nor would the argon-
ion laser. This situation started the great confusion over what
light will adequately polymerize which restorative material, a
phenomenon that lasts even to this day. Needless to say, the
effectiveness of LEDlights over that of conventional QTHunits
took a while to understand, but it had to do withthe amount of
radiation emitted within the maximal absorption needs of CQ:
with blue LEDs providing much more output within this area
(450470nm) than from a typical QTH light [90]. As a result,
it was possible to provide equivalent resin curing in shorter
time with an LED light that provided less measurable output
than from a longer exposure from a QTH light emitting more
total light. In general, however, the overall curing potential of
this rst-generation LED light was much less than those of
conventional, competitive source types of the time [91].
2.12. Second generation LED
Advances in the LED chip industry in the early 2000s led to
the ability of placing multiple emitting die pads on a sin-
gle chip, greatly increasing overall light output [84]. Again,
dental manufacturers incorporated the new 1-W chips into
curing lights, developing what is referred to as the second
generation LED lights. Chip manufacturers were now fabri-
cating chips specically within the wavelength requirements
for dentistry, and labeling them as dental LED blue. Luxeon
is Philips Lumileds Lighting Companys trade name for their
high-power LEDs which dissipate 1W or more. At rst, there
were two types of Luxeon chips used in second generation
lights, according to the development of the technology: the
1W chip (Luxeon LXHL-BRD1 or MRD1 generating 140mW
output), and the 5W chip (Luxeon LXHL-PRD5 or MRD5, gen-
erating 600mW output). Characteristic of these units is the
great increase in output power over that of the rst gener-
ation [81], with one 5-W chip providing similar luminance
as 1020 of the individual 5-mm types of the rst genera-
tion. However, a similar wavelength range output persisted as
with the rst generation, resulting in a continued inability to
photocure restorative materials using only short wavelength
initiators. Battery technology also improved, and NiMHenergy
packs became the typical power source. However, because of
the generation of tremendously high power in such a small
area, the temperature within the chip was now a concern, as
too high a temperature would result in permanent chip dam-
age, if not thermostatically cut off prior to that point [84]. Thus,
units had heavy metal heat sinks or large metal surfaces to
dissipate chip heat [81,92]. In addition, the return of fans [92]
to curing lights was seen something everyone thought was
gone forever. Recently, a 10W blue LED has become available
especially for dental applications (LZ4-00DB10, LedEngin, Inc.,
Santa Clara, CA, as well as a 15W unit (LZ4-00CB15, LedEn-
gin, Inc.), and can provide up to 4.2W and 5.6W of radiant
ux, respectively. With the dramatically increased chip out-
put, second generation LED lights were now reliably able to
outperform their commercial competitive curing light types
using shorter exposure times [93,94].
2.13. Third generation LEDS
In order to enable polymerization of restorative materials
utilizing more than only CQ as initiator, curing light manufac-
turers resorted to providing LED chip sets that emitted more
thanone wavelength[95]. The rst of these units utilizedasep-
arate 5W blue LED central chip surrounded by four low power
violet (around 400nm) LEDs: the Ultralume 5, Ultradent Prod-
ucts, South Jordan, UT. Thus, by combining the output from
these two wavelengths, light was provided at wavelengths
that were effective for not only CQ, but for the alternative
set of initiators as well, creating the equivalent of a broad
banded LED curing light. Other manufacturers incorporated
the violet chips located next to other blue chips within a sin-
gle LEDelement: LZ4-00D110, High Efciency Dental Blue+UV
LED Emitter, Led Engin, Inc. with 1 UV die emitting 0.76W and
3 blue dies each emitting 3W. This ability to generate multiple
wavelengths from a single LED light led a third generation
of LED dental curing lights. Typically, these units use either
NiMH or Li-ion battery technology. One manufacturer cur-
rently incorporates three different wavelength chips: VALO,
Ultradent Products. Units of this generation are quite effective
in providing sufcient irradiance at appropriate wavelengths
tobe able topolymerize anytype of dental restorative material.
2.14. LED construction styles
Contemporary LED lights are either those styled after the old
QTH guns, with a turbo-tip ber optic bundle, or are a pencil-
type unit, having the emitting chip set at the distal end of
the unit, or a similar ber optic guide. The lights are either
totally driven by mains connection, are battery operated, or
both. Those with the chips at the distal end of the unit either
have no coverage over the elements, a sealed or removable
clear plate covering it, or utilize a xed lens. Advantages of
the pencil style body include the ability to gain access to many
more locations in the mouth than possible with the hard, long
dental materi als 2 7 ( 2 0 1 1 ) 3952 45
glass bundled guide, as well as less possibility of breakage,
should the unit drop.
2.15. Summary of history
Even with all the advantages that solid state light curing has
brought to dentistry, many of the issues correlated with other
types of light sources (polymerization shrinkage and stress,
intrapulpal temperature rise, and confusion over method of
light intensity application) persist at present. Misunderstand-
ing and frustration still exist over compatibilities between
lights andrestorative resins, as well as the advantages anddis-
advantages of using curing units withsuchtremendously high
output levels [9698]. Even with all the improvements made
in photocuring over the last 40 years, after 10 years of service,
only 43% of almost 100,000 resin restorations were still in ser-
vice, with performance described as comparable only to the
worst performing amalgam restoration [99]. Only with this
background, can the most contemporary ndings and issues
can be better placed in context of the entire eld.
3. Contemporary issues
3.1. Adequacy of exposure durations
There is still much confusion over the ability of a given light or
a specic composite combination to be used together to pro-
vide optimal polymerizationwithina short clinical timeframe.
Clinicians desire to perform quality dentistry using minimal
chair time. Curing light manufacturers advertize use of their
lights for a single duration of output, often regardless of com-
posite type, shade, or clinical distance the tip is held from
the restoration. Likewise, manufacturers of composite recom-
mend specic exposure durations for their products that often
do not match those of lights made by competitive companies
[93,100104]. Thus, the clinician is left wondering which sug-
gested time is correct, and as a result, tend to over-expose
restorations to be on the safe side. However, in so doing, the
longer exposure results in generation of more heat within the
tooth and surrounding, exposed tissues, leading to possible
post-operative, iatrogenic complications [100,105,106]. Clini-
cians will often utilize a hand-held dental curing radiometer
as an indicator of the potential a curing unit has for photocur-
ing resin-based materials. However, these instruments have
been shown to be inaccurate [107] and not good predictors
of clinical performance [108], and are really only meant to be
used as a relative indicator of light output value over time
[108].
3.2. Custom, in-ofce exposure guide
Recently, a simple in-ofce test has been introduced whereby
a clinician can develop a custom curing exposure guide, using
their own light unit, any type of composite, and at any tip-
to-composite distance using simple items readily available
in a common ofce [109]. This method relies upon the clini-
cian establishing the relationship between exposure duration,
and tip distance on the thickness of cylinder of remaining,
unscrapable composite made from exposing composite-lled,
single-dose compules. The test also works for syringe mate-
rial. The results fromthis procedure have beencorrelated with
those of a more sophisticated, laboratory test when deter-
mining optimal exposure using biaxial exural strength [109].
This method allows for the determinationof optimal exposure
time for any given combination of curing light and composite,
thus avoiding the confusion of relying on manufacturer-
recommendations for each. However, the test requires time
as well as use of an existing stock of composite material. If
the test is performed on a periodic basis, the clinician can
also know exactly how to adjust exposure duration of a light,
found to be decreasing in output, to provide optimally effec-
tive results once again. In addition, the relative performance
of a given composite when using two or more different light
units can be determined, as well as relating the performance
of different composites when using a given curing light.
3.3. Photocuring training device and precision curing
unit evaluation
A newer device, combining precise, laboratory spectral tech-
nology with clinically relevant measuring conditions within
prepared dentiform teeth in a manikin head has been devel-
oped (MARC (Managing Accurate Resin Curing), BlueLight
analytics inc., Halifax, Nova Scotia, Canada). This device uses
cosine correctors to capture emitted light from curing units,
and directs the output to a calibrated spectral radiometer
embedded within the manikin head. The sensors can be
placed anywhere in the dentiform, replicating a variety of
different classications of tooth preparations, locations, and
preparation depths. Output from the radiometer is fed into
a laptop computer, where custom software is used to pro-
vide a myriad of real-time and accumulated data: spectral
irradiance, total energy delivered over a given exposure dura-
tion, and the estimated exposure duration needed to deliver
a specied energy dosage. Training ofce personnel to prop-
erly perform light curing is very effective using a device such
as this. The effects of minor alteration in tip position, move-
ment, or location are instantly displayed in real-time, and the
ultimate consequence in terms of altered energy delivered is
determined. The unit can also be used in a scientic mode,
whereby a calibrated, high resolution spectral irradiance plot
is available for display or digital output to a spreadsheet
device. The device has been successfully used to test literally
hundreds of clinicians in a before training and after train-
ing mode, and has shown that, with effective education of
the operator with respect to hand stabilization, tip angula-
tion and position, and direct visualization the operating eld
through blue blocker glasses, use of the instrument provides
the optimal result in energy delivery [110]. The device can also
discriminate the ability of different lights to deliver adequate
energy levels between various tooth locations using this sim-
ulated clinical model [111]. Accurate, recordable curing light
performance over time is also capable of being determined
using the same device, for without such determination, clini-
cians are totally with the knowledge of the condition of their
photocuring unit [112].
The relevance of this type measurement relies on the fact
that there is a critical energy level needed to optimally poly-
merize dental composites [113]. In addition, the estimation of
46 dental materi als 2 7 ( 2 0 1 1 ) 3952
adequate energy delivery currently relies on the reciprocity
between exposure duration and power density. Some liter-
ature indicated that such a relationship exists [114], while
others show evidence that it does not [115,116], and that the
polymer network developedusing fast or slowdelivery of ener-
gies is different [117]. In addition, the spectral delivery of
energy within the absorptive needs of the photoinitiator sys-
tem present in a given composite is also not accounted for
[42,48,90,118,119]. However, the device is capable of such dis-
criminative capacity with software improvement, and minor
hardware changes should allow in situ testing of real-time
energy delivery to actual resin composites while curing.
4. Current methods and ndings in curing
unit characterization
4.1. Hand held curing radiometers
With wide ranging claims of curing light performance touted
by manufacturers, it becomes of great importance to be able
to distinguish the true operating characteristics of curing
lights so that valid evaluation of those claims can be made
[120]. Unfortunately, many published articles rely onthe valid-
ity devices called hand-held curing radiometers to provide
accurate data from which performance among lights is cor-
related to some parameter measuring polymerization extent:
depth of cure, exural strength, hardness, etc. Great discrep-
ancies among measurement of light unit output have been
found using such hand-held dental curing radiometers, val-
idating that they are not considered reliable indicators in
ranking the potential for depths of cure among lights [108].
The hand held radiometers are really just a photometers cal-
ibrated in radiometric units [30,107]. A typical device consists
of a detector port on which light from the emitting end of the
unit is directly placed. A drawback of this type unit is that
the detector must be smaller than the diameter of the tip in
order for the meter to work correctly [120]. Thus, the unit is
not exposed to the total emitted power, and is assuming that
emissions are homogeneously distributed over the emitting
face end. Secondly, there is no way to discriminate among the
spectral emission of lights, as the unit only responds to all
radiation passed to the photodiode through whatever restric-
tive bandpass lter it uses. This limitation means that not
only is the distribution of power with respect to frequency is
not known, but the unit may also not be responding to wave-
lengths outside of the bandpass which might be present. In
addition, these type devices only provide an indication of exi-
tance irradiance (the emitting tip-end value), which is not an
indicator of light performance when held at a distance from
the tooth [121,122]. Thus, these devices are really not meant
to report accurate data to characterize light unit emission, but
are instead designed to operate as a method to evaluate the
periodic performance of a curing light over time for purposes
of detecting output changes [107,123].
4.2. Conventional irradiance measurement
True characterization of the emissions from dental curing
lights has been provided in the literature since the introduc-
tion of the devices [17]. With more current technology, these
processes have become less expensive and provide higher
resolution, and respond much faster than the older types of
instruments [124]. Awell equipped light measurement facility
would rst determine the total power output of the unit mea-
sured using a well calibrated thermopile. These instruments
are black body absorbing plates with layers of thermocou-
ples that respond to absorption of radiant energy in a linear
manner over a very wide range of frequencies. For accurate
measurement, all radiation from the exiting port must fall on
an area larger than the beam. Because dental curing lights
have a very wide difference with respect to beam diversion
and increasing tip distance, this means that the tip end needs
to be held as close to the detector plane as physically possible,
without touching it [122]. Unfortunately, when following ISO
106500-1 testing standard for determining exitance radiation
of curing lights, the tip ends are held at a distance from the
detector plate [125]. Depending on the distance between the
top plane of the thermopile to the depth where the black plate
is located, the tip will be held at varying distances, and will
thus provide inaccurate results for light power emission [126].
Therefore a wide diameter, shallow-welled thermopile is best
for evaluation of dental curing lights. In addition, it is opti-
mal to have at least two independent, calibrated thermopile
systems so that the tolerance of calibration measurements
can be checked. However, a thermopile will provide accurate
indication of the emitted power, but without respect to its
spectral distribution: measuring the radiant ux (mW). Know-
ing this value, the area of the emitting end over which light
is being projected is measured accurately using a microscope
and is divided into the total power to derive the irradiance
or exitance irradiance (more casually referred to as power
density): mW/cm
2
.
4.3. Spectral irradiance
As mentioned previously, the thermopile does not discrimi-
nate with respect to frequency over which it measures power:
it only measures total power. Spectroradiometers are used to
evaluate dental curing radiometers and measure power gen-
erated over the visible spectrum. The spectral distribution
of dental curing lights has been determined since UV units
were introduced [17,21]. Early technology required large and
very expensive equipment. However, advancements inthe sci-
ence have allowedvery precise measurements tobe accurately
made using only a modest investment. These instruments
are commonly referred to as hand-held spectroradiometers
(model USB2000+RAD, Ocean Optics, Dunedin, FL).
To analyze light emission, a device needs to be utilized that
captures all radiant output from the emitting end. One type
device is an integrating sphere, which consists of an entrance
port into which the emitting end of a curing light is placed,
and within which light reects multiple times off of a highly
reective, diffusing lm. A ber optic cable is tted to an exit
port of the sphere, and connects to a small spectroradiometer.
This device thenseparates the input light intoits spectral com-
ponents using a grating, and projects that beam onto a xed,
multiple element diode array. The more diodes in the array,
the smaller the entrance slit size, the more nely the spectrum
can be resolved. The array output is analyzed using software,
dental materi als 2 7 ( 2 0 1 1 ) 3952 47
where the contents of each pixel captured over a specic time
frame are determined and displayed on screen as a plot of
emitted power (photon count) with respect to wavelength.
These systems must be calibrated against a highly accurate
light source that typically resides inside of the sphere, so that
the sphere, connecting cables, and spectral radiometer are all
calibrated as a single instrument. Any change in tightening or
cabling will negate the calibration. This type system is bulky,
as the sphere is typically 6in in diameter, and requires a ded-
icated, computer-controlled power supply for the calibration
lamp. A limitation of the device is that it cannot determine
variation in power or wavelength values across the emitting
tip, as the internal reections average out all such differences,
providing only a single, value. The output measure fromusing
such equipment is the spectral radiance: mW/nm.
A simpler experimental system involves use of a cosine
corrector (CC-3, Ocean Optics) connected to a ber optic cable,
which again is attached to the spectroradiometer. The cosine
corrector is a lambertian diffuser (typically opaline glass,
Spectralon

, or Teon) that captures light from all incident

angles within 180 degrees from the plane on its exposed side.
Typically, the optical input diameter of the corrector is approx-
imately 4mm, so it does not capture all emitted power from
a tip larger in size, and assumes a uniform distribution of
bothirradiance and wavelengthacross the curing unit tip face.
However, by providing a known capture area, the resulting
spectral distribution can be reported using irradiance units,
not just power. The entire system (cosine corrector, and spec-
trometer, must also be calibrated using a traceable source that
is capable of providing uniformlight of known quantity across
the cosine corrector face. However, once calibrated, the instru-
ment is portable, as it consists only of a small cosine corrector,
a ber optic cable, and palm-sized spectral radiometer, and
easily operates from a laptop computer. Data generated using
this type setup provides the spectral irradiance of a light cur-
ing unit: mW/nm/cm
2
.
4.4. Determining beam irradiance inhomogeneity
Beamirradiance mapping (intensity contour generation) is not
new to the dental eld, as large discrepancies were detected
in the UV curing lights [21] and as early as 1985 for visible
light models [127]. Recent work [124,128,129] has developed
a method for observing the uniformity of light across the
emitting end of contemporary light curing units. The instru-
mentation needed for such work is adapted from analysis of
laser beams, where knowledge of how the laser interfaces
with a surface is essential to its performance: if the beam
power is higher in the core or higher in the periphery. The
basic setup of such an instrument consists of a CCD camera
upon which the beam is targeted. The system is congured
differently for analyzing dental curing light beam uniformity,
as there must be a translucent target present and a lens-
ing/iris system to adjust for focusing and saturation of the
detector. The distance between the camera and target is xed
so that accurate dimensional measurements can be made of
the beam image at that plane. The target material is criti-
cal to obtaining accurate results, in that the material must
be opaque enough to block imaging the tip through the tar-
get, but translucent enough to provide sufcient light to pass
and make an image on the camera side. A target material that
seems to perform quite well for tip-end imaging is 1500 grit
ground glass (DG100X100-1500, Thorlabs, Newton, NJ). First,
the total power emitted from the tip end is measured using a
calibrated system: either a thermopile or integrating sphere.
Next, the emitting end of the curing unit is placed in direct
contact with the target glass. It is essential to obtain accurate
distinction from a signal and background noise, so a system
must be used that provides uniform baseline values for all
pixels when no signal is present (UltraCal
TM
, Ophir-Spiricon,
Logan, UT). The camera-side image is then analyzed using
software anddisplayedonthe computer screen. The lens aper-
ture must be adjusted so that the maximal power observed by
the camera is set just under the saturation limit of the detec-
tor, providing full dynamic range to scale the result. The total
measured power obtained using the thermopile is entered
into software, and the computer distributes that value across
the pixels within the beam image, and color renders different
value ranges. By providing accurate dimensional information
at the target plane, the result is a calibrated, color-codedimage
of the beam irradiance dispersion across the emitting face.
4.5. Importance of beam imaging to curing light
characterization
Beam imaging is a necessary component for characterizing
output from a curing light. Often, it is very difcult to deter-
mine the exact area over which light is being emitted fromthe
unit end. This situation is especially true for LED curing lights
that have chips located at the distal end of the handpiece, and
utilize no lensing system, but instead, have the emitters only
behind a clear plastic plate, or behind nothing at all. Unless
the precise emission area is known, determination of valid
irradiance values are not possible to calculate. When deter-
mining the irradiance of curing lights utilizing glass bundled
ber optic guides, many researchers measure the diameter of
the bundle and assume that all exiting light is actively dis-
persed across the entire bundle end. Using the beam proler,
recent research has identied specic incidences where the
active, lighted area of a ber optic bundle is less than that of
the actual bundle area itself [124]. Without such knowledge,
large errors in irradiance values assigned to such a light would
occur.
A measure of the uniformity of power distribution within
the beam is called the top hat factor, or THF. In this calcula-
tion, software determines the weighted average of each pixel
making up the beam image, and relates it to the maximum
response seen. Thus, a number from unity (representing per-
fectly uniform distribution) to zero is presented, with lower
values indicating less uniformity [124].
The extremely important aspect of such type analysis is
that a histogram of the irradiance distribution as a function
of pixel values occupying the area on the beam face can be
calculated [124]. When such procedures are performed, it is
seen that many lights display very wide ranges of irradiance
values, while others seemto be more narrow-ranged [124].The
critical point being made is that conventional methods for irra-
diance determination assign a single, average value (using an
integrating sphere or cosine corrector) to a curing light. How-
ever, what should be reported is the histogram of irradiance
48 dental materi als 2 7 ( 2 0 1 1 ) 3952
distribution, as it is not normally distributed and truly indi-
cates the range of output values the unit presents. Providing
such information gives a much better comprehension of the
quality of a unit than does presentation of a single, averaged
value. In addition, the effect of irradiance distribution when
different types of light guides are used on the same unit body
can be identied and quantied [124]. The clinical relevance
of such differences in irradiance is pointed out by the fact
that localized areas of irradiance value deviation at the tip
end have been precisely matched to the mapping of hardness
values on the surface photocured by that unit, as well as at
a depth of 2mm [129]. These differences could affect the rate
of localized curing, and of the resulting polymerization stress
development, whichcouldalsoaffect the integrity of the resin-
tooth interfacial bond. In addition, the differences could affect
localized conversion values and wear resistance, leading to a
differential in restoration surface wear over time [130].
4.6. Nonuniformity of wavelength distribution within
the beam
The beam analysis system can also be used to measure the
homogeneity of wavelength dispersion across the beam tip
[131]. For units having broad banded sources (QTH and PAC
lights), there is no difference, as all portions of light in the
beam contain all output wavelengths. However, in the third
generation LEDs, the off axis arrangement of the different
color chips is reproduced in the forward beam image, result-
ing in localized areas of radiation occupied by only one chips
wavelength: very little frequency mixing within the beam
[130]. Such a condition may result in disproportionate utiliza-
tionof resinsystems containing multiple photoinitiators, each
requiring different wavelengths for activation, not only at the
top, irradiated surface, but also within the depths of the com-
posite. Again, conventional methods of curing light analysis
would have not detected such differences, however with these
new analytical techniques, clinically relevant characteristics
are detectedandquantied, andvaliddistinctions among light
units can be made.
4.7. Curing tip movement
Knowing that discrepancies inbothirradiance andwavelength
may exist in a light beam obviates the reaction to move the
beam during exposure in order to better distribute values.
Large discrepancies were noted in the beam proles for the
early UV light [21], and as a result, the clinician was advised
to move the tip during exposure to purposefully average out
localized diffrerences and hopefully create a more uniformly
polymerized restoration [1]. Later work was done in this area
using large diameter and smaller diameter QTH light guides
[132]. It was found that circular movements, as opposed to
xed, or overlapping exposures resulted in a much poorer
distribution of composite hardness, and that large and small
diameter light guides provided the best results when used in
a rigidly xed position. Similar, but contemporary work per-
formed using LED lights also conrmed that tip movement
(either fast or slow circular or rastering motion) resulted in
lower overall hardness at both the top, irradiated surface,
as well as at a 2mm depth [133]. However, in that study,
all exposures lasted the same amount of time: 20s. It was
contemplated that, if longer exposure duration had been
applied when moving the tip, hardness values would have
beengreater better due to the increasedenergy appliedto each
location.
5. Future developments
With respect to curing light characterization, the methods
outlined above should be considered for incorporation into
national as well as international standards, as existing stan-
dards and evaluation protocols are obviously decient. The
physical properties of resins cured with various lights have
been found to be inferior, although all units passed the ISO
standard for measuring depth of cure, conforming that the
standard method is not truly discriminating in characteriz-
ing curing light performance [134]. In the near future, curing
light manufacturers, and the clinical ofces using light emit-
ting devices will more than likely be held responsible for
monitoring the radiant output from such units as a result
of regulatory agency requirements. Such requirements are
already being adopted in Europe for nearly all classes of prod-
ucts that emit any sort of electromagnetic radiation [135,136].
However, because of the well documented retinal damage of
light within the spectral range currently used for photoinitia-
tioncauses, curing lights may be helpedto anevenhigher level
of scrutiny. Therefore, clinical ofces may have to either pay
for professional, certied services to periodically provide char-
acterization of their lights (as they currently are required to do
for their X-ray machines), or purchase a qualied device that
has beencertiedandworthy of suchmeasurements. Withthe
alarmingly poor performance and maintenance noted from
multiple studies assessing curing light status in private prac-
tice [137,138], accountability of the clinicianto provide optimal
polymerization performance should, and hopefully will, be
required.
Future studies investigating material properties of resins
resulting from photopolymerization by dental curing lights
should provide better documentation and description related
to the true output characteristics of the lights usedinthe study
so that better correlationcanbe made betweenresulting prop-
erties and exposure to radiation. The research community
must revisit current standardized methods of determining
performance of restorative resins (suchas determining depths
of cure), and devise more appropriate testing that accounts for
discrepancies in localized irradiance and wavelength discrep-
ancy. Currently, only a 4-mm diameter composite specimen is
used for this purpose. Clearly, any great off-axis distribution
of either irradiance or applied wavelength may signicantly
alter the performance of a light, relative to one where the
distributions have resulted in a high concentration of light
in the center of the tip. To this end, it would be the bur-
den of manufacturers to develop lights having more uniform
output characteristics. Internationally accepted standards for
allowing specied amounts of deviance in beam characteris-
tics could be developed, permitting more valid comparison of
resin specimens photocured with such units.
With world energy sources dwindling and the need for
energy efcient use of power, the application of light emit-
dental materi als 2 7 ( 2 0 1 1 ) 3952 49
ting diodes in medicine and dentistry will continue to grow.
Already, use of light for diagnostic and therapeutic purposes
has become wide spread. However, again, as the LED indus-
try makes advances inlight-generating capabilities, the dental
eld will typically be the rst to incorporate any new tech-
nology into clinical practice. Of specic interest is the use of
organic light emitting diodes (OLEDs). These products allow
extremely thin and exible video displays to be made, but the
current technology is such that output levels remain much
lower than those of conventional LED chips. However, it is
not unreasonable to envision impression trays with walls and
oors lined with these emitting lms, designed to evenly irra-
diate all surfaces of a photo-curable impression material. In
addition, use of quadrant type trays for the simultaneous and
wide area illumination of teeth for photocuring of sealants or
light-enhanced vital bleaching or veneer bonding would be a
great advantage, as would be the applicationof thin, adaptable
lms for photocuring resins retaining orthodontic brackets.
Another area where tremendous advances have beenmade
with incorporation of state-of-the-art lighting technology in
medical therapy has been the eld of quantum dots. These
substances are semiconductors with conducting characteris-
tics closely related to the size and shape of their individual
crystals. Smaller crystals display a larger band gap. Thus, as
the difference in energy between the highest valence band
and lowest conducting band increases, more energy is needed
to excite the dot, but also, more energy is released when the
crystal is back in its resting state. Such technology allows
uorescence to occur at shorter wavelengths than those of
excitation. This condition would allow red light exposure
to result in emission of blue light, which might be used
for photoinitiation. If such dots were incorporated into a
photopolymerizable resin composite, it might be possible to
enable the entire mass to release light within itself, resulting
in a curing from within, which is an aspect always dreamed
of, but never realized for dental applications.
6. In summary
It is truly a remarkable time in dentistry. So many recent tech-
nical advancements have become clinical realities and are
now necessary tools for the contemporary practice of den-
tistry, it is difcult to imagine how techniques could get much
more automated. However, the beauty of our profession is
that, despite the complexity of instruments and tools used,
the dentist is still the health care provider who spends the
most time in direct contact with a non-sedated patient. Thus,
dentists tend to build loyal patient bases, because the practice
of the profession remains a one-on-one, individualized treat-
ment, and not a remote, robotic, impersonal procedure. This
is truly a great time for dentistry.
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